Innovation summary

Empirical studies investigating the mental health of Syrian refugees have found that many children in war-affected settings with a need for psychological treatment don’t have access to mental health services1-2. Humanitarian health organisations working in these settings tend to be confronted with many obstacles, including lack of funding to set up new mental health services, difficulties in recruiting qualified local staff, and restricted access of the refugee population to primary health care centres3.

These challenges are difficult to address with conventional mental health services, which tend to be provided by mental health specialists in centralised primary health care centres. In order to overcome these hurdles, this project will adapt and evaluate the existing transdiagnostic psychological treatment programme called Common Elements Treatment Approach (CETA) for the delivery by trained lay counsellors over phone.

The project has two objectives:

  1. Development of a telephone-delivered CETA (t-CETA) by adapting the existing face-to-face CETA intervention
  2. Evaluation of the effectiveness of t-CETA with a small mixed-methods pilot trial

If found to be effective, telephone-delivered CETA (t-CETA) will facilitate the provision of psychological intervention for children in humanitarian emergency and other low-resource settings with limited access to mental health services.

Impact summary

This pilot trial is still ongoing and in patient recruitment phase. Current information is based on the research protocol and will be updated when the trial is completed.

I am convinced of the importance of what we do in the CETA study and the potential impact on the refugees we are working with. CETA is very useful for refugees in the difficult circumstances they have gone through and still live in. This treatment helps those who come in with depression a lot, and it can also help with other mental health problems such as anxiety and adapting to changes. Even though we sometimes face challenges such as having patients with complex mental health problems and caregivers not believing in the importance of mental health treatment of their children, we have been able to overcome these challenges one by one. In fact, every time we encounter such challenges, I remind myself that we are conducting important research on a new treatment approach that has never been implemented here before and we have to find out whether it will be useful. Hence, overcoming these challenges is a must. At the end of the day, we are often getting great results which encourage us a lot.”

 - Diana Abdul Rahman (lay CETA counsellor)

Innovation details

There are currently more than 2 million internationally displaced Syrian refugee children in countries surrounding Syria, with more than 500,000 living in Lebanon4. Children are particularly vulnerable in humanitarian settings, and psychological treatments are not easily accessible for them, or may be provided in settings that do not allow to address individual needs2.

This project focuses on the development of a new innovative approach for the delivery of an effective mental health treatment (Common Elements Treatment Approach – CETA) to children in low-resource and humanitarian settings over the phone. t-CETA is Cognitive Behavioural Therapy (CBT) based approach that will be delivered over the telephone. Components are available for common problems, including anxiety, depression, PTSD, conduct problems, substance abuse, and safety issues (including self-harm or suicidal ideation), and a tailored treatment package is produced for each child based on the presenting problem(s) and response to treatment. t-CETA sessions of up to 30 minutes will be delivered 1-2 times per week for approximately 8-12 weeks. The active Comparator will be treatment as usual (TaU) provided by Médecins du Monde. The number and content of sessions will vary depending on the needs of the child. Primary and Secondary outcomes being measure will include:

Primary outcome measures:

  1. Emotional and behavioural problem composite score
  2. Adaptive functioning score

Secondary outcome measures:

  1. PTSD symptom score
  2. Depression symptom score
  3. Anxiety symptom score
  4. Externalising behaviour problems
  5. Response to intervention
  6. Well-Being score
  7. Optimism

The delivery of psychological services over the phone has the potential to significantly reduce the burden associated with requiring specialist services within the fragmented health systems in humanitarian settings with poor access to mental health care services. Moreover, it seeks to make psychological interventions much more accessible at a significantly reduced cost compared to current standard methodologies.

Outcomes:

  • To produce a detailed manual and training materials for t-CETA
  • Obtain first empirical evidence for the efficacy of t-CETA.
  • Engage in uptake activities such as workshops to introduce t-CETA and provide information on its implementation to interested academics, clinicians, organisations and agencies

Key drivers

Accurate measurements

  • Reliable and valid measures are one of the most important aspects of any research study. Measures should be adapted to the culture, educational and literacy levels of the target population, while also allowing for comparisons with other contexts.

Culturally-competent and local staff

  • Counsellors were local community workers with good knowledge of language and culture and interest in mental health.

Challenges

Fieldwork challenges

  • Challenges involved in the actual conduct of the research included adverse weather, security concerns and transport issues. Furthermore, many refugee families that initially expressed a need for treatment, appear reluctant to use mental health services which creates significant challenges to recruit children into the study.

Academic-NGO partnership

  • Close partnerships between researchers and practitioners in the field are key to high-quality research. They can also be challenging. NGOs’ lack of experience in implementing research, and academics’ lack of connection to the community and limited knowledge of operational procedures in the field, can result in significant differences in expectations and institutional culture.

Continuation

Face-to-face CETA has been implemented and evaluated in multiple settings within Africa (Ethiopia, Somalia, Ukraine, Zambia) and Asia (Thailand, Myanmar).

Partners

Funders

Evaluation methods

This study involves the development and piloting of a phone delivered intervention (t-CETA) in Syrian refugee children in Lebanon. CETA will be culturally adapted for Syrian refugees and adapted for phone delivery. It will then be evaluated using a single blind small mixed-methods trial, comparing t-CETA to treatment as usual.

  • Phase I: A small number of children will participate in face-to-face CETA in order to adapt CETA for telephone administration (t-CETA). t-CETA will then be delivered in the clinic to up to 10 children in order to finalise the t-CETA manual.
  • Phase II: Between 15-30 children will be randomised to receive either t-CETA at home or treatment-as-usual in the clinic (standard treatment provided by Médecins du Monde).
  • Both children and primary caregivers will be interviewed to assess the child’s mental health, including measures of psychopathology (anxiety, depression, PTSD, and externalising behaviour problems) and wellbeing.
  • Independent assessments are conducted at baseline (pre-intervention assessment) and immediately after treatment.
  • t-CETA will be delivered in weekly or twice weekly sessions of 30-60 minutes over the span of 8-16 weeks.
  • The team carrying out independent assessments and the investigator team carrying out data analysis will be blind to treatment allocation.

Cost of implementation

Given that t-CETA does not require local facilities and mental health professionals, it can be delivered more easily, more quickly and at lower cost than traditional mental health services which are centre based and delivered by professionals. This will also enable non-medical humanitarian organisations to offer t-CETA (in collaboration with medical organisations who are able to provide the required training and supervision).

Impact details

The primary data analysis for the RCT implemented in this research project is still pending and will be updated when published.

References

  1. Kieling C, Baker-Henningham H, Belfer M, Conti G, Ertem I, Omigbodun O, Rohde LA, Srinath S, Ulkuer N, Rahman A. Child and adolescent mental health worldwide: evidence for action. The Lancet. 2011 Oct 22;378(9801):1515-25.
  2. Bronstein I, Montgomery P. Psychological distress in refugee children: a systematic review. Clin. Child Fam. Psychol. Rev. Mar 2011;14(1):44-56.
  3. el Chammay R, Kheir W, Alaouie H. Assessment of Mental Health and Psychosocial Support Services for Syrian Refugees in Lebanon. UNHCR; Beirut, Lebanon.
  4. UNHCR. Syria Regional Refugee Response Inter-agency Information Sharing Portal. 2016; http://data.unhcr.org/syrianrefugees/regional.php. Accessed 29.11.2016, 2016.

Research

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