Smartphone-delivered mental health care interventions for refugees: A systematic review of the literature

Assessing the Cultural Fit of a Digital Sleep Intervention for Refugees in Germany: Qualitative Study

BACKGROUND

Digital interventions have been suggested to facilitate access to mental health care for refugees, who experience structural, linguistic, and cultural barriers to mental health care. Sleep-e, a digital sleep intervention originally developed for German teachers, has been culturally adapted for refugees in Germany mainly coming from African and Middle East countries. With the increasing number of refugees from Ukraine and the associated diversity of cultural backgrounds among refugees in Germany, it is essential to assess whether existing digital interventions are culturally appropriate for this target group as well.

OBJECTIVE

The study aimed to investigate the perceived cultural appropriateness of Sleep-e in both its original and culturally adapted versions among refugees in Germany, hereby exploring and possibly contrasting the needs of refugees coming from Ukraine and other countries of origin.

METHODS

Overall, 13 refugees (6 from Ukraine, 23-66 years old; and 7 from other countries, 26-41 years old) participated in the study. Each participant went through parts of the original or culturally adapted version of the digital sleep intervention, with 5 participants going through both versions. A total of 17 semistructured interviews (11 for the adapted, 6 for the nonadapted intervention version) and 9 think-aloud sessions (6 for the adapted, 3 for the nonadapted intervention version) were conducted to assess cultural appropriateness, suggestions for adaptations, and perceived relevance. Data were transcribed, categorized, and analyzed using structured qualitative content analysis.

RESULTS

The findings showed key differences in the perceived appropriateness and identification between the 2 refugee groups and the 2 intervention versions. Ukrainian participants expressed positive (n=70) and negative (n=56) feedback on the adapted intervention version, which revealed identity conflicts, as the adapted intervention version was targeted at a refugee population with whom they could not fully identify (18 negative feedback quotes concerning the refugee example characters). Whereas they identified with the European context in the original version, they found the problems described less relevant to their experiences. In contrast, participating refugees from other countries found the culturally adapted version more comprehensible and culturally appropriate (55 positive and 5 negative feedback quotes). No significant usability issues were reported, but several participants highlighted the need for an individualization of the intervention content.

CONCLUSIONS

Neither the original nor culturally adapted version of the digital sleep intervention fully met the needs of all refugee groups, highlighting the complexity of culturally adapting digital interventions for this population. Particularly, the identity conflict of participating Ukrainian refugees regarding the refugee context suggests that adaptation should go beyond regional considerations and consider the dynamics of social identity. These findings emphasize the relevance of including co-design processes with different refugee populations to ensure broad identification and, herewith, cultural appropriateness of digital interventions.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00036484; https://drks.de/search/de/trial/DRKS00036484.

Cultural adaptation of a self-help app for grieving Syrian refugees in Switzerland. A feasibility and acceptability pilot-RCT

Background

The global refugee population has significantly increased, with Syrian refugees being one of the largest displaced groups. Bereavement represents a major challenge. However, access to mental health care is limited by structural and cultural barriers. Internet-based interventions (IBIs) offer a promising solution, but most are developed in Western contexts, limiting their cultural relevance. This study aimed to evaluate the acceptability, feasibility, and preliminary efficacy of a culturally adapted self-help IBI for bereaved Syrian refugees in Switzerland.

Methods

In a mixed-methods pilot randomized controlled trial (RCT), 30 bereaved Syrian refugees were randomly assigned to a 5-week app-based intervention or a waitlist control group. Semi-structured interviews with the intervention group provided qualitative insights on feasibility and acceptability and were analyzed with framework analysis. Quantitative data assessed treatment satisfaction, adherence, and preliminary efficacy on grief, depression, posttraumatic stress disorder (PTSD), anxiety, well-being, disability, post-migration difficulties, and social support. Descriptive statistics were used for feasibility and acceptability, while linear mixed-effects models assessed efficacy.

Results

High treatment satisfaction, a low dropout rate and adherence of 40 % were found. Qualitative interviews indicated the intervention was relevant and beneficial, further adaptations were suggested. No significant group differences were found on bereavement or secondary outcomes. However, trends indicated reduced grief, anxiety, PTSD, and depression, with improved well-being and social support in the intervention group.

Conclusions

The results suggest that this culturally adapted IBI is both feasible and acceptable for Syrian refugees. While trends are promising, a larger RCT is needed to investigate efficacy. This intervention shows potential as meaningful support for bereaved Syrian refugees.

Digital solutions for migrant and refugee health: a framework for analysis and action

Digital technologies can help support the health of migrants and refugees and facilitate research on their health issues. However, ethical concerns include security and confidentiality of information; informed consent; how to engage migrants in designing, implementing and researching digital tools; inequitable access to mobile devices and the internet; and access to health services for early intervention and follow-up. Digital technical solutions do not necessarily overcome problems that are political, social, or economic. There are major deficits with regard to (1) reliable data on the health needs of migrants and mobile populations and on how they can use digital tools to support their health; (2) evidence on effectiveness of solutions; and (3) a broad framework to guide future work. This article provides a wide socio-technical perspective, as a framework for analysis and developing coherent agendas across global-to-local spaces, with particular attention to the European region.

A low-cost digital first aid tool to reduce psychological distress in refugees: A multi-country randomized controlled trial of self-help online in the first months after the invasion of Ukraine

Armed conflicts increase distress levels among affected populations, particularly impacting refugees who often face barriers to accessing psychological support. We evaluate an online version of a previously tested in-person and endorsed for online adaptation by the WHO Self-Help Plus (SH+) program among Ukrainian refugees dispersed across 17 countries, internally displaced and not displaced Ukrainians. This is the first randomized controlled trial to test an online psychological intervention simultaneously on refugees, internally displaced, and non-displaced conflict-affected populations. This study is an online two-arm, individually randomized controlled trial among participants above 18 years old in Ukraine or EU countries who were randomly assigned to receive either the Self-Help Online (SHO) intervention and passive informational resource or the passive informational resource alone. We recruited 652 participants starting the program on July 7th, 2022. The analysis focused on 292 participants who completed the final survey one week after the end of the program. Results indicated significant distress reduction among refugees (β -2.16, 95% CI -4.17 to -0.16; p = 0.03; d -0.47) but not among internally displaced in Ukraine (β 0.56, 95% CI -1.1 to 2.99; p = 0.17; d 0.2) or non-displaced participants in Ukraine (β 0.2, 95% CI -0.95 to 1.35; p = 0.73; d 0.08). The effect size in stress reduction for refugees was comparable to other similar interventions but with lower average costs. The average cost per participant was €11, with €46.16 for each benefiting (refugee) participant, suggesting cost-effectiveness for scale-up. These findings suggest that Self-Help Online is an effective psychological intervention for reducing stress among geographically dispersed refugees at a low cost. We also find that the online delivery format of psychological interventions is feasible for internally displaced and non-displaced conflict-affected populations.

Effects of a self-guided digital mental health self-help intervention for Syrian refugees in Egypt: A pragmatic randomized controlled trial

BACKGROUND

Digital mental health interventions for smartphones, such as the World Health Organization (WHO) Step-by-Step (SbS) program, are potentially scalable solutions to improve access to mental health and psychosocial support in refugee populations. Our study objective was to evaluate the effectiveness of SbS as self-guided intervention with optional message-based contact-on-demand (COD) support on reducing psychological distress, functional impairment, symptoms of posttraumatic stress disorder (PTSD), and self-identified problems in a sample of Syrian refugees residing in Egypt.

METHODS AND FINDINGS

We conducted a 2-arm pragmatic randomized controlled trial. A total of 538 Syrians residing in Egypt with elevated levels of psychological distress (Kessler Psychological Distress Scale; K10 > 15) and reduced psychosocial functioning (WHODAS 2.0 > 16) were randomized into SbS + CAU (N = 266) or CAU only (N = 272). Primary outcomes were psychological distress (Hopkins Symptom Checklist 25) and impaired functioning (WHO Disability Assessment Schedule 2.0) at 3-month follow-up. Secondary outcomes were symptoms of PTSD (PTSD Checklist for DSM-5 short form, PCL-5 short) and self-identified problems (Psychological Outcomes Profiles Scale, PSYCHLOPS). Intention-to-treat (ITT) analyses showed significant but small effects of condition on psychological distress (mean difference: -0.15; 95% CI: -0.28, -0.02; p = .02) and functioning (mean difference: -2.04; 95% CI: -3.87, -0.22; p = .02) at 3-month follow-up. There were no significant differences between groups on symptoms of PTSD and self-identified problems. Remission rates did not differ between conditions on any of the outcomes. COD was used by 9.4% of participants for a median of 1 contact per person. The main limitations are high intervention dropout and low utilization of COD support.

CONCLUSIONS

The trial provides a real-world implementation case, showing small positive effects of a digital, potentially scalable and self-guided mental health intervention for Syrian refugees in Egypt in reducing psychological distress and improving overall functioning. Further user-centered adaptations are required to improve adherence and effectiveness while maintaining scalability.

TRIAL REGISTRATION

German Register for Clinical Studies DRKS00023505.

Digital mental health interventions for the mental health care of refugees and asylum seekers: Integrative literature review

This study aimed to provide a critical analysis of the current literature on the use of digital mental health interventions (DMHIs) for the management and treatment of mental health disorders among refugees and asylum seekers. These groups are among the most disadvantaged compared to the general population in terms of health and socio-economic status, due to conflicts and wars. The number of refugees fleeing their home countries is growing exponentially, and refugees experience trauma, torture, persecution and human right abuses, which have a profound effect on their mental health and overall well-being. The researchers conducted an integrative literature review from electronic databases Medline, CINAHL and Google Scholar, selecting articles published in English from 2010 to 2023. The thematic analysis of the 10 articles identified in the review revealed four main themes and two sub-themes: (1) types of digital health intervention/apps used; (2) barriers encountered in digital health intervention; (3) user experience of the digital health intervention and (4) mapping gaps. Two sub-themes were identified located in Theme 2: (2.1) Language and demographic barriers and (2.2) Structural barriers. The study showed that the use of DMHIs was associated with positive experiences among refugees and asylum seekers. Limited mental health care is offered to refugees and asylum seekers due to a range of logistical, political, economic, geographical, language, cultural and social barriers. DMHIs have the potential to overcome and/or moderate these barriers. The study concludes that the scaled implementation of effective DMHIs holds the possibility to improve the wider distribution of mental health care among refugees and asylum seekers. However, further research is needed to confirm the effectiveness of DMHIs and to scale up studies for their utilisation among this group. In summary, this study highlights the potential of DMHIs in improving the mental health care of refugees and asylum seekers. The results of this study have important implications for mental health service providers, policymakers and researchers to address the mental health needs of this vulnerable/priority group.

Arabic-language digital interventions for depression in German routine health care are acceptable, but intervention adoption remains a challenge

Migrants face many barriers to mental health care, such as different cultural concepts of distress, unfamiliar pathways to care, and language. Digital mental health interventions are effective and scalable in multi-language versions. However, their implementation into routine care is in its infancy. Here, we report on the Arabic- and German-language implementation of two digital interventions in Germany: The iFightDepression® website, providing information about depression to the public, and the iFightDepression® tool, offering guided self-management for depression. Our main goal is to gain empirical knowledge about the success of their implementation and provide evidence-based recommendations for improvement. Data for the current analyses stem from convenience samples, utilizing anonymized user logs of the iFightDepression® website and 15.307 user accounts in the iFightDepression® tool. We found that the acceptability (time on page, usage behavior) of both digital interventions was comparable between the two user groups. The website pervasiveness of the target populations was nine times lower among Arab migrants in Germany than Germans (89 vs. 834 unique page views/ 100,000 inhabitants), but the increase in views was superior and sustained over three years. The adoption of the tool was lower among Arabic than German users (conversion rate from invitation to completed registration: 30.8% vs. 59.0%, p < 0.001) and appropriateness was challenged as Arabic users reported higher depression severities upon first registration (p = 0.027). Our results show that the uptake of digital interventions for migrants requires facilitation and further tailoring to the needs of the target group.

Digital Mental Health Approaches to Improve Well-Being of Refugee Families

Refugee populations face disproportionately high risk for mental health challenges because of their exposure to geopolitical conflict, persecution, violence, and human rights violations. Dedicated, sustained psychological services are scarce in refugee contexts. Access to mental health treatment is limited by stigma and discrimination, linguistic and cultural barriers, and lack of privacy and confidentiality. Digital health approaches can increase access to mental health services in refugee contexts where need is high, mobile device infrastructure is common, and digital options may transcend contextual barriers. Tailored digital mental health interventions that may overcome barriers to mental health treatment among refugee populations are outlined.