Savaş ve iltica:travmatik olaylara maruz kalmış geçici koruma statüsündeki Suriyeli kadınlara yönelik inceleme ve psikolojik müdahale

Aims of this study are examining the traumatic experiences of Syrian women under temporary protection in Turkey, the relationship between these experiences and women’s symptoms of depression, anxiety, post-traumatic stress disorder (PTSD) and degree of post-migration living difficulties in the first stage of the study; and evaluating feasibility, acceptability and effectiveness of Culturally Adapted Cognitive Behavioral Therapy (CA-CBT) through a randomized controlled trial in the second stage. Sample of the descriptive study that took place in the first stage consisted of 89 Syrian women, while the sample of randomized controlled trial that took place in the second stage consisted of 23 Syrian women. Demographical information Form, Harvard Trauma Questionnaire (Part I and IV), Hopkins Symptom Checklist -25 and Post Migration Living Difficulties Checklist were used in data collection process. Descriptive analysis showed that 89 women who participated in the screening have been exposed to the common traumatic experiences and post-migration living difficulties that take place in the literature and have anxiety and depression symptoms at a clinical level. Correlation analysis demonstrated the statistically significant relationships between lifelong traumatic experiences and anxiety, depression, PTSD symptoms, degree of post-migration living difficulties and; between post-migration living difficulties and anxiety, depression, PTSD symptoms. In order to assess the feasibility and acceptability of CA-CBT, drop-out rates and presence of adverse events were examined and the results indicated that CA-CBT is a feasible and acceptable psychotherapy approach for Syrian women who are under the temporary protection of Turkey. Linear mixed model analysis that was conducted to test the efficiency level of CA-CBT demonstrated that CA-CBT has a statistically significant and positive effect on participants’ PTSD symptoms. Obtained results were discussed in accordance with literature and suggestions for the future studies and clinical applications were mentioned.Öz .............................................................................................................................. iv Abstract ..................................................................................................................... vi Teşekkür .................................................................................................................... viii İçindekiler ................................................................................................................... x Tablolar Listesi ............................................................................................................ xiii Şekiller Listesi ............................................................................................................ xiv BÖLÜMLER 1. Giriş .......................................................................................................................... 1 1.1. Psikolojik Travma .............................................................................................. 2 1.1.1. Psikolojik Travma Tanımı............................................................................ 2 1.1.2. Psikolojik Travmanın Etkileri ...................................................................... 3 1.1.3. Travmayla Baş Etme ................................................................................... 6 1.1.4. Travma ve İyileşme..................................................................................... 7 1.2. Göç, İltica ve Travma ......................................................................................... 8 1.2.1. Göç ve iltica ................................................................................................ 8 1.2.2. İlticanın Travmatik Etkisi ve Mültecilerin Ruh Sağlığı ................................ 9 1.2.3. Kadın Mültecilerin Yaşadıkları Sorunlar ve Ruh Sağlığı ............................ 11 1.2.4. Türkiye’deki Suriyeli Mülteciler ............................................................... 12 1.2.5. Suriyeli Mültecilerin Ruh Sağlığı ............................................................... 14 1.2.6. İltica Sonrası Yaşam Zorlukları ................................................................. 19 1.3. Psikolojik Travma Sonrası Ortaya Çıkan Rahatsızlıkların Tedavisi ve Kültüre Uyarlanmış Bilişsel Davranışçı Terapi (KU-BDT) ..................................................... 21 1.3.1. Psikolojik Travma İle Çalışırken Sıklıkla Kullanılan Tedavi Yöntemleri ..... 21 1.3.2. Grup Terapiler .......................................................................................... 24 1.3.3. Kültüre Uyarlanmış Bilişsel Davranışçı Terapi, KU-BDT (Culturally Adapted Cognitive Behavioral Therapy, CA-CBT) ............................................................. 25 1.4. Araştırmanın Amacı ve Soruları ....................................................................... 33 1.4.1. Araştırma Soruları/Hipotezleri ................................................................. 35 2. Yöntem ................................................................................................................... 36 2.1. Katılımcılar ....................................................................................................... 36 2.1.1. Tüm Katılımcılar ....................................................................................... 36 2.1.2. Seçkisiz Kontrollü Çalışma Katılımcıları .................................................... 39 2.2. Veri Toplama Araçları ...................................................................................... 41 2.2.1. Demografik Bilgi Formu............................................................................ 41 2.2.2. Hopkins Belirti Tarama Listesi – 25 (Hopkins Symptom Checklist, HSCL25) ...................................................................................................................... 42 2.2.3. Harvard Travma Anketi (Harvard Trauma Questionnaire, HTQ) ............. 43 2.2.4. İltica Sonrası Yaşam Zorlukları Ölçeği (Post Migration Living Difficulties Checklist, PMLD) ................................................................................................ 43 2.3. Araştırma Deseni ............................................................................................. 44 2.3.1. Seçkisiz Kontrollü Çalışma ........................................................................ 44 2.4. KU-BDT’nin Kültürel Uyarlama Süreci …………………...………………………………….. 45 2.5. İşlem ................................................................................................................ 47 2.5. Verilerin Analizi ............................................................................................... 50 3. Bulgular .................................................................................................................. 51 3.1. Maruz Kalınan Travmatik Olaylar, İltica Sonrası Travmatik Deneyimler, Deneyimlenen Depresyon, Anksiyete, Psikolojik Travma Belirtilerine Dair Betimleyici Bilgiler ve İlintili Değişkenler Arasındaki İlişkilere Dair Bulgular ......... 51 3.1.1. Türkiye’deki Geçici Koruma Statüsündeki Suriyeli Kadınların Maruz Kaldıkları Travmatik Deneyimler ve Depresyon, Anksiyete, Travma Belirtilerine Dair Betimleyici Bilgiler ...................................................................................... 52 3.1.2. Maruz Kalınan Travmatik Olayların Sayısı ve Çeşidi ile Deneyimlenen Depresyon, Anksiyete, Psikolojik Travma Belirtilerinin ve İltica Sonrası Travmatik Deneyimlerin Şiddeti Arasındaki İlişkilere Dair Bulgular ................... 53 3.2. Kültüre Uyarlanmış Bilişsel Davranışçı Terapi’nin (KU-BDT) Uygulanabilirlik ve Kabul Edilebilirlik Düzeyine Dair Bulgular .............................................................. 55 3.3. Kültüre Uyarlanmış Bilişsel Davranışçı Terapi’nin Katılımcıların Anksiyete, Depresyon ve Travma Belirtilerinin Şiddeti Üzerindeki Etkilerine Dair Bulgular ... 56 4. Tartışma .................................................................................................................. 58 4.1. Maruz Kalınan Travmatik Olaylar, İltica Sonrası Travmatik Deneyimler, Deneyimlenen Depresyon, Anksiyete, Psikolojik Travma Belirtilerine Dair Betimleyici Bilgilerin ve İlintili Değişkenler Arasındaki İlişkilere Dair Bulguların Değerlendirilmesi ................................................................................................... 58 4.1.1. Katılımcıların Hayat Boyu Maruz Kaldıkları Travmatik Olayların ve Travmatik Olayların Psikolojik Rahatsızlık Belirtileriyle İlişkisine Dair Bulguların Alanyazın Çerçevesinde Değerlendirilmesi ........................................................ 59 4.1.2. Katılımcıların İltica Sonrasında Maruz Kaldıkları Travmatik Olaylar ve İltica Sonrası Yaşam Zorluklarının Psikolojik Rahatsızlık Belirtileriyle İlişkisine Dair Bulguların Alanyazın Çerçevesinde Değerlendirilmesi ....................................... 62 4.2. Kültüre Uyarlanmış Bilişsel Davranışçı Terapi’nin (KU-BDT) Uygulanabilirlik ve Kabul Edilebilirlik Düzeyine Dair Bulguların Değerlendirilmesi .............................. 65 4.3. Kültüre Uyarlanmış Bilişsel Davranışçı Terapi’nin Katılımcıların Anksiyete, Depresyon ve Travma Belirtilerinin Şiddeti Üzerindeki Etkilerine Dair Bulguların Değerlendirilmesi ................................................................................................... 67 4.4. Genel Değerlendirme, Klinik Doğurgular ve Yeni Çalışmalar İçin Öneriler ..... 69 4.5. Çalışmanın Sınırlılıkları .................................................................................... 71 Kaynakça .................................................................................................................... 73 Ekler ........................................................................................................................... 91 A. Etik Kurul Onayı ................................................................................................. 91 B. Göç İdaresi Araştırma Onayı ............................................................................. 92 C. Bilgilendirilmiş Onam Formu (Tarama Çalışması) ............................................. 95 D. Bilgilendirilmiş Onam Formu (Seçkisiz Kontrollü Çalışma) ............................. 100 E. Demografik Bilgi Formu – Türkçe .................................................................... 105 F. Demografik Bilgi Formu – Arapça .................................................................... 108 G. Hopkins Belirti Tarama Listesi – 25 (HSCL-25) ................................................. 110 H. Harvard Travma Anketi (HTQ) – Birinci Bölüm ................................................ 112 İ. Harvard Travma Anketi (HTQ) – Dördüncü Bölüm ............................................ 115 J. İltica Sonrası Yaşam Zorlukları Ölçeği (PMLD) ................................................. 118 K. Zihinsel Kapasite Değerlendirme Formu – Türkçe ........................................... 120 L. Zihinsel Kapasite Değerlendirme Formu - Arapça ........................................... 12

Beliefs about sleep paralysis in Turkey: Karabasan attack.

The present study examined explanations of sleep paralysis (SP) in Turkey. The participants were 59 college students recruited in İstanbul, Turkey, who had experienced SP at least once in their lifetime. Participants were administered the Sleep Paralysis Experiences and Phenomenology Questionnaire (SP-EPQ) in an interview. When asked whether they had heard of a name for SP, the vast majority (88%) mentioned the "Karabasan"-a spirit-like creature rooted in Turkish folk tradition. Seventeen percent of the participants believed that their SP might have been caused by this supernatural creature. Thirty-seven percent of participants applied various supernatural and religious methods to prevent future SP attacks such as dua (supplicating to God), reciting the Quran, and wearing a musqa (a type of talisman inscribed with Quranic verses). Case studies are presented to illustrate these findings. The Karabasan constitutes a culturally specific, supernatural interpretation of the phenomenology of SP in Turkey

Cost-effectiveness of the Self-Help Plus Intervention for Adult Syrian Refugees Hosted in Turkey

Importance: The cost-effectiveness of the Self-Help Plus (SH+) program, a group-based, guided, self-help psychological intervention developed by the World Health Organization for people affected by adversity, is unclear.Objective: To investigate the cost-utility of providing the SH+ intervention combined with enhanced usual care vs enhanced usual care alone for Syrian refugees or asylum seekers hosted in Turkey.Design, setting, and participants: This economic evaluation was performed as a prespecified part of an assessor-blinded randomized clinical trial conducted between October 1, 2018, and November 30, 2019, with 6-month follow-up. A total of 627 adults with psychological distress but no diagnosed psychiatric disorder were randomly assigned to the intervention group or the enhanced usual care group.Interventions: The SH+ program was a 5-session (2 hours each), group-based, stress management course in which participants learned self-help skills for managing stress by listening to audio sessions. The SH+ sessions were facilitated by briefly trained, nonspecialist individuals, and an illustrated book was provided to group members. Th intervention group received the SH+ intervention plus enhanced usual care; the control group received only enhanced usual care from the local health care system. Enhanced usual care included access to free health care services provided by primary and secondary institutions plus details on nongovernmental organizations and freely available mental health services, social services, and community networks for people under temporary protection of Turkey and refugees.Main outcomes and measures: The primary outcome measure was incremental cost per quality-adjusted life-year (QALY) gained from the perspective of the Turkish health care system. An intention-to-treat analysis was used including all participants who were randomized and for whom baseline data on costs and QALYs were available. Data were analyzed September 30, 2020, to July 30, 2021.Results: Of 627 participants (mean [SD] age, 31.3 [9.0] years; 393 [62.9%] women), 313 were included in the analysis for the SH+ group and 314 in the analysis for the enhanced usual care group. An incremental cost-utility ratio estimate of T£6068 ($1147) per QALY gained was found when the SH+ intervention was provided to groups of 10 Syrian refugees. At a willingness to pay per QALY gained of T£14 831 ($2802), the SH+ intervention had a 97.5% chance of being cost-effective compared with enhanced usual care alone.Conclusions and relevance: This economic evaluation suggests that implementation of the SH+ intervention compared with enhanced usual care alone for adult Syrian refugees or asylum seekers hosted in Turkey is cost-effective from the perspective of the Turkish health care system when both international and country-specific willingness-to-pay thresholds were applied.</p

Effectiveness and cost-effectiveness of Self-Help Plus (SH+) for preventing mental disorders in refugees and asylum seekers in Europe and Turkey : study protocols for two randomised controlled trials

Abstract Introduction This article describes two randomised controlled trials that will evaluate the effectiveness and cost-effectiveness of Self-Help Plus (SH+), a group self-help intervention developed by the WHO to reduce distress. In these trials SH+ is being tested as a preventative intervention to lower the incidence of mental disorders in asylum seekers and refugees with psychological distress resettled in Europe and Turkey. Methods and analysis Two prospective, multicentre, randomised, rater-blinded, parallel-group studies will follow participants over a period of 12 months. One trial will be conducted in Europe and one in Turkey. In each trial, 600 asylum seekers and refugees screening positive on the General Health Questionnaire (≥3), but without a formal diagnosis of any mental disorders according to the Mini International Neuropsychiatric Interview, will be randomly allocated to SH+or to enhanced treatment-as-usual. The primary outcome will be a lower incidence of mental disorders at 6 month follow-up. Secondary outcomes will include the evaluation of psychological symptoms, functioning, well-being, treatment acceptability and indicators of intervention cost-effectiveness. Ethics and dissemination The two trials received ethical clearance from the local Ethics Committees of the participating sites (seven sites), as well as from the WHO Ethics Committee. All participants will provide informed consent before screening and before study inclusion (a two-step procedure). The results of the trials will be disseminated in agreement with a dissemination plan that includes publication(s) in peer-reviewed journals and presentations at relevant national and international conferences and meetings

Culturally Adapted Cognitive Behavioral Therapy for Syrian Refugee Women in Turkey: A Randomized Controlled Trial

Clinical Impact Statement A Syrian version of CA-CBT was effective (large effect sizes for the HTQ), feasible, and potentially scalable (easy application, conducted with trained facilitators, short-term therapy, group format), and acceptable (as evidenced by very low drop out and no adverse events). Thus, the Syrian version of CA-CBT appears to be a valuable psychological intervention for traumatized Syrian refugees, particularly given the lack of effective treatments for this group

Cost-effectiveness of the Self-Help Plus Intervention for Adult Syrian Refugees Hosted in Turkey

Importance: The cost-effectiveness of the Self-Help Plus (SH+) program, a group-based, guided, self-help psychological intervention developed by the World Health Organization for people affected by adversity, is unclear.Objective: To investigate the cost-utility of providing the SH+ intervention combined with enhanced usual care vs enhanced usual care alone for Syrian refugees or asylum seekers hosted in Turkey.Design, Setting, and Participants: This economic evaluation was performed as a prespecified part of an assessor-blinded randomized clinical trial conducted between October 1, 2018, and November 30, 2019, with 6-month follow-up. A total of 627 adults with psychological distress but no diagnosed psychiatric disorder were randomly assigned to the intervention group or the enhanced usual care group.Interventions: The SH+ program was a 5-session (2 hours each), group-based, stress management course in which participants learned self-help skills for managing stress by listening to audio sessions. The SH+ sessions were facilitated by briefly trained, nonspecialist individuals, and an illustrated book was provided to group members. Th intervention group received the SH+ intervention plus enhanced usual care; the control group received only enhanced usual care from the local health care system. Enhanced usual care included access to free health care services provided by primary and secondary institutions plus details on nongovernmental organizations and freely available mental health services, social services, and community networks for people under temporary protection of Turkey and refugees.Main Outcomes and Measures: The primary outcome measure was incremental cost per quality-adjusted life-year (QALY) gained from the perspective of the Turkish health care system. An intention-to-treat analysis was used including all participants who were randomized and for whom baseline data on costs and QALYs were available. Data were analyzed September 30, 2020, to July 30, 2021.Results: Of 627 participants (mean [SD] age, 31.3 [9.0] years; 393 [62.9%] women), 313 were included in the analysis for the SH+ group and 314 in the analysis for the enhanced usual care group. An incremental cost-utility ratio estimate of T£6068 ($1147) per QALY gained was found when the SH+ intervention was provided to groups of 10 Syrian refugees. At a willingness to pay per QALY gained of T£14 831 ($2802), the SH+ intervention had a 97.5% chance of being cost-effective compared with enhanced usual care alone.Conclusions and Relevance: This economic evaluation suggests that implementation of the SH+ intervention compared with enhanced usual care alone for adult Syrian refugees or asylum seekers hosted in Turkey is cost-effective from the perspective of the Turkish health care system when both international and country-specific willingness-to-pay thresholds were applied

Effectiveness of a WHO self-help psychological intervention for preventing mental disorders among Syrian refugees in Turkey: a randomized controlled trial

Refugees are at high risk of developing mental disorders. There is no evidence from randomized controlled trials (RCTs) that psychological interventions can prevent the onset of mental disorders in this group. We assessed the effectiveness of a self‐help psychological intervention developed by the World Health Organization, called Self‐Help Plus, in preventing the development of mental disorders among Syrian refugees experiencing psychological distress in Turkey. A two‐arm, assessor‐masked RCT was conducted in two Turkish areas. Eligible participants were adult Syrian refugees experiencing psychological distress (General Health Questionnaire ≥3), but without a diagnosis of mental disorder. They were randomly assigned either to the Self‐Help Plus arm (consisting of Self‐Help Plus combined with Enhanced Care as Usual, ECAU) or to ECAU only in a 1:1 ratio. Self‐Help Plus was delivered in a group format by two facilitators over five sessions. The primary outcome measure was the presence of any mental disorder assessed by the Mini International Neuropsychiatric Interview at six‐month follow‐up. Secondary outcome measures were the presence of mental disorders at post‐intervention, and psychological distress, symptoms of post‐traumatic stress disorder and depression, personally identified psychological outcomes, functional impairment, subjective well‐being, and quality of life at post‐intervention and six‐month follow‐up. Between October 1, 2018 and November 30, 2019, 1,186 refugees were assessed for inclusion. Five hundred forty‐four people were ineligible, and 642 participants were enrolled and randomly assigned to either Self‐Help Plus (N=322) or ECAU (N=320). Self‐Help Plus participants were significantly less likely to have any mental disorders at six‐month follow‐up compared to the ECAU group (21.69% vs. 40.73%; Cramer's V = 0.205, p<0.001, risk ratio: 0.533, 95% CI: 0.408‐0.696). Analysis of secondary outcomes suggested that Self‐Help Plus was not effective immediately post‐intervention, but was associated with beneficial effects at six‐month follow‐up in terms of symptoms of depression, personally identified psychological outcomes, and quality of life. This is the first prevention RCT ever conducted among refugees experiencing psychological distress but without a mental disorder. Self‐Help Plus was found to be an effective strategy for preventing the onset of mental disorders. Based on these findings, this low‐intensity self‐help psychological intervention could be scaled up as a public health strategy to prevent mental disorders in refugee populations exposed to ongoing adversities