Title: Feasibility study and pilot trial of an evidence-based low intensity psychosocial intervention delivered by lay therapists for asylum seekers and refugees (PROSPER)
Funder: Department of Health and Social Care

Abstract: Asylum seekers and refugees (AS&Rs) experience reduced mental health and wellbeing, related to stresses in their country of origin, experiences in transit and reception on arrival, including exclusion from mainstream services such as income support, housing and healthcare. Their contact with healthcare is often crisis-driven and mediated through non-governmental organisations (NGOs), whose staff lack knowledge and skills in the management of distress. This study will test the feasibility of a randomised controlled trial to evaluate an intervention based on Problem Management Plus (PM+), a psychosocial intervention recommended by the World Health Organization (WHO) for adults impaired by distress in communities exposed to adversity. PM+ provides clients with skills in managing practical problems and mental health problems. In this context, is proposed that an adapted PM+ will be delivered by lay therapists with lived experience as AS&Rs, through NGOs working with AS&Rs in Liverpool City Region. Research question. Is it feasible to undertake a randomised controlled trial of PM+, delivered by lay therapists in NGOs, for distressed and functionally impaired asylum seekers and refugees? Methods. The research will be undertaken in Liverpool City Region over 24 months. First, we will refine and adapt PM+ to suit local context. We will do this by a) systematic review of barriers and facilitators to psychosocial interventions led by lay therapists to improve migrant health and wellbeing, and in parallel, b) focused inquiry with local stakeholders to ensure acceptability, linguistic and cultural relevance to target populations. Second, we will assess the feasibility of the proposed training procedures. These will involve master training and supervision in PM+ provided to a counselling NGO who, in turn, provide training and supervision for lay therapists in NGOs in contact with AS&Rs. Then we will undertake a pilot randomised controlled trial of five 90 minute sessions of PM+ delivered individually or in groups by lay therapists to AS&Rs with emotional distress and functional impairment, compared with usual peer support offered by the NGOs. Distress and impairment at baseline will be measured by Hospital Anxiety and Depression Scale (HADS) and WHO Disability Assessment Schedule (WHO-DAS). For this pilot trial we will aim for three arms (individual, group and control) with 35 participants per arm. Primary health outcomes will be anxiety and depressive symptoms at 3 months, measured by HADS. Secondary outcomes will include subjective wellbeing, functional status, progress on identified problems, post-traumatic stress disorder, depressive disorder and service usage. Longer term impact will be assessed at 6 months post baseline assessment on the same parameters. We will assess the feasibility of conducting a randomised controlled trial in relation to the following elements: * adaptation of PM+ to local context; * recruitment, training and retention of lay therapists; * delivery model: participant recruitment and retention; acceptability and fidelity; * outcome measures: acceptability and suitability. We will use these findings to specify the parameters for a full randomised controlled trial to test the effectiveness and cost effectiveness of PM+ in reducing emotional distress and health inequalities, and improving functional ability and wellbeing, amongst asylum seekers and refugees.

Lay abstract: Aim: To explore the conduct of a brief psychosocial intervention, by trained lay workers in voluntary organisations, in order to improve mental health and wellbeing amongst distressed asylum seekers and refugees. Background: Asylum seekers and refugees mostly come from developing countries where there is abuse of human rights, war and conflict. Consequently, the majority of them suffer from physical and mental health problems due to their experiences and untreated illness in their home countries, multiple dangers while travelling and the difficulties they face when they arrive. In the UK, they often do not receive the help they need to address their mental health problems. Several barriers prevent them making use of the health care system and commonly receive care only in an emergency. Usually the possible support they can access is from people in voluntary organisations who, although highly motivated, may not be skilled in helping people with high levels of distress. Problem Management Plus (PM+) is a new psychological intervention, recommended by the World Health Organization for distressed adults living in adversity. Delivered by lay workers, it offers people the skills they need to improve their management of practical and common mental health problems. In a recent study in a conflict-affected region of Pakistan PM+ improved people’s mental health and their ability to lead their daily lives. However, PM+ has yet to be tried among socially excluded groups such as asylum seekers and refugees living in the UK. Methods: The study will take place over two years, in Liverpool City Region. First, the literature on the subject will be reviewed and experts who have experience as well as service providers and policy makers will be interviewed about how PM+ may be adapted to meet the needs of distressed asylum seekers and refugees locally. After the initial study, the next stage will involve focus group interviews with experts and individuals including refugees living locally on how to deliver it to distressed asylum seekers and refugees. Afterwards, the procedures will be tested on a trial of the adapted intervention offered to distressed asylum seekers and refugees in contact with local voluntary organisations. The trial will involve either individuals or small groups, and a comparison with a control group who will receive usual support from a voluntary organisations. There will be about 35 people in each of these three groups. Participants will be asked about symptoms of anxiety and depression, and about problems with daily living; further questions on their wellbeing, the progress being made and problems identified as important, whether post-traumatic stress or depressive disorders, and the services recently being used. This will be done at three months and again at six months after first contact. The results will be checked to verify whether it is possible to run a full trial on the basis of: adapting PM+ to meet local needs; keeping therapists and participants involved in the study; ability of therapists to deliver the intervention in the ways they were trained to do; and whether the intervention itself, and the questionnaires we plan to use to evaluate it, make sense and are acceptable to study participants. Based on the evidence, the decision will be made to either to design a full randomised controlled trial of a psychosocial intervention delivered by lay therapists to distressed asylum seekers and refugees.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH