Culturally adapted digital intervention to reduce suicidal ideation for Syrian asylum seekers and refugees in the United Kingdom: A qualitative study (Preprint)
Authors: Beuthin Oliver , Bhui Kamaldeep , Yu Ly-Mee , Shahid Sadiya , Harba Alnarjes , Nasser Yasmine , Almidani Louay , Bilalaga Maria Malak , Hussein Roshan 
Published: January 2024

BACKGROUND

The conflict in Syria has produced the largest forced displacement crisis since the Second World War. As a result, Syrians have experienced various stressors across the migratory process, putting them at an increased risk of developing mental health issues, which for some Syrian asylum seekers and refugees has resulted in suicidal ideation. Despite their high rates of SI across Europe, there remain various barriers to accessing treatment. One way to increase access is the use of culturally adapted digital interventions. The study therefore aimed to better understand Syrian asylum seekers’ and refugees’ cultural conceptualizations, coping strategies, and help-seeking behavior for SI. This involved a unique cultural adaptation framework to intervene at points of lived experience with the migratory process where Syrian mental health beliefs and signs of psychopathology converge. Likewise, co-design events were used to adapt points of experience with the intervention where Syrian culture and the intervention conflict. In addition to providing unique insights into the mental health and SI of Syrian asylum seekers and refugees in the UK, the study provides an intuitive methodology for culturally adapting digital interventions for refugee populations in general.

OBJECTIVE

The objective of the study was to increase access to mental health treatment for Syrian asylum seekers and refugees in the United Kingdom by culturally adapting a digital intervention to reduce SI.

METHODS

The study used experience-based co-design, an action research method, to culturally adapt a digital intervention to reduce SI for Syrian asylum seekers and refugees in the United Kingdom. This involved conducting 16 interviews to understand their cultural concepts, coping-strategies, help-seeking behaviour for mental health and SI in relation to their lived experiences with the migratory process, as well as their perceptions of digital mental health interventions. In addition, 3 co-design events with 4 participants in each were be held to collaboratively adapt the intervention. Touchpoints and themes extracted from each phase were prioritized by a community panel before adapting the intervention.

RESULTS

The following are the main findings of the study protocol (RR2-10.2196/47627). First, participant's cultural concepts and help-seeking behaviour for mental health became more complex across the migratory process due to their increased experiences of mental health symptoms and mental health literacy. Their coping-strategies however remained the same and included both personal (religious beliefs and practices, exercise, and hobbies) and collective (volunteering, collective problem-solving, etc.) coping-stratgies. Second, participant's core cultural concepts and help-seeking behaviour for suicidal ideation (SI) remained relatively stable across the migratory process, however they showed increased awareness of its causes. Given the prohibition of suicide in Islam, participants either experienced a wish for death or an SI crisis. While participants attributed SI to torture, the asylum process, social isolation, and a lack of mental health services, they believed that stressors and suicide were mediated by weak iman (faith), junun (insanity), and a loss of ruh (soul) and shakhsiyya (character). Their coping-strategies for SI were overall religious in nature including understanding their experiences as ibtila' (a test) from God, and engaging salat (ritual prayer) and reading the Quran. Third, the study revealed facilitators and barriers to engagement with digital mental health interventions. Facilitators included cultural adaptation for Arab populations; Arabic translation; anonymity; no burden of travel; early post-migration intervention; cultural brokers; etc. Barriers included low mental health and digital literacy, and a lack of electricity and internet access in Syria. Forth, the study revealed themes related to guidance, methods of delivery, case examples, culture shock, exercises, and language. While it was previously expected that the intervention required shortening, participants preferred a non-directive approach and therefore a variety of exercises accompanied with explanations, encouragement, reminders, and goal setting. Importantly, participants emphasised adapting the intervention for Syrian asylum seekers' and refugees' experiences in the first year after arriving to the UK. In this year, Syrian asylum seekers and refugees deal with culture shock as well as uncertainty about their asylum application and the possibility of returning to Syria.

CONCLUSIONS

Access to treatment for some of the most severe mental health issues is still limited for Syrian asylum seekers and refugees in the United Kingdom. Cultural adaptations of digital interventions developed for general populations have the potential to increase access to treatment for this population. This study has shown that this can be achieved with only minor adaptations to the intervention. The main component of the cultural adaptation was Syrian asylum seekers' and refugees' cultural concepts of SI including the lived experiences that give rise to it, which in turn helped identify points at which to provide the intervention. A future feasibility study will assess the acceptability of the intervention and identify optimal recruitment strategies.