Mental Health Research among Syrian Refugees: Challenges and Solutions

Background

Lebanon faces a growing mental health emergency

More than 5.4 million Syrian refugees are registered in countries surrounding Syria, including an estimated 1.5 million in the Beqaa region of Lebanon. Many live in informal settlements, often in poor conditions, with limited access to basic services. As such, emotional, cogntive, behavioural and physical difficulties are common among children. Yet, conducting robust mental health research in this context is fraught with logistical, ethical and cultural challenges.

 

Two initiative to understand mental health and improve access to care

The BIOPATH study

The Biological Pathways of Risk and Resilience in Syrian Refugee Children (BIOPATH) study aimed to explore how environmental and biological factors influence the mental health and resilience of Syrian refugee children. This involved researcher obtaining data through interviewing 1,600 refugee children and their primary caregivers about common mental health problems as well as collecting saliva and hair samples to understand stress hormones and genetic variations.

 

The t-CETA study

The Common Elements Treatment Approach (CETA) study evaluated whether a psychological treatment, designed for low-resource settings, could be successfully adapted for delivery over the telephone – making it more scalable and accessible in humanitarian contexts. This involves testings its efficacy in a randomised controlled trial.

 

Encountered challenges and insights for future research

Academic-NGO relationship

High-quality research depends on a collaborative approach that leverages the complimentary expertise of NGO’s and academic institutions. NGO’s typically possess extensive field experience but limited research capacity, whereas academics contribute methodological rigor but often lack direct community engagements and familiarity with operational challenges. To bridge these gaps shared roles and joint recruitment processes were implemented. For instance, local study coordinators in Lebanon collaborated closely with Medecins due Monde, receiving continuous support from the academic team in London. Regular communication fostered mutual understanding, enabling NGO staff to comprehend research requirements and academics to appreciate the practical realities of conducting fieldwork in refugee settlements.

 

Complexities of planning and budgeting

Planning research budgets and timelines prior to staff recruitment is inherently challenging. In the researchers’ experience, unforeseen obstacles arose during implementation. For example, it became apparent that formal authorisation from the Ministry of Defence was necessary to conduct research in certain refugee settlements, resulting in an extended preparatory phase. Additionally, initial projections for data collection underestimated the time required for travel and pilot testing. Moving forward, researchers intend to engage representatives from both academic institutions and NGO’s at the earliest planning stages. This will ensure realistic and adaptable plans that accommodate the operational constraints of all stakeholders is formulated.

 

Navigating approvals and ethical concerns

Research involving vulnerable populations in humanitarian settings demands rigorous ethical oversight. The studies received approvals from multiple institutions including UK and Lebanese universities, the Ministry of Public Health, the Ministry of Defence and local authorities. Building trust with community leaders was vital but took longer than expected.

In future projects, a consideration is to engage relevant government departments even earlier, ideally before funding is secured, to anticipate and address any ethical or security concerns upfront.

 

Measure what matters: Adapting tools to context

Selecting the right tools to measure mental health is critical. Researchers reviewed existing scales like the Screen for Child Anxiety Related Emotional Disorders (SCARED) and the WHO-5 Well-being Index, both validated in Lebanon. Some tools required adaptation, translation and careful cultural review.

Syrian refugees were involved in focus groups to ensure questions were understood and relevant. For example, we found that the concept of “locus of control” did not resonate culturally, as many participants attributed life outcomes to divine will rather than personal agency. Other items needed rephrasing or removal to fit the local context, such as questions about riding bikes or attending religious meetings, which did not reflect refugee children’s experiences.

Novel measures tailored to this population were also developing, such as the Perceived Refugee Environment Index (PREI), which assesses the quality of the refugee environment, and the Mental Health Service Use and Needs (MhSUN) questionnaire.

 

Overcoming fieldwork challenges

Research in refugee settlements involves unpredictable conditions: weather, security concerns and varying settlement infrastructure all impact fieldwork. Refugees often expected immediate assistance for such variables, requiring researchers to balance data collection with referrals and support.

 

Ensuring data quality amidst complexity

Collecting high-quality data in remote settings with large teams in challenging. To maintain standards, extensive training for fieldworkers in Arabic was provided, covering everything from ethics and communication to data handling and security. Tablets were used for data entry, with daily uploads to a secure server. Automated processing allowed the academic team in London to quickly review data, identify errors and provide feedback – minimising errors and ensuring reliable results.

 

Guidance for future research

Collecting high-quality research in Beqaa presents significant challenges but is attainable through close collaboration between academic and NGO partners employing systematic and innovative data collection methods.

A critical recommendation is maintaining consistent communication with fieldworkers, logistics, security personnel, and the community throughout the planning and implementation phases. Although this process can be time-intensive, incorporating feedback early reduces delays and complications later.

Recognising that obstacles are inevitable, particularly during data collection, a well-trained, dedicated team and strong communication between partners are essential to establishing a robust foundation and enhancing project success.

 

About the study group

This research was carried out by a team of experts in psychology including: Patricia Moghames (Médecins du Monde (MdM) France in Lebanon) who was the Field Work Coordinator for the BIOPATH and t-CETA research studies; Fiona McEwen (Postdoctoral Researcher in Developmental Psychology at the Department of Biological and Experimental Psychology at Queen Mary University of London) and was the Study Coordinator for the BIOPATH and t-CETA studies; Michael Pluess ( an Associate Professor in Developmental Psychology at the Department of Biological and Experimental Psychology at Queen Mary University of London) and  the Principal Investigator for the BIOPATH and t-CETA studies.