Globally 281 million people are international migrants [2020, https://www.iom.int/data-and-research] and 84 million are forcibly displaced (48 million are internally displaced, 26.6 million are refugees, and 4.4 million are asylum seekers). Among those forcibly displaced, 35 million are children and 1 million were born as refugees (mid-2021, https://www.unhcr.org/refugee-statistics/). In 2021, countries from which the highest number of refugees originated were Syrian Arab Republic, Venezuela, Afghanistan, South Sudan, and Myanmar, while countries hosting the highest number of refugees were Turkey, Colombia, Uganda, Pakistan, and Germany [https://www.unhcr.org/refugee-statistics/].

Refugees’ premigratory experience may include witnessing or experiencing violence, torture, murder, and/or physical and emotional trauma. They may also have experienced a long and hazardous journey to the resettlement or destination country and/or to refugee camps. Challenges in the post-migratory phase may include vulnerability, poverty, discrimination, a foreign environment, and linguistic-cultural barriers. Therefore, these children and adolescents are at risk of developing mental health problems [where mental health is defined as ‘a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively, and is able to make a contribution to his or her community (WHO 2018)]. It is necessary to provide appropriate, effective, community-level mental health support and intervention.

The aim of this review was to assess the effectiveness and acceptability of such community-based interventions for preventing and treating mental health problems in comparison with controls (no treatment, waiting list, or alternative treatment is provided). Participants were refugee children and adolescents (age 18 years or younger) in high-income countries.

This review is relevant for

Primary care workers (working with refugee children and adolescents), their parents or families, academicians (evaluating community-based interventions), researchers, implementers, and policymakers.

Data analyzed

The review included 38 studies [randomized controlled trials (RCTs), cluster-RCTs, cross-over RCTs] where participants were diagnosed with major depression, anxiety, post-traumatic stress disorder (PTSD), or other mental health problems (e.g., emotional suffering affecting day-to-day life, psychological distress such as sadness, fatigue, anger, irritability, restlessness, or delusions). The prevention and remediation consisted of community-based interventions that may have been executed in schools, faith-based organisations, neighbourhoods, or other community settings.

Authors used the IASC five-layered pyramid approach to categorize the interventions (IASC 2007):  the bottom layer represents social considerations in basic services and security; the second layer reflects community/family/peer support and cultural-recreational activities; the third represents non-specialised care; the fourth covers specialised services like cognitive behavior therapy; and the top layer consists of multi-modal, multi-layered interventions.

Findings of this review

As primary outcomes of these community-based interventions, there was no evidence of positive effects on PTSD symptoms and anxiety. Low-certainty evidence was observed for stress and depression symptoms, whereas very low-certainty evidence was observed for psychological distress. There were no data on suicide, self-harm, or other adverse events.

As secondary outcomes, a few studies reported short-term changes in children’s behavior (low- to very low-certainty). None of the trials reported on (a) overall quality of life or well-being, (b) participation and functioning, or (c) participant satisfaction.

Authors' conclusion

There was no evidence to suggest that such interventions could promote or prevent or treat mental health conditions among refugee children and adolescents in high-income countries. Some of the largest gaps in the evidence include the absence of RCTs that are statistically powered to detect moderate effects, evaluations of interventions, and outcomes.

What next?

Limited evidence implies no practising recommendation, and this low certainty is due to variability in symptoms, needs, available resources, outcomes, and bias. Therefore, collaboration is needed among academics (to evaluate the interventions) and policymakers. Challenges may include (i) conducting RCTs of mental health interventions, and (ii) participants’ reluctance, health conditions, negative perceptions, living conditions, language barriers, etc. All of these factors complicate participant recruitment and follow-up. This review emphasizes the need for sound study design, methodology, and statistical power. Also needed are transparent reporting of the study population, baseline symptoms, target interventions (based on IASC 2007), results, relevant outcomes, and side effects.

Sunita Gudwani