Barriers to Accessing Mental Health Services among Syrian Refugees in Ankara

Syrian refugees are seriously traumatized by the conict in their country. Consequently, mental health problems, particularly depression and PTSD, are prevalent among refugees. Despite this fact, they make little use of mental health services. Using a population sample of Syrian refugees living in Ankara, we assessed the perceived need for and contact with mental health services, as well as the barriers to access these services. This was a cross-sectional study of 420 Syrian refugees living in Ankara city center, using face to face interviews administered at the respondents’ home by trained, Arabic-speaking interviewers. The data were collected in October–November 2016 in two neighborhoods of Ankara, where most of Syrian refugees were concentrated. PTSD and depression were assessed using Harvard Trauma Questionnaire and Beck Depression Inventory, respectively. Both measures have been validated in Arabic.


Background
Syrian refugees have been seriously traumatized by the con ict in their country.Consequently, mental health problems, particularly depression and PTSD, are prevalent among them [1].Even though mental health problems are common among refugees, they are also known to make little use of mental health services [2][3][4][5][6].Mental health research on Syrian refugees has focused mainly on the rates of mental disorders; the barriers to utilizing mental health services are less commonly studied [5,7,8].Common barriers to seeking care reported by previous studies were: not speaking the language of the host country, lack of knowledge on available mental health services, inability to recognize mental health problems and their severity, fear of stigmatization, trust-related issues, transportation problems, nancial di culties and cultural factors [7,[9][10][11].Problems related to service provision, such as di culties in accessing mental health services, the high cost of services, long waiting times, stigmatizing and discriminating attitudes in the host country, and hardline policies and practices related to refugees also have signi cant and negative effects on refugees' access to mental health services [12][13][14][15].Consequently, studies conducted in host countries show that up to 80-90 percent of refugees with Post-Traumatic Stress Disorder (PTSD) or other mental disorders do not utilize mental health services at all.For example, in Germany, only around 5% of refugees in need of mental health services, are able to receive them [5].In a study conducted with Iraqi asylum seekers in the Netherlands, only 8.8% of those with a mental disorder were found to utilize mental health services [16].In a study conducted in Lebanon, only 1% of Syrian refugees were found to have access to mental health services [8].Using a population sample of Syrian refugees living in Ankara, we aimed to assess the perceived need for mental health services and the barriers to access these services.The results on the rates and predictors of mental health status of the refugees, as well as a more detailed description of the methods can be found in Kaya et al 2019 [1].

Methods
Sample: This was a cross-sectional study of 420 Syrian refugees living in Ankara, using face to face interviews administered at the respondents' home by trained, Arabic-speaking interviewers.The interviews were conducted in October-November 2016 in two neighborhoods of Ankara, populated mostly by Syrian refugees.

Measures:
Although our measures were developed to be lled-in by the respondent (i.e.self-report), the interviewers were instructed to read out the items and record the responses.This was necessary, since a large majority of the respondents had either no formal education or minimal (i.e.primary school) education.
Demographics: This section was developed by the researchers for the purposes of the current study.It included items assessing sociodemographic characteristics of the participants, their perceived physical and mental health status, utilization of and access to general and mental health services, and factors preventing access to those services.Social network variables such as having Turkish friends and speaking the language (i.e., Turkish).The services use section was quite detailed and inquired about the presence of physical or mental conditions diagnosed by a doctor, subjective assessment of physical and mental status by the respondent, alcohol/drug use history, current psychotropic use, contact with health and mental health services in the past year, the subjective need to contact mental health services, and nally reasons for non-contact, if the respondent reported need for contact and did not contact.
Harvard Trauma Questionnaire (HTQ): The HTQ is a widely-used self-report measure of traumatic stress [19].We used the Arabic version that assesses DSM-IV PTSD symptoms [20].The participant is asked to rate each item on a four-point Likert scale (1=not at all, 2=a little, 3=quite a bit, and 4=extremely).The rst 16 items such as "recurrent thoughts or memories of the most hurtful or terrifying events" or "feeling as though the event is happening again" assesses the presence of probable PTSD.The validation study of the original version was conducted with 91 patients originally from Cambodia, Laos, and Vietnam, using a semi-structured interview.Probable PTSD is computed following the algorithm suggested by the authors, since there is no established cutoff for the Arabic version.Cronbach's alpha for the 16 PTSD symptoms in the current study was 0.82.
Beck Depression Inventory (BDI): This widely used, 21-item, self-report questionnaire measures depressive symptomatology for the last week [21].All items are coded between 0 and 3; higher scores suggest more severe depression.Validity and reliability in Arabic were established by West [22] and Abdel-Khalek [23].In the present study, both the BDI total score (range: 0-63), and the probable depression score (using a cutoff of 19) were used in analyses.Cronbach's alpha for the current sample was 0.85.

Variable selection and transformations:
We used both categorical and continuous variables in reporting our results.We recoded some variables before analyses.For example, marital status (married, single, divorced) was recoded as married/not married.Command of Turkish language, which was coded on a 5-point scale (0=none, to 4 =very good), was recoded as 0=no, 1=yes, where yes=good, very good.Education (0=no education, 4=university graduate) and effect of symptoms on social functioning (1=none, 4=very much) were used as continuous variables.Since BDI and HTQ scores were highly correlated, we decided to include HTQ only as a measure of current psychopathology in our predictor analyses.
Procedure: Convenience sampling method was used to recruit participants into the study.The houses in the two neighborhoods, populated mostly by Syrian refugees, were visited by our six interviewers who were uent in Turkish and Arabic.Each household was visited by at least two interviewers.Of the households visited, 15 declined to participate and so were not included in the study.Figure 1 shows the recruitment of participants to the study.SPSS 23.0 statistical software package was used for data analysis.

General description of the sample:
The participants had a mean age of 35.4 years (Range: 18-80, SD:13.0);56.4% were female and 84.7% were married.A large majority of the participants (70.1%) had an elementary school education or less; 2.9% reported having a diagnosed mental disorder in the past, and 2.1% reported currently being on medication for their mental disorder.The refugees were found to be highly traumatized; 88.8% reported having witnessed war or armed con ict, 44.0% reported having lost a family member; and 31.1% reported having witnessed a killing.The prevalence of probable PTSD and depression as measured by HTQ and BDI were 36.5% (N=152) and 47.7% (N=198), respectively.238 people (%56.7) had either probable PTSD or depression.

Need for and contact with services:
Despite the high rate of traumatization and consequent mental disorders, only 14.8% of the refugees reported they felt the need for help for their mental health problems; and an even smaller minority actually sought help (6 out of 62; 9.7% of those who felt they needed help; 1.4% of the total sample).Although most of those with probable PTSD or depression did not report a need for help, ve out of the 6 people who actually made a contact had probable PTSD and/or depression (Table 1).The rate of contact with mental health services among those with probable PTSD/depression (5 out of 238) was therefore much lower (2.1%).

Correlates of perceived need for mental health services:
The bivariate analyses showed that refugee women, refugees with a doctor-diagnosed physical or mental disorder, refugees who had contacted general health services in the last year, who are currently on psychotropics, and nally, refugees with high depression or PTSD scores were in signi cantly greater need for mental healthcare (Table 2).The most common barriers cited by those who felt they needed mental healthcare, but did not contact any services, were language problems/lack of translators and lack of information on available mental health services (Figure 2).

Correlates of contact with mental health services:
Although the actual number contacting services was very low, we nevertheless conducted bivariate analyses to examine the correlates of contact with mental health services.The six refugees who actually contacted services were more likely to have a past psychiatric diagnosis (4 out of 6, p=.001) and to be currently on psychotropics (p=.001).All six of them said they felt they needed contact with services for their problems (p=.001).The six participants who contacted mental health services had signi cantly higher scores of PTSD (p=.001) and depression (p=.04) than others (Table 3).

Regression analyses:
We employed binary logistic regression analyses in order to determine the independent predictors of subjective need for mental health services, as well as for actual contact.We entered the variables in two steps, entering the demographic variables in the rst step and the clinical variables in the second.Table 4 shows that the subjective need for contact with services was related to female gender.The prediction by gender disappeared, however, after we added the clinical variables to the model at the second step.The HTQ score (severity of traumatic stress) was the sole predictor in the nal model.
The regression analyses run to determine the predictors of actual contact revealed that those with good command of Turkish were signi cantly more likely to have contacted services.Although this prediction lost its signi cance after clinical variables were added, there still was a trend.Traumatic stress score as measured by the HTQ predicted contact in the nal model (Table 5).

Discussion
This study has shown that contact with mental health services was very low among Syrian refugees in Turkey despite the high prevalences of reported traumatization and mental disorder.The ndings of the present study are consistent with those of previous studies with Syrian refugees and other refugee groups, indicating that many refugees are in need of mental health support, and that very few of them make use of these services [18, [24][25][26].Although the study designs were different, our results on the rates of contact were strikingly similar to those reported by Fuhr et al for Syrian refugees in Istanbul [18].The contact rates reported in these two studies are much lower compared to studies done in the general population of Turkey [27].Refugees with mental health problems were more likely to contact services.This is not comforting, however, since nine out of ten refugees do not look out for help, even though they acknowledge a need for help.
The main barriers to access mental health care reported in the refugee literature are language problems [3,5,28,29] and lack of knowledge about where and how to get access to mental health services [24,25,30], which were our main ndings as well.The language barrier was especially important: many refugees said they would go to the hospital if they knew there was a translator or an Arabic-speaking doctor/psychologist at the premises.Most said they were not able to read signs on the buses or buildings, showing that the problem is two-fold: a bus-sign in an unknown language as well as in an unknown alphabet.With the exception of the study by Fuhr et al [18], all studies on the mental health services use of Syrian refugees showed that the refugees regarded language as the major barrier to care [7,11,31].Our study we believe is unique, in that we managed to show, through predictor analyses, that a good command of the (Turkish) language independently predicts services use.
Although the subjective reported need for services was three times higher among women than men, and women reported a higher interference of mental health symptoms with social functioning, there was no gender difference among those who contacted mental health services.This nding is alarming and shows that the mental health treatment gap is much wider for refugee women than men.We did not assess the possible reasons for this gender disparity, but it de nitely deserves a closer look.Future research should examine the reasons why refugee women, who report they need psychological help, do not prefer to seek help: are they forced to stay behind by their spouses; are they discouraged because of language problems (those who can speak Turkish are much lower among female refugees); or are they too busy tending household duties?Finally, as would be expected, a large majority of refugees are under serious nancial hardship, and nd it di cult to meet even their most basic needs [26].Financial problems and transportation problems were among the main reasons for non-contact.It is therefore possible that mental health provision is not high on their agenda.
Many efforts have been made in Turkey to remove the language barrier and increase refugees' access to healthcare services.With the support of an EU-funded health project titled ''Improving the health status of the Syrian population under temporary protection and related services provided by Turkish authorities'' (SIHHAT Project), The Ministry of Health has established Migrant Health Centers (MHCs) and Strengthened MHCs to provide primary and secondary healthcare services to refugees [32].Syrian health care workers and bilingual (Arabic-Turkish) patient guidance staff have been employed in these centers to overcome the language barrier [33].In addition, translators have been employed in the secondary and tertiary public hospitals most frequently visited by refugees; signs in Arabic have been posted and informational lea ets have been distributed in those hospitals.Still, observations in the eld suggest that we have a long way to go to eliminate the language barrier.Despite its strengths, this study also has some limitations.Most importantly, the study sample was not representative of refugees in Ankara, let alone all refugees in Turkey.The second limitation relates to the multivariate analyses we conducted to identify predictors of contact with mental health services: there were only six people who made use of those services, which limited more in-depth analyses.Finally, although we used clinically valid instruments in face-to-face interviews, we did not employ clinical interviews that would allow us make clinical diagnoses.

Conclusions
This study con rmed the ndings of previous studies showing that Syrian refugees rarely contacted mental health services, despite having experienced high rates of war traumas and current mental problems.The most important barrier to accessing mental health services was reported to be language problems.Lack of information on available mental health services was the second most commonly reported barrier.It is obvious that the second reported barrier is highly dependent on the rst one; i.e language.The inequality favoring men over women in terms of contact was apparent, as well as the advantage of speaking the language in accessing care.The ndings indicate that there is a need to strengthen mental health policies and services for refugees, as well as to increase their access to services.The struggle against barriers to mental health care should always be coupled with a ght against gender inequality.

List Of Abbreviations
Today, Syria is the origin country of the largest number of refugees in the world.According to the United Nations High Commissioner for Refugees (UNHCR) data (March 2021), 5.6 million refugees have taken refuge in other countries as a result of the war in Syria.Hosting more than 3.6 million Syrian refugees, Turkey is the country with the largest number of refugees in the world [17].There are not many studies on the rate of mental health services use for refugees in Turkey.In a recent study on a large sample of refugees in Istanbul, Fuhr et al. have shown that only 9% of those in need of mental health care actually sought help, which is in line with other studies showing low rates of contact [18].
Post-Traumatic Stress Disorder; UNHCR: United Nations High Commissioner for Refugees; HTQ: Harvard Trauma Questionnaire; DSM: Diagnostic and Statistical Manual of Mental Disorders; BDI: Beck Depression Inventory; MHCs: Migrant Health Centers. PTSD:

Table 2
Univariate analysis of factors associated with refugees' perceived need for mental health care (n=420)

Table 4
Predictors of refugees' perceived need for receiving mental health care (Logistic regression)

Table 5
Predictors of contact with mental health services (Logistic regression) OR: Odds Ratio, CI: Con dence interval, HTQ: Harvard Trauma Questionnaire Figures