The effectiveness, mechanisms of change, and acceptability of Family Focused PsychoSocial Support (FFPSS) for at-risk adolescents in Lebanon

This mixed-method study is an international collaboration between the American University of Beirut and War Child Holland, supported by project partners the Danish Refugee Council and Terre des Hommes Italy, the Ministry of Public Health Lebanon, UNICEF, and international expertise from University College Dublin, the Boston College School of Social Work, and Queen's University Belfast. The study aims to develop and test a culturally and contextually sensitive Systemic Family Intervention Module for at-risk adolescents that can be run alongside existing focused psychosocial programmes in Lebanon. Focused psychosocial support aims to promote wellbeing and resilience and to reduce mental ill-health in young people at risk of child protection violations, including gender-based violence, child marriage, and child labour.
One in five children globally live in conflict affected areas, and these children experience a high incidence of mental disorders. The global burden of disease for mental disorders is 5 times higher in conflict-affected areas than the global average. Young people are affected not only by the violence, loss, and insecurity of war, but the systemic impact on their living conditions, access to school and health care, structural discrimination, and gender-based violence, as well as their caregivers trauma, stress, and compromised parenting capacity. The devastating impact of war, conflict, and extreme adversity on the mental health and wellbeing of children and adolescents has been extensively researched, but with continuing challenges in improving the quality and scope of interventions for these populations.
The treatment gap in low resourced settings is as high as 90%, with major barriers of limited infrastructure and trained specialists. As a strategy to close this gap, psychosocial support interventions as part of a stepped care coordinated approach have been developed and widely implemented. There is a small but growing evidence base for psychosocial interventions in conflict and humanitarian emergencies, however adolescent mental health and family-based interventions are drastically under-researched and under-resourced. Nurturing family environments are essential for healthy child development, and parenting and systemic family interventions in other populations and country settings show strong effectiveness for both mental health and protection outcomes. This study therefore aims to develop and evaluate a Family Systemic Intervention Module to use alongside UNICEF Lebanon's focused psychosocial support programme, to enhance current humanitarian programming and addressing a significant weakness of the current evidence base for at-risk adolescents and their families in conflict-affected contexts. Findings will inform the Mental Health System Reform in Lebanon led by the National Mental Health Programme of the Ministry of Public Health.
Lebanon is a middle-income country, home to an estimated 1.5 million refugees in a population of around 5.9 million. The majority of refugees come from Syria, as well as almost half a million Palestinian refugees. Almost 60% of Syrian refugees are living in extreme poverty, unable to meet basic survival needs, whilst 30% of Lebanese host communities also live below the poverty line. The many social and economic pressures facing these populations increases the risk of child protection issues, through sexual and gender-based violence, domestic violence, child marriage, child labour and recruitment intro armed groups. In 2015, a 5-year Mental Health and Substance Use strategy for Lebanon 2015-2020 was launched with the aim of reforming the Mental Health System, and whilst much has been achieved, there remains a gap in the provision of family systemic interventions. Lebanon is therefore an ideal location for this study because it has both large vulnerable populations in need of focused support, as well as political will to integrate learning into the national mental health strategy.

The direct and immediate impact of the study is that 351 at-risk adolescents and their caregivers will receive Focused Psychosocial Support (FPSS) plus our systemic family intervention module. The programme is the first systemic focused psychosocial intervention for at-risk populations in Lebanon, and findings from other contexts indicates that this intervention is likely to be more effective and accessible than what is currently available. The intervention is targeted at families with high risks of child protection issues, and helps to address endemic issues facing vulnerable young people in Lebanon, such as domestic violence, gender-based violence, child marriage, and child labour.
Other direct impacts include the integration of the systemic family module into existing FPSS activities across Lebanon. This scale up will be achieved primarily through the Psychosocial Committee, chaired by UNICEF and Terre des Hommes Italy (both of whom are field partners in this project) who conduct monthly meetings with all psychosocial support providers to coordinate and improve activities; and through the Community Advisory Board who will support local and community engagement. Workshops will be completed directly with stakeholders who have oversight for psychosocial programming in the country (e.g. Ministry of Public Health) or who are actively delivering interventions (e.g. Save the Children), in order to spread awareness of the study's results, the intervention, and training methods. A training package, developed with the support of the Global Health Institute (GHI) at the American University of Beirut (AUB), will be accessible through an online platform. Key facilitators in each participating organisation will be provided with additional training and supervision in order to build capacity to be able to train and supervise new facilitators, through a Train the Trainer model. Through engaging with the main implementing organisations and providing the first round of training at no cost, we aim to disseminate the family module to the majority of at-risk youth accessing focused psychosocial support in Lebanon.
In addition to active engagement of implementing organisations, we will also engage with the Ministry of Public Health (MoPH) for longer term impact on psychosocial support provision. By improving the evidence base for systemic interventions in at-risk populations, we will provide a rationale to include such interventions in the country's Mental Health Reform Strategy, as part of the National Mental Health Programme (NMHP). We will inform the MoPH of the results of the study and intervention aims directly through the director of the NMHP, who has provided a letter of support for this study, and through a workshop with key stakeholders in NMPH and the wider MoPH.
Beyond improving and informing public mental health policy in Lebanon, wider regional and international dissemination will be achieved through the research findings report, peer reviewed open access publication, press and media, oral presentations and workshops at relevant conferences, and through the open access online platform for the delivery of training to interested regional and international organisations. In addition, field partners WCH, Danish Refugee Council (DRC) and Terre des Hommes (TDH) work in multiple countries with war affected children, and the programme can be contextually adapted and applied in these different contexts.