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

Lead Research Organisation: American University of Beirut
Department Name: Faculty of Arts and Sciences


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.

Planned Impact

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.
Description Significant achievements

Between June 2020 and February 2021 the most significant achievements for this project are a program review of family interventions in low and middle income countries, a qualitative exploration of family challenges and coping, and the development of the Family Systemic Intervention Module through workshops, expert review and Community Advisory Board (CAB) meetings. These achievements are detailed below:

• Firstly, the study was set up and is on track despite the economic disaster in Lebanon, the Beirut port explosions and the COVID-19 pandemic. A research team was set up at the American University of Beirut (Sally Farah, Anas Mayya and Zahraa Shaito), subcontracts set up with partners War Child Holland, the Danish Refugee Council and Terre des Hommes Italia, and IRB approval granted for the first phase of the study, including two amendments. Phase 2 has also been prepared and submitted for IRB approval.

• The first phase of the study involved the development of the Family Systemic Intervention Module based on a review of programs and qualitative interviews. The program review protocol was registered with the PROSPERO database. We searched multiple academic databases and regional and international service mapping exercises, as well as conducting a grey literature search through key implementing organizations in Lebanon. We picked up on 84 studies of 52 programs. We conducted practice element coding, using PracticeWise methodology, to identify the key components of effective programs for child and adolescent mental health outcomes. We also conducted an Implementation Component Analysis to identify best practice in implementing family interventions, and to pre-empt challenges. The findings are being prepared for publication in the journal Clinical Child and Family Psychology Review. The qualitative interviews involved interviews and follow-up interviews with 32 families of at-risk adolescents (adolescents and caregivers) and mental health and psychosocial support facilitators. We transcribed and translated all interviews and analyzed them using Thematic Content Analysis. The findings are being prepared for publication in the Journal of Family Psychology.

• Findings from the program review and interviews were used to inform the intervention development. We held a series of three workshops to develop our Theory of Change and a detailed intervention concept; workshops were attended by the research and implementing partner team and by a number of local and international leaders and experts in the field of family therapy and mental health and psychosocial support. Findings were synthesized and applied to the context of at-risk adolescents in Lebanon. Two Community Advisory Boards (CAB) were set up in different locations, made up of adolescents and caregivers, to provide additional discussion and amendments to the Theory of Change and intervention outline, based on lived experiences. The intervention first draft of the manual was then drafted by co-lead Dr Felicity Brown, and this draft is currently being reviewed by the research team, implementing partners, and CABs.

• In addition, collaborator Hady Naal at the Global health Institute has begun developing the intervention training materials ready for the pilot, and War Child Holland are leading on developing competency checklists for facilitators adapted to family work in low resource non-specialist settings. War Child Holland are also leading on revising the UNICEF Focused Psychosocial Program (FPSS) to ensure that the delivery is standardized across different implementing partners, and that extensive feedback from field testing is taken into account. Due to COVID-19 containment measures, which are currently strict in Lebanon, we have decided to run the pilot of the Family Systemic Intervention Module without the FPSS program, as delivery of face-to-face group programs has been paused by all organizations in Lebanon.

• Finally, we have added the adaptation of two of our outcome measures, as they had never been adapted and validated in Arabic or in Lebanon before. We are conducting a rigorous translation and contextualization process of the SCORE (for measuring family functioning) and the DERS (for measuring emotional regulation), along with visual aids in case assessments have to be conducted over the phone. The process involves multiple forward and back translations and translation workshops with lay persons and bilingual mental health professionals, as well as cognitive interviewing with adolescents and caregivers.


All the objectives of Phase 1 have been met, with the exception of the piloting of the Family Systemic Intervention Module, which is planned to start in May 2021. This allows time for a comprehensive review of all the intervention manual and training materials. Minor delays due to IRB approvals, analysis of larger than expected amounts of quantitative and qualitative data, and recovery time needed by the Lebanon based team after the Beirut port explosions, means that we are currently running 3 months later than our original timeline. As we will not be running the lengthy FPSS program for the pilot case studies, we should be able to compensate for these delays.
Exploitation Route Moving forward

Next steps involve integrating findings from the pilot in preparation for the Phase 2 randomized control trial. PI Dr Tania Bosqui and co-lead Dr Felicity Brown will lead Phase 2 as planned. In addition, a stakeholder mapping exercise is planned with partners in order to start to build a plan for scale-up and sustainability of the Module with key stakeholders in Lebanon and in the region, in preparation for the end of Phase 2; and we have planned a gender analysis of the Module to ensure our intervention is not just contextually sensitive, but also gender sensitive.
Sectors Communities and Social Services/Policy,Healthcare

Description Findings of the program review and qualitative interviews were shared to a large audience of academics, practitioners and families through the Theory of Change and Intervention Development workshops and Community Advisory Board meetings, as well as through additional engagements with key stakeholders in UNICEF Lebanon and the National Mental Health Program. This was particularly relevant after the Beirut port explosions when such agencies wanted to react quickly to the needs of families affected by the blast. We were consulted and our findings drawn on to inform immediate family and parental support in the aftermath of the blasts. In the longer term, the team are in open communication with UNICEF Lebanon, the WHO and UNODC to integrate the module and other elements (such as the training and family competency checklist for facilitators) into existing international and local guidance. We are also working closely with partners and the Global Health Institute to ensure the sustainability of the Family Systemic Intervention Module as part of their existing programs. We have also been able to provide consolidated feedback from all three implementing partners to UNICEF Lebanon on the FPSS Manual currently endorsed for use by child protection actors, alongside suggested changes to improve the manual. Revisions are underway, and this is expected to provide a stronger curriculum.
First Year Of Impact 2020
Sector Communities and Social Services/Policy,Healthcare
Impact Types Societal

Description Theory of Change and Intervention Development workshops
Geographic Reach National 
Policy Influence Type Influenced training of practitioners or researchers
Description Community Advisory Board 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Patients, carers and/or patient groups
Results and Impact A Community Advisory Board was set up in Tripoli through War Child Holland and in North Beqaa through Terre des Hommes Italia, made-up of at-risk adolescents and their parents, from refugee or host communities. Monthly meetings were held in person and then online due to COVID-19, to 1) introduce the study, team, and intervention plans, 2) to share findings from phase 1 and discuss integration into the intervention, 3) to share measures selected for the research and discuss their relevance and phrasing in local Arabic, and 4) to review and feedback on intervention manual drafts. Future meetings are envisaged to maintain community relationships, and to continue to collaborate with families in developing and testing the family intervention. Families on the Community Advisory Board will also continue to be compensated for their time and acknowledged in all study and intervention-related outputs and publications.
Year(s) Of Engagement Activity 2020,2021