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Item Health Care Services Utilization and Health-Related Quality of Life of Syrian Refugees with Post-Traumatic Stress Symptoms in Germany (the Sanadak Trial)(MDPI (Basel, Switzerland), 2021-04-01) Grochtdreis T; Röhr S; Jung FU; Nagl M; Renner A; Kersting A; Riedel-Heller SG; König H-H; Dams JRefugees who have fled from the ongoing civil war in Syria that arrived in Germany often develop post-traumatic stress symptoms (PTSS). The aim of this study was to determine health care services utilization (HCSU), health care costs and health-related quality of life (HrQoL) of Syrian refugees with mild to moderate PTSS without current treatment in Germany. The study was based on the baseline sample of a randomized controlled trial of a self-help app for Syrian refugees with PTSS (n = 133). HCSU and HrQoL based on the EQ-5D-5L and its visual analogue scale (EQ-VAS) were assessed with standardized interviews. Annual health care costs were calculated using extrapolated four-month HCSU and standardized unit costs. Associations between health care costs, HrQoL and PTSS severity were examined using generalized linear models. Overall, 85.0% of the sample utilized health care services within four months. The mean total annual health care costs were EUR 1920 per person. PTSS severity was not associated with health care costs. The EQ-5D-5L index score and the EQ-VAS score was 0.82 and 73.6, respectively. For Syrian refugees with higher PTSS severity, the EQ-5D-5L index score was lower (−0.17; p < 0.001). The HCSU and the resulting health care costs of Syrian refugees with mild to moderate PTSS without current treatment are low and those with a higher PTSS severity had a lower HrQoL.Item Predictors of psychological distress in Syrian refugees with posttraumatic stress in Germany(Public Library of Science (PLoS), 2021-08-04) Renner A; Jäckle D; Nagl M; Hoffmann R; Röhr S; Jung F; Grochtdreis T; Dams J; König H-H; Riedel-Heller S; Kersting ASyria has been the main country of citizenship of refugees in Germany since 2013. Syrians face numerous human rights violations in their country that can be accompanied by the experience of potentially traumatic events, loss and displacement. Along the migration process, refugees are exposed to various factors that can have an impact on mental health. The aim of this study is to investigate sociodemographic, war- and flight-related as well as post-migration factors as predictors of posttraumatic stress, depression, somatization and anxiety in Syrian refugees with posttraumatic stress symptoms based in Germany. Data were based on the baseline sample of the “Sanadak” randomized-controlled trial. A total of 133 adult Syrian refugees participated in the study. A questionnaire covered sociodemographic and flight-related questions as well as standardized instruments for symptoms of PTSD (PDS-5), depression (PHQ-9), somatization (PHQ-15), anxiety (GAD-7), generalized self-efficacy (GSE), religiousness (Z-Scale), social support (ESSI) and mental health stigma (SSMIS-SF). Linear regression models were executed to predict mental health outcomes. Sociodemographic predictors (i.e., female sex, higher education) and flight-related predicting factors (i.e., variability of traumatic events) have a negative impact on mental health in Syrian refugees with posttraumatic stress symptoms in Germany. Mental health stigma predicts worse mental health outcomes. Post-migration factors have a major impact on mental health, such as low income, lack of social support, low life satisfaction or a strongly felt connection to Syria. Somatization is an important manifestation of mental distress in Syrian refugees with posttraumatic stress symptoms. Our study showed a range of factors predicting the mental health of Syrian refugees with posttraumatic stress symptoms. Measures to foster mental health could be securing financial security, promoting gender equality and tailored psychosocial programs addressing mental health stigma, loss and social support networks.Item HELP@APP: development and evaluation of a self-help app for traumatized Syrian refugees in Germany – a study protocol of a randomized controlled trial(BioMed Central Ltd, 2019-04-30) Golchert J; Roehr S; Berg F; Grochtdreis T; Hoffmann R; Jung F; Nagl M; Plexnies A; Renner A; König H-H; Kersting A; Riedel-Heller SGBackground Syrians represent the largest group among refugees in Germany. Many of them were exposed to sequential traumatizing events including war, escape and post-migration stressors, which significantly increase the risk to develop symptoms of posttraumatic stress and other mental disorders. However, there is a lack of adequate treatment options for traumatized refugees in Germany. Moreover, their access to psychosocial care is often restricted due to legal regulation, language barriers, and unclear cost coverage. We therefore aim to develop a low-threshold supportive self-help app for Syrian refugees with posttraumatic stress symptoms. By conducting a randomized controlled trial, we further aim to evaluate the apps’ efficacy, usability, acceptance, and economic health benefit/cost-effectiveness. Methods We will develop a modular, interactive self-help app in Arabic, which will be grounded on cognitive-behavioral models for the treatment of posttraumatic stress. Subsequently, screened positive (i.e., Syrian refugees, 18–65 years old, mild to moderate posttraumatic stress symptomatology as quantified by the Posttraumatic Stress Diagnostic Scale for DSM-5/PDS-5) participants (ideally up to n = 234) will be randomly allocated to an intervention (IG) and control group (CG), respectively. Participants in the IG will gain access to the self-help app for one month, while participants in the CG will receive psychoeducational reading material in form of a comprehensive brochure on traumatization and posttraumatic stress. Measurements are scheduled before the intervention (T0), directly after the intervention (T1, one month later) and three months after the intervention (T2). Using linear mixed effect models, we will investigate change in posttraumatic symptomatology. We will also test for changes in secondary outcomes such as depression, anxiety, and quality of life. Moreover, we will inspect the usability and user acceptance of the app. To evaluate the app in terms of its economic health benefit, the incremental cost-effectiveness ratio will be calculated. Discussion We plan to make the app freely available to the general public after evaluation. Thus, the app can help to add-on to routine care, which currently lacks sufficient and appropriate treatment options for Syrian refugees. Trial registration German Clinical Trials Register/Deutsches Register Klinischer Studien (DRKS). Registration ID: DRKS00013782. Registered: 06th of July 2018.Item Traumatized Syrian Refugees with Ambiguous Loss: Predictors of Mental Distress(MDPI (Basel, Switzerland), 2021-04) Renner A; Jäckle D; Nagl M; Plexnies A; Röhr S; Löbner M; Grochtdreis T; Dams J; König H-H; Riedel-Heller S; Kersting ARefugees from war zones often have missing significant others. A loss without confirmation is described as an ambiguous loss. This physical absence with simultaneous mental persistence can be accompanied by economic, social or legal problems, boundary ambiguity (i.e., uncertainty about who belongs to the family system), and can have a negative impact on mental health. The aim of this study was to identify sociodemographic and loss-related predictors for prolonged grief, anxiety, depression, post-traumatic stress disorder (PTSD) and somatization in treatment-seeking Syrian refugees with post-traumatic stress symptoms in Germany experiencing ambiguous loss. For the present study, data were based on the treatment-seeking baseline sample of the “Sanadak” randomized-controlled trial, analyzing a subsample of 47 Syrian refugees with post-traumatic stress symptoms in Germany experiencing ambiguous loss. Sociodemographic and loss-related questions were applied, along with standardized instruments for symptoms of prolonged grief (ICG), anxiety (GAD-7), depression (PHQ-9), PTSD (PDS-5) and somatization (PHQ-15). Linear regression models were used to predict mental health outcomes. Having lost a close family member and higher boundary ambiguity showed a statistically significant association with higher severity in prolonged grief. The overall model for somatization reached statistical significance, while no predictor independently did. Boundary ambiguity showed a statistically significant positive association with depression, while the overall model showed no statistically significant associations. Boundary ambiguity and missing family members seemed to be important predictors for prolonged grief. These findings support the importance of reunification programs and suggest an inclusion of the topic into psychosocial support structures, e.g., including psychoeducational elements on boundary ambiguity in support groups for traumatized individuals and families experiencing ambiguous loss. Further research is needed for a more detailed understanding of the impact of ambiguous loss on refugee populations.Item Recruitment and Baseline Characteristics of Participants in the “Sanadak” Trial: A Self-Help App for Syrian Refugees with Post-traumatic Stress(MDPI (Basel, Switzerland), 2020-10) Röhr S; Jung FU; Renner A; Plexnies A; Hoffmann R; Dams J; Grochtdreis T; König H-H; Kersting A; Riedel-Heller SGMany Syrian refugees residing in Germany have been exposed to traumatizing events, while treatment options are scarce. Therefore, the self-help app “Sanadak” was developed to target post-traumatic stress in Syrian refugees. We aimed to inspect the recruitment and baseline characteristics of the participants in the trial, which is conducted to evaluate the app. Analyses were based on the recruitment sample (n = 170) and the trial sample (n = 133). Data were collected during structured face-to-face interviews in the Arabic language. Targeted outcomes included post-traumatic stress (primary; Post-traumatic Diagnostic Scale for DSM-5/PDS-5) and depressive symptoms, anxiety, resilience, among others (secondary). Recruited individuals were M = 32.8 (SD = 11.2, range = 18–65) years old; 38.8% were women. The average PDS-5 score was 23.6 (SD = 13.2) regarding trauma exposure, which was most frequently related to experiencing military- or combat-related events (32.9%). Moreover, 46.5% had major depression and 51.8% showed low resilience. Anxiety was present in 40.6% of the trial participants. Psychological distress was high in Syrian refugees residing in Germany, enrolled in a trial targeting post-traumatic stress. This underlines the need for intervention. Our results provide important figures on the mental health of a not well-studied population group in Germany.Item A Self-Help App for Syrian Refugees With Posttraumatic Stress (Sanadak): Randomized Controlled Trial(JMIR Publications, 2021-01) Röhr S; Jung FU; Pabst A; Grochtdreis T; Dams J; Nagl M; Renner A; Hoffmann R; König H-H; Kersting A; Riedel-Heller SGBackground: Syrian refugees residing in Germany often develop posttraumatic stress as a result of the Syrian civil war, their escape, and postmigration stressors. At the same time, there is a lack of adequate treatment options. The smartphone-based app Sanadak was developed to provide cognitive behavioral therapy–based self-help in the Arabic language for Syrian refugees with posttraumatic stress. Objective: The aim of this study was to evaluate the effectiveness and cost-effectiveness of the app. Methods: In a randomized controlled trial, eligible individuals were randomly allocated to the intervention group (IG; app use) or control group (CG; psychoeducational reading material). Data were collected during structured face-to-face interviews at 3 assessments (preintervention/baseline, postintervention/after 4 weeks, follow-up/after 4 months). Using adjusted mixed-effects linear regression models, changes in posttraumatic stress and secondary outcomes were investigated as intention-to-treat (ITT) and per-protocol (PP) analysis. Cost-effectiveness was evaluated based on adjusted mean total costs, quality-adjusted life years (QALYs), and cost-effectiveness acceptability curves using the net benefit approach. Results: Of 170 screened individuals (aged 18 to 65 years), 133 were eligible and randomized to the IG (n=65) and CG (n=68). Although there was a pre-post reduction in posttraumatic stress, ITT showed no significant differences between the IG and CG after 4 weeks (Posttraumatic Diagnostic Scale for DSM-5, Diff –0.90, 95% CI –0.24 to 0.47; P=.52) and after 4 months (Diff –0.39, 95% CI –3.24 to 2.46; P=.79). The same was true for PP. Regarding secondary outcomes, ITT indicated a treatment effect for self-stigma: after 4 weeks (Self-Stigma of Mental Illness Scale/SSMIS–stereotype agreement: d=0.86, 95% CI 0.46 to 1.25; stereotype application: d=0.60, 95% CI 0.22 to 0.99) and after 4 months (d=0.52, 95% CI 0.12 to 0.92; d=0.50, 95% CI 0.10 to 0.90), the IG showed significantly lower values in self-stigma than the CG. ITT showed no significant group differences in total costs and QALYs. The probability of cost-effectiveness was 81% for a willingness-to-pay of €0 per additional QALY but decreased with increasing willingness-to-pay. Conclusions: Sanadak was not more effective in reducing mild to moderate posttraumatic stress in Syrian refugees than the control condition nor was it likely to be cost-effective. Therefore, Sanadak is not suitable as a standalone treatment. However, as the app usability was very good, no harms detected, and stigma significantly reduced, Sanadak has potential as a bridging aid within a stepped and collaborative care approach. Trial Registration: German Clinical Trials Register DRKS00013782; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013782 International Registered Report Identifier (IRRID): RR2-10.1186/s12888-019-2110-yItem Foreign policy discourses of the United States and Iran regarding the Syrian Civil War, 2011-2015 : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Politics at Massey University, Manawatū, New Zealand(Massey University, 2019) Lee, Joo HanThis thesis offers a detailed and systemic analysis of the recent foreign policies on Syria crafted by the United States and Iran. In particular, it identifies the major ways in which key institutions from both countries’ political systems represent various aspects of the Syrian civil war before comparing the similarities and differences among these representational practices. It argues that, between 2011 and 2015, both countries’ foreign policies used humanitarian concern in order to legitimise their respective postures on Syria, though the pursuit of their respective national interests widened the scope for new opportunities to act, including the use of armed force, in the Middle East. Drawing on Norman Fairclough’s model of Critical Discourse Analysis as a means of framing its analysis, the thesis finds that diplomatic language expressing views on matters of war and peace is seldom a-political and can be shaped significantly by institutional practices and socio-cultural contexts.Item Islamic State, Syria's civil war and the reshaping of the Middle East : a thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Defence and Security Studies at Massey University, Manawatu, New Zealand(Massey University, 2017) White, MichaelThe Islamic State grew out of the ashes of a defeated al-Qaeda in Iraq. The continued conflicts in Iraq and Syria have provided the catalyst for a resurgent Islamic State. Syria’s civil war has allowed the Islamic State to remerge like a terrorist phoenix, reborn from its own ashes. This thesis analyses the origins of the Islamic State, and the geo-political conditions and on-going conflicts in Iraq and Syria which have permitted the growth and expansion of the Islamic State. It also analyses how the fight against the Islamic State is changing the security environment within the Middle East.Item Horizontal collaboration between international and local non-governmental organisations : a cross-sectional study regarding the Syrian refugee crisis in Jordan : a thesis presented in partial fulfilment of the requirements for the degree of Master in Supply Chain Management at Massey University, Manawatu, New Zealand(Massey University, 2017) Al Adem, SamarPurpose-This thesis seeks to explore supply chain collaboration within a humanitarian context, and to appraise relationships between international non-governmental organisations and community-based organisations during disaster relief. It also aims to identify challenges facing such collaboration in the humanitarian supply chain, and to discover whether effective partnerships contain a set of identifiable facilitators, drivers and mechanisms which promote relationships between local and international NGOs. Design/Methodology/Approach-Literature from both commercial and humanitarian sectors is discussed in the context of horizontal partnerships. A Jordanian cross- sectional study spanning a network of NGOs is explored via semi-structured interviews. Insights are synthesised into a conceptual model of how NGOs can form partnerships during a humanitarian response. Findings-The research provides valuable insights into the challenges facing local and international NGOs when developing partnerships. Four types of challenge are identified: organisational, inter-organisational, external, and donor-related. The conceptual model highlights the essential elements required for effective partnerships. Research limitations/Future research-The research is built on a single cross-sectional study from one country during an extended humanitarian crisis. The majority of the empirical data is only from one actor’s perspective, thus further research into dyadic and network relationships is required. Further investigation is required into approaches to addressing the diverse cultural and decision-making perspectives of local and international NGOs. Practical Implications-Recognising the challenges and major elements to horizontal partnerships between local and international NGOs will assist managers, both at strategic and operational levels, to find solutions and evolve strategies to build effective partnerships. Compromise and consideration for partner’s drivers and cultural views are essential for effective humanitarian relief. Originality/Value- The research extends supply chain collaboration to a humanitarian context. Overcoming the challenges facing collaborative efforts and the complementary nature of the facilitators, drivers, and mechanisms provides a means to achieve effective partnerships. Despite the uniqueness of the humanitarian context, such as the secondary nature of cost and dynamic demand, the core principles of collaboration still hold. Keywords-Humanitarian, supply chain collaboration, partnerships, community-based organisations (CBOs), non-governmental organisations (NGOs), international NGOs (INGOs).Item Considerations for a collaborative approach to post-conflict development and transitional justice in Syria : a research report presented in partial fulfilment of the requirements for the degree of Master of International Development, Master in International Development, at Massey University, Manawatū, New Zealand(The Author, 2014) Patterson, AmandaNeither transitional justice nor post-conflict development is possible without the other. Thinking about reconstruction, and development more generally, requires an understanding of core political issues of ownership, governance and participation which are similarly key concerns of transitional justice. Such issues also need to be informed by longer-term processes for development which includes strategies for rehabilitation, reform and reparation, all consequences of war which influence development outcomes. A consideration of how post-conflict development objectives can inform a transitional justice process for Syria identifies key areas of convergence and divergence between the two fields as well as debates pertaining to the prioritisation of justice versus peace, international law, and contextualising strategies to individual states and post-conflict situations. In Syria, where work is already under way by multiple organisations and activist groups to facilitate, gather and document evidence of human rights violations in preparation for a future transitional justice process: a 'good-enough' approach to governance (Grindle, 2004), the strengthening of civil society to provide national level support, and institutional reform are identified as key areas for development intervention. However, the success or otherwise of development interventions in these areas will rely upon a number of critical factors: the willingness of a transitional government to take ownership of post-conflict development and transitional justice processes, facilitate citizen participation by first addressing Syria's severe humanitarian crisis, and accept independent or international involvement where required; the capacity of Syrian civil society to provide national level support following an intense and prolonged period of conflict; the state of Syria's post-conflict physical and human resource; and the willingness of a divided Syrian society to accept cross-community human rights initiatives or a transitional government comprised of any one party where violations have been committed by both sides of the conflict.