A systematic review of psychological group interventions for adult refugees in resettlement countries: development of a stepped care approach to mental health treatment

Figures & data

Figure 1. PRISMA 2020 flow diagram outlining study selection.

Table 1. Summary of included articles.

Author/date	Aim/study focus	Study design	Sampling	Intervention type	Outcome focus/measures	Main findings
Quantitative Studies (N = 13)
Gurung et al. (2020)	To examine the effectiveness of MHFA training offered with and without culturally-appropriate orientation to mental health terminology and concepts	Quantitative: non-randomised pre-post design	Refugees (N = 458) (55% male, country of origin= Bhutan)	Health promotion (mental health literacy)	Mental health symptom recognition, MHFA response, confidence helping mentally ill person, stigma, mental health literacy	Pre- to post-training improvement in ability to recognise schizophrenia, depression, and the overall mental health literacy was greater for refugees who attended orientation relative to other participants
Han et al. (2012)	Evaluate a pilot psychosocial treatment program developed by combining Cambodian traditions and with Western mental health techniques	Quantitative: one-group pre-post-test design	Refugees (N = 9) (77% female, country of origin= Cambodia)	Therapeutic group (CA-CBT+)	Harvard Trauma Questionnaire (HTQ), family-related acculturation stress questionnaire	All participants reported significantly lowered mean of the HTQ PTSD scores from the pre-test to the post-test. Family-related acculturation stress level also indicated significant reductions after the intervention.
Jeon et al. (2020)	To compare the effectiveness of CBT to simple relaxation in reducing depression and anxiety among North Korean refugees	Quantitative: pre-post design	Refugees (N = 38) (92% female, country of origin= North Korea)	Therapeutic group (CBT)	Centre for Epidemiologic Studies Depression Scale (CES-D), State-Trait Anxiety Inventory Scale, Impact of Event Scale-Revised	Participants had a significant decrease in CES-D scores after treatment. The decrease was significantly larger in those who participated in CBT compared to those in relaxation. Participants with high levels of anxiety showed significant decreases in Stare-Trait Anxiety Scale scores after treatment, regardless of which type of program they participated in.
Kananian et al. (2017)	To evaluate the effectiveness of culturally adapted CBT (CA-CBT) in an uncontrolled pilot study with a sample of Farsi-speaking refugees	Quantitative: uncontrolled pilot study	Refugees (N = 9, country of origin= Afghanistan, Iran)	Therapeutic group CA-CBT	General Health Questionnaire Posttraumatic Checklist for DSM-5 Patient Health Questionnaire (PHQ-9), Somatic Symptom Scale World Health Organisation Quality of Life Brief Questionnaire (WHO-QOL BREF), Affective Style Questionnaire Emotion Regulation Scale	Improvements were found on almost all questionnaires.
Kananian et al. (2020)	To evaluate the effectiveness of CA-CBT plus problem-solving training (CA-CBT+) in a randomised controlled pilot trial with a sample of Farsi-speaking refugees	Quantitative: randomised controlled pilot trial	Refugees (N = 24, country of origin= Afghanistan, Iran)	Therapeutic group (CA-CBT+)	M.I.N.I diagnostic interview, General Health Questionnaire-28, PTSD Checklist for DSM5, Patient Health Questionnaire, Somatic Symptom Scale, WHOQOL-BREF, Emotion Regulation Scale	Large between-group effect sizes were seen at posttreatment in the GHQ-28 and for most secondary outcome measures.
Lehnung et al. (2017)	To investigate the effectiveness of two sessions of Eye Movement Desensitisation and Reprocessing Therapy Group Traumatic Episode Protocol	Quantitative: waitlist control group design	Refugees (N = 18) (77% male, country of origin = Syria & Iraq)	Therapeutic group (Eye Movement Desensitisation and Reprocessing)	IES-R (Impact of Event Scale-Revised), Beck Depression Inventory	There was a significant difference in groups in the IES-R scale measures between T1 and T2 between the two groups. Differences in the BDI between groups at T1 and T2 was not significant.
Mitschke et al. (2013)	To examine the effect of a group-based financial education program for Bhutanese refugee women who had been recently resettled in the United States	Quantitative: quasi-experimental, non-equivalent group design	Refugees (N = 65) (100% female, country of origin = Bhutan)	Community-based intervention (financial empowerment)	Post-Traumatic Stress Disorder Checklist-Civilian, Patient Health Questionnaire-Somatic, Anxiety and Depressive Symptoms Scale Medical Outcomes Study Social Support Scale	Results from pre/post and follow-up assessments indicate that participants in both intervention groups experienced significantly less depression, anxiety, somatisation, and PTSD symptoms at post-test, which were maintained at 3-month follow-up.
Robertson et al. (2019)	To examine the effects of a culturally adapted Somali health realisation intervention on coping and mental health outcomes in Somali refugee women post-resettlement	Quantitative: three-arm comparison group trial	Refugees (N = 65) (100% female, country of origin= Somalia)	Health promotion (psychoeducation))	Ways of Coping Questionnaire, Symptom Checklist 90, Osman-Mohammed-Gobena Coping questionnaire	The intervention significantly affected multiple dimensions of coping: WAYS-distancing, seeking social support. positive reappraisal. The health realisation intervention also demonstrated improvement in depression symptom ratings.
Slewa-Younan et al. (2020a)	To conduct a preliminary trial of a culturally tailored mental health promotion program designed to improve mental health literacy among two Arabic-speaking refugee populations.	Quantitative: uncontrolled, repeated measures pre-post design	Refugees (N = 31) (42.4% male, country of origin= Iraq & Syria)	Health promotion (mental health literacy)	Personal Stigma in Response to Mental Illness Scale, Social Distance Scale, K-10	Improvements in most aspects of mental health literacy assessed were found immediately post-intervention and at follow-up.
Slewa-Younan et al. (2020b)	To evaluate if a mental health literacy training program was effective in Arabic-speaking religious and community leaders.	Quantitative: uncontrolled, repeated measures pre-post design	Refugees and service providers (N = 52) (69% female, country of origin= Iraq, Australia & Lebanon)	Health promotion (mental health literacy)	Pre-post intervention questionnaires	Significant differences were found post-training in measures such as the ability to recognise mental health problems and understanding of medication in treating PTSD. An improvement in negative attitudes was observed.
Small et. al. (2016)	To evaluate the effectiveness of three different mental health interventions among refugees	Quantitative: quasi-experimental pre-post design	Refugees (N = 81) (71% male, country of origin= Burundi, Burma, Democratic Republic of Congo, Bhutan)	Health promotion (psychoeducation)	PTSD Checklist, Patient Health Questionnaire, Medical Outcomes Social Support Survey	At post-test, decreases in PTSD, anxiety and somatisation were noted across all treatment groups. Participants in home-based counselling reported higher levels of improvement.
van Heemstra et al. (2019)	To evaluate the potential effectiveness of 7ROSES, a transdiagnostic intervention that aims to increase self-efficacy among treatment-seeking refugees in dealing with postmigration stressors.	Quantitative: observational cohort design	Refugees (N = 49) (65% male, multiple countries of origin)	Therapeutic group (transdiagnostic)	Self-efficacy & general psychopathology (as measured by the General Self Efficacy Scale and Brief Symptom Inventory	Results indicated a significant increase in GSES scores and significant decrease in Brief Symptom Inventory scores with medium-small effects.
Qualitative Studies (N = 5)
Hashimoto-Govindasamy and Rose (2011)	To evaluate a Sudanese women’s group exercise program designed from a community development strengths-based model.	Qualitative: ethnographic process evaluation	Refugees (N = 12) (100% female, country of origin= Sudan)	Community-based intervention (exercise)	Experiences of exercise group	Participants viewed the program positively due to educational components and the opportunity for respite. Transport and childminding support were seen as vital.
Mitschke et al. (2017)	To evaluate refugees’ experiences of treatment for depression, post-traumatic stress symptoms, or anxiety.	Qualitative: semi-structured interviews	Refugees (N = 30) (59% female, country of origin= Bhutan, Burma, Burundi, Congo & Rwanda)	Therapeutic group (mixed)	Experiences of treatment for mental health	Themes generated from the interviews emphasised the need for strong group-based social support as well as a focus on practical needs such as acquiring and maintaining employment, language, and literacy training, and access to care.
Nilsson et al. (2019)	To explore the experience of participation in physical activity and exercise as part of treatment for trauma-affected refugees	Qualitative: explorative design	Refugees (N = 33) (70% male, country of origin= Iraq, Syria, Lebanon, Jordan & Palestine)	Community-based intervention (exercise)	Experiences of participating in group physical activity & exercise treatment	Participants felt exercise helped build resilience. Participants experienced improvements in both physical and mental health domains. The treatment groups helped overcome social fear and isolation.
Poulsen et al. (2020)	To evaluate the impact of a horticultural vocational program for refugees	Qualitative: Interpretive phenomenological analysis (IPA)	Refugees (N = 28) (60% males, countries of origin= multiple)	Community-based intervention (gardening)	Experiences of GROW project	The natural environment helped participants feel safe, and relationships with staff initiated a recovery process. The programme helped decrease feelings of isolation.
Praetorius et al. (2016)	To assess the impact of a group-based financial education course on the self-reported mental health of Bhutanese refugee women resettled in the United States	Qualitative: grounded theory	Refugees (N = 12) (100% female, country of origin = Bhutan)	Community-based intervention (financial empowerment)	Experiences of social enterprise/financial literacy group	Both intervention groups (financial literacy and social enterprise) had clear and significant mental health improvements
Mixed-Methods Studies (N = 10)
Baird et al. (2017)	To evaluate the acceptability and feasibility of a 10-week community-based, culturally tailored mental health intervention	Mixed methods: community-based participatory research	Refugees (N = 12) (100% female, country of origin= South Sudan)	Health promotion (psychoeducation)	Hopkins Symptom Checklist (HSCL-25), field notes, focus groups	A majority of the post-intervention HSCL scores were higher than the pre-intervention scores for both the anxiety and depression subscales. Qualitative results attributed this increase to women’s improved mental health awareness.
Bernardi et al. (2019)	To investigate the feasibility and acceptability of a modified cognitive processing therapy (CPT) group program for Karen refugees with PTSD	Mixed methods: explorative design	Refugees (N = 7) (100% female, country of origin= Myanmar)	Therapeutic group (CPT)	Clinician-Administered PTSD scale (CAPS-5), Life Events Checklist-5; Posttraumatic Stress Disorder Checklist (PCL-5), Hopkins Symptom Checklist (HSCL)	At posttreatment all participants no longer met PTSD diagnostic criteria and had a reliable improvement in PTSD symptoms when compared with pre-treatment scores. However, at follow‐up four participants had a reliable worsening in PTSD symptoms
Brochmann et al. (2019)	The study aimed to explore service providers’ experiences of facilitating group therapy with refugees	Mixed methods: explorative design	Service providers (N = 32) (74% female, country of origin= Denmark)	Therapeutic group (mixed)	Experiences of facilitating group therapy with refugees	Most practitioners reported favourable experiences of group treatment.
Eriksson-Sjöö et al. (2012)	To evaluate self-perceived health-related quality of life among refugees participating in a group health promotion activity	Mixed methods: prospective design	Refugees (N = 39) (54% male, country of origin= Arabic-speaking)	Health promotion (general health information)	European Quality of Life Five Dimension participant observations, oral evaluations	Significantly fewer participants experienced pain as well as depression at the second follow-up compared to baseline. Qualitatively, participants still experienced intrusive thoughts and memory problems.
Gerber et al. (2017)	To evaluate the effectiveness of a community gardening intervention for refugees	Mixed methods: exploratory design	Refugees (N = 50) (62% female, country of origin= Bhutan)	Community-based intervention (gardening)	Refugee Health Screener (RHS-15), Patient Health Questionnaire-15 (PHQ-15), Medical Outcomes Study Social Support Scale; Adapted Client Assessment Tool, semi-structured interviews	Distress in gardeners versus nongardeners was not significantly different as indicated by the Refugee Health Screener. Gardeners reported greater social support than nongardeners. Qualitatively, gardeners reported increased autonomy and self-efficacy.
Haefner et al. (2019)	To evaluate the effectiveness of using a veterans PTSD group therapy program with refugees	Mixed methods: pre-post design Note: no qualitative data reported	Refugees (N = 18) (83% male, country of origin=not described)	Therapeutic group (CBT+)	PTSD Checklist for DSM-5 (PCL-5)	Participants reported a decrease in PTSD postintervention compared to preintervention
Hartwig and Mason (2016)	To evaluate a gardening project with Karen and Bhutanese refugees	Mixed methods: surveys and focus groups	Refugees and service providers (N = 97) (65% female, country of origin= South East Asian)	Community-based intervention (gardening)	Depression and food security, as measured by the PHQ, and Supplemental Nutrition Assistance Program	Refugee gardeners expressed receiving physical and emotional benefits from gardening
Husby et al. (2020)	To study the acceptability and impacts of a community group intervention for refugees	Mixed methods: convergent parallel design	Refugees (N = 32) (65% female, country of origin= Syria, Palestine)	Health promotion (psychoeducation)	World Health Organisation Five Wellbeing Index (WHO-5), focus group interviews	Results showed a significant improvement in wellbeing (p = .003).
Im and Swan (2020)	To evaluate a cross-cultural trauma-informed care training program in building competencies and providing resources professionals and refugee community leaders.	Mixed methods: semi-structured retrospective pre- and post-training evaluation	Refugees and service providers (N = 124) (77.4% female, country of origin= Afghanistan, Bhutan, Congo & Karen)	Health promotion (trauma-informed care)	Pre-and post intervention questionnaires	Significant improvements were observed in providers’ knowledge of trauma impacts, cultural expressions of trauma/stress-related symptoms, and culturally responsive trauma-informed care.
Salt et al. (2017)	To pilot the RHS-15 to assess mental health and the Pathways to Wellness group intervention with a refugee women’s sewing group.	Mixed methods: social ecological and community-based participatory research	Refugees (N = 12) (100% female, country of origin= Somalia, Iran, Nepal, Burma, Chad & Karen)	Health promotion (psychoeducation)	Refugee Health Screener (RHS-15)	No significant difference in the total scores for the baseline RHS-15 and the post-intervention RHS-15. The women conveyed several current stressors: language barriers, financial stress and transportation as barriers to maintaining good health.
Subedi et al. (2015)	To evaluate the effectiveness of Mental Health First Aid (MHFA) training in improving knowledge of mental health problems and treatment processes	Mixed methods: uncontrolled pre-test post-test design	Refugees (N = 58) (83% male, country of origin= Bhutan)	Health promotion (mental health literacy)	Mental health literacy, stigmatising attitudes	Between the pre- and post-test, participants showed significant improvement in the recognition of symptoms of depression. However, there was no reduction in negative attitudes towards people with mental disorders.

CA-CBT: Culturally Adapted Cognitive Behaviour Therapy; CBT: Cognitive Behavioural Therapy; CES-D: Centre for Epidemiological Studies Depression Scale; CPT: Cognitive Processing Therapy; HSCL-25: Hopkins Symptom Checklist; HTQ; Harvard Trauma Questionnaire; IES-R: Impact of Event Scale-Revised; MHFA: Mental Health First Aid; PCL-5: Post-traumatic Stress Disorder Checklist for DSM5; PHQ: Patient Health Questionnaire; PTSD: Post-traumatic Stress Disorder; RHS15: Refugee Health Screener; World Health Organisation Quality of Life Brief Questionnaire (WHO-QOL BREF).

Figure 2. Stepped care service model integrating group-based and community-based interventions.

Gurung, A., Subedi, P., Zhang, M., Li, C., Kelly, T., Kim, C., & Yun, K. (2020). Culturally-appropriate orientation increases the effectiveness of mental health first aid training for Bhutanese refugees: Results from a multi-state program evaluation. Journal of Immigrant & Minority Health, 22(5), 957–964. https://doi.org/10.1007/s10903-020-00986-8

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Data availability statement

As a review, the data for this study is the papers that are included. These are fully referenced and can therefore be freely found.