--Manuscript Draft-- of the Syrian Refugees in Lebanon. Psychological First Aid, children, Syrian refugee, emergency response, mental health,training.

Transcription

1 Psychological Trauma: Theory, Research, Practice, and Policy Psychological First Aid Training for Lebanese Field Workers in the Emergency Context of the Syrian Refugees in Lebanon --Manuscript Draft-- Manuscript Number: Full Title: Article Type: Keywords: Corresponding Author: TRA R3 Psychological First Aid Training for Lebanese Field Workers in the Emergency Context of the Syrian Refugees in Lebanon Unmasked Article Psychological First Aid, children, Syrian refugee, emergency response, mental health,training. Leyla Akoury Dirani, PhD Clinical psychology American University of Beirut Beirut, LEBANON Corresponding Author Secondary Information: Corresponding Author's Institution: American University of Beirut Corresponding Author's Secondary Institution: First Author: Leyla Akoury Dirani, PhD Clinical psychology First Author Secondary Information: Order of Authors: Leyla Akoury Dirani, PhD Clinical psychology Tina Sahakian, MA Fahed Hassan, MA psychology Ranya Hajjar, MA Psychology Khalil el Asmar, MS public health Order of Authors Secondary Information: Manuscript Region of Origin: Abstract: LEBANON The Syrian refugee crisis in Lebanon required a fast and efficient comprehensive rescue strategy. Professionals working in Emergency Response were neither prepared to provide psychological first aid nor prepared to screen for mental health disorders in child refugees. This paper examines the efficacy of a national training program in Psychological First Aid (PFA) to enhance the readiness of mental health field workers in the Syrian Refugee Response. One hundred and nine participants were recruited from Lebanese ministries and NGOs. They received a two-and-a-half-day training on PFA and on screening for mental health disorders in children. Their knowledge and perceived readiness were assessed before the training, immediately after the training, and one month after the training using two evaluation forms. Evaluation form A was a multiple choice questionnaire composed of 20 questions and created based on the content of the training, and Evaluation form B was a Likert-type scale of 20 items created based on the core components of PFA. The data of sixty participants was analyzed. The results showed a significant increase in knowledge and readiness, most specifically on the components related to the principles and techniques of PFA. Suggested Reviewers: Opposed Reviewers: Response to Reviewers: I have followed the recommendations of Reviewer 3 and Reviewer 4 and methodically revised the spelling, grammar, writing style and APA format of the text. I have meticulously verified the references and matched between the references in the text and those listed at its end. I have refined the formulation of the hypotheses to make them more specific. Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation

2 Reviewer 4 advised me to either remove the Exploratory Factor Analysis (EFA) or to conduct a Confirmatory Factor Analysis (CFA) and ideally to remove both analyses since the data set is too small. After I have reviewed the literature, I found that EFA is more adequate in our study since the Form s construct is not predefined. We need to discover how items will load freely. In addition, although EFA is commonly used in large samples, it is also performed in small data sets in the field of behavioral sciences. By reviewing our statistics, I was able to correct some hasty interpretations. Thank you, Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation

3 Response to Reviewers Click here to download Response to Reviewers: PFA Rebutal 29Dec14.docx Psychological First Aid Training for Lebanese Field Workers in the Emergency Context of the Syrian Refugees in Lebanon- 3 rd revision 29 December 2014 Rebuttal: I have followed the recommendations of Reviewer 3 and Reviewer 4 and methodically revised the spelling, grammar, writing style and APA format of the text. I have meticulously verified the references and matched between the references in the text and those listed at its end. I have refined the formulation of the hypotheses to make them more specific. Reviewer 4 advised me to either remove the Exploratory Factor Analysis (EFA) or to conduct a Confirmatory Factor Analysis (CFA) and ideally to remove both analyses since the data set is too small. After I have reviewed the literature, I found that EFA is more adequate in our study since the Form s construct is not predefined. We need to discover how items will load freely. In addition, although EFA is commonly used in large samples, it is also performed in small data sets in the field of behavioral sciences. By reviewing our statistics, I was able to correct some hasty interpretations. Thank you, Leyla Akoury Dirani

4 Manuscript Running head: PFA TRAINING ADDRESSING SYRIAN REFUGEES IN LEBANON 1 Psychological First Aid Training for Lebanese Field Workers in the Emergency Context of the Syrian Refugees in Lebanon Leyla Akoury-Dirani, Tina S. Sahakian, Fahed Y. Hassan, Ranya V. Hajjar, Khalil El Asmar American University of Beirut Author Note Leyla Akoury-Dirani, Department of Psychiatry, Child and Adolescent Psychiatry Program, American University of Beirut Medical Center; Tina S. Sahakian, Department of Psychiatry, Child and Adolescent Psychiatry Program, American University of Beirut Medical Center; Fahed Y. Hassan, Department of Psychiatry, Child and Adolescent Psychiatry Program, American University of Beirut Medical Center; Ranya V. Hajjar, Department of Psychiatry, Child and Adolescent Psychiatry Program, American University of Beirut Medical Center; Khalil El Asmar, Department of Epidemiology & Population Health, American University of Beirut. This project was funded in partnership between UNICEF-Lebanon Office and the American University of Beirut. It received the full support of the main Lebanese NGOs and the Lebanese Ministry of Health and the Ministry of Social Affairs. Correspondence concerning this article should be addressed to the principal investigator Leyla Akoury-Dirani, Child and Adolescent Psychiatry Program, American University of Beirut Medical Center, Riad El Solh, Beirut , Beirut Lebanon. la55@aub.edu.lb

5 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON 2 Abstract The Syrian refugee crisis in Lebanon required a fast and efficient comprehensive rescue strategy. Professionals working in Emergency Response were neither prepared to provide psychological first aid nor prepared to screen for mental health disorders in child refugees. This paper examines the efficacy of a national training program in Psychological First Aid (PFA) to enhance the readiness of mental health field workers in the Syrian Refugee Response. One hundred and nine participants were recruited from Lebanese ministries and Non-Governmental Organizations. They received a two-and-a-half-day training on PFA and on screening for mental health disorders in children. Their knowledge and perceived readiness were assessed before the training, immediately after the training, and one month after the training using two evaluation forms. Evaluation form A was a multiple choice questionnaire composed of 20 questions and created based on the content of the training, and Evaluation form B was a Likert-type scale of 20 items created based on the core components of PFA. The data of 60 participants were analyzed. The results showed a significant increase in knowledge and readiness, specifically on the components related to the principles and techniques of PFA. Keywords: Psychological First Aid, children, Syrian refugee, emergency response, mental health, training.

6 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON 3 Psychological First Aid (PFA) Training for Field Workers in the Context of Ongoing Emergency: The Case of Syrian Refugees in Lebanon Emergency situations range from natural disasters to man-made crises, such as war and terrorist attacks. During the immediate aftermath of a crisis, individuals exposed to lifethreatening situations are often in need of practical assistance such as food, shelter, and medical care, as well as immediate emotional and psychological support. Several approaches were developed over the years, but the two most prominent are Critical Incident Stress Debriefing (CISD), also known as psychological debriefing, and, more recently becoming the leading approach, Psychological First Aid (PFA). There have been controversial findings about the efficacy of CISD. Studies have shown that CISD was either ineffective or potentially harmful, rather than acting to reduce symptoms of post-traumatic stress (Roberts, 2009; Bledsoe, 2003; Van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002). Yet, Hawker, Durken, and Hawker (2011) rehabilitated this intervention by showing that debriefing was beneficial for teams working in crisis, while it may not be as efficacious for victims of traumatic events. The confusion in this case may arise from the lack of differentiation between psychological debriefing and operational debriefing specific to police and professional rescuers. To close the debate, a meta-analysis of therapeutic interventions in children suffering from PTSD showed that any psychological intervention is better than no intervention. It also showed that the earliest the intervention the better the outcome would be (Newman et al., 2014) Psychological First Aid (PFA) is considered the chief approach in early mental health crisis interventions. Preliminary models of the current version of PFA can be traced back in disaster literature to the 1950s (Kantor & Beckert, 2011). While PFA has evolved over the years, its fundamental principles have largely remained the same.

7 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON 4 In 2005, the National Child Traumatic Stress Network (NCTSN) and the National Center for PTSD (NCPTSD) of the United States of America (USA) published the first edition of a semi-structured Psychological First Aid Field Operations Guide, and in 2006, the second and most current edition was published (National Child Traumatic Stress Network and National Center for PTSD (NCTSN), 2006). PFA is described as a structured, evidenceinformed intervention that should be implemented immediately after exposure to lifethreatening emergency situations. The PFA intervention is composed of eight core actions: Contact and Engagement, Safety and Comfort, Stabilization, Information Gathering: Current Needs and Concerns, Practical Assistance, Connection with Social Support, Information on Coping, and Linkage with Collaborative Services. These core actions are based on five empirically supported principles: sense of safety, calm, hope, self-efficacy, communication, and connectedness (Hobfoll et al., 2007). By implementing these five principles, PFA aims to promote coping and adaptation to immediate circumstances in order to improve the potential for long-term adjustment and better future life outcomes. The PFA manual has been used extensively worldwide and translated into several languages. In conformity with the World Health Organization s (WHO) (2007) inter-agency contingency plan, rescuers are urged to learn about the cultural context before acting and to apply their skills sensitively. PFA developers mentioned this caution explicitly in the manual. Due to the chaotic nature of emergency contexts, it is difficult to assess the efficacy of PFA in decreasing stress and fostering coping, adaptation, and resilience in affected populations. The closest evidence for PFA s effectiveness is derived from a small number of studies that assessed the provider s perception about the usefulness and applicability of PFA s core concepts after implementing PFA activities with victims of trauma. These studies found PFA to be useful and relevant to assisting survivors with their immediate psychological needs (Allen et al., 2010; Haskett, Scott, Nears, & Grimmett, 2008; Schafer, Snider, & Ommeren,

8 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON ). Allen et al. (2010) observed that PFA providers reported feeling more confident applying PFA interventions with adults than with children. They suggested that PFA providers might benefit from additional training that focused on administering PFA with children. Other PFA research assessed the feasibility and efficacy of PFA training by evaluating acquired knowledge, providers self-reported confidence, and self-efficacy in implementing PFA intervention (Brown et al., 2009; McCabe et al., 2011). Studies about PFA training included participants from a wide range of backgrounds: nurses at elderly homes (Brown et al., 2009), emergency responders (Cheung, Chan, Lin, & Lee, 2011), lay persons living in the community (McCabe et al., 2011), and managers and their peer supports in companies situated in high risk areas (Lewis, Varker, Phelps, Gavel, & Forbes, 2013). These studies found that PFA training was efficacious, with the majority of participants acquiring knowledge and expressing increased confidence and self-efficacy in administering PFA. Context Since April 2011, Lebanon has been facing a major challenge with an ever-growing steady influx of Syrian refugees. As of April 2014, the number of refugees registered at the UNHCR was 953,626 and among those registered, 52.5% were 17 year olds or younger (UNHCR update on April 4, 2014). By the time of the publication of this paper, the number of UNHCR-registered Syrian refugees living in Lebanon is projected to reach 1,500,000. Among the hosting countries, Lebanon is the most crowded with 37.5% of its population now composed of registered refugees. The significant increase in population has resulted in straining the country s available resources, including electricity, water sanitation, and healthcare (The Lancet, 2014). El-Khatib et al. (2013) reported that 11% of the refugees suffer from psychiatric symptoms. In addition, Syrian refugees families and communities are fragmented as many take shelter anywhere in the country, challenging the systematic distribution of humanitarian aid. However, and to counterbalance this negative reality, the

9 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON 6 historical ties between the inhabitants of the border zones (Lebanon shares its northern and eastern frontiers with Syria) allow for a more welcoming and supportive hosting community. Moreover, Syrian citizens are familiar with the Lebanese socioeconomic network and characteristics. This is because of the extensive exchanges of companies products and the importation of human power, workers in construction sites, etc. However, and despite all good will, refugee children are in need of basic social and mental health support. This ranges from basic nutrition and vaccine coverage to psychosocial support. Although Lebanon is frequently exposed to terrorist attacks, war, and natural disasters, only a few of the responders (health and mental health workers, social workers, etc.) who are assigned to conduct crisis intervention are adequately trained and equipped to address emotional distress. The lack of well-designed PFA and other more advanced services tackling mental health issues in children and adolescents weakens the emergency response readiness and leads to erratic services with fragmented approaches and substandard outcomes. In response, the Child Protection Committee and the Child and Adolescent Program at the Psychiatry Department of the American University of Beirut Medical Center (AUBMC), in partnership with UNICEF started a project called The Psychological First Aid Training and Support for Children Exposed to Trauma. The overarching project was twofold. The first component was dedicated to strengthening the readiness and capabilities of field workers by teaching them how to implement PFA, with an emphasis on implementing PFA activities with children and adolescents, and on training them on how to screen for severe psychological distress in child refugees. The second component involved training mental health professionals to provide Trauma-Focused Cognitive Behavioral Therapy in groups for children diagnosed with psychological distress or Post-Traumatic Stress Disorder.

10 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON 7 This paper covers the first component of the project. It examines whether the PFA training provided is considered an evidence-based initiative that better serves the region and helps strengthen the readiness and capabilities of mental health workers to respond to the mental and emotional needs of children and families affected by the emergency crisis in Syria. More specifically, we examine the efficacy of the PFA training through assessing the knowledge acquired and the readiness of the trainees to deliver psychological first aid services in addition to identifying children at risk of mental health problems. We also explore the presence of an association between knowledge of PFA training and readiness to deliver psychological first aid services. Three hypotheses are raised: there will be statistically significant improvements from knowledge and readiness levels at baseline to knowledge and readiness levels immediately after the training and one month after the training. Knowledge and readiness levels will remain stable in the time between the immediate end of the training and one month follow-up, and PFA training and readiness to deliver the PFA services will positively correlate. The Institutional Review Board of the American University of Beirut has approved this study. Method Participants The recruitment of the participants was done in close collaboration with the UNICEF officers. An ed letter was sent to 35 UNICEF partners covering Lebanese territory (including 13 Non-Governmental Organizations (NGOs), the Ministry of Social Affairs (MoSA), and the Ministry of Public Health (MoPH)) inviting interested fieldworkers working directly with Syrian refugee families and families of the hosting community to join the PFA training. Thirteen NGOs, MoSA, and MoPH referred 145 candidates, from which 109 candidates met the criteria to participate in the training. The criteria included having a degree

11 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON 8 related to mental health (ideally psychology, social work, or education), experience with children, and a position that involved working directly with the Syrian refugee families, children and members of the hosting community affected by the Syrian crisis. Of the recruited candidates, a total of 77 attended and completed the full two-and-ahalf-day PFA training. The division of the 77 participants across the four training sites was as follows: 18 trainees in Beirut, 25 trainees in Halba-North Lebanon, 21 trainees in Taanayil- Bekaa, and 13 trainees in Tyre-South Lebanon. These candidates were local inhabitants of the regions, which made their contact with the refugee community more natural and easy. The number of participants diminished to 60 at the first follow-up meeting (i.e.one month after the training). The division of the 60 participants across the four training sites was as follows: 16 trainees in Beirut, 18 trainees in Halba, 18 trainees in Taanayil, and 8 trainees in Tyre. In terms of their educational background, 7 of the 60 participants had a psychology degree, 6 participants had a degree in social work, and 6 participants had a degree in education. Moreover, 18 of the 60 participants had a degree in sociology, 2 had a degree in political science, 4 participants had a degree in nursing, and 4 had a degree in business. The remaining 13 participants either had other degrees or had not provided information about their degrees. Training design The original English PFA manual was used as baseline material (NCTSN, 2006). It was translated into Arabic and contextualized to fit the specificities of the current humanitarian crisis. In addition, since the field workers were asked to detect children at risk of severe emotional distress, notions of mental health as well as screening tools were added to the content of the training. Two preparatory meetings between the leaders and the trainers of

12 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON 9 the PFA training, and the two UNICEF representatives were dedicated to this purpose. During these meetings, the educational materials and support documents were reviewed and adjusted to the baseline knowledge of the candidates, the operational contingencies, as well as to the needs of the population. The PFA training was conducted in Arabic and four training sessions were implemented in four different regions of Lebanon to cover the national territory: North Lebanon, the Bekaa Valley (East Lebanon), Beirut, and South Lebanon. The first training session took place in Halba (North Lebanon), the second and third training sessions took place in Taanayil-Bekaa and Beirut, and the last training took place in Tyre (South Lebanon). Each training session was two and a half days long. The PFA training aimed at providing the participants the skills to deliver appropriate psychological first aid, and enabling them to identify behaviors that may be the manifestation of mental health issues and traumarelated symptoms. More specifically, the objectives of the training were to enhance understanding of the basic principles of ethics and increase behaviors that abide by these principles, to enhance understanding of the concepts of mental health, including mental wellbeing, trauma, post-traumatic stress disorder, depression, anxiety, to enhance understanding of PFA principles and how to provide PFA, to develop self-care and self-help skills of fieldworkers, and to improve communication skills. To fulfill these objectives the training was comprised of seven sessions: Getting to Know Each Other (including modeling icebreaker exercises which may be used with children); Ethics; Mental Health, Depression, Anxiety, and Trauma: Definitions and Warning Signs; A Quick Presentation of Screening Tools to Support the Observation of Emotional Distress; The Core components of the Psychological First Aid; Communication with Children: Helping Children in Distress and Conflict Situations; and Self-care. The material concerning these seven sessions was presented in PowerPoint format and some were supplemented with

13 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON 10 handouts. The trainers used an interactive strategy of teaching. They combined informative talks, sharing experiences, role-plays, and self-reflections. They showed flexibility in adjusting the material and techniques to the participants professional profiles and specificities while maintaining the core objectives and core components of the training. Instruments To assess the participants baseline knowledge and skills in the field, the accuracy of the PFA training, and the maintenance or improvement of learned materials with time and experience, the participants were asked to complete two evaluation forms three times during the study: directly before the training, immediately after the training, and one month after the training. Evaluation Form A. To assess knowledge of the PFA training provided, a 20-item form was created based on the content of the training. The questions were in multiple-choice format with each question having 5 possible answers. The 20 questions covered the following topics: definitions of mental health concepts (i.e. anxiety, depression, and post-traumatic stress disorder) (7 questions), PFA principles and core actions (11questions), and administration of screening tools (2 questions). Evaluation Form B. To assess readiness of the trainees to deliver PFA in the field, a 20-item form was created based on the core components of PFA: the ability to initiate the communication with the refugee, to provide safety and comfort, to stabilize the person, to assess for current needs and concerns, and to provide the adequate support and referral. The items were scored on a 5-point Likert-type scale from 1 (strongly agree) to 5 (strongly disagree).

14 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON 11 Statistical Analysis A Chi-square test for proportion of trends was used to assess the differences in proportion of correct answers to questions from evaluation form A across the three evaluation periods (pretest, posttest, and one month posttest). Analysis of Variance was used to compare the difference in the total score of the readiness of the trainees to deliver the PFA services (Evaluation form B) across the three waves (pretest, posttest, and one month posttest). To examine the factor structure and internal consistency of the Evaluation Form B, since it was not known how the items would load, an Exploratory Factor Analysis was conducted with Varimax rotation and reliability analysis. Such statistical analysis, usually performed in large sample size is also applicable in small samples in psychological sciences (De Winter, J. 2009). Items with factor loadings higher than 0.4 were grouped together. Cronbach s coefficient alpha (α) was calculated to measure the instrument s internal consistency. The Pearson correlation coefficient was used to assess the correlation between knowledge of PFA (proportion of correct answers on Evaluation Form A) and readiness to deliver psychological first aid services (total score on Evaluation Form B). An alpha level of 0.05 was considered to indicate statistical significance. All analyses were performed using Stata MP Version 13. Results The factor analysis with Varimax rotation revealed that all items have factor loadings higher than 0.3 across the three measurement periods (pretest, posttest, and one month posttest) suggesting that Evaluation form B is unidimensional. Cronbach s alpha was calculated for the 20 items for the three different measurement periods (pretest, posttest, and

15 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON 12 one month posttest) and its value exceeded 0.90 for the three testing periods, indicating a strong internal consistency of the instrument. (Table 1) Table 1 illustrates the proportion of correct item answers on Evaluation form A at three different time points: before the training, after the training, and at one month follow-up. The respondents were marginally significantly (p = 0.084) able to define mental health correctly at the three different time points. Furthermore, the importance of the training was clear in terms of correctly identifying and defining trauma noted by a 10% marginally significant increase in the proportion of correct answers (p = 0.077) after taking into account the respondents that were lost in follow-up. Although the results were not significant, the majority of respondents were able, at the three different time points, to successfully define Clinical Depression (p = 0.258) and Anxiety (p = 0.941). There was a 5% increase in the proportion of respondents that were successfully able to define PTSD. However, this result was not significant (p = 0.382). The respondents significantly benefited from the training through gaining a 15% increase in knowledge on what to avoid when administering PFA (p = 0.029) and a staggering 45% increase in knowledge on how to approach and interact with refugees when administering PFA (p < 0.001). There was a significant 26% increase in knowledge on how to behave with refugees (p < 0.001). Moreover, the knowledge on how to deal with children who experienced traumatic events significantly doubled (p < 0.001) after the training. Furthermore, there was a significant 35% increase in knowledge after the training on the things that need to be avoided when listening to the story of a traumatized person (p < 0.001). When it came to comprehension of the PTSD screening tool and how to administer it, the respondents exhibited a significant 20% increase in knowledge (p = 0.003). An average score for Evaluation form B was calculated for each of the three time points pretest, posttest, and one month posttest with lower scores indicating increased readiness. The results showed that

16 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON 13 there was a significant difference in readiness to deliver PFA services across the three periods (p < 0.001), with participants responses shifting from agreements to strong agreement, indicating increased readiness to deliver PFA services after receiving training. An attempt to stratify the proportion of correct answers on the items of Evaluation form A at three different time points, by the type of respondents education showed no significant results. Table 2 depicts the items of Evaluation form A that were significantly associated with the scores of Evaluation form B at one month follow-up. The results indicate that out of the 20 items from Evaluation form A, there were 12 that showed a significant positive association with the mean of the items of form B. Knowledge about the administration of PFA, the methods of support and comfort of trauma survivors, exploring emotions of children experiencing traumatic events, establishing trust and confidence and communicating empathy and understanding with refugees, and finally, on properly administering the PTSD symptom screening questionnaire for children, were all found to be significantly and positively associated with the perceived readiness of the trained respondents to administer PFA core actions and principles. (Table 2) Discussion The results of this study showed that the PFA training significantly increased the trainees baseline knowledge concerning mental health disorders in children, regardless of their background. This result was significant or marginally significant for all definitions except for that of PTSD. This increase was between 5% and 15% concerning knowledge of

17 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON 14 definitions of mental health disorders and between 15% and 45% concerning knowledge of applying PFA principles and actions with children and families. The results also indicated that the trainees, who are mental health providers working in the Syrian Refugees Emergency Response, found that the knowledge acquired during the PFA training significantly increased their readiness to deliver PFA services. These findings are in line with previous finding in the literature of the effectiveness of PFA training in enhancing knowledge and self-reported confidence in implementing PFA intervention (Brown et al., 2009; Cheung et al., 2011; Lewis et al., 2013; McCabe et al., 2011; Everly et al., 2014). In addition, the scales developed by the research team were shown to be effective in capturing the trainees feedback and in measuring the efficacy of the training. They can be used later to evaluate future PFA training programs. The implementation of this study faced limitations frequently observed in emergencies. The recruitment criteria of the participants were not stringently respected since the priority was to support the first line agents working directly with children and families in the Syrian Refugee Emergency Response. In addition, 22% of the trainees did not return to the follow-up meetings. In the North, this was due to the increase of military actions, which restricted the movement of the field workers due to safety concerns, and in the Bekaa, the large increase of refugees made the field workers prioritize the direct rescuing of the new comers over attending meetings. Finally, the trainers ability to define trauma and mental health across the three time points was marginally significant, rather than significant, which decreases the power of these specific findings. Nonetheless, this study is the first in Lebanon and the Middle East region to show that providing PFA training strengthened the knowledge and self-reported readiness of mental health workers to respond to the psychological needs of children and families affected by the

18 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON 15 Syrian crisis. In this chronically volatile environment of the Middle East, initiating an evidence-informed approach is necessary if stakeholders want to ensure good quality of emergency response. This necessity is heightened in Lebanon in light of the massive nationwide influx of Syrian refugees into a country beset by internal conflicts and lacking an organized and sustainable nationwide crisis response system.

19 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON 16 References Allen, B., Brymer, M. J., Steinberg, A. M., Vernberg, E. M., Jacobs, A., Speier, A. H., & Pynoos, R. S. (2010). Perceptions of Psychological First Aid among providers responding to hurricanes Gustav and Ike. Journal of Traumatic Stress, 23, doi: /jts Brown, L. M., Bruce, M. L., Hyer, K., Mills, W. L., Vongxaiburana, E., Polivka-West, L. (2009). A pilot study evaluating the feasibility of Psychological First Aid for nursing home residents. Clinical Gerontologist, 32, doi: / Bledsoe, B. E. (2003). Critical incident stress management (CISM): Benefit or risk for emergency services? Prehospital Emergency Care, 7(2), doi: / Cheung, E. Y. L., Chan, E. Y. Y., Lin, C. L. Y., & Lee, P. P. Y. (2011). Clinical effectiveness of Psychological First Aid Training among emergency responders in Chinese population: Preliminary results of 3-month follow-up [abstract]. Prehospital and Disaster Medicine, 26(1), s137-s138.doi: De Winter, J., Dodou D., Wieringa P.A, (2009) Exploratory factor analysis with small sample sizes. Multivariate Behavioral Research, Volume 44, Issue 2. DOI: / El-Khatib et al. (2013) Syrian refugees, between rocky crisis in Syria and hard inaccessibility to healthcare services in Lebanon and Jordan. Conflict and Health :18. Everly G., McCabe L., Semon N., Thompson C., Jonathan M. (2014) The Development of a Model of Psychological First Aid for Non Mental Health Trained Public Health Personnel: The Johns Hopkins RAPID-PFA. Journal of Public Health Management

20 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON 17 Practice, 2014, 20(5), S24 S29 DOI: /PHH Haskett, M. E., Scott, S. S., Nears, K., & Grimmet, M. A. (2008). Lessons from Katrina: Disaster mental health service in the Gulf Coast region. Professional Psychology: Research and Practice, 39(1), doi: / Hawker D.M., Durkin J., Hawker D. S. J. (2011) To Debrief or Not to Debrief Our Heroes: That is the Question. Clinical Psychology and Psychotherapy 18, (2011) DOI: /cpp.730 Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., Friedman, M. J., Ursano, R. (2007). Five essential elements of immediate and midterm mass trauma intervention: empirical evidence. Psychiatry, 70(4), doi: /psyc antor,. M., eckert,. R. (2011). Psychological First Aid. n F.J. toddard, A.A. Pandya & C. L. Katz (Eds.), Disaster psychiatry: Readiness evaluation, and treatment (pp ). Virginia, A American Psychiatric Publishing, nc. Lewis, V., Varker, T., Phelps, A., Gavel, E., Forbes, D. (2013). Organizational implementation of Psychological First Aid (PFA): Training for managers and peers. Psychological Trauma: Theory, Research, Practice, and Policy. No Pagination Specified. doi: /a McCabe, O. L., Perry, C., Azur, M., Taylor, H. G., Bailey, M., Links, J. M. (2011). Psychological first Aid training for paraprofessionals: A systems-based model for enhancing capacity of rural emergency responses. Prehospital and Disaster Medicine, 36(4), doi: /S X National Child Traumatic Stress Network and National Center for PTSD (NCTSN), Psychological First Aid: Field Operations Guide, 2 nd Edition. July, Available on: and

21 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON 18 Newman E., Pfefferbaum B., Kirlic N., Tett R., Nelson S., Liles B. (2014) Meta- Analytic review of Psychological Interventions for Children Survivors of Natural and Man-Made Disasters; Current Psychiatry Reports 16:462 DOI /s z Roberts NP, Kitchiner NJ, Kenardy J, Bisson JI. (2009) Multiple session early psychological interventions for the prevention of post-traumatic stress disorder. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD DOI: / CD pub2. Schafer, A., Snider, L., & Van Ommeren, M. (2010). Psychological First Aid pilot: Haiti emergency response. Intervention, 8, doi: /wtf.0b013e cb The Lancet editorial: Syrian health crisis in Lebanon Vol 383 May 31, 2014 United Nations High Commissioner for Refugees. (2014).Syria Regional Refugee Response [Data file]. Retrieved from Van Emmerik, A. A. P., Kamphuis, J. H., Hulsbosch, A. M., & Emmelkamp, P. M. G. (2002). Single session debriefing after psychological trauma: A meta-analysis. The Lancet, 360, doi: /s (02) World Health Organisation (2007) Inter-agency contingency planning guidelines for humanitarian assistance

22 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON 19 Table 1 Proportion of Correct answers on Evaluation form A and average score on Evaluation form B at each wave pre post follow-up n % N % n % p-value Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question Mean of Evaluation form B ± S.D 2.16 ± ± ±

23 PFA AND TRAINING AND SYRIAN REFUGEES AND LEBANON 20 Table 2 Significant correlations between items of form A with mean of form B in follow-up survey Mean of form B coeff. p-value Question Question Question Question Question Question Question Question Question Question Question Question