Design
This was a mixed methods study. The quantitative element involved a retrospective analysis of mental health data recorded by psychologists working in the MSF clinics in Serbia. The qualitative aspect included selected testimonies anonymized) of intentional violence.
Study Setting
General setting
The location of MSF mobile clinics was Serbia, which is situated in the central Balkans, and which borders Hungary to the north; Romania and Bulgaria to the east; FYROM to the south; and Croatia, Bosnia and Montenegro to the west. Serbia’s geographical location makes it a key area as a transit hub for migrants/refugees. Consequent to the growing influx of migrants/refugees, border closures were introduced along the Balkan route (Table 1, Fig. 1). Furthermore, in March 2016, the European Union (EU) and Turkey established a deal to tackle ‘irregular’ migration termed the EU-Turkey deal. Since 20 March 2016, irregular migrants and refugees arriving in Greece are supposed to be systematically sent back to Turkey if they do not apply for asylum or if their claim is declared inadmissible. For each Syrian sent back to Turkey, one Syrian refugee from Turkey was to be resettled in the EU. The EU Turkey deal was accompanied by border closures along the Balkan route for migrants.
Specific setting and study sites
MSF teams had been present at key migrant transit locations in Serbia since late 2014 where they offered mobile medical services (including mental health clinics), distribution of non-food items, shelter (tents) and water and sanitation facilities. The MSF strategy in Serbia was to have a flexible and dynamic approach that took into consideration the ever changing migration context. The number of medical teams was thus tailored accordingly, from one team when MSF started working in Serbia, to eight teams at the peak of influx. Mobile teams offered medical and mental health care in the following locations which also corresponded to the study sites:
Belgrade
MSF teams were present at the central park and train station. Migrants/refugees typically gathered at these locations during the day to talk to each other, find useful information for the continuation of their journeys, and make plans for travel with smugglers who are usually present. MSF teams also provided care at a reception center for Asylum (the Krnjaca Center for Asylum) which housed registered asylum seekers and those needing accommodation while in transit to other countries.
Subotica
MSF teams provided mobile clinic services at two border transit zones, (Kelebjia and Horgos) in this Serbian town bordering Hungary. These zones are entry points into the EU but fenced off with barbed wire fences and manned by armed police and military personnel.
Presevo and Sid
These two sites are border entry points into Serbia from Macedonia and into Croatia from Serbia, respectively. Similar to Subotica in the North, MSF clinics in these two location provided primary health care and mental health care for migrants. The period of activities spanned from June 2015 to May 2016.
MSF mental health clinics and traumatic events
Mental health care is provided in line with MSF guidelines for the implementation of mental health and psychosocial activities in humanitarian contexts [12–14]. A person was considered as having experienced a traumatic event if he/she experienced one or more of a standard list of destabilizing situations (including physical or sexual violence, torture, killings, incarceration) as defined in MSF guidelines [13, 14]. The definitions of traumatic events were developed in-house. A custom designed mobile van was made available for providing mental health consultations. Migrants/refugees were made aware of the existence of the MSF clinics through cultural mediators who conducted group awareness and psycho-education sessions at various gathering points (food access points, parks, sit-outs). These mediators spoke the languages of the migrants/refugees and were from similar cultural backgrounds.
Individuals self-presented to the MSF clinics where care was offered by Serbian psychologists supported by cultural mediators. These mediators are vital to ensure a trans-cultural understanding of mental distress in relation to the social, political, economic, spiritual and cultural views of the beneficiary. Mental health care was focused on three aspects a) psycho-education which involves providing information and education on stress reactions and reinforcing positive coping skills, b) Individual/family psychological support sessions to support people with moderate and severe mental health conditions/disorders and c) crisis interventions involving emergency psychological support after a critical traumatic situation. The intervention facilitated emotional expression (“ventilation”) and stabilization.
Systematic inquiry about traumatic events (including violence) were part of the clinical consultation by the psychologist. Additionally, anyone found with signs of physical trauma was referred to experienced MSF doctors for management. Persons with complicated physical trauma were referred to public hospitals and related costs were covered.
Study population and period
The study population included all migrants/refugees who presented to MSF clinics and received mental health care in Serbia from July 2015 to June 2016. These migrants were considered “currently on their journey” as they were in transit in Serbia and waiting to travel further into Europe.
Data collection, variables and data sources
A routine questionnaire for each patient was filled out by psychologists and included socio demographic variables (including age, sex, nationality, vulnerability type) and mental health care information. The latter included types of traumatic event(s), if the event(s) involved violence, type and location of physical trauma (if any), country where the incident(s) took place, perpetrators of violence and categories of mental health symptoms. Psychologists entered these data on a dedicated pro forma which was then transferred into a standardized data base (Microsoft Excel).
For the purpose of this study, traumatic events were classified into violent and non-violent events. A violent event included one or more the following: physical or sexual violence by State authorities or communities, incarceration/kidnapping, family violence, and ill treatment-by State authorities, smugglers or others. All other events were classified as being non-violent. Testimonies of traumatic events and physical violence were collected as part of the routine clerking, transcribed and translated the same day into English and included in the clinical files. Cross-validation of data was done by comparing details in the standardized database with clinical files.
Information on registered arrivals of migrants/refugees to Serbia were sourced from the United Nations High Commissioner for Refugees [3]. This information was used to verify if there was an association between border closures and numbers of arrivals in Serbia.
Statistical analysis
Trends in violent events seen by month in MSF mental health clinics in Serbia were standardized per 100 mental health consultations. This information along with numbers of migrant/refugee arrivals in Serbia was expressed graphically for the period October 2015 to June 2016. Data on arrivals in Serbia were only available from UNHCR as from October 2015.
Descriptive statistics (numbers, proportions, medians and inter-quartile intervals) were used to report results. Linear trends in violent events (as a proportion of all traumatic events per month) were examined using the chi-square test for linear trend. The level of significance was set at P ≤ 0.05 with 95% confidence intervals. Selected testimonies of violent events were reported verbatim after removing any identifiers.