Evaluating the Feasibility and Acceptability of SH+ Combined with Cash Assistance: An Implementation Study Among Afghan Refugee Women In Türkiye

Background and Purpose: Afghan refugees in Türkiye report experiencing legal uncertainty and post-migration stressors such as language barriers, discrimination, unemployment and financial difficulties. As a result, they are at high risk of experiencing mental health symptoms. Considering the existing mental health gap, researchers and practitioners call for the implementation of scalable mental health interventions to improve the well-being of refugees. This study aims to report on the feasibility and acceptability of a mental health intervention developed by the World Health Organization, Self-Help Plus (SH+), following its implementation among Afghan refugee women in Türkiye.

Methods: This study is based on a qualitative process evaluation conducted following a pilot randomized controlled trial (RCT) in 2025 to test the preliminary effect of SH+ in combination with a cash assistance program among Afghan refugee women living in Kayseri, Türkiye. Cash assistance was set at an amount equivalent to the average monthly salary for refugees in Kayseri, and the five SH+ sessions were delivered on a weekly basis. Following the RCT phase and after the cash assistance-only waitlisted group also received SH+, qualitative interviews and focus groups were conducted with Afghan women who had received SH+ (n = 38), facilitators who delivered the intervention (n = 4), and professionals working with Afghan refugee women at the time of the study (n = 3) purposively to obtain in-depth information regarding the feasibility and acceptability of the intervention, in addition to identifying implementation barriers. The interviews and focus groups were conducted in either Dari or Turkish, took around 45-60 minutes; and were audio-recorded. The recordings were then transcribed and qualitatively analyzed using a reflexive thematic analysis approach. Half of the transcripts were independently coded by bilingual coders. Open coding was conducted and the research team met to resolve discrepancies and to develop and refine the codebook. The remaining transcripts were coded by the lead author, with any newly identified codes reviewed and discussed with the team. To enhance rigor, we employed negative case analysis and member checking.

Results: Afghan refugee women who received SH+ combined with cash assistance and peer providers who delivered the intervention both reported that the combined intervention was overall feasible and acceptable. High satisfaction was reported about the SH+ content and the combined component of cash assistance. Engagement and adherence were fostered by availability of the childcare at the community partner organization delivering the intervention. However, participants reported barriers to adherence, such as the need for childcare for older children, transportation related barriers, and restrictive immigration policies that impact the daily lives of refugees. Participants also provided suggestions for future implementation and scale-up.

Conclusions and Implications: At a time when the number of forcibly displaced people is at its peak, it is necessary to address the mental health needs of individuals and evaluate whether evidence-based mental health interventions are acceptable and feasible when integrated with broader interventions, such as economic empowerment programs, for the communities. The results of this study informs social work profession as front line service providers with refugees.