Project Smile: How A Community-Based Psychosocial Intervention Is Transforming Mental Health in the Middle East

Photo by Nick Fewings on Unsplash

Authors: Madeera Mian, Ahmed Alazbat, Dr. Julie Franck, Dr. Jess Ghannam. Header photo by Nick Fewings on Unsplash.

Background

The mental health crisis in Gaza is a profound and urgent issue that demands our attention. Amidst ongoing conflict, economic hardship, and societal disruption, the mental well-being of Gaza’s population is facing unprecedented challenges. For many, daily life is marked by severe stress, trauma, and a pervasive sense of uncertainty. The scarcity of basic necessities, including food and healthcare, affects approximately 80% of the population who rely on international aid. These challenges are compounded by the high levels of poverty and unemployment in the region, with approximately 65% of individuals living below the poverty line and 60% being unemployed. This crisis affects not just individuals but entire families and communities, making it crucial for us to understand the scope of the problem and explore effective responses.

Particularly vulnerable are the children of Gaza. Growing up amidst relentless violence and instability, these young minds are bearing the brunt of the crisis. In 2020, a research study conducted in the Gaza Strip found that out of a sample of approximately 900 adolescents and children in the Gaza Strip, 88% experienced personal trauma, 83% witnessed trauma to others, and 88% observed the demolition of property. The constant exposure to traumatic events, coupled with the lack of adequate psychological support, is profoundly impacting their emotional and cognitive development. Previous data shows that among adolescents in the Gaza Strip, 69% develop PTSD, 95% have severe anxiety, and 40% have moderate to severe depression. (Also, most data is from previous years, before the ongoing war and it is important to note that conditions have markedly deteriorated and these statistics are likely to change). For many children, fear and anxiety have become a part of their everyday existence, affecting their ability to learn, play, and envision a hopeful future.

“Sourire (Smile) Program”

An initiative that’s making a real difference in Gaza amidst the ongoing mental health crisis: the “Sourire (Smile) Program”. This community-based psychosocial intervention, led by the YAFFA association in collaboration with the Sama Jafra Center based in Gaza, is designed to bring support to around 10,000 children and their families across 16 of Gaza’s most vulnerable neighborhoods, including the UNRWA refugee camps. The Smile Program is about creating a safe space for children aged 5 to 14 to express their emotions and begin to heal from trauma. Through engaging activities like art, dance, and other creative methods, supervised by skilled psychologists, the program helps kids process their experiences and foster a sense of hope and social connection. However, due to the ongoing crisis, they have prioritized an emergency supply program, delivering interventions when safe, to address immediate needs effectively.

But it’s not just about the children. The program also takes a family systems approach, recognizing the crucial role of the family in supporting mental health. By addressing both individual and family needs, the Smile Program aims to build resilience and promote social cohesion in a region facing significant challenges.

A program evaluation was conducted from May to June 2023 in partnership with the UCSF Global Health Sciences department and the YAFFA association. This evaluation involved gathering critical feedback from parents and providers through qualitative interviews, revealing compelling and eye-opening stories. The insights collected highlighted several areas for improvement. In light of the current crisis in Gaza, this valuable feedback has been instrumental in tailoring the program to better address the urgent needs and challenges faced by the community.

The evaluation consisted of 32 parents who had their children enrolled in Project Smile along with 12 program providers located in Gaza who were also sampled to gather their perspectives. The method to conduct this evaluation was a semi-structured interview lasting around 45-60 minutes and participants were asked questions surrounding the behavior of the children, perceptions of psychological well-being and family functioning, and local key informants’ interpretation of the program’s impact. These qualitative interview transcripts were then coded, and an added social network matrix was constructed.

Parents expressed positive attitudes toward the program by stating observations of behavioral changes in their children, such as reduced agitation and improved emotional expression. Additionally, parents have shared their enthusiasm and positive feedback, particularly highlighting how the program helped their children. For example, one parent noted, “When the kindergarten principal sent me a message about the program, saying that there is psychological support for our children, I was very happy because we always need this thing, and the children do not have the right to play.” Another parent shared, “During times of war, I learned to keep my son occupied with activities like drawing.” This illustrates how the program not only offers immediate support but also helps families navigate the ongoing crisis. It’s clear that the program has made a meaningful difference, helping children manage their emotions and fostering stronger community ties.

Providers in the Gaza Strip identified challenges in delivering psychosocial interventions, including location issues, stigma and lack of awareness, and institutional barriers. Despite these hurdles, their commitment to this program shines through. One provider shared, “I was interested because I live in Gaza and Gaza affects your mental health in an active way. And I know these effects and that’s why I want to help these children go from the very bad state of depression and anxiety to a more elevated state of happiness and good feeling.”

Similar to parent observations, on-site providers also reported seeing significant improvements in the kids, noting that children have become less shy, less violent, and more engaged. One provider stated, “I notice a lot of improvements, children are less shy, less violent, less likely to physically attack other children, also less bullying, and less aloofness.” Looking ahead, providers are hopeful about finding ways to address the resource gaps and continue making a difference in the lives of these children.

The findings of this study underscore the potential impact of projects like “Project Smile” on the global mental health crisis, particularly in conflict-affected regions such as South Sudan, Bangladesh, and Rohingya population in Myanmar. The positive outcomes observed in Gaza can serve as a blueprint for addressing the diverse needs of children and families in similar contexts worldwide. Providers in these regions can learn from the adaptability and dedication demonstrated by those in Gaza, to effectively deliver mental health support despite limited resources and institutional barriers. By emphasizing community connections and the family unit, the program can promote resilience and positive behavioral outcomes on a broader scale. As the demand for mental health services continues to grow amidst ongoing conflicts, expanding and enhancing programs like Project Smile is crucial to meet the escalating needs of vulnerable populations globally.

Acknowledgements

I would also like to express an acknowledgment to Ahmed Alazbat, President of Yaffa, and Dr. Julie Franck, Vice President of Yaffa, for their invaluable support, guidance, and generosity in providing me with crucial information and educating me on the context of Gaza and the remarkable work carried out by their organization. I am also grateful for the guidance and support provided by my capstone mentor, Dr. Jess Ghannam. Lastly, I would also like to acknowledge the Yaffa Team and parents in Gaza for participating in this study.

About the Authors

Madeera Mian graduated from the University of California, San Francisco, in 2023 with a Master’s in Global Health Sciences, where she conducted her capstone research project in collaboration with the Yaffa Association and the Institute for Global Health Sciences. Her project focused on evaluating Project Smile, sparking her interest in supporting immigrant and refugee populations on a global scale. Madeera is committed to continuing her work in this field, driven by a passion for improving health outcomes for vulnerable communities. 

Ahmed Alazbat is the President of the Yaffa Association and a social worker with a degree from the University College of Applied Sciences in Gaza. Originally from Gaza, he has been a refugee in Switzerland since 2016, bringing eight years of experience in social work with organizations such as UNRWA and the Palestine Trauma Centre UK, where he focused on psychosocial support for war-affected children and families. In Geneva, he has worked on various social, educational, and cultural projects with refugees and children, collaborating with organizations like the Geneva Red Cross and the University of Geneva’s Espace de Vie Enfantine. 

Julie Franck is the Vice-President of the Yaffa Association and a Doctor of Psychology, serving as a lecturer and researcher at the Faculty of Psychology and Educational Sciences at the University of Geneva. Her research focuses on cognitive processes related to language in infants, children (both typical and atypical), and adults, and she has developed various programs related to the migrant population in Geneva since 2017. Julie also coordinates an interdisciplinary course on forced migration and leads the UNI-R program, while overseeing the Cafés solidaires initiative, which fosters weekly meetings between academics and migrants at the university cafeteria. 

Jess Ghannam is a faculty member in the Department of Psychiatry and Behavioral Sciences and the Institute for Global Health Sciences at UCSF, focusing on the long-term health effects of war on displaced communities, particularly children. He has established community health clinics in the Middle East and developed mental health treatment programs to support refugees and immigrants from the Middle East, North Africa, and South Asia. A consultant for various international NGOs, Dr. Ghannam also trains healthcare professionals in culturally respectful practices and specializes in chronic illness, global health, and post-traumatic stress disorder.