Understanding and Responding to Grief-Related Needs: A Differentiated Community Approach

Introduction Grief in later life is a common yet under-recognized public health issue. Although most older adults adapt to bereavement without formal intervention, a significant minority develop Prolonged Grief Disorder (PGD), characterized by persistent yearning, emotional pain, and functional impairment. Older adults are particularly vulnerable due to cumulative losses, declining health, social isolation, and reduced access to psychosocial resources. Despite the documented psychological, physical, and social consequences of adverse grief reactions, prevention and early intervention remain marginal in health and social care systems.

Current responses to grief are often reactive and clinically oriented, focusing primarily on individuals who already present severe symptoms. This approach overlooks a large group of bereaved individuals experiencing substantial distress that does not yet meet diagnostic thresholds and limits opportunities for prevention. Furthermore, most existing interventions are hospital-based and individual-focused, while community-based and scalable approaches remain underdeveloped.

In line with international policy frameworks, including the World Health Organization's stepped-care model for mental health, differentiated models of grief support propose that interventions should be matched to individuals' levels of need. Such models are typically organized as a pyramid, ranging from low-intensity informational support to more structured and specialized interventions. This approach aims to optimize resource allocation, increase accessibility, and promote equity in mental health care.

Aims The primary objective of the GriefDiff study is to implement and evaluate the effectiveness of a differentiated, tiered model of grief intervention in reducing prolonged grief symptoms and psychological distress among older bereaved adults. Specifically, the study compares three intervention levels-IGLiteracy, ISelfHP, and MSHGroups-in terms of their impact on grief outcomes.

A secondary objective is to test the added value of matching interventions to participants' risk levels and relational needs, examining whether matched allocations lead to superior outcomes compared to non-matched conditions. The study also aims to identify predictors of engagement and response to intervention, including attachment patterns, social support, and traumatic stress. Ultimately, this research seeks to inform public health strategies by providing evidence for a cost-effective, community-centred, and preventive model of bereavement care.

Procedures Participants will be recruited through community and health organizations, including a national grief association and partner institutions. Individuals referred by these entities will undergo a screening process assessing eligibility, risk of PGD, and relational needs. Eligible participants will receive detailed information about the study and will provide written informed consent prior to participation.

Data collection will follow strict ethical and confidentiality standards. All data will be anonymized and securely stored. Participants will be informed of their right to withdraw at any time without consequences.

To promote retention and minimize attrition, several strategies will be implemented, including flexible scheduling, regular contact with the research team, reminders for assessment points, and the availability of both digital and non-digital intervention formats. A feedback mechanism will be established to allow participants to share their experiences and concerns throughout the study.

All interventions will be delivered within a community-based framework and will be supported by standardized manuals and materials. Intervention providers will receive specific training and ongoing supervision to ensure fidelity and consistency across conditions.

Trial Design The GriefDiff study is a rater-blinded, randomized controlled trial with three parallel intervention arms. Following baseline assessment, participants will be stratified according to risk of prolonged grief and relational needs and then randomized to one of the three intervention conditions: IGLiteracy, ISelfHP, or MSHGroups.

Randomization will be conducted using block randomization within predefined risk-by-needs strata to ensure balanced allocation across conditions. Allocation concealment will be maintained through the use of a computer-generated random sequence, managed by an independent member of the research team.

Outcome assessors will be blinded to participants' allocation. Participants will be assessed at baseline (T0), post-intervention at three months (T1), and follow-up at six months (T2). In addition to evaluating overall intervention effects, the design allows for the examination of matching effects by comparing outcomes between participants who were allocated to matched versus non-matched intervention conditions. This trial provides a rigorous methodological framework to test a differentiated, community-based model of grief care, with the potential to inform future service organization and policy in bereavement support.

• Depression, Anxiety and Stress Scales - Short Form (DASS-21) [Time frame: Baseline (T0), Post-intervention at 3 months (T1), and Follow-up at 6 months (T2)]