|Year : 2019 | Volume
| Issue : 2 | Page : 117-121
From the editors: introducing Intervention’s special issue on the mental health and psychosocial wellbeing of Rohingya refugees
Wendy Ager1, Rebecca Horn2, Muhammad Kamruzzaman Mozumder3, Andrew Riley4, Peter Ventevogel5
1 MSc. Editor in Chief, Intervention
2 PhD, Queen Margaret University Edinburgh and Act Church of Sweden/ACT Alliance Psychosocial Roster Member
3 PhD, Department of Clinical Psychology, University of Dhaka, Bangladesh
4 MA, Independent Human Rights and Mental Health Consultant, Bangladesh
5 MD, PhD, Senior Mental Health Officer, UNHCR, Bangladesh
|Date of Submission||14-Oct-2019|
|Date of Decision||14-Oct-2010|
|Date of Acceptance||14-Oct-2019|
|Date of Web Publication||29-Nov-2019|
Editor in Chief, Intervention
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ager W, Horn R, Mozumder MK, Riley A, Ventevogel P. From the editors: introducing Intervention’s special issue on the mental health and psychosocial wellbeing of Rohingya refugees. Intervention 2019;17:117-21
|How to cite this URL:|
Ager W, Horn R, Mozumder MK, Riley A, Ventevogel P. From the editors: introducing Intervention’s special issue on the mental health and psychosocial wellbeing of Rohingya refugees. Intervention [serial online] 2019 [cited 2020 Jun 4];17:117-21. Available from: http://www.interventionjournal.org/text.asp?2019/17/2/117/271901
Welcome to the second Intervention of the year. This is a special issue focusing on the mental health and psychosocial wellbeing of Rohingya refugees.
In this issue, our contributors describe a range of challenges around mental health and psychosocial support in the Rohingya refugee context. They report on coordination and programming at the frontline and reflect on the impact of the response on the Rohingya people themselves and on the humanitarian staff and volunteers involved in this protracted crisis. Additionally, contributors provide evidence-based recommendations for improving the mental health and psychosocial wellbeing in this challenging context. We hope the issue provides valuable MHPSS resources to those working with Rohingya populations globally.
The Rohingya crisis
Over the past several decades, consistent violence and discrimination against Myanmar’s Rohingya population have led to regular mass displacements. The Rohingya are one of the most ill-treated and persecuted refugee groups in the world (Ibrahim, 2016; UN Office of the High Commissioner for Human Rights (OHCHR), 2017), with life in Myanmar characterised by systematic deprivation and human rights violations and official state policies in place to restrict Rohingya in their ability to marry, travel, have children, access to medical care, attend schools, etc. (Amnesty International, 2017; Fortify Rights, 2014). Around two million Rohingya are currently dispersed across Asia; many have fled to camps in Bangladesh and others live in neighbouring countries including Malaysia, India, Thailand, Pakistan, Saudi Arabia and elsewhere (UNHCR, 2019).
The number of Rohingya refugees in Cox’s Bazar district in south east Bangladesh has soared to a current estimation of over 910,000 people (United Nations High Commissioner for Refugees, 2019). The majority are women and children (52% are women and girls; 55% are children under 18 (Strategic Executive Group, 2019). As any other community exposed to conflict-driven displacement, they have to cope with the consequences of human rights violations in their countries of origin and with ongoing life as a refugee such as poor living conditions, dependency on humanitarian assistance for food, water, shelter, and persistent domestic violence and other protection issues. The health and nutritional status of the newly arrived refugees was dire, particularly for women and children (Hasan-ul-Bari & Ahmed, 2018; Leidman et al., 2018)
Within the humanitarian response, the need for mental health and psychosocial support (MHPSS) was acknowledged and many organisations became involved in the provision of MHPSS interventions (Tay et al., 2018). This special issue demonstrates how far the humanitarian world has come with regards to MHPSS, but it also painfully demonstrates how much more needs to be done.
The special issue
We are very pleased to present 28 articles in this special issue. We have nine research articles: six focusing on the response in Bangladesh and three on work in Malaysia. There are 14 field reports: seven about broader MHPSS programming or coordination issues in Bangladesh and Australia and the other seven about particular programmes or approaches. And finally, there are five personal reflections from humanitarian workers involved in mental health and psychosocial support with Rohingya populations.
The range of authors is remarkably diverse: we have a total of 86 authors and co-authors, the majority of whom are from Bangladesh or Malaysia. Authors work with a range of different institutions such as international and local non-governmental organisations, agencies of the United Nations, universities in Bangladesh, Malaysia and Australia, and government institutions in Bangladesh. Contributors have provided relevant data, analysis and recommendations, while acknowledging challenges and shortcomings in the current MHPSS support of the Rohingya. In many ways, this issue provides an evidence base for improving the mental health and psychosocial wellbeing of the Rohingya, as well as a basis for moving forward with further studies focused on Rohingya MHPSS concerns.
The collection is unique and provides a perspective which is rarely offered and which gives insights into the challenges and potentially useful approaches in working with such a multiple disadvantaged population.
The articles in the special issue
Mental health and psychosocial needs
Earlier research from 2013 with Rohingya refugees who had arrived decades earlier in Bangladesh showed high levels of mental health symptoms (Riley et al., 2017). An assessment by the International Organization of Migration in early 2018 suggested high levels of psychosocial distress among the newly arrived refugees (International Organization for Migration, 2018), and a small survey among Rohingya refugee children in 2018 found symptoms of emotional problems in half of the surveyed children (Khan et al., 2018) but there are as yet no other prevalence data for mental disorders and emotional distress among Rohingya who fled to Bangladesh country after 2017. The paper by Montanez, Prativa, Ormel, Banu, Gulino, & Bizouerne (pp. 259–277) reports on interviews held with 24 Rohingya adolescents in Bangladesh. Some adolescents had arrived before 2017 and other had arrived with the mass exodus from the second half of 2017. The adolescents in both groups showed high levels of suffering related to the violence that happened in Myanmar and were concerned about the mental health of their parents and siblings. There are also significant numbers of Rohingya refugees in Malaysia. Little is known about their mental health problems. The paper by Shaw, Karim, Bellows, & Pillai (pp. 174–180) presents findings from a sample of 115 Rohingya refugees living in urban settings in Malaysia. They found that emotional distress ran very high and was in fact ubiquitous (Shaw et al., 2019).
Welton-Mitchell, Bujang, Hussin, Husein, Santoadi, & James (pp. 187–196) reports on information collected through structured household interviews and focus groups discussions among Rohingya in Malaysia. They found that intimate partner abuse was abundant among this group and that it was strongly linked to chronic stressors in the lives of refugees. Few women sought help due to social norms considering intimate partner abuse as normal with active discouragement of help-seeking.
Assessment and coordination
A major challenge in large and complex humanitarian emergencies is the coordination and planning of interventions. The Rohingya refugee crisis is extraordinary in size and in the speed with which it unfolded: in the last months of 2017, hundreds of thousands of forcibly displaced persons arrived in the Cox’s Bazar district in just a few months. This prompted a large aid operation which had its own complexities and sensitivities. A large number of organisations started to plan MHPSS activities. In such situations, it is often difficult to make a coherent and well-coordinated response. This issue features four contributions focusing on coordination and prioritisation. Harrison, Ssimbwa, Elshazly, Mahmuda, & Rebolledo (pp. 122–129) describe a joint situational analysis of mental health and psychosocial support services for Rohingya refugees in Cox’s Bazar, using a range of assessment methods that may be useful in other humanitarian settings. A second paper, by Harrison et al. (pp. 206–211), describe an interactive method for priority setting among stakeholders united in the MHPSS Technical Working Group, using a participatory ranking exercise that led to the top ten strategic priorities that the participants wished to see addressed. High on the list is the need to extend interventions focussing on individuals to innovative interventions with families and communities; develop more predictable and transferable packages of MHPSS care; integrate MHPSS into non-traditional sectors and address the needs of children with severe or complex mental health issues who need clinical care. A third paper, by Elshazly, Alam, & Ventevogel (pp. 212–216) describes some of the quandaries of service coordination. Dozens of organisations are in one way or another involved in activities around MHPSS. This understandably causes formidable challenges for service coordination. Often such coordination is centralised in the place where most organisations have their offices, in this case in the district capital, Cox’s Bazar. Elshazly et al. argue that in addition to such central level coordination, a more area-based, decentralised form of MHPSS coordination should be introduced and they illustrate this with practice examples. Elshazly, Bodusan, Alam, Khan & Ventevogel (pp. 197–205) extend the discussion in identifying challenges and potential responses in relation to care delivery systems, factors in the affected community and in the wider humanitarian emergency context itself.
Integration of MHPSS in multiple sectors of the humanitarian response
The need to integrate MHPSS within multiple sectors is the focus of a paper by Borja, Khondaker, Durant, & Ochoa (pp. 231–237) from Save the Children. They describe how this international NGO integrates child centred MHPSS interventions within their work on child protection, health, nutrition, and education in the refugee settings in Bangladesh. Entry points for MHPSS work with children can be many and include child friendly spaces, community centres, health posts and nutrition services. The authors make the case for the necessity to cross sectors, but also indicate that it can at times be challenging for staff in other sectors to integrate MHPSS in their work. This is also a major point in the field report by Shair, Akhter, & Shama (pp. 238–242) who argue that women in Bangladesh also face considerable challenges in accessing formal services for gender-based violence. As demonstrated in two poignant and moving case descriptions of Rohingya women with gender-based violence, the addition of psychosocial support elements in the response, such as teaching relaxation techniques, reinforcing of positive coping strategies (such as prayers, spending time with trusted people) and life skills training can help Rohingya survivors of gender-based violence to strengthen their relationships with other women, and improve their confidence and social competence and as such results in more holistic healing.
Pereira et al. (pp. 181–186) describe four case studies of Rohingya refugees in Malaysia who sought treatment with a local NGO, Health Equity Initiatives. The case studies make clear that MHPSS work with Rohingya refugees requires a holistic framework of action that includes clinical work, psychosocial support interventions and require capacity building on cultural competency for organisations working with Rohingya.
Collective healing and working with communities
In their homelands in Myanmar, the Rohingya had been severely restricted in expressing their cultural and religious identity: For example, they were not allowed to organise themselves in groups or to hold gatherings and mosques were closed or destroyed (Tay et al., 2018). When they arrived in Bangladesh, the Rohingya could freely practise their religion and express their cultural belonging. Some MHPSS activities actively fostered the restoration of a sense of collective identity. As depicted by Rebolledo (pp. 278–283), the psychosocial activities of the International Organization for Migration provided safe, social spaces through healing ceremonies, with the aim to assist community members to reconnect with their collective memory and cultural identity. This helps them in healing collective wounds caused by experiences and distress related to a history of structural violence and oppression of their identity.
Ozen & Ziveri (pp. 290–295), who work with the NGO, Humanity & Inclusion, faced significant challenges in their attempts to provide psychosocial services to Rohingya refugees in the context of their disability inclusion work. Many refugees were not open for ‘talking’ or assistive devices, but wanted ‘treatment’ or material support. A particular challenge was related to the Rohingya language that does not have words for many concepts associated with MHPSS. A major lesson learned by Ozen and Ziveri is that it is of critical importance to allocate time to meet communities and facilitate mutual learning and build trust.
Many Rohingya fled to Bangladesh and Malaysia, but others went to other countries. Our special issue contains a field report from Némorin, Momartin, & Junaid (pp. 225–230) who work with Rohingya refugees who are resettled in Australia. While the context is of course very different from that in Bangladesh and Malaysia, it is interesting to see how also in the resettlement setting there is a need to combine clinical approaches with community development activities and that it is important to work in consultation with the refugee community.
Jerin & Mozumder (pp. 169–173) explore the attitudes of the local host population in Bangladesh towards Rohingya refugees. Although they found, for example, an openness to extend adequate medical care for the Rohingya, for the most part attitudes appear to be largely negative. The host community expressed many concerns such as apparent social problems, security threats, environmental imbalances and a perceived sense of deprivation of opportunities. The authors indicate different strategies in improving intergroup relationship such as intergroup dialogue (see Dessel & Rogge, 2008), use of media and intergroup contact (Pettigrew & Tropp, 2006).
Integration of mental health into general health care
Momotaz et al. (pp. 243–251) and Tarannum, Elshazly, Harlass, & Ventevogel (pp. 130–139) both discuss their experiences of the integration of mental health into the primary health care system in the Rohingya settings in Bangladesh from the perspective of the World Health Organisation and UNHCR respectively. The authors of both these papers report positive experiences of training general health workers, but also highlight that to sustain impact, a consistent system of supportive clinical supervision is essential. These papers fit well with the conclusions of the paper by Dyer and Biswas (pp. 217–224) who document the impressive work of the non-governmental organisation, Médecins sans Frontières, around mental health for Rohingya. The authors argue that while psychosocial interventions are becoming increasingly available in humanitarian contexts, care for people with severe mental often gets limited attention.
Corna, Tofail, Chowdhury, & Bizouerne (pp. 160–168) did a pre- and post-evaluation of a community based psychosocial support intervention for 260 pregnant Rohingya women in Bangladesh. The intervention consisted of biweekly support groups and monthly home visits by non-specialist psychosocial workers who were regularly trained and supervised. At the end of the three-month programme, women showed significant improvement in their mental health status, as measured through multiple questionnaires. As the authors acknowledge, this was not a randomised controlled trial, but a single arm intervention evaluation and there may be other reasons for the symptom improvement, although this seems unlikely. Moreover, the study was done in 2012, long before the current emergency, but there is little reason to believe that the results would be any different at the present time.
A topic of increasing interest in current global mental health research are scalable psychological interventions which are brief, often manualised interventions that can be delivered by non-specialists. Our special issue has two field reports on the experiences with one scalable psychological intervention, ‘integrative adapt therapy’, which was specifically designed for refugees. The Rohingya refugees in Malaysia constitute one of the first refugee populations where this approach has been used. Tay et al. (pp. 267–277) present data from qualitative work with Rohingya clients and counsellors focused their experiences with IAT. Overall, informants found the method culturally relevant and reported increased self-awareness and enhanced capacity in managing emotional distress and self-management. The same psychological intervention has been introduced among Rohingya in Bangladesh, as described by Mahmuda, Miah, Elshazly, Khan, Tay, & Ventevogel (pp. 149–159). Here too, this proved to be feasible, but considerable implementation challenges were encountered related to the complicated humanitarian context with low staff retention and relatively low, organisational buy-in.
Another way of providing psychosocial support through non-specialists is described by Sullivan, Thorn, Amin, Mason, Lue, & Nawzir (pp. 252–258) who trained Rohingya community health workers in using simple relaxation techniques based on acupressure and mindful breathing in an evaluation seeking to improve mental health and increase self-care.
Use of sport and games in MHPSS interventions
Interestingly, two contributions in this issue discuss the relevance of physical activities and sports for Rohingya refugees. Wells, Némorin, Steel, Guhathakurta, & Rosenbaum (pp. 140–148) used an innovative method (the ‘community readiness model’) to assess whether physical activity could be an entry point for community driven psychosocial intervention. Their results indicate that community members see physical activity as an effective strategy for relieving tension. However they report that space and resources to support physical activities are extremely limited. Similarly, Ahmed, Mahmuda, Mahmudul, & Alam (pp. 284–289) conclude, based on the results of focus groups in refugee settlements in Bangladesh, that particularly for adolescents the use of sport and games could be a way of providing psychosocial support. However, they too report considerable challenges related to cultural restrictions and contextual realities which will particularly limit the participation of women and girls in such activities.
Reflections from MHPSS workers
We are very pleased with the high number of personal reflections from national MHPSS workers from Bangladesh. The voice of local professionals is not often heard in the professional literature and we are proud that this special issue contains several personal reflections by Bangladeshi psychologists involved in the humanitarian response in their country. Shah (pp. 316–318), a young graduate from medical school in Bangladesh, shares her observations from the time she worked in the Rohingya settlements as an intern. She describes how, while religious Islamic values play an important role in the lives of Rohingya, they sometimes compete with cultural values. Islam, a UK-based and UK-trained psychologist from Bangladesh, returned to her country of origin as a consultant for BRAC, one of the largest NGOs involved in the Rohingya response. In her article (pp. 310–315) she reflects on how culture, including organisational culture, is involved in the interface between international humanitarian workers and local clinicians, and between Bangladeshi professionals and the refugees they serve.
The importance of organisational humanitarian culture also has a central role in the personal reflection of Bubendorff, an experienced humanitarian worker who worked in Myanmar as coordinator of an MHPSS team in Rakhine State in Myanmar during the Rohingya crisis (see pp. 305–309). She describes how the emergency context deeply affected the wellbeing of the local team members, but also how psychosocial techniques helped building resilience in the team.
Voices from Rohingya
This issue also has voices of Rohingya themselves: Arafat Uddin is a Rohingya psychosocial volunteer. With the support of the Bangladeshi psychologist, Hasni Sumi, he documents his own traumatic history in Myanmar and how becoming a psychosocial volunteer in the Rohingya camps in Bangladesh was a transformational experience for him that helped him to regain control of his life and play a useful role in his community (pp. 296–300). The contribution of Montanez, Uddin, Zohra, Ormel, Gulino, & Bizouerne (pp. 301–304) around the lived experience of people within a humanitarian emergency is the moving story of a Rohingya woman in Bangladesh who adopted a severely malnourished Bangladeshi baby and so saved her live.
On behalf of the main editorial board of Intervention
We wish to pay tribute to Dr. Ton Haans who is taking his leave from the editorial board of Intervention. Ton, a clinical psychologist and psychotherapist, was involved almost from the beginning of Intervention. He has helped many contributors over the years to highlight the key messages in their writing. Dr. Janice Cooper, a current editorial board member, writes: ‘When I joined as a new board member, Ton was particularly helpful and welcomed me. At my first in-person board meeting, it was as if I had known him and the team for the longest time. The memory that sticks with me most is when I was in Liberia during Ebola, I wrote a piece from my personal perspective. It was not very good but the editor and Tons made it a piece that was publishable. It was a privilege to work with him.’
Financial support and sponsorship
We would like to acknowledge with thanks the generous financial support of IOM, UNHCR and WHO which has been given to Intervention to fund this issue. The funding enables this issue to be published online with free access, for 450 copies to be printed and for selected sections of the issue to be translated into Bangla.
Conflicts of interest
There are no conflicts of interest.
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