|Year : 2019 | Volume
| Issue : 2 | Page : 197-205
Challenges and opportunities for Rohingya mental health and psychosocial support programming
Mohamed Elshazly1, Boris Budosan2, A.N.M. Mahmudul Alam3, Nabila Tarannum Khan4, Peter Ventevogel5
1 MD, MSc, ABPsyc, IMMHPS, Public Health and Nutrition Unit, UNHCR Cox’s Bazar, Bangladesh
2 MSc, MPH, Consultant Psychiatrist and MHPSS in Emergencies Consultant, Zagreb, Croatia
3 MSc, MS, Public Health and Nutrition Unit, UNHCR Cox’s Bazar, Bangladesh
4 MSc, MS and MPhil, Mental Health and Psychosocial Support Officer, Gonoshashthaya Kendra, Cox’s Bazar, Bangladesh
5 MD, PhD, Public Health Section, High Commissioner for Refugees, Geneva, Switzerland
|Date of Submission||10-May-2019|
|Date of Decision||21-Aug-2019|
|Date of Acceptance||14-Oct-2019|
|Date of Web Publication||29-Nov-2019|
Public Health and Nutrition Unit, UNHCR Cox’s Bazar
Source of Support: None, Conflict of Interest: None
Mental health and psychosocial support (MHPSS) for Rohingya refugees in Bangladesh has been acknowledged as an important component of the humanitarian response. Despite this recognition, MHPSS programmes are still facing many challenges. These challenges are related to the care delivery systems, to factors in the affected community or to the humanitarian emergency context. Examples of these challenges include language barriers, monsoon-related events, coordination of MHPSS services and community perceptions of mental health and mental health services. Drawing from local, regional and global experiences, we recommend practical solutions to overcome these challenges and improve the outcome of the MHPSS response to the Rohingya refugee crisis.
Keywords: Bangladesh, challenges, opportunities, refugees, Rohingya
|How to cite this article:|
Elshazly M, Budosan B, Mahmudul Alam A, Khan NT, Ventevogel P. Challenges and opportunities for Rohingya mental health and psychosocial support programming. Intervention 2019;17:197-205
|How to cite this URL:|
Elshazly M, Budosan B, Mahmudul Alam A, Khan NT, Ventevogel P. Challenges and opportunities for Rohingya mental health and psychosocial support programming. Intervention [serial online] 2019 [cited 2020 Jul 5];17:197-205. Available from: http://www.interventionjournal.org/text.asp?2019/17/2/197/271898
| Introduction|| |
The number of Rohingya refugees in Cox’s Bazar District in south-east Bangladesh has multiplied to an estimated 910,619 people (United Nations High Commissioner for Refugees, 2019). During the massive influx of Rohingya in the last months of 2017, new arrivals sought shelter in spontaneous settlements. They were in great need for humanitarian assistance, including shelter, food, clean water and sanitation. The arrival of so many Rohingya to Cox’s Bazar district has put pressure on the host Bangladeshi community, particularly in the sub-districts (upazilas) of Teknaf and Ukhia. Cox’s Bazar district was already among the most disadvantaged districts of the county. It figures in the top 20 (of 64) of ‘lagging districts’ of Bangladesh, and the sub-districts of Ukhia and Teknaf are among the 50 most socially deprived sub-districts in the country (of 509). The remote location, the difficult (hilly) terrain, bad road conditions and insufficient infrastructure contribute to poor living conditions of the local population.
Health services for Rohingya refugees and the surrounding host community are provided by more than 100 different entities including the Government of Bangladesh, United Nations agencies and national and international nongovernmental organisations (NGOs). In total, these organisations operate 170 basic health units (1 per 7,647 people in need), 33 primary health centres (1 per 39,394 people in need) and 10 secondary care facilities (1 per 130,000 people in need). Cox’s Bazar district has around 910 hospital beds, 290 in government-run facilities and others in private facilities or in temporary hospitals that have been set up as part of the humanitarian response (Health Sector − Inter Sector Coordination Group, 2018).
Within the refugee settlements, there is a geographical division for the coordination of health care services between two large UN agencies, the International Organization for Migration (IOM) and the United Nations High Commissioner for Refugees (UNHCR), each covering different zones with their partners. In response to health issues that have arisen from the humanitarian emergency, a Strategic Advisory Group for Health was established by the World Health Organization (WHO) and the Ministry of Health and Family Welfare (MOHFW) of Bangladesh, comprising of UN agencies and major NGOs.
The objective of this paper is to discuss the most important challenges in the MHPSS response in the Rohingya crisis in Bangladesh and to explore opportunities to improve the MHPSS assistance to the Rohingya population. The authors are all mental health professionals with working experience in the Rohingya humanitarian response and work for different organisations. The challenges discussed in this paper came up during conversations among the authors. In an iterative exchange process, a total of nine most important challenges were formulated. Each challenge will be briefly presented followed by suggestions of how to overcome this challenge.
BOX 1: Challenges for mental health and psychosocial support in the Rohingya humanitarian setting
- Communication with Rohingya: language barriers
- Rohingya community perceptions of mental health, mental illness and mental health services
- Coordination of mental health and psychosocial support (MHPSS) services
- Human resources
- Monsoon-related events
- The use of psychological measurement tools
- Lack of capacity to manage people with severe or complex mental health issues
- Insufficient staff care
- Tensions between refugee and host communities
Challenge 1: Communication with Rohingya: language barriers
In November 2017, Translators without Borders conducted a rapid language assessment in Rohingya refugee camps and found that 62% of the study sample were unable to speak to the humanitarian services’ providers (Translators without Borders, 2017). The refugees speak the Rohingya language, which is an oral language without a recognised written script. It has a large overlap (between 70% and 90%) with Chittagonian that is spoken in the south-eastern areas of Bangladesh. Chittagonian is a variety of standard Bengali, with which it is not mutually intelligible (Hoque, 2015). Bangladeshi humanitarian staff involved in the Rohingya refugee response come from various parts of the country. Some speak the Chittagonian dialect and can communicate reasonably effectively with refugees. Others, especially those who have been working with Rohingya refugees for many years, have learnt the Rohingya language. But many other humanitarian staff are not familiar with the Chittagonian dialect, let alone the Rohingya language. This greatly limits the options to communicate effectively with the refugees.
This communication challenge is particularly significant when it comes to MHPSS services where clear communication with people and understanding their expressions and idioms of distress are essential (Kletečka-Pulker, Parrag, Drožđek, & Wenzel, 2019). Many diagnostic concepts and terms used by MHPSS professionals, such as depression or posttraumatic stress disorder (PTSD), have no corresponding terminology in the Rohingya language (Tay et al., 2019). Some medical terms used in Chittagonian are derived from standard Bangla, and the Rohingya often do not comprehend these terms (Translators without Borders, 2018).
These communication challenges may affect treatment adherence and decrease willingness to seek help or support especially when communication barriers are combined with other cultural factors. Some health facilities recruit interpreters and volunteers from both the host and refugee communities, but their use in MHPSS services’ delivery is quite limited.
Ways to overcome challenges related to language
In order to be communicate more effectively with Rohingya refugees, it is important that MHPSS workers familiarise themselves with the Rohingya language and the terms around mental health. To facilitate this, some glossaries have been made. An extensive list can be found as annex in the primer on ‘Culture, Context and Mental Health of Rohingya Refugees’ (Tay et al., 2018). However, many of the more specialised terms are only known by Rohingya with a higher level of education. A very practical glossary of day-to-day terms including health and protection has been made by Translators without Borders with entries in Rohingya, Chittagonian, Bangla, Burmese and English.1
Language is more than just ‘different words’ for the same things. Language is a cultural construct and terms are often rooted in a shared understanding and conception of the world and personhood. Learning the refugees’ language without in-depth knowledge of their culture will have a limited impact on communication. This is particularly important when communication involves discussions about psychosocial issues. Creating glossaries of terms is a first step, but is insufficient for practitioners to develop clinical ‘cultural competence’. For that, clinicians need to take a ‘deep dive’ into the world of the people they serve and attempt to understand their views on mental health and illness. Therefore we argue that it is of paramount importance to use community-based approaches that build on existing resources and strengths within affected communities in order to create services and supports that make sense to populations affected by forced displacement. Engaging volunteers from the community, listen to their views and strengthening their capacities to provide support to their communities can help to overcome many communication challenges and improve the cultural relevance of MHPSS interventions.
Challenge 2: Rohingya community perceptions of mental health, mental illness and mental health services
A related challenge in the provision of appropriate services is the lack of correspondence between the perceptions and expectation of Rohingya refugees about mental health, mental illness and mental health services on one side and what MHPSS services tend to offer on the other side. The Rohingya understandings of mental health issues are in many ways dissimilar to those of western-trained mental health professionals. Rohingya use different concepts and terms and explain the causes of mental illness in different ways, often in religious terms. For more details on Rohingya mental health terms and their ‘explanatory models’, see recent reviews (Tay et al., 2018, (2019)). Basically, Rohingya do not see mental health problems as issues to be brought to a medical facility. Only when a problem is perceived as physical in origin will medical care be sought. Consequently, when Rohingya patients with mental health conditions visit a health centre, they will usually present with physical symptoms such as body pains, tiredness, general weakness, etc. This is not unique for the Rohingya: It is well documented that in many south Asian and south-east Asian communities, the presenting complaints for depression, anxiety and PTSD are often somatic (Kroll et al., 1989; Pereira, Andrew, Pednekar, Pai, Pelto, & Patel, 2007; Selim, 2010). Rohingya usually do not seek formal help for mental health problems. When Rohingya people with psychosocial distress seek help, they prefer to meet with an imam/religious leader/ustad for traditional supports or to perform rituals. Many Rohingya believe that mental illnesses, particularly those with psychotic or dissociative symptoms, are caused by spirit possessions. In these cases, religious leaders (imams) are often preferred for help. In the Rohingya community, traditional healers are known as boidu. In Myanmar, with many formal health services absent or not accessible, the Rohingya community depended strongly on traditional and religious healers for any physical and mental illness. Many Rohingya are curious about western medicine, but some of them believe that traditional medicine is better than Western medicine and has less side effects.
Ways to overcome challenges related to community perceptions
Doing a cultural review based on existing resources is the first and most important step to understand how the affected population perceives issues related to mental health and mental illness (Greene et al., 2017). The reviews by Tay et al. (2018, 2019) are recent examples for the Rohingya, while the NGO, Action Contre la Faim, has done in-depth reviews on the perceptions around malnutrition, pregnancy and mental health in Myanmar (Boutry, 2015; Boutry, Eh Htoo, & Myo Win, 2015). But literature reviews are by themselves not enough. It is important to include the affected communities in assessment, planning and evaluation of mental health activities. This is likely to improve the utilisation of mental health services.
‘Community participation’ is a concept that is often talked about and that is mentioned in many guidance documents (Inter-Agency Standing Committee, 2007; UNHCR, 2008) but that is not always easy to realise, particularly when the majority of the MHPSS staff are trained in clinical approaches and are not familiar with community approaches. In the Rohingya emergency, staff sometimes ask for specific guidance on community-based MHPSS. Such guidance exists, but in contrast to manualised psychological interventions, working in community-based ways is not a ‘skill’ or a ‘tool’ but a ‘way of working’ in which the views and strengths of the communities are taken as a starting point to build programmes (Inter-Agency Standing Committee (IASC) Reference Group for Mental Health and Psychosocial Support in Emergency Settings, 2018). That implies working with and not just for refugees. An example of the empowering effects of working with community volunteers is presented elsewhere in this issue (Uddin & Hasna, 2019).
It is also important that MHPSS programmes reach out to traditional and religious healers to understand their methods, provide them with information about MHPSS programmes and foster collaborative links (Chen, 2018). Because of stigma, Rohingya with severe mental health problems are often taken care of by family members and in some instances are ostracised by community members. However, if the quality of the therapeutic relationship between clinician and client is strong, and particularly when the client is given space to express their experiences freely and confidentially, Rohingya can be motivated to adhere to treatment (Tay et al., 2018). It is essential that both national and international practitioners involved in MHPSS programmes for Rohingya reach out to their clients and make active efforts to understand and explore their clients’ cultural idioms of distress and the ways that people explain and make sense of their symptoms or illness, which influence their expectations and coping strategies (Jiwrajka, Mahmoud, & Uppal, 2017).
Challenge 3: Coordination of mental health and psychosocial support services
Coordination of MHPSS in humanitarian emergencies is crucial and improves utilisation of available resources. MHPSS activities are partially coordinated by health, partially by protection actors and sometimes overlooked by both of them. In Cox’s Bazar, the MHPSS working group was established soon after the influx of Rohingya in August 2017. It includes a wide range of actors who have been providing services related to health and protection. The working group is a subgroup of the health sector, but it extends close ties to other sectors especially protection. Two main challenges can be identified in relation to coordination of MHPSS in the Rohingya emergency in Bangladesh. The first challenge is that the working group has a limited impact on actual coordination of services on the ground. This is related to the structure of the humanitarian response in which most MHPSS activities are mainstreamed within health or protection activities rather than being standing alone services. Though this is a recommended approach to improve the access and acceptability of services (Inter-Agency Standing Committee, 2007), it makes the coordination of MHPSS services challenging, as it is not always feasible to keep track of services that have been already planned through platforms for health and protection.
A second challenge is that while the role of the working group has been largely recognised by the humanitarian response in Bangladesh, with significant attention from the government, UN agencies and international and local NGOs, it is not strongly linked to affected populations. Therefore, the discussions and decisions of the MHPSS working group are not necessarily informed by community views on mental health and mental health services, and the decisions and policies are not always communicated with the community in a culturally sensitive and participatory way.
Ways to overcome challenges related to coordination of MHPSS services
We see a few ways to make coordination around MHPSS more effective. First of all, more efforts must be made to ensure that all actors who are involved in MHPSS are represented in the MHPSS coordination group. In Cox’s Bazar, the psychosocial activities related to child protection are coordinated through the child protection working group. Recently, a child MHPSS taskforce within the larger MHPSS working group has been formed to improve coordination of child focused MHPSS activities. Second, and related to this, the MHPSS working group needs to have strong functional links to the protection working group and the health coordination group. Experience from other large and complex emergencies such as in South Sudan and in the Syria refugee situation in Jordan, Lebanon and Turkey shows that good coordination requires significant resources and a careful manoeuvring of the chairpersons to keep the group inclusive and credible. Third, engagement of the community in coordination of MHPSS services in large-scale emergencies is invaluable. Community engagement in coordination efforts can be a strong advocacy tool for MHPSS services, can establish supportive networks within the communities especially for highly vulnerable populations and can prepare the community in cases of emergencies.
Challenge 4: Human resources
MHPSS services for Rohingya refugees are provided mainly by national (Bangladeshi) mental health professionals. There is only one psychiatrist working in Cox’s Bazar’s 250-bed Sadar Hospital, providing outpatient services for the host community and sometimes receiving referrals from refugee camps. Some organisations have recruited psychiatrists on a full time or part time basis, with as a main task to train primary health care staff on assessment and management of mental health priority conditions using the Mental Health Gap Action Programme (mhGAP)Humanitarian Intervention Guide (World Health Organization & United Nations High Commissioner for Refugees, 2015). Maintaining the engagement of psychiatrists has been challenging as they are not from Cox’s Bazar but mainly from Dhaka or Chittagong and their presence in Cox’s Bazar often interferes with their regular work commitments.
The MHPSS working group estimates that around 150 psychologists are currently working in Rohingya response and are affiliated with different sectors and subsectors e.g. health, community-based protection, child protection and sexual and gender-based violence programmes. Most psychologists were trained in Dhaka, and some in Chittagong and Rajshahi, and graduated from either general, clinical, counselling or educational psychology departments. Some MHPSS programmes recruit volunteers from the refugee communities especially in outreach and promotional activities (e.g. community health workers, community psychosocial volunteers, and community outreach members).
While it is generally good that most services are provided by professionals from the host country, there are also risks. First of all, as mentioned above, many Bangladeshi mental health specialists have communication barriers in their work with Rohingya, because of the language and because of cultural differences. Secondly, the rapid deployment of ill-prepared national mental health professionals to work in refugee camps without adequate training or supervision can lead to unclarity about the roles and responsibilities of mental health professionals in these humanitarian settings. This amounts sometimes to a kind of ‘culture shock’ and leads to high attrition rates. Lastly, there is a risk that the heavy reliance of the humanitarian operation on the small number of mental health professionals may lead to draining Bangladesh of essential human resources.
Ways to overcome challenges related to human resources
Shortage of mental health professionals to support the humanitarian response for Rohingya refugees requires new and innovative strategies. Utilisation of the existing workforce in different sectors is one of these strategies e.g. building the capacity in the health sector (e.g. through integration of mental health into primary health care) and within protection (e.g. integration of child focused MHPSS health interventions in child friendly spaces) to respond to different mental health and psychosocial concerns.
Recruitment and training of psychosocial counsellors from the Rohingya communities is important to help to address this gap. Capacity building of the refugees could provide sustainable solutions to both challenges in MHPSS service provision, as Rohingya MHPSS workers are intimately familiar with their culture, local idioms of distress and coping mechanisms. This approach could also avoid dependency on Bangladeshi and international staff with high turnover rates. Agencies are doing this, but it takes a long time to build a competent community workforce and possibilities of recruitment of refugees in paid positions are restricted given the regulatory labour frameworks by the government of Bangladesh. Changing this would require joint advocacy by humanitarian agencies with the government to increase opportunities for Rohingya to do paid work (see General Assembly of the United Nations, 2018).
Challenge 5: Monsoon-related events
Every year, from June to November, Bangladesh faces a monsoon season, characterised by heavy rainfall and storms (including cyclones) leading to risks for landslides and floods. Monsoon-related events complicate the humanitarian response and can be seen as emergencies on top of an ongoing emergency (Intersectoral Coordination Group, 2019). Already, life for refugees in a crowded camp environment is hard and stressful (Riley, Varner, Ventevogel, Hassan, & Welton-Mitchell, 2017), with limited opportunities for livelihoods, and the monsoon season makes it worse, being a particularly troubling period of increased stress and potential disaster.
In 2018 and 2019, the humanitarian response in Bangladesh was affected by the need for emergency preparedness and response plans. With expected loss of properties, damage of shelters, social disconnection and loss of loved ones, there is a risk of increased mental health concerns among the affected populations. Also, there is a high probability of interruption of services due to physical damage of facilities and hindered access or absence of staff. Before and during the monsoon season, refugees in particularly vulnerable locations had to be moved to safer locations, which sometimes increased psychosocial distress among the refugees.
Ways to overcome challenges related to the monsoon season
The health system in Bangladesh, including the mental health system, must be further strengthened, both in terms of its preparedness and its capacity to respond to emergency situations. This is particularly relevant in Bangladesh, because cyclones and cyclone-related events interfere with the delivery of humanitarian assistance to Rohingya. The MHPSS working group in Cox’s Bazar launched an emergency preparedness and response plan (EPRP) taskforce to coordinate the activities to mitigate the impact of monsoon-related events. Four problem areas were identified: (1) increased incidence of mental health problems, (2) interruptions of MHPSS services, (3) relocation of families from high-risk areas to safer zones and (4) lack of staff care measures especially for volunteers from the Rohingya community. Activities to address these areas were discussed within the MHPSS working group (e.g. assigning camp-level emergency focal points for coordination, capacity-building activities such as psychological first aid (PFA) and self-care and support to the relocation process), and responsibilities were assigned to different working group members.
Challenge 6: The use of psychological measurement tools
Globally, psychological measurement tools are widely used in MHPSS services. However, these tools need to be culturally relevant for use with local communities. Most tools are developed and tested in western countries and the original scripts are in English. Some organisations working in Bangladesh translated tools into the Bangla language and use them in the humanitarian setting in Cox’s Bazar. This is, however, often problematic because many Rohingya do not fully understand the Bengali language and therefore assessors have to translate terms into the Rohingya language at the time of the assessment, which causes inconsistencies. Another challenge is that only few tools are culturally validated and contextually adapted.
Ways to overcome challenges related to the use of psychological measurement tools
The MHPSS working group in Cox’s Bazar initiated a taskforce for translation and adaptation of psychological measurement tools. This work is challenging, as the tools have to be translated into the Rohingya language using the Bengali script so that they can be used consistently by field staff. It is important that instruments are not merely translated but are adapted (i.e. using terms that make sense to the people, providing culturally relevant examples, ensuring that the formulations of question are not too long or too difficult). There is international research guidance on how to do this (see, e.g., https://www.who.int/substance_abuse/research_tools/translation/en/) but this is time consuming and labour intensive. We believe that it is possible to come to reasonable adaptation through a shorter process that has been described elsewhere (Mahmuda, Awal Miah, Elshazly, Khan, Tay, & Ventevogel, 2019).
Challenge 7: Lack of capacity to manage people with severe or complex mental health issues
The WHO estimates that around 5.1% of conflict-affected populations suffer from severe mental disorders such as schizophrenia, bipolar disorder, severe depression, severe anxiety and severe PTSD (Charlson, van Ommeren, Flaxman, Cornett, Whiteford, & Saxena, 2019). There are almost a million Rohingya refugees in Bangladesh and this amounts to a significant number of people in need. Many of these severe mental disorders can be treated within general health services if there are sufficient numbers of staff who are adequately trained and supervised. An MHPSS service 4Ws service mapping from April 2019 by the MHPSS working group showed that less than 1% of MHPSS services were specialised mental health services that could effectively assist persons with severe mental disorders.
While much has improved in the two years of the humanitarian emergency, specialised clinical services are stiill insufficient. There are several reasons for this. First, most of the psychologists providing services for refugees did not receive comprehensive clinical training on different psychotherapeutic approaches, and many of the current capacity development initiatives focus on generic counselling skills, mental health case management and scalable psychological interventions. The second reason is that ‘psychiatric services’ are provided by non-psychiatrists; general doctors trained on mental health using curricula like mhGAP due to limited number/absence of psychiatrists working in refugee camps. Another challenge is the shortage of inpatient services for persons with severe mental disorders when hospitalisation is indicated. There is no psychiatric ward in the district hospital, however some ‘mild to moderate’ cases can be admitted into the general ward. Otherwise, patients have to be referred to Chittagong teaching hospital, which may take up to six hours for patients to reach. To the best of our knowledge only one field hospital run by an international NGO (MSF Holland) has the capacity to provide short-term hospitalisation services for patients with severe mental disorders, but only a small number of beds is dedicated for this purpose. Availability of psychotropic medications recommended by WHO in the mhGAP materials (World Health Organization, 2016a; World Health Organization & United Nations High Commissioner for Refugees, 2015) remains inconsistent. There are limitations for procurement of medications locally by some international NGOs and international shipments of medications may take longer than expected.
Ways to overcome challenges related to the lack of capacity to manage people with severe or complex mental health issues
Capacity building in the provision of clinical services is important. Initiatives that are popular in the initial stages of an emergency such as psychological first aid and child friendly spaces lose much of their value when the situation stabilises and it is questionable how effective they are to improve mental health outcomes (Hermosilla, Metzler, Savage, Musa, & Ager, 2019; Horn, O’May, Esliker, Gwaikolo, Woensdregt, Ruttenberg, & Ager, 2019). Within the humanitarian setting of Cox’s Bazar, we currently see how scalable psychological interventions consisting of brief (five to ten session) manualised psychotherapies are increasingly being introduced. Examples are Problem Management Plus (World Health Organization, 2016b), group Interpersonal Therapy for Depression (World Health Organization & Columbia University, 2016) and Integrative Adapt Therapy (Mahmuda et al., 2019). The introduction of such methods is not easy in the context of an ongoing humanitarian emergency. An important lesson learnt is that successful scaling up of such methods needs to be accompanied by sustained and intensive clinical supervision (Kohrt & Bhardwaj, 2019; Murray et al., 2011; Verdeli, Clougherty, & Sonmez, 2016). This requires a sufficient number of competent clinical supervisors on the ground and longer term investment from donors who are willing to transcend the borders between humanitarian assistance and development aid.
With regards to medical staff, similar issues arise: it is unlikely that the humanitarian operation will be able to retain local psychiatrists for sufficient periods of time. A solution could be to shift the tasks of clinical supervision to non-specialised healthcare providers who are already ‘mhGAP trained’ and give them additional training on support and supervision skills.
For the medicines to be accessible to those most in need, it is essential that the distribution of medicines be done in health posts (the lowest level health facility) in Rohingya camps, because Rohingya are restricted in their movement outside the camps and the cost of transportation to health facilities can be prohibitive. Rigorous adherence to the Bangladesh Drug National Formulary (BDNF) (Directorate General of Drug Administration, 2015) is essential to ensure continuous supply of medicines, familiarity with prescribing and monitoring requirements and ultimately more cost-effective procurement and integration into national systems.
Challenge 8: Insufficient staff care
Staff working in the humanitarian response (either national, international or from the refugee communities) are exposed to high levels of distress, including long working hours, work overload, problems with work environment. Among humanitarian workers, the risks for negative mental health outcomes such as anxiety, depression, PTSD, secondary stress, alcohol misuse and burnout are much higher than in the general population and this is to a large extent related to organisational factors in combination with limited social support (Curling & Simmons, 2010; Suzic, Thomas, Jachens, & Mihalca, 2016). While all UN agencies and many international organisations have systems in place for staff support, many humanitarian staff on the ground in Cox’s Bazar perceive this support as too limited and not tangible enough. Staff care or support programmes are very limited across most of the organisations in Cox’s Bazar. Local NGOs and smaller international NGOs often do not have any systems or staff support in place. For volunteers from the refugee and host community almost no care is place.
The MHPSS working group receives many requests for guidance on staff care policies and practices. This area remains a grey area between the MHPSS programming for refugees and human resource departments of different organisations.
Ways to overcome challenges related to staff care
Staff care programmes should include at least two main components: measures to improve individual self-care and institutional responses. Self-care measures are supported currently by the MHPSS working group in Cox’s Bazar through training of trainers on self-care, but the institutional response remains beyond the scope of the MHPSS working group. Humanitarian organisations have a duty of care and should foster healthy work environments and take measures to prevent undue burden on their staff (Antares Foundation, 2012). It is important to foster an institutional climate with positive and open attitudes to stress and wellbeing, and to provide opportunities for staff (including volunteers) to distract themselves in healthy ways and have options for them to talk about mental health issues. Some examples of local initiatives in humanitarian settings have been described elsewhere, such as providing learning opportunities for individual stress management techniques such as mindfulness-based approaches (Pigni, 2014), explicitly including staff wellbeing in the clinical supervision and peer supervision of MHPSS staff (Francis & van der Veer, 2011) and organising workshops or retreats in which the experience of participants are put central (Anonymous, 2010). Ultimately, improving staff welfare depends more on people coming up with ideas and learning from each other than on routine implementation of protocols and checklists (Gray, 2010).
Challenge 9: Tensions between refugee and host communities
The massive increase in the Rohingya population in Cox’s Bazar Disctrict has led to increased tension and violent incidents between refugees and host communies. Such incidents are related to the dramatic social and economic changes in the area since the crisis began (Strategic Executive Group, 2019). There is considerable environmental degradation and competition between local and refugee populations over resources. Moverover, the massive humanitarian operation, while explicitly also attempting to address the needs of the host communities, is at time locally perceived as skewed toward the refugees, and depleting the local communities of resources and opportunities.
Ways to overcome challenges related to tension between refugees and host community
Engaging the host community and increasing the interaction between the host community and refugees should be addressed at different levels, policy levels (e.g. funding opportuities for both host community and refugees) and down to the community level (e.g. making refugee services more accessible to the host community and strengthening the community activities that may include both of them). The government of Bangladesh, confronted with a massive influx of refugees, has taken a multitude of actions to support the Rohingya and has implemented policies to promote peaceful relationships with the host community. UN agencies, INGOs and local NGOs should pay more attention to this matter and direct more sustainable support to the host community and ensure that they do not feel disenfranchised by the humanitarian support to refugees.
| Discussion|| |
Towards a system of care in the Rohingya settings
MHPSS services need to be scaled up to assist refugees and host communities. Such services have to be provided according to the SPHERE recommendations (Sphere Association, 2018) and IASC guidelines (Inter-Agency Standing Committee, 2007). See [Figure 1].
In the humanitarian response in Cox’s Bazar, considerable attention has been given to MHPSS and the balance is moderately positive. IOM and UNHCR have worked with partners to map all MHPSS service providers. WHO, UNHCR and others helped train health workers in mhGAP-HIG (Momotaz et al., 2019; Tarannum, Elshazly, Harlass, & Ventevogel, 2019) and are now supporting the roll out of MHPSS training for mobile medical teams. Much has been achieved, but we feel still much should be improved.
According to the data from 4Ws MHPSS mapping, activities at layer 1 (social considerations in providing basic needs) and layer 2 (community and family supports) are limited compared to layer 3 (focused non-specialised support). There are also very limited services available at layer 4 of the IASC MHPSS pyramid (specialised services).
Suggested solutions to strengthen layer 1 could consist of more explicitly encouraging and assisting humanitarian actors to mainstream ‘psychosocial approaches’ into food distribution, organisation of shelters, health response and livelihood opportunities (United Nations High Commissioner for Refugees, 2013).
We discussed various solutions to strengthen layer 2, striving much more explicit involvement of refugees in the provision of MHPSS. Increased community participation can also be solicited when it comes to improvement of living conditions, actions to avoid family separation in relocation activities, enhancing parental skills and strengthening reaching out to Rohingya communities through mass communication campaigns.
For strengthening of layer 3, we described various strategies related to ‘task sharing’ and capacity building of non-specialised staff. Finally, the clinical services (layer 4) need to be strengthened as well and in our view this can best be done by engaging mental health specialists as trainers and supervisors for non-specialised staff and by making explicit steps to link the provision of clinical mental health services for refugees to the general development of mental health services in Bangladesh.
| Conclusion|| |
In this field report, we have described a range of challenges around MHPSS in the Rohingya refugee context and reflected on possible solutions. We realise that there are no simple answers and that setting up a system for comprehensive services takes time and joint efforts. As has been described before (Pérez-Sales, Férnandez-Liria, Baingana, & Ventevogel, 2011; Ventevogel, DeMarinis, Perez-Sales, & Silove, 2013), it is important to use a long-term perspective from the onset of the humanitarian response and to anchor the response to community support systems and to link MHPSS to services in health and protection. This field report shows that this is not at all easy, but we believe that with concerted efforts from all stakeholders the mental health and wellbeing of Rohingya refugees can be sustainably improved.
Financial support and sponsorship
Conflicts of interest
All authors are or have been involved in the humanitarian response for the Rohingya refugees in Bangladesh. The views expressed in this article are those of the authors and not necessarily those of the institutions that they serve.
| References|| |
Anonymous. (2010). Care for the caretakers: Rolling out a protocol or developing tailor-made programmes on the spot? Intervention
, 8(2), 165-169.
Boutry M. (2015). Qualitative exploration on displaced and non-displaced communities of Sittwe Township
. Action Contre la Faim Myanmar (unpublished report).
Boutry M., Eh Htoo S., Myo Win T. M. (2015). Qualitative exploration on malnutrition in Maungdaw District. Action Contre la Faim Myanmar
Charlson F., van Ommeren M., Flaxman A., Cornett J., Whiteford H., Saxena S. (2019). New WHO prevalence estimates of mental disorders in conflict settings: A systematic review and meta-analysis. The Lancet
, 394(10194), 192-194.
Chen D.-H. (2018). In Rohingya camps, traditional healers fill a gap in helping refugees overcome trauma. IRIN
Curling P., Simmons K. B. (2010). Stress and staff support strategies for international aid work. Intervention
, 8(2), 93-105.
Francis F. T., van der Veer G. (2011). Peer support supervision as a procedure for learning from practical experience in a mental health setting. Interventioin
, 9(2), 154-158.
General Assembly of the United Nations. (2018). Global compact on refugees. 73rd Session Supple. No. 12
. New York.
Gray A. (2010). Staff support in Haiti. Intervention
, 8(3), 255-262.
Greene M. C., Jordans M. J. D., Kohrt B., Ventevogel P., Kirmayer L. J., Hassan G., Tol W. A. (2017). Addressing culture and context in humanitarian response: Preparing desk reviews to inform mental health and psychosocial support. Conflict and Health
, 11, 21.
Health Sector − Inter Sector Coordination Group. (2018). Rohingya crisis in Cox’s Bazar, Bangladesh: Health Sector Bulletin nr 5 (11 June 2018)
. Cox's Bazar. Retrieved from https://bit.ly/2p8lihK
Hermosilla S., Metzler J., Savage K., Musa M., Ager A. (2019). Child friendly spaces impact across five humanitarian settings: A meta-analysis. BMC Public Health
, 19, 576.
Horn R., O’May F., Esliker R., Gwaikolo W., Woensdregt L., Ruttenberg L., Ager A. (2019). The myth of the 1-day training: The effectiveness of psychosocial support capacity-building during the Ebola outbreak in West Africa. Global Mental Health
, 6, e5. doi:10.1017/gmh.2019.1012
Inter-Agency Standing Committee. (2007). IASC guidelines on mental health and psychosocial support in emergency settings
. Geneva: IASC.
Jiwrajka M., Mahmoud A., Uppal M. (2017). A Rohingya refugee’s journey in Australia and the barriers to accessing healthcare. BMJ Case Reports
, 2017-219674. doi:10.1136/bcr-2017-219674
Kletečka-Pulker M., Parrag S., Drožđek B., Wenzel T. (2019). Language barriers and the role of Interpreters: A challenge in the work with migrants and refugees. In Wenzel D. B. (Ed.), An Uncertain Safety
(pp. 345-361). Cham: Springer.
Kohrt B. A., Bhardwaj A. (2019). Considerations for training and supervision in global mental health. In Stein D. J., Bass J. K., Hofmann S. G. (Eds.), Global Mental Health and Psychotherapy: Adapting Psychotherapy for Low-and Middle-Income Countries
(pp. 47-65). London: Academic Press.
Kroll J., Habenicht M., Mackenzie T., Yang M., Chan A. O., Vang T., Cabugao R. (1989). Depression and posttraumatic stress disorder in Southeast Asian refugees. American Journal of Psychiatry
, 146(12), 1592-1597.
Mahmuda M., Awal Miah M. A., Elshazly M. A., Khan S., Tay A.K, VentevogeL P. (2019). Contextual adaptation and piloting of Group Integrative ADAPT Therapy (IAT-G) amongst Rohingya refugees living in Bangladesh. Interventioin
, 17(2), 149-159.
Momotaz H., Ahmed H. U., Uddin M. M. J., Karim R., Khan M. A., Al-Amin R., Kessaram T. (2019). Implementing the Mental Health Gap Action Programme in Cox’s Bazar, Bangladesh. Intervention
, 17(2), 243-251.
Murray L. K., Dorsey S., Bolton P., Jordans M. J., Rahman A., Bass J., Verdeli H. (2011). Building capacity in mental health interventions in low resource countries: An apprenticeship model for training local providers. International Journal of Mental Health Systems
, 5(1), 30. doi:10.1186/1752-4458-5-30
Pereira B., Andrew G., Pednekar S., Pai R., Pelto P., Patel V. (2007). The explanatory models of depression in low income countries: Listening to women in India. Journal of Affective Disorders,
102(1-3), 209-218. doi:10.1016/j.jad.2006.09.025
Pérez-Sales P., Férnandez-Liria A., Baingana F., Ventevogel P. (2011). Integrating mental health into existing systems of care during and after complex humanitarian emergencies: rethinking the experience. Intervention
, 9(3), 345-358.
Pigni A. (2014). Building resilience and preventing burnout among aid workers in Palestine: A personal account of mindfulness based staff care. Intervention
, 12(2), 231-239.
Riley A., Varner A., Ventevogel P., Hassan M. M. T., Welton-Mitchell C. (2017). Daily stressors, trauma exposure and mental health among stateless Rohingya refugees in Bangladesh. Transcultural Psychiatry
, 54(3), 304–331.
Selim N. (2010). Cultural dimensions of depression in Bangladesh: A qualitative study in two villages of Matlab. Journal of Health, Population and Nutrition
, 28(1), 95.
Sphere Association. (2018). The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response (fourth edition)
. Geneva, author.
Strategic Executive Group. (2019). Humanitarian crisis joint response plan for Rohingya (January − December 2019)
. Dhaka, Bangladesh.
Tarannum S., Elshazly M., Harlass S., Ventevogel P. (2019). Integrating mental health in Rohingya refugee settings in Bangladesh: experiences of UNHCR. Intervention
, 17(2), 130-139.
Tay A., Islam R., Riley A., Welton-Mitchell C., Duchesne B., Waters V., Ventevogel P. (2018). Culture, context and mental health of Rohingya refugees: A review for staff in mental health and psychosocial support programmes for Rohingya refugees
. Geneva, Switzerland. Retrieved from https://www.unhcr.org/5bbc6f014.pdf
Tay A., Riley A, Islam R, Welton-Mitchell C, Duchesne B, Waters V, Ventevogel P. (2019). The culture, mental health and psychosocial wellbeing of Rohingya refugees: A systematic review. Epidemiology and Psychiatric Sciences
Translators without Borders. (2017). Rohingya Zuban: A Translators without Borders rapid assessment of language barriers in the Cox’s Bazar refugee respons
. Retrieved from https://arcg.is/PGfSu
Uddin A., Hasna S. (2019). The story of a Rohingya refugee: becoming a community psychosocial volunteer (CPV). Intervention
, 17(2), 296-300.
UNHCR. (2008). A community-based approach in UNHCR operations
. Geneva: Office of the United Nations High Commissioner for Refugees.
United Nations High Commissioner for Refugees. (2013). Operational guidance for mental health and psychosocial support programming in refugee operations
. Geneva: Author.
Ventevogel P., DeMarinis V., Perez-Sales P., Silove D. (2013). Long term perspectives on mental health and psychosocial programming in (post) conflict settings (Introduction to a special issue). Intervention
, 11(3), 227-236.
Verdeli H., Clougherty K., Sonmez N. (2016). Training in Interpersonal Psychotherapy (IPT) in Lebanon
. Amman/New York: Unpublished report.
World Health Organization. (2016a). mhGAP Intervention Guide (mhGAP-IG) version 2.0 for mental, neurological and substance use disorders for non-specialist health settings
. Geneva: WHO.
World Health Organization. (2016b). Problem management plus (PM+): Psychological help by paraprofessionals for adults exposed to adversity
. Geneva: WHO.
World Health Organization, & Columbia University. (2016). Group Interpersonal Therapy (IPT) for Depression
. Geneva: WHO.
World Health Organization, & United Nations High Commissioner for Refugees. (2015). mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies
. Geneva: WHO.