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Table of Contents
FIELD REPORT
Year : 2019  |  Volume : 17  |  Issue : 2  |  Page : 231-237

Child-centred, cross-sectoral mental health and psychosocial support interventions in the Rohingya response: a field report by Save the Children


1 Mental Health and Psychosocial Support (MHPSS) Lead, Save the Children in Bangladesh, Bangladesh
2 MHPSS Specialist, Save the Children in Bangladesh, Bangladesh
3 Deputy Team Leader for Program Development and Quality, Save the Children in Bangladesh Rohingya Response, Bangladesh
4 Former Humanitarian Advocacy Manager, Save the Children in Bangladesh, Bangladesh

Date of Submission15-May-2019
Date of Decision21-Sep-2019
Date of Acceptance06-Oct-2019
Date of Web Publication29-Nov-2019

Correspondence Address:
Aladin Borja Jr.
Mental Health and Psychosocial Support Lead. Save the Children Bangladesh, Rohingya Humanitarian Response, Cox’s Bazar
Bangladesh
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INTV.INTV_17_19

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  Abstract 


Rohingya refugee children make up 55% of the refugee population living in camp-like settlements in Cox’s Bazar, Bangladesh (Rohingya Humanitarian Joint Response Plan, 2019). The ongoing humanitarian and protection crisis are a result of the displacement of over 700,000 Rohingya during and after a brutal crackdown by the Myanmar military after attacks on border police posts in August 2017. The Independent International Fact-Finding Mission has since concluded that the widespread and systematic attacks amount to crimes against humanity and genocide perpetrated against the Rohingya (United Nations, 2018). With the aim to highlight the impact of the humanitarian situation on Rohingya children’s wellbeing, this field report presents insights on child-centred, cross-sectoral mental health and psychosocial support (MHPSS) interventions in the Rohingya response. Save the Children’s (SC) MHPSS programming framework is discussed, as it reflects the global consensus to push for an integrated approach to MHPSS service provision. Approaches within the child protection, health, nutrition and education sectors are outlined. This report then presents several lessons learned, delving into resources needed and challenges encountered in implementing cross-sectoral MHPSS programming. Gaps in resourcing, technical capacity of personnel and adaptation of tools used in programming figure prominently. This report proposes some recommendations including linking the gains made in the Rohingya response with sustainable prospects such as supporting the Government of Bangladesh in integrating MHPSS into primary health care service delivery in keeping with the recently passed National Mental Health Act of 2018.

Keywords: children, cross-sectoral MHPSS, mental health, psychosocial, refugees, Rohingya


How to cite this article:
Borja Jr. A, Khondaker R, Durant J, Ochoa B. Child-centred, cross-sectoral mental health and psychosocial support interventions in the Rohingya response: a field report by Save the Children. Intervention 2019;17:231-7

How to cite this URL:
Borja Jr. A, Khondaker R, Durant J, Ochoa B. Child-centred, cross-sectoral mental health and psychosocial support interventions in the Rohingya response: a field report by Save the Children. Intervention [serial online] 2019 [cited 2019 Dec 8];17:231-7. Available from: http://www.interventionjournal.org/text.asp?2019/17/2/231/271878




  Introduction Top


Rohingya refugee children constitute 55% of the refugee population in need of humanitarian and protection assistance in Bangladesh. This is a children’s emergency. Rohingya refugee children and their caregivers have exhibited high levels of distress after fleeing extreme violence and gross human rights violations and abuses in Myanmar that amount to crimes against humanity, war crimes and possible genocide (United Nations, 2018). Continuously exposed to the stressful and uncertain living conditions upon arrival in Bangladesh, including fear of repatriation, relocation to Bhasan Char and potential devastation should a cyclone hit, children face serious risks to their wellbeing including, but not limited to, neglect, physical abuse, sexual and gender-based violence, trafficking, child marriage, child labour, lack of access to basic needs and social services and substance dependence, among others. In late 2017, a mental health and psychosocial support (MHPSS) assessment conducted by SC identified that refugee children manifested signs of distress such as frequent crying, inattention, poor concentration, disturbed sleep, fear of others, being clingy and easily distracted. Further, the poor living conditions in the camps and restrictions on freedom of movement outside the camps seem to contribute to toxic stress that engulfs children’s capacity to cope. SC’s report, Healing the Wounds of War: A roadmap for addressing the mental health needs of children (Save the Children, 2018), indicated that prolonged exposure to such distressing conditions can have a pervasive and permanent negative impact on children’s development and wellbeing.

SC’s MHPSS programme in the Rohingya response consisted initially of an emergency response phase that included rapid needs assessment, provision of psychological first aid (PFA) and basic community-based psychosocial support such as recreational activities, structured play, sports and games among children, as well as sessions with caregivers and teachers on how to identify and support distressed children. These interventions have evolved into child-centred, cross-sectoral MHPSS programming with various interventions delivered through the child protection, education, health and nutrition sectors. SC has seen benefits of integrated programming at all levels of the pyramid of MHPSS interventions, and how such programming can be implemented in various phases of the response in keeping with the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (Inter-Agency Standing Committee, 2007).

SC’s MHPSS programming framework in the Rohingya response

As a global child rights organisation, SC recognises that children’s optimal development and wellbeing are contingent upon a number of contextual factors at various levels of the social ecology, as illustrated below (Save the Children, 2019).



Referencing the above model, SC’s MHPSS Programme Guidelines (Save the Children, 2017) put the child at the centre of programming with caregivers, community and the larger society playing equally critical roles in promoting young people’s development and wellbeing. Emphasis is given on community members’ potential to recover following a distressing event. As MHPSS is a rapidly evolving field, this field report seeks to contribute new learning for child-centred, cross-sectoral MHPSS programming to the field of humanitarian response.

Mental health and psychosocial wellbeing is dependent on a myriad of factors including biology, environment (social, physical, economic, political), experience, as well as availability and access to supportive services. [Figure 1] recognises that multiple layers of MHPSS interventions delivered across humanitarian sectors are necessary to meet the mental health and psychosocial needs of children, caregivers and communities during and after emergencies. This cross-sectoral approach has the following bases:
  • As an issue that cuts across various thematic areas and levels of human ecology, a range of complementary services and support structures is therefore needed to reduce psychosocial distress.
  • Considering elements of wellbeing and support needs in any sectoral interventions improves both outcomes of projects themselves as well as the wellbeing of the participants.
  • Children’s wellbeing is closely connected to other broader issues including health, nutrition, education and protection issues.
  • MHPSS and early childhood development integrated programmes have been shown to improve outcomes for babies and young children. The wide range of imaginative, creative, communicative, physical and manipulative activities delivered in safe spaces help stimulate children’s cognitive and affective abilities and help restore a sense of normalcy in their lives following an emergency (Save the Children, 2008).
Figure 1 Cross-sectoral MHPSS programming in the Rohingya response

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With the overall goal of strengthening children’s coping mechanisms and resilience while ensuring that severely affected children receive appropriate support, [Figure 1] presents the intended outcomes at the child, caregiver and community levels of MHPSS programming in the Rohingya response. [Figure 2] suggests various MHPSS interventions that may be delivered in various sectors.
Figure 2 Cross-sectoral MHPSS interventions supporting the intended outcomes at child, caregiver and community levels. Source: Developed by Maria Waade and Monica Ciompi (2018); updated by Aladin Borja (2019).

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The above MHPSS interventions that put the child at the centre of social ecology justifies the need for meaningful engagement of the community where the child lives. It is only by having an enabling environment that children can thrive and build resilience especially in humanitarian situations. It may then be argued that community-based approaches that promote the capacity of its members to support the most vulnerable groups including children merit attention, as these encompass preventative, promotive and responsive services, which not only have the most significant impact but are also cost effective. Simply put, the more child-centred interventions are at various layers of the social ecology, particularly at family and community levels, the greater the impact they can have in terms of promoting children’s wellbeing. It is, therefore, important for actors across all sectors to put in place a continuum of MHPSS services and to ensure functional referrals across the different layers of interventions (Inter-Agency Standing Committee, 2007). Interventions can best reach children and families when they are integrated within sectors rather than as stand-alone programmes. In SC’s Rohingya response, structures such as child-friendly spaces (CFS), community centres and organisations, temporary learning centres (TLC) and health and nutrition posts serve as entry points for MHPSS services, as discussed below.

MHPSS in child protection

Every child has the right to be protected from all forms of violence including psychological violence (see article 19, UNCRC, 1989). Child protection programming has always included MHPSS interventions to help reduce physical and psychosocial risks among children. A critical component implemented by the child protection sector during emergencies is family tracing and reunification (FTR). While crossing the Naf River, the body of water that separates south-eastern Bangladesh and western Myanmar, many children got separated from their caregivers. As a priority, a team of FTR workers helped to reunite children with their families which significantly contributed to having a sense of safety and security on both sides. This is important to begin the process of regaining control over their lives following their displacement.

Trained psychosocial support (PSS) focal points conduct sessions with caregivers and community members to build their capacity to identify signs of distress among children. These sessions are delivered in CFS and adolescent-friendly spaces and through outreach with support from community mobilisers. PSS focal points also work closely with social case workers and case managers who provide more focused support to children and caregivers with specific needs such as those who are having difficulties coping. Children, caregivers and community members assessed to be needing specialised services are referred to Médecins Sans Frontières (MSF), International Committee of the Red Cross (ICRC), International Organization for Migration (IOM) and the United Nations High Commission for Refugees (UNHCR) for appropriate treatment.

MHPSS in education

One in every four Rohingya children aged 4–14 years are being denied their right to education. Only 3% of adolescent girls have access to a two-hour learning session conducted twice a week, which is insufficient to meet the learning needs of young people. This is alarming as children miss a critical aspect of their development.

The protective learning environment that TLCs in the camps provide contributes to restoring a sense of normalcy and predictability among children, caregivers and the community. To complement basic literacy and numeracy outcomes, social and emotional learning in the form of life skills training allows children to learn competencies such as self-awareness and social awareness, self-management, positive interpersonal skills and responsible decision making (Collaborative for Academic and Social and Emotional Learning (CASEL), 2018)

MHPSS in nutrition

About 20% of pregnant and lactating women registered in SC’s nutrition posts are of adolescent age, which contributes to both the mother’s and infant’s increased vulnerability. Through SC’s infant and young child feeding in emergencies (IYCF-E) and community management of at-risk mothers and infants (C-MAMI) nutrition programmes, PSS focal points work closely with IYCF-E and C-MAMI counsellors to teach young mothers appropriate care practices for their babies. They are also coached on proper breastfeeding, cognitive stimulation of infants and promoting healthy attachment with their child.

MHPSS in health

In SC’s Rohingya response, MHPSS is included in the essential package of emergency health services. Assessment of possible mental health problems is included in the triage process, and a room manned by a supervised psychosocial support officer is dedicated to MHPSS services. PSS officers in SC’s health facilities conduct mental health promotion and education, psychoeducation sessions, as well as individual and group work. For cases needing specialised mental health support, referrals are made to relevant partners as cited above.

The facility-based services are complemented by the outreach activities implemented by a cadre of community mental health workers, who are in charge of mental health promotion and education in different blocks and camps, identification and referral of possible mental health cases, and following up and support for treatment adherence.

The MHPSS in health team is also preparing to roll out the Mental Health Gap Action Programme (World Health Organization, 2016) and has started sending doctors to relevant trainings organised by the World Health Organization (WHO) in Cox’s Bazar. There is also a plan to conduct training on Problem Management Plus (PM+), Group Interpersonal Therapy (IPT) and Thinking Healthy.

Lessons learned

As its MHPSS programme in the Rohingya response shifted from the initial emergency response phase towards early recovery, SC conducted a lessons learned exercise to inform its way forward. This initiative identified lessons learned and generated recommendations relating to cross-sectoral MHPSS programming. The key points in the report can be summarised into three main areas.

Technical capacity of personnel. As early as September 2017, SC had already started integrating MHPSS components into its multi-sectoral response to the rapidly growing humanitarian crisis in Cox’s Bazar. In the initial response phase, international experts assisted in rather short tenures which led to strategies changing several times. The lack of a consistent MHPSS expert meant that teams on the ground experienced difficulty in implementation and management of integrated MHPSS programming. Other sectors were also reluctant to prioritise MHPSS services as it was not seen as a lifesaving intervention.

The composite term, ‘mental health and psychosocial support’, is also a new concept and practice in Bangladesh, and as a result SC experienced challenges finding trained personnel to provide safe and appropriate MHPSS services at the height of the emergency. It was also necessary to include proficiency in the Rohingya or Chittagonian language in the selection criteria, which made the recruitment of staff even more challenging. Staff turnover also became a major issue during the first year of the response. To address this bottleneck, SC exerted significant efforts that included provision of professional development opportunities through training, coaching and mentoring by thematic experts as well as MHPSS services for staff themselves to preserve and promote their wellbeing.

Community’s evaluation of MHPSS services. It was necessary for SC to understand the Rohingya people’s perception and attitude towards MHPSS services. Baseline assessments were carried out and tools documenting the participants’ feedback were also rolled out. In a recent evaluation, for instance, the separate place or room for MHPSS at the health posts provided refugee women an opportunity to ‘breathe’ as they engaged in conversations with other women while reporting feeling less tensed. They referred to the MHPSS room as ‘shanti’ which means ‘calm’ in the Rohingya language.

Caregivers and children including adolescents expressed feeling safe in the CFS and GFS. Children and community members articulated that the physical space seems to help improve their mental health and psychosocial wellbeing. In fact, a recent evaluation exercise conducted in the CP sector that showed eight out of ten adolescents aged 11–17 and seven out of ten children aged 4–10 have improved wellbeing outcomes compared to last year.1 Adolescent girls suggested having more gardening opportunities, as they feel more relaxed and able to concentrate when attending to the plants and vegetables they tend. Rohingya children have come to enjoy the sessions and stay longer compared to their initial refusal to spend time in these spaces.

Contextualization of MHPSS tools and resources. Given that MHPSS in emergency settings remains a new discipline in Bangladesh, there was a lot of ‘back and forth’ in terms of choosing appropriate tools that may be used for assessment, training, monitoring and evaluation in the beginning of the response. Most resources developed by SC and other agencies had to be adapted to ensure that they were culturally appropriate and relevant for the Rohingya context.

Continued MHPSS gaps in the Rohingya response

While gains have been made on cross-sectoral MHPSS programming in the Rohingya response, there remain important gaps including the following:
  1. Physical barriers to accessing services
  2. Continuing factors for distress
  3. Issues concerning staffing and capacity building
  4. Adaptation of MHPSS programming tools
  5. The evolving context of the Rohingya humanitarian crisis.


Physical barriers to accessing services. The land where the camps have been built presents additional challenges for both staff and people in need trying to access services due to often being situated on top of hills or in remote areas of the camps. SC’s Shelter team is now reassessing these structures as part of strengthening emergency preparedness and ensuring accessibility standards of facilities are met.

Continuing factors for distress among children and their caregivers. In a study conducted in February 2019, IOM found that adults and children continue to experience sadness, lack of sleep, limited appetites and somatic complaints. Nearly two-thirds of the adults said they were constantly grieving for lost family members. Among the major gaps that continue to contribute to high levels of distress include inadequate food aid, limited access to education, camp and shelter conditions, poor health conditions, movement restrictions and the uncertainty about their citizenship. The Child Protection sub-sector in Cox’s Bazar also identified protection risks such as physical and sexual violence, separation from family members, trafficking of children, child labour and being forced to engage in illegal activities such as drug smuggling as contributing factors to ongoing distress experienced by children in the camps.

Staffing and capacity building concerns. The recruitment, training and supervision of MHPSS staff were extremely challenging, with MHPSS supervisors describing the quality of staff − referring to their relevant psychological/social work backgrounds − as having been compromised in favour of having Rohingya language speakers working in the programmes.

While trainings on the Mental Health Gap Action Programme (mhGAP) are expected to begin again in 2019 to improve access to specialised care and as a means to strengthen local health services, there is still a gap in terms of continuing supervision. Continuing support is necessary to help ensure quality and safety of mental health services and build the confidence of service providers.

WHO in Bangladesh recently entered into an official agreement with the Government’s National Institute for Mental Health to take the mhGAP initiative forward with the goal of sustaining the efforts to integrated MHPSS into primary healthcare service delivery across the country.

Adaptation of MHPSS programming tools. There was a lack of contextualised tools and materials available for staff to use. While attempting to adapt available resources, much of the MHPSS concepts have been lost in translation, with resources and training on these often conducted in English, translated to Bangla and then further translated to Rohingya. A task force on MHPSS tools adaptation has been formed within the MHPSS Working Group in Cox’s Bazar to help address this challenge. There is already a Bangla version of resources on PFA, and there is a plan to deliver mhGAP in Bangla as well.

The evolving context of Rohingya humanitarian crisis. All indicators point to the ongoing humanitarian situation in Cox’s Bazar turning into a protracted crisis. There is a need for programme implementers and other stakeholders, through meaningful consultation with members of the Rohingya communities, to revisit their strategies, particularly on resourcing and sustainability.

The way forward

It is imperative to translate these gains achieved in the response to the wider context in Bangladesh. Efforts to increase awareness and making MHPSS services available, acceptable and accessible through the primary health care system should be prioritised by the Government of Bangladesh with support from other stakeholders such as donors, academia and professional bodies. This is also aligned with the provisions of the Bangladeshi National Mental Health Act passed in 2018, which requires more investments on MHPSS services in the country. This new law can help ensure appropriate investments in MHPSS programmes that may include integration of MHPSS into primary health care service delivery. SC in Bangladesh can push for training and continuing supervision on mhGAP for medical practitioners in Bangladesh to strengthen the primary health care system.

Moreover, investments in focused MHPSS interventions should likewise be made to provide support to children, caregivers and community members needing further support. Approaches such as mindfulness-based stress management, relaxation and grounding techniques, structured therapeutic play, counselling for specific groups such as survivors of gender-based violence, curriculum-based social and emotional learning, as well as WHO-endorsed low-intensity psychological treatments such as PM+, Self Help Plus, Group Interpersonal Therapy and Thinking Healthy for women experiencing post-natal depression may be considered.

There is also an opportunity to formally integrate MHPSS within the education sector through social and emotional learning, an emerging field that aims to build competencies such as self-awareness and social awareness, self-management, developing positive interpersonal relationships and responsible decision making among young people (CASEL, 2018).


  Conclusion Top


As multiple layers of MHPSS interventions are necessary to adequately meet the needs of children and their caregivers, the use of a child-centred, cross-sectoral MHPSS programming approach presents the potential for improved programme outcomes. Given that MHPSS is a cross-cutting portfolio and children’s wellbeing and resilience are closely connected to other broader issues including health, education and protection issues, there have been successes, challenges and gaps in implementing this model. It is important for actors across all sectors to be aware of the continuum of MHPSS needs of children and families in emergencies, and to ensure functional referrals up and down the layers of the pyramid.

As SC’s MHPSS programme in the Rohingya response evolves to fit the changing humanitarian landscape in Cox’s Bazar, it is critical for all stakeholders with meaningful participation among the affected populations to revisit their strategies particularly on resourcing and sustainability of programmes. In particular, the donor community may consider multi-year funding to ensure continuity of essential MHPSS services. This approach is now being implemented in other humanitarian contexts such as South Sudan, Iraq and Syria.

Moving forward, attempts to engage host communities may be highlighted, as the present situation is predicted to become protracted in nature. Sectoral structures such as CFSs and health posts may be turned into multi-purpose community centres so children and their caregivers as well as other community members can access integrated services in one space. Linking humanitarian gains achieved during the emergency and early recovery phases to long-term systems development approaches may also prove to be the most cost-effective way of meeting the many mental health and psychosocial needs of both Rohingya refugees and host communities across the Rohingya response.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

1End of project evaluation for a Child Protection project funded by Global Affairs Canada conducted in April 2018.



[13]



 
  References Top

1.
Collaborative for Academic and Social and Emotional Learning (CASEL). (2018). Social and emotional learning and wellbeing framework.  Back to cited text no. 1
    
2.
Inter-Agency Standing Committee. (2007). Inter-agency guidelines on mental health and psychosocial support in emergency settings. Geneva, Switzerland: IASC.  Back to cited text no. 2
    
3.
International Organization for Migration in Bangladesh. (2019). Preliminary evaluation of MHPSS services in the Rohingya Response presented in the MHPSS working group in Cox’s Bazar.  Back to cited text no. 3
    
4.
Inter-sectoral Coordination Group. (2019). Joint response plan for Rohingya humanitarian crisis.  Back to cited text no. 4
    
5.
Inter-sectoral Coordination Group. (2020). Draft child protection sub-sector strategy for 2020.  Back to cited text no. 5
    
6.
Inter-sectoral Coordination Group in Bangladesh.(2019). Rohingya Humanitarian Joint Response Plan. UNOCHA.  Back to cited text no. 6
    
7.
Save the Children. (2008). Child friendly spaces in emergencies: A handbook for save the children staff. Save the Children Fund.  Back to cited text no. 7
    
8.
Save the Children. (2018). Healing the invisible wounds of war: a roadmap for addressing the mental health needs of children. Wilton Park, UK: Save the Children UK.  Back to cited text no. 8
    
9.
Save the Children. (2019). Cross-sectoral MHPSS Strategy. Save the Children Fund.  Back to cited text no. 9
    
10.
Save the Children Denmark. (2017). Mental health and psychosocial support full programme guidelines.  Back to cited text no. 10
    
11.
United Nations. (1989). United Nations Convention on the Rights of the Child. United Nations.  Back to cited text no. 11
    
12.
United Nations. (2018). Independent international fact-finding commission on Myanmar full report. United Nations.  Back to cited text no. 12
    
13.
World Health Organization. (2016). Mental health gap action programme intervention guide: version 2. Geneva, Switzerland: World Health Organization.  Back to cited text no. 13
    


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