|Year : 2019 | Volume
| Issue : 2 | Page : 252-258
Using simple acupressure and breathing techniques to improve mood, sleep and pain management in refugees: a peer-to-peer approach in a Rohingya refugee camp
Joseph Sullivan1, Natasha Thorn2, Murad Amin3, Kaitlin Mason4, Noreen Lue5, Muhammad Nawzir6
1 Assistant Clinical Professor, Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
2 FH/MTI Volunteer Clinical Instructor, Joint Rohingya Response Program, Cox’s Bazar, Bangladesh
3 FH/MTI Programme Officer, Joint Rohingya Response Program, Cox’s Bazar, Bangladesh
4 Registered Nurse, FH/MTI Health Services Support Officer, Joint Rohingya Response Program, Cox’s Bazar, Bangladesh
5 FH/MTI Programme Support Officer, Joint Rohingya Response Program, Cox’s Bazar, Bangladesh
6 FH/MTI Interpreter, Joint Rohingya Response Program, Cox’s Bazar, Bangladesh
|Date of Submission||04-May-2019|
|Date of Decision||06-Aug-2019|
|Date of Acceptance||06-Sep-2019|
|Date of Web Publication||29-Nov-2019|
Source of Support: None, Conflict of Interest: None
Many of the 626,500 Rohingya refugees in the Kutupalong camp in Bangladesh (OCHA, 2019) suffer from feelings of hopelessness, excessive worry, insomnia and somatic complaints such as headache and total body pain (UNHCR, 2018; Riley et al., 2017; Tay et al., 2019; Milton et al., 2017). The provision of mental health and psychosocial support and treatment within camp remains inadequate and under-resourced (UNHCR, 2019; UNHCR, 2018; Tay et al., 2019). This innovative project utilises Rohingya community health workers (CHWs) to pilot the use of peer-to-peer teaching of low-cost tools for potential alleviation of mental health complaints. CHWs learned six simple relaxation techniques: four acupressure points and two breathing exercises. A cohort of 13 CHWs taught 46 community members these techniques, advised participants to use them daily for one week and completed a feedback questionnaire with each participant. In total, 78% of participants, aged 22–75 years, reported that the techniques were ‘very good’. A total of 70% reported the techniques to be ‘very easy’ and used them daily during the week. During a reflective conversation, the CHWs shared specific cases where the complaints of difficulty in sleeping, stress and pain had improved. Both men and women found the techniques easy to teach. The CHWs felt that the community would benefit from utilising these techniques throughout the camp. This pilot project is inadequate in scope and design to claim effect attribution. However, the positive findings warrant a more rigorous examination of how these low-cost techniques and peer-to-peer teaching may empower self-care amongst refugees in managing their mental health complaints.
*Both the authors contributed equally.
Keywords: acupressure, breathing technique, community-based intervention, mindfulness, peer-to-peer, refugee mental health, Rohingya
|How to cite this article:|
Sullivan J, Thorn N, Amin M, Mason K, Lue N, Nawzir M. Using simple acupressure and breathing techniques to improve mood, sleep and pain management in refugees: a peer-to-peer approach in a Rohingya refugee camp. Intervention 2019;17:252-8
|How to cite this URL:|
Sullivan J, Thorn N, Amin M, Mason K, Lue N, Nawzir M. Using simple acupressure and breathing techniques to improve mood, sleep and pain management in refugees: a peer-to-peer approach in a Rohingya refugee camp. Intervention [serial online] 2019 [cited 2019 Dec 14];17:252-8. Available from: http://www.interventionjournal.org/text.asp?2019/17/2/252/271874
Both the authors Joseph Sullivan and Natasha Thorn contributed equally
| Background|| |
The Rohingya exodus
For generations the Rohingya people have been persecuted and marginalised by the Burmese junta and more recently by the democratically elected government of Myanmar. Despite their long history in Burma, the Rohingya are labelled as illegal immigrants and thus denied the benefits of citizenship including protection, education, due process of the law, freedom of movement and healthcare. After regional skirmishes in 2017, the Myanmar military carried out ‘widespread and systematic attack on [civilians] including murder, imprisonment, enforced disappearance, torture, rape, sexual slavery and other forms of sexual violence, persecution and enslavement’ with ‘elements of extermination and deportation’ as well as ‘systematic oppression and discrimination [that] may also amount to the crime of apartheid’ (Human Rights Council, 2018). This persecution led to a massive forced migration into neighbouring Bangladesh. Currently, there are over 900,000 Rohingya refugees in the Cox’s Bazar region of southern Bangladesh. A total of 626,500 of these live in the Kutupalong refugee camp (OCHA, 2019). It is the largest refugee camp in the world today (Jewell, 2019). The Rohingya remain stateless and their future is uncertain.
Mental health complaints amongst the Rohingya
Given their recent history of subjection to violence and ongoing insecurity, it is not surprising that mental health complaints amongst these refugees are common. Anecdotally, health care workers in the camp describe high levels of feelings of hopelessness, excessive worry, insomnia and fear, in addition to frequent somatic complaints of headache, fatigue and total body pain that cannot be ascribed to an organic cause. This is supported by recent reports and surveys (UNHCR, 2018; Milton et al., 2017; Tay et al., 2019; Riley et al., 2017). However, as others have noted (Silove, Ventevogel, & Rees, 2017) prevalence data yielded by cross‐sectional epidemiological studies do not allow a clear distinction to be made between situational forms of distress and frank mental disorder. That said, there are some estimates of the burden of mental health problems in major humanitarian crises (WHO/UNHCR, 2012). The rate of severe mental illness (psychosis, severe depression, immobilising anxiety) can double from 2% to 4% and a similar doubling can be seen for moderate mental illness including posttraumatic stress disorder (PTSD), moderate anxiety and depression from 10% to 20% (WHO/UNHCR, 2012). As importantly, they note that a large percentage of the population without a definable disorder suffer from normal distress and other psychological reactions including somatisation.
Inadequate mental health resources
The mental health and psychological support services (MHPSS) in the Kutupalong camp are inadequate for the number of people affected (Tay, 2019). In fact, despite great need, a recent operational dashboard showed that <1% of the refugees were engaged with the MHPSS services (UNHCR, 2019). There are an increasing number of non-governmental organisations (NGOs), including Food for the Hungry/Medical Teams International (FH/MTI) pioneering programmes, which work with Rohingya lay community psychosocial workers (UNHCR, June 2018). Based on foundational work in Myanmar, these NGOs are training community volunteers to facilitate community meetings for refugees to voice concerns and be offered strategies for resilience and mutual support. These include: providing parental psychosocial support to address behaviour change in their children; group interventions emphasising peer support and collective problem solving; safe spaces for children and women; and group meetings for children and adolescents focusing on how to handle feelings of sadness or anger within themselves, their friends or their families (UNHCR, 2018; Duchesne, 2016; Paratharayil, 2010). Furthermore, FH/MTI employs counsellors to support and assist victims of sexual and gender-based violence (SGBV). Finally, there is a doctor with a psychiatric background who, due to a heavy caseload, is available on an infrequent, rotating basis to support health clinics in managing the severely mentally ill. Most Rohingya refugees with mental health complaints will initially turn to family, traditional healers or religious leaders prior to seeking help at a ‘Western’ medical health post (UNHCR, 2018). When they are seen at the health clinics within the camps they are often managed by staff who have limited training and time to adequately diagnose, counsel or treat (WHO, 2016). Somatic symptoms often go unrecognised or are treated with repeated prescriptions of analgesics. Compounding this is a paucity of trained mental health experts who speak the Rohingya language.
Current strategies amongst the Rohingya to address mental health complaints include herbal remedies, using amulets with herbs combined with a verse of the Quran, coloured herbal pastes that are applied to affected body parts and use of prayer from religious leaders or traditional healers (UNHCR, 2018).
Despite the use of these traditional methods, there remains a high prevalence of mental health complaints amongst the Rohingya (UNHCR, 2018) which, given the limitations of the current MHPSS systems in camp, results in an ongoing, unmet need. It was hypothesised that additional, community-based, self-help measures to address mental health complaints may be beneficial (Ventevogel, 2014).
Acupressure and mindful breathing techniques
Acupressure point stimulation has been used effectively in adolescent survivors of genocide in Rwanda (Sakai, Connolly, & Oas, 2010) but has not been systematically studied in refugee settings. However, acupressure for many of the psychological and somatic complaints experienced by the Rohingya has been studied in other settings and these suggest a potential role. Acupressure has been shown to decrease anxiety (Au, Tsang, Ling, Leung, Ip, & Cheung, 2015; Clond, 2016), improve sleep quality (Waits, Tang, Cheng, Tai & Chien, 2018) and improve symptom management including nausea, vomiting, fatigue and insomnia (Lee & Frazier, 2011).
Mindful breathing is a collection of techniques that have been used for centuries in meditation to help calm the mind and body. There is evidence that it can help to address many common complaints including decreasing pain (Kabat-Zinn, 1982), decreasing anxiety (Cho, Ryu, Noh, & Lee, 2016), improving attention span, decreasing negative affect, decreasing cortisol levels (Ma et al., 2017) and improving sleep quality (Rusch et al., 2018).
Both of these techniques are free, safe, easy to teach and therefore lend themselves well to a pilot in the refugee population. The final consideration is how to deliver the training and disseminate teaching to the community.
Rohingya peer-to-peer training
FH/MTI has run the Joint Rohingya Response Programme since the beginning of the crisis in 2017 and has since trained 182 Rohingya community health workers (CHWs). This cohort currently provides preventative health services to 17,322 households and over 77,000 individuals, as of March 2019. The activities of the CHWs have traditionally included delivering health messages regarding nutrition, immunisation, hygiene practices, antenatal and postnatal counselling and advice on community resources. Whereas CHWs are generally literate, the majority of adult Rohingya refugees are illiterate (South & Lall, 2017; Bhatia et al., 2018). These activities are therefore undertaken using a variety of means including regular household visits, courtyard sessions for groups of refugees and radio listening groups. CHWs are often the first responders in emergencies, have gained the respect and trust of the Rohingya community and have become an integral part of their survival. It was recognised that this large cohort of respected community members could be an appropriate conduit to introduce innovative self-help tools for mental wellbeing and to improve mood, sleep and pain management.
| Methods|| |
In April 2019, six simple techniques were piloted in a small number of households across three camps in Kutupalong. Four acupressure points (large intestine four [LI-4], Yin Tang [EX-HN3], gallbladder 20 [GB-20] and pericardium six [PC-6]) were selected based on their classical Chinese indications to reduce pain, insomnia, anxiety, fear, depression, stress, headache, nausea and vomiting (Deadman, 2007). In addition, these were selected due to being located at neutral, unintimidating body areas, identifiable using visual clues or bony landmarks without removal of clothing or hijab. Two mindful breathing techniques were chosen to address insomnia, stress and anxiety: the 4-7-8 technique and diaphragmatic breathing (Legg, 2018; Cleveland, 2018a, Cleveland Clinic, 2018a,b).
All six techniques were taught in 90-minute group sessions to Rohingya CHWs by explanation, demonstration and practice in same-sex pairs. Sessions were led by an English-speaking volunteer with Rohingya interpretation. No religious or cultural associations with the techniques were taught nor implied. CHWs were advised not to use acupressure in the case of wounds, fractures, injuries, bruising or other concerns. CHWs were also advised that these techniques were not a replacement for medical care, but rather an adjunct.
Thirteen CHWs from Kutupalong camps six, seven and eight west were selected by their team leaders to take part in this pilot project. Teaching resources were provided: written instructions for breathing techniques and acupressure points, in both English and Burmese (see Appendix 1)* [Additional file 1], illustrations of the acupressure points and instructional audio recordings of the breathing techniques in Rohingya language which had been recorded by two community members.
Each CHW then selected and taught the techniques to two or three households in which they would usually work and where they felt low mood, stress, difficulty in sleeping or pain may pre-exist. No other criteria for household selection were given: as this project was in part assessing cultural acceptability to Rohingya of acupressure and mindful breathing, it was felt that CHWs should be given freedom to pilot these new techniques in households where they felt comfortable and where it felt appropriate to teach. Household members were asked to use just one or two techniques at least once daily for the next week. In a separate teaching session, brief feedback questionnaires for participants were reviewed with CHWs (see Appendix 2) [Additional file 2]. Rohingya equivalent words for terms such as ‘stress’ and ‘low mood’ were clarified via Rohingya interpreters. Forms were in English and Burmese and terms were purposefully simple to facilitate ease of use with an unfamiliar tool. CHWs returned to households after seven days of using the techniques to complete questionnaires with each participant. Feedback sheets were collated and data were analysed using Microsoft Excel. A reflective discussion with six CHWs was then held to hear their experiences and feedback.
| Results|| |
Results from feedback forms
A total of 13 CHWs, seven males and six females, taught techniques to 46 Rohingya household members, 25 males and 21 females, with ages 22–75 years ([Table 1]). Participants practised mostly acupressure techniques, with one or more being selected for use by 42 household members versus 10 participants opting for breathing techniques. Four feedback forms did not have the selection recorded. Of the ten who chose to use breathing techniques, eight were male. A total of 70% (32) of participants chose to use more than one technique throughout the week. The most popular acupressure point was EX-HN3 ([Table 2]).
|Table 2 The number of instances each technique was selected for use by 42 household members (four not recorded)|
Click here to view
Participants were asked how often they had used the techniques during the preceding seven days; 70% (32) reported daily use, 26% (12) three to six times and the rest fewer than three times. On a five-point scale ranging from ‘very difficult’ to ‘very easy’, 70% (32) of participants reported to have found the techniques ‘very easy’ to use. Just one female participant reported them ‘very difficult’. The CHW reported the participant felt she lacked the time to practise. When asked their general opinion on the techniques using a five-point scale ranging from ‘very bad’ to ‘very good’, 78% (36) felt they were ‘very good’ and the remaining 10 participants reported ‘good’ ([Table 3]).
|Table 3 Respondent feedback on the use of techniques in a seven-day period|
Click here to view
Using a further five-point scale, ranging from ‘helped a lot’ to ‘made worse’, participants were asked to consider general mood, difficulty sleeping, stress and pain. A large number of forms had no recorded answers in this section ([Table 4]) but for those that did, difficulty in sleeping and pain were reported as most improved with 25 and 23 participants, respectively, reporting the techniques had ‘helped a lot’. A further 24 and 20 participants reported techniques had ‘helped’ or ‘helped a lot’ with stress and general mood, respectively. No negative effects on complaints were reported ([Table 4]).
Reflective discussion group
Two male and four female CHWs were present for a reflective discussion to gather opinions and feedback on: the experience of peer-to-peer teaching in general including any issues around cross-gender teaching; how the community reacted to the techniques; whether there may be scope for future use; and any negative feedback from either the community or themselves. Reflective discussion was led by an English-speaking volunteer with Rohingya interpretation.
CHWs reported that the participants had been ‘thankful to get these techniques’. The CHWs described their experience of the teaching as ‘good’, that the participants had found the techniques ‘very good’ and were ‘interested to learn them’. They reported happiness that the techniques ‘cost no money’ and that the participants had ‘found these techniques satisfying’. Both males and females were keen to share individual cases of success including three cases of improved sleep difficulty; a male community member said: ‘now I am able to sleep’. Other cases of improved stress in a mother, reduced nausea in pregnancy and decreased neck pain in a male were shared. CHWs had extended the scope of teaching to their own family members and additionally reported positive use for themselves.
CHWs reported that participants sometimes performed acupressure for themselves, but mostly wives and husbands used the techniques for each other. One CHW noted that this interaction had promoted loving and caring touch between partners and within the community.
Neither males nor females reported problems with cross-gender teaching; a male CHW noted that ‘they (the households) know us’ and implied that familiarity with families removed some of the common, cultural, gender barriers. A female CHW reported that when teaching, neighbouring non-selected families also expressed an interest in learning and that, in future, she was motivated to organise teaching larger groups.
When asked about negative attitudes or experiences, CHWs reported that ‘a few’ people were reluctant to try the techniques and thought they were ‘pointless’ but ‘most liked them’. One case was described of an older female who experienced shoulder pain after using PC-6 acupressure point which was resolved after two days of using hot compresses. CHWs expressed enthusiasm for continuing this teaching, stating ‘this can be useful for our community’.
| Discussion|| |
An integrated mental health safety net
The United Nations High Commission for Refugees (UNHCR) Operational Guidance on Mental Health and Psychosocial Support (MHPSS) presents a framework to guide mental health and psychosocial activities in the humanitarian response (UNHCR, 2013). The MHPSS guidelines promote an integrated four-level pyramid of programmes ‘supporting a shift from delivering services for refugees to promoting their self-reliance’ (UNHCR, 2013). This mental health pyramid includes at its lowest foundational level, basic services (food, shelter, water, sanitation and health care) and security. The second level promotes activities that foster social cohesion among refugees and participatory approaches that reinforce community-based structures. The third level approaches provide emotional and practical support through individual, household or group interventions to those having difficulties coping by using only their personal strengths and existing support system. Finally, the highest level interventions are carried out by mental health professionals who provide clinical mental health services to those with severe intolerable symptoms (psychosis, disabling depression or anxiety, those at risk of harming themselves or others).
This pilot looks at interventions which may strengthen the UNHCR MHPSS operational framework on both the second (community) and third (individual) levels. In relation to community, CHWs play an essential role within the refugee community providing timely information, appropriate referrals and teaching on health and hygiene matters. This pilot expands that role to include the teaching of simple acupressure and mindful breathing techniques for use in self-managing of mental health and somatic complaints. In terms of the individual, this pilot offers new, simple, self-management options to manage mental health and somatic complaints.
High level of acceptance
A total of 70% of the respondents used the techniques daily and a full 96% of the respondents tried the techniques at least every other day. This remarkably high acceptance rate may reflect an eagerness to address an unmet need to self-manage symptoms such as anxiety, difficulty in sleeping and poor pain control. However, several other critical factors may have played a role in these findings.
Traditional Rohingya healing includes marking with coloured paste or massaging areas of the body that are symptomatic (UNHCR, 2018). This may explain why acupressure is adopted more readily than the breathing techniques. Furthermore, given that the Rohingya actively use traditional remedies and prayer to treat mental health and somatic complaints, they may not share the negative preconceptions of complementary and alternative medicine techniques sometimes seen in the west.
In Kutupalong camp there are often minimal educational, social or entertainment opportunities; this may also have contributed to the willingness and enthusiasm of both CHWs and participants to engage in learning novel techniques. But the trusting relationship between the CHWs and the community may be the most important factor in the willingness of the respondents to try a novel therapeutic approach. The FH/MTI CHWs have an intimate knowledge of the households they serve and have earned the trust and respect of the Rohingya community over the last year and a half. We believe that this translated into a higher than expected acceptance level in this pilot. The comment made by one CHW about acupressure promoting loving and caring touch in the community is an interesting one; it is possible that some of the positive effects came simply from this. This is an interesting area which requires more evaluation than this pilot provides.
The high percentage of respondents who were ‘helped a lot’ in all of the measured categories (mood, stress, sleep and pain) is encouraging given the simplicity of the design and instruction. The pilot design, with its inherent limitations (discussed below), does not allow one to draw conclusions regarding effectiveness of any individual acupressure point or breathing technique in alleviation of any particular complaint. However, it does suggest a potential benefit for the Rohingya refugees if these techniques are shared widely.
Limitations and sources of error
There are significant limitations and sources of error which affect the findings. The small number of participants limits the power and prevents meaningful disaggregation of the results by age or sex. The study time period was too short for true effect attribution; time and resource limitations did not allow for a longer period of follow-up. Selection bias may have played a significant role as CHWs self-selected households without criteria. This may have led to selection of participants more affected by mental health complaints or more amenable to new ideas. CHWs themselves were also selected by team leaders; others may have been less open to taking part. Cultural and privacy concerns precluded supervised in-home teaching and therefore participant teaching was not standardised. No baseline symptom review was catalogued for each respondent so there is no accurate baseline prevalence at the beginning of the pilot resulting in inability to assess the impact of any particular technique on any individual or specific complaint. Feedback questionnaires were poorly completed in some areas, especially the ‘effects on complaints’ section as noted above, preventing meaningful data being drawn from this area. Additional error may have been introduced if the CHWs felt a cultural pressure to ‘please the investigators’ by recording positive results. This cultural pressure may have also affected the participants’ answers to the CHWs questioning. Finally, the trainer is a qualified physician but not an expert in acupressure or mindful breathing. These potential errors prevent any effect attribution, yet the findings provide impetus for further more rigorous study on the effectiveness of these techniques in the Rohingya refugee setting.
During teaching groups with CHWs it was clear that techniques were met with great interest; new teaching material such as this is an infrequent occurrence. There was occasional embarrassment at practising new physical techniques and females were less vocal during the sessions; future teaching in separate gender groups may go some way to mitigate this.
Feedback forms were reportedly easily understandable by the CHWs in Burmese but certain sections were poorly completed. Forms such as these are likely a new concept for many Rohingya and to increase reliability and completeness of data in the future, more in-depth teaching on collecting and recording feedback would be useful. Alternative ways of recording opinions, for example via pictorial representation, may be more engaging and intuitive.
CHWs reported that using pictures and demonstration were effective teaching methods. The audio recordings were not widely utilised, but lack of telephones and other access issues may have limited this. A more ubiquitous method for delivering recordings may be useful in future as audio instruction in Rohingya language could be an accessible and engaging teaching resource.
Mindful breathing techniques were a more challenging concept for CHWs and therefore likely the wider community; this may be the reason for them being comparatively less popular than acupressure. Teaching separately on acupressure and breathing techniques and in smaller groups would allow slower and more detailed exploration of both.
Despite suspicion of potential cultural barriers to using techniques that require physical touch in this community, it appears that acupressure was well accepted by participants and that trust in CHWs superseded cultural barriers. We were pleased to observe that there is interest and engagement amongst Rohingya CHWs to continue learning and disseminating this approach.
| Conclusions|| |
This pilot study suggests that acupressure and mindful breathing techniques, taught peer-to-peer via trusted Rohingya CHWs, may improve mental health complaints, empower refugees to use self-care and promote caring relationships within families. This approach bolsters the mental health safety net at both the community and individual level as part of the UNHCR four-tiered approach to mental health care in humanitarian responses. The next challenge will be to more rigorously study this approach on a larger scale.
We believe that these practices may be helpful in other refugee settings and humanitarian crises where mental health services are insufficient. It is our hope that in the future, simple self-help tools for mental health will be included as part of all comprehensive CHW training programmes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]