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FIELD REPORT
Year : 2019  |  Volume : 17  |  Issue : 2  |  Page : 290-295

Making psychosocial support programmes in emergencies inclusive: lessons learned from interventions in Rohingya camps


1 MA, MHPSS Technical Advisor, Humanity & Inclusion Bangladesh Programme, Belgium
2 PhD, MHPSS Specialist at Humanity & Inclusion Headquarters, Belgium

Date of Submission22-May-2019
Date of Decision20-Sep-2019
Date of Acceptance29-Sep-2019
Date of Web Publication29-Nov-2019

Correspondence Address:
Sanem Ozen
Humanity & Inclusion, Rue de l’Arbre Bénit 44 Box 1, B-1050 Brussels, Belgium
Belgium
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INTV.INTV_29_19

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  Abstract 


This personal reflection describes how Humanity and Inclusion (HI) has implemented inclusive modalities of intervention since the Rohingya influx in Bangladesh in 2017. We focus on how to improve the cultural acceptance of mental health and psychosocial support (MHPSS) services in this context. We explore the issue of stigma towards users of mental health services and misconceptions about this kind of service within the Rohingya community. This article provides an overview of HI’s programme, describing how it was adapted to address barriers and better contribute to the right to health of vulnerable populations. During the influx period, operating through mobile teams was found to be one of the best ways to respond to increasing needs. However, as the months unfolded and needs changed, a key modality of this intervention was community self-support based on peer-to-peer activities. Without advocating for replication of this specific case study, this field report documents ongoing practice in an emergency context and shows how professionalism and creativity are entangled in making MHPSS services really inclusive.

Keywords: community-based approach, inclusion, psychosocial services, Rohingya response


How to cite this article:
Ozen S, Ziveri D. Making psychosocial support programmes in emergencies inclusive: lessons learned from interventions in Rohingya camps. Intervention 2019;17:290-5

How to cite this URL:
Ozen S, Ziveri D. Making psychosocial support programmes in emergencies inclusive: lessons learned from interventions in Rohingya camps. Intervention [serial online] 2019 [cited 2019 Dec 8];17:290-5. Available from: http://www.interventionjournal.org/text.asp?2019/17/2/290/271887




  Introduction: Handicap International support for Rohingya in Bangladesh Top


Humanity and Inclusion

Humanity and Inclusion, the new name of Handicap International (hereafter HI), has been present in different regions of Bangladesh since 1997 (Humanity & Inclusion, 2019a), implementing development projects focused on inclusive development. HI has been providing humanitarian aid in Cox’s Bazar area to Rohingya people who fled from the Burmese military’s operations since 2006. The initial phase of intervention focused on supporting the host community around the Kutupalong and Nayapara Registered Camps. After one year from the beginning of the project, HI expanded the area of intervention to include both host and refugee communities in Ukhiya and Teknaf. With the major influx of Rohingya in August 2017, HI decided to launch an early response based on humanitarian principles (Wessells, 2009) and global guidelines (Inter-Agency Standing Committee, 2007) through mobile teams to identify and provide physical rehabilitation services to the most vulnerable populations. Following the ‘leave no one behind’ commitment (United Nations Office for the Coordination of Humanitarian Affairs, 2016), HI widened the scope of its programme to take into account the most vulnerable individuals (Bevington & Lunsford, 2018). As the needs were massive and multilayered, HI created multidisciplinary teams composed of nurses, physical rehabilitation, protection, sports and psychosocial support (PSS) officers and started supporting persons with disabilities who have been disproportionately affected by this emergency (World Health Organization, 2013).

A recent survey (Bhatia et al., 2018) found high levels of mortality among young Rohingya men, alarmingly low levels of vaccination among children, poor literacy and rising poverty. Moreover, as they have been denied formal refugee status, the Rohingya cannot access health services, education or jobs that are available in the country. With the setup of the so-called ‘mega camp’ and the high density of population (United Nations High Commissioner for Refugees, 2019), HI mobile teams started identifying vulnerable people with psychosocial needs. Initially, the mobile teams identified isolated individuals who suffered from a lack of information and reduced access to services, as well as persons showing signs of distress among the individuals who were already assisted by physiotherapists and nurses.

Progressively, HI teams have started screening the general population to identify those with needs of PSS regardless of physical or functional impairment. Functioning as one team, the mobile team has been able to apply a holistic approach when responding to needs. However, each specialist is also able to work independently according to each case, offering sometime PSS alone.


  Barriers to Services Top


Implementing such programmes, we identified three main barriers that limited the access of people in need of services and especially PSS. Classic strategies based on strengthening the service provider’s team in order to overcome those barriers did not seem very effective. Therefore, we decided to integrate a complementary strategy focused on the local community as an actor of the service. This resulted in a process of mutual growing in knowledge, reciprocal trust and shared practices. However, research on knowledge, practices and attitudes towards people suffering from psychosocial distress and other impairments in their functioning among Rohingya people as well as an analysis of the impact of the proposed strategies of intervention is still needed. Despite these limitations, sharing HI’s ongoing experience in such complex emergency could promote a debate on the importance of the inclusion of users in PSS services within humanitarian responses.

Barriers are factors that prevent a person from having full and equal access and participation in society. Beside environmental and physical barriers, often communication and attitudinal barriers could limit the access to services. Some of them may be created by the humanitarian response (Humanity & Inclusion, 2019b). This article focuses on attitudinal and communication barriers and those associated with stigma.

Attitudinal barriers consisted in lack of acceptance of any non-medical service. By non-medical services we refer to those services that do not provide or do not rely exclusively on medication or assistive devices. For instance, PSS interventions focus often on talking and building coping skills via social, recreational and cultural activities; likewise physical rehabilitation programmes implement, among others activities, exercises to strengthen muscles and regain or develop new functionality.

Communication barriers refer to language. As we will describe below, it is not just a matter of different languages used between international staff, the host community and beneficiaries. Rather, what could affect the impact of PSS activities is the range of terms to define emotions and negative connotations regarding psychological concepts. It is not matter of words, but of ‘frames’.

The third barrier we met during fieldwork is the stigma among the community towards people with disabilities and people facing psychosocial distress, mental health conditions and psychosocial disabilities. Psychosocial disabilities that result from situations of psychosocial distress should be acknowledged as such. They may adversely affect the social life of those concerned in terms of incapacities related to behaviour, language or intellectual activities. Individuals may lose their social skills and their ability to take care of themselves (Humanity & Inclusion, 2011).

While elaborating on these barriers, we also discuss the measures HI tried to put in place to overcome them, discussing their perceived effectiveness.

Barriers in accessing psychosocial support: lack of acceptance of non-medical services

The low acceptance of non-medical services was apparent since the first interventions by HI mobile teams. As mentioned above, the services provided by HI focused on physical and functional rehabilitation and PSS. The families HI met were very hesitant in accepting these services, expressing the need of and expectation for direct solutions to their difficulties.

Some families stated clearly that, ‘We need medication and devices to be better’. We encountered comments such as, ‘Talking never helps, why we have to talk, give me a medicine’. People were mostly requesting medication and did not want to obtain services that did not give them something tangible. As one staff member reported, ‘Individuals were looking for band-aid solution for their problems’. Even if people affected by natural and social crisis face multilevel needs simultaneously, they tended to focus on basic needs first, as described by the Maslow’s pyramid of human needs (Matei Gherman, 2012). Such an attitude is not just a matter of surviving, but it could be related to the relationship between foreign providers and help seekers that find a balance between dependency and empowerment.

To overcome these issues, the teams tried explaining in person to individuals the added value of the services but with little success. Because in some cases HI’s intervention included the provision of assistive devices, the team thought that these could have been used to introduce further interventions. However, some of our staff stated that, ‘We were rejected by beneficiaries after they receive their assistive devices, without even giving time to explain services’.

In order to support the team, HI technical unit developed a package of trainings to explain how non-medical interventions could be useful. Always keeping in mind that a beneficiary has the right to refuse (completely or partially) the service at any time during the service pathway, we believed that we could improve our staff communication skills in order to create conditions for fully informed consent. Introducing the organisation and explaining the services is one of the tasks of the mobile team. The trainings also focused on discussing the community’s perspective on people facing psychosocial difficulties. Even though such trainings aimed to highlight the importance of understanding the perception of the community we work with, the focus was still on the service provider.

The training package included working on real, case scenarios adapted to the local context and it used role-play techniques. According to our internal evaluation, those trainings increased the understanding of the services in order to better represent it to the potential users. Moreover, the trainings were an opportunity to open a discussion within the HI staff on personal views towards people with disabilities and psychosocial disabilities and the importance of being non-judgmental and open to the point of view of the users. It resulted in a shift in staff attitudes and it helped promote a different strategy. After the training, the team started to explain services not only to individuals that could benefit from it, but also to the whole community around them.

Regular technical supervision was introduced to fill the gap between training and fieldwork, ensuring that insights and knowledge gained during the training were applied in the field. Indeed, we observed that team members started meetings by clearly introducing services, highlighting the potential benefits of the services.

It is important to note that we do not focus exclusively on the negative consequences of not accessing PSS, but seek to promote positive messages about the service. This approach raises questions in a sense about creating a new demand instead of simply responding to perceived needs. However, we found this way of presenting information about PSS as well as the outreach service of mobile teams seemed to improve the access to the service. Nevertheless, it was clear that staff training could not be the only strategy to transform the perception of what a service could provide.

Barriers to accessing psychosocial support: how to refer to MHPSS and language implications

The second barrier that limited access to the PSS service was the language between actors involved in the humanitarian response and its consequences on how assistance was represented to the people experiencing distress and stories about them. We also expected there to be a language barrier as a result of the negative connotations in the words used for referring to psychosocial issues in the Rohingya language (Tay et al., 2018).

As reported by Clay (2018), the Rohingya language is not understood by the host community (including service providers); moreover, the majority of the Rohingya are not familiar with what mental health services are and their potential benefits. Linked to the importance given to medicines described above, we noted that the Rohingya community has a very physical and behavioural explanation of psychological and psychosocial concepts. For example, a person that is demonstrating aggressive behaviour (but also a person who is leaving home without letting anyone know) is described in the literal translation as ‘your mind going bad’. The expression for a person experiencing grief could be translated as ‘burning feeling inside’, which is also the same word used to express stomach acid. As noted by Translators without Borders (TwB), the Rohingya language has fewer terms than other languages and it is complicated to convey many concepts that seem straightforward in English (Yasin, Yusuf & Junita, 2018).

We observed these difficulties in translation and the features of the Rohingya language during our PSS response. PSS often relies on language to express, acknowledge, share and work on emotions. The lack of a precise, rich, vocabulary to describe the complexity of human feelings has made PSS work more complex. Conducting assessments asking people to disclose and discuss their feelings instead of their physical manifestations blocks mutual understanding and limits the relationship between helper and service user. Creating trust refers not only to ensure a safe and confidential space, but also to speak about events that have an emotional impact. In this space, the service provider and the beneficiary define together the object of the PSS according to perceived needs, resources, expectations and hope. If this common ground could not be reached due to language-related barriers, we wondered if more creative activities (not just language-focused) could be used to foster a positive relationship, allowing alternative ways for working on feelings.

In order to address this issue, we worked with TwB increasing the capacity of our staff in better understanding the language of service users. In 2018, TwB (Translators without Borders, 2018) launched a glossary specifically designed to support humanitarian workers in that context. This was created in collaboration with organisations directly working in the field and holding multiple, focus group discussions in the local community. TwB organised training for HI staff based on the glossary, available for off-line use. We found our staff had a better understanding of local expressions after using this tool. Even just a few, key words were useful in starting to establish the common ground between helper and service user. However, our staff still said that, ‘the glossary was helpful, but something more was needed’. We wondered if the fact that Rohingya do not have written language was a limitation, although TwB have worked extensively on writing it down. It has also been difficult to mainstream a shared written glossary created into and for a community that is mostly illiterate.

Barriers to accessing psychosocial support: stigma towards people with disabilities, psychosocial disabilities and mental health conditions

The third barrier that limits access to PSS services is the stigma towards people with physical and psychosocial disabilities, people demonstrating difficulty dealing with psychosocial distress and people suffering from mental health conditions. Within the Rohingya community, we have encountered people saying that people with disabilities ‘are crippled, they can’t do anything’ or ‘they can’t even take care of themselves’. Across cultures, stigma can play a role in determining health-seeking behaviour (Bharadwajab, Pai & Suziedelyted, 2017) and is therefore a major barrier for caring. Stigma involves many interconnected factors such as etiological beliefs, attitudes, prejudices, personal and social problems as well as the role of different cultures (Mannarini & Rossi, 2018). As such, it represents a significant barrier to services. Although stigma towards people with disabilities is strong, the Rohingya community also demonstrates well-established community ties and support for this group. For example, the HI team worked with a family whose daughter needed specialised mental health services due to a high risk of harming herself. When we suggested a referral to the hospital, the family refused because ‘last time we took her there, they kept her for two days’. However, the family agreed to be linked with a 24-hour safety network, set up to help the daughter avoid harming behaviours without detaining her. However, even family networks such as these, having survived separations and giving support, often see the persons with disabilities or mental health condition as unable to take care of themselves and to contribute to the society.

Aware of the weight of stigma in the community, we tried to break the taboo. We invited the community to a dedicated information session to explain the causes and the conditions experienced by persons with different types of disabilities including mental health conditions. We shared positive examples of how persons with disabilities could contribute as anyone else to their community. The ultimate goal of rehabilitation within our organisation is to promote full participation in society. We found that participants were open to listening to the staff, but not to accept the messages. At the end of the session, one participant still stated that, ‘People with disabilities here can’t do anything but to be a burden, and lay at home all the day long’.


  Need for a Strategy Shift Top


Challenged by the limited progress in addressing these barriers despite the efforts of the team, we decided to adopt a new strategy. Our initial response in tackling the lack of acceptance of non-medical services was by providing staff training in delivering clear information about PSS. At first glance, this sounds logical and useful and indeed staff increased their self confidence in facilitating the debate with the community about sensitive topics. However, based on our experience, rationale arguments and a cost-benefit analysis could not change inner beliefs and habits. Our experience of addressing language issues in using the glossary of PSS terms was equally not enough to improve access to PSS service. And in relation to the third barrier described here, our attempts to target the larger community and talk directly about stigma were not very helpful in promoting a real change in attitudes.

We are aware that sometimes changes promoted by external actors are refused just because they are perceived as strangers, despite what they are offering and the potential benefits to those receiving support. We decided therefore to involve community members themselves as agents of change.

Involving the community

Understanding each other’s vision of the problems and solutions and creating a common ground for meeting and giving/receiving help in services is a long-term and complex process. For example, we cannot presume that a few training programmes are sufficient to acquire a sound understanding of psychosocial issues. We also cannot assume that our definition of concepts and their implications are necessarily shared by others.

The first step to create this dialogue between different visions expressed in a different language with a different cultural background is to invite all the actors directly concerned to participate. So, the key of the new strategy of intervention has been the inclusion of community members. This means shifting towards community-based programmes (International Organization for Migration, 2019), led by the community members themselves. This new phase of the HI programme is currently ongoing and further research on its impact will be needed.

We are now in the process of creating a pool of volunteers to be trained in supporting their own communities. Such training will be an opportunity to share some key concepts (such as PSS, emotions, stigma and inclusion, as well as some concepts on protection) to committed people, discussing and adapting them. The role of volunteers is not just to spread key messages delivered by a more recognisable voice, adding a cultural adaptation to translation, but also to facilitate debates within the community. The rationale is the belief that the community has its own resources to support its members. The Socratic method used by the sociologist and nonviolent activist, Danilo Dolci (1981), in the south of Italy in the period after the Second World War and the pedagogy of Paulo Freire (1970) are inspirational references.

Volunteers, with the support of PSS staff, will be enabled to lead conversations that ask the community ‘What can we do together to overcome current challenges?’ Involving the community in the response also increases the sustainability of the programme. Since the community came up with the answers and ideas about problem-solving, we may hope that they will be more inclined to implement it.

We see the implementation of such an approach as presenting new challenges. First of all, the potential high turnover of volunteers could undermine the principles mentioned above, not allowing enough time to create trust, which is a prerequisite for any impactful intervention. Moreover, exchange and coordination between volunteers and PSS staff need to be structured and nourished rather than just relying on short, morning, operational, briefings. Then, we need to organise a system to ensure the knowledge management (from professionals to volunteers and the other way round from the field to the coordination level). It is not only a matter of capitalising on what we could learn by doing, but also to ensure an alignment and coherence of messages.

As noted above, the new strategy shifting the focus onto community programming does not mean substituting direct implementation of services with trained, not-specialised teams. Both approaches are integrated, fostering, synergies between different modalities of interventions. Therefore, besides implementing talking groups facilitated by volunteers, HI staff will still continue with the mobile teams. By mixing these two modalities to support each other, we are expecting to increase the impact and move towards more sustainable programming. We aim to merge both modalities to create a stronger community-led response.

A group of allies

HI staff continues to facilitate group discussions open to the community (without a specific target of sex or age). These groups represent a safe space for people to talk about what they are facing. Because no fixed topics are specified, the team is open to discuss any stressors that participants want to share. According to our observations, the first group was very much focused on difficulties faced about getting around the camp due to the challenging physical conditions of living in such a context, as well as basic needs (food, kitchen staff and medication). In individual sessions, the difficulty of focusing the discussion on the emotional impact of daily stressors is still present. However, we noted some changes over time. After three sessions conducted in one month, during the second supervision session, we listened to a different kind of conversation. Participants were talking about the difficulty of settling in Bangladesh not regarding shelter, but about how such situations made them feel and how they try to deal with these feelings. This positive output reminds us about the importance of respecting the time of the community (and, of course, of each participant in the group) to decide freely when it is the right moment to open certain issues. It also shows that a simple intervention like allowing safe space for open discussion is not wasted time. The same may happen during home visits, as one of the beneficiaries stated: ‘I did not understand it would help, but now you will come again to talk to me?’

In order to make those groups more effective, we started focusing not on the community as a whole, but on small group of allies. We decided to start from the first circle of support that people with disabilities have − their families and caregivers. We designed a multidisciplinary group activity. The group is a five-week module. It includes the benefit of rehabilitation exercises, sharing experiences, looking at what stressors caregivers face and how they overcome stressors, how to create a more inclusive and accessible environment (inside and outside the house), stigma that people with disabilities face, the role of caregivers and the available support in the larger community. The group methodology is based on a variety of techniques from discussion to drama. The first feedback from this new activity is encouraging. One participant stated that ‘the community thinks that they can’t do anything, but it is not true and we will show to the community’. Discussions within groups start from those kind of comments.


  Lessons Learned Top


Our work in involving the community in this new way is still ongoing, so we are not yet in the position to share final conclusions. However, we have shared some of the lessons learned in this field report about our attempts to improve the PSS offered to Rohingya refugees. We have found some of the classic humanitarian responses, such as trainings, professional translation and direct awareness sessions, have been of only partial usefulness. Instead, integrated direct services like talking groups and community-led programmes seem promising.

In sum, the key lessons learnt through this experience are the following: Firstly, capacity building of PSS staff is essential. However, volunteers from the local community also have an important role to play. The consequences of this approach involve more creative ways of working on PSS that go beyond interventions that focus exclusively on health systems and counselling models. Secondly, we consider work on language, cultural beliefs and individual ways of thinking to be an integral part of PSS activity. Such consideration pushes us to review classic awareness sessions towards activities based on dialogue. Thirdly, allocating time to meet the community, facilitate mutual learning and build trust are crucial. Too often, due to contextual restraints during post-emergency interventions and short-term commitment by donors, this aspect is neglected or overlooked.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



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