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   Table of Contents - Current issue
Coverpage
July-December 2019
Volume 17 | Issue 2
Page Nos. 117-318

Online since Friday, November 29, 2019

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EDITORIAL  

From the editors: introducing Intervention’s special issue on the mental health and psychosocial wellbeing of Rohingya refugees Highly accessed article p. 117
Wendy Ager, Rebecca Horn, Muhammad Kamruzzaman Mozumder, Andrew Riley, Peter Ventevogel
DOI:10.4103/INTV.INTV_54_19  
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ARTICLES Top

How to conduct a mental health and psychosocial support situational analysis in a refugee-based emergency context: a case study example from Cox’s Bazar, Bangladesh p. 122
Sarah Harrison, Alex Ssimbwa, Mohamed Elshazly, Mahmuda Mahmuda, Olga Alexandra Rebolledo
DOI:10.4103/INTV.INTV_42_19  
Early in 2019, a situational analysis of mental health and psychosocial support services for Rohingya refugees in Cox’s Bazar was carried out jointly by International Federation of Red Cross Red Crescent Societies Reference Centre, International Organisation for Migration and United Nations High Commissioner for Refugees. The main objective of this situational analysis was to identify the approaches that were working well within the current response, the gaps within existing mental health and psychosocial support (MHPSS) services for Rohingya refugees in Cox’s Bazar and to provide practical options and recommendations for MHPSS service providers working through different sectors. The methodology included: 1) a review of existing knowledge about MHPSS services for Rohingya refugees in Cox’s Bazar through desk review methodology; 2) analysis of updated 4Ws (who is where, when and doing what) MHPSS service mapping; 3) strategic priorities mapping which was conducted with members of the MHPSS Working Group in Cox’s Bazar; 4) focus group discussions with camp populations; and 5) meetings with service providers. The results from the strategic priorities mapping are shared in another article in the Special Issue of Intervention (Harrison et al., 2019, pp. 206–211). This article draws upon the Cox’s Bazar case study to outline the methodological approaches and process used to conduct a situational analysis, with a view to guiding agencies interested in undertaking future situational analyses in other, ongoing, refugee and humanitarian contexts. Key implications for practice
  • An MHPSS situational analysis conducted in an ongoing emergency or refugee setting is a useful programming and advocacy tool for country-level MHPSS working groups and the agencies that co-lead these working groups.
  • The process of conducting an inter-agency MHPSS situational analysis supports the functioning, purpose and coordination activities of a country-level MHPSS working group.
  • Future MHPSS situational analyses should be conducted with the full involvement of persons with severe mental health conditions, to ensure that the perspectives of service users are included, in addition to persons suffering from psychological distress and persons with transient MHPSS problems.
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Integrating mental health into primary health care in Rohingya refugee settings in Bangladesh: experiences of UNHCR p. 130
Sadya Tarannum, Mohamed Elshazly, Sandra Harlass, Peter Ventevogel
DOI:10.4103/INTV.INTV_34_19  
Hundreds of thousands of Rohingya refugees fled from Myanmar to Bangladesh. The greatly increased mental health needs are paired with limited resources for mental health care, particularly human resources. Therefore, UNHCR, the refugee agency of the United Nations, designed a programme to integrate mental health within refugee primary health care, using the Mental Health Gap Action Programme Humanitarian Intervention Guide (mhGAP-HIG) as the central tool. The aim was to scale up mental health services through capacity building of medical staff in refugee health facilities to enable them to identify and manage people with mental, neurological and substance use conditions. This paper is a process description of the programme, using direct experience of the authors, analysis of training evaluations and data from the refugee health information system and clinical supervision reports. Sixty-two primary health care workers were trained. Participants of the mhGAP training showed clear improvements in the post-training knowledge test. These trained staff started providing mental health and psychosocial services after the training in primary health care centres in the refugee camps. Fifteen of them participated in a bi-weekly supervision/on-the-job training visit. Within this period of time, almost 1,200 mental health consultations were realised in the primary health care facilities. Supervision reports of mhGAP-trained participants showed that in order to become effective mental health providers, the participants need to strengthen various skills including performing mental state examinations, providing psychoeducation and using psychosocial support techniques. In conclusion, the integration of mental health within the Rohingya refugee settings faced many challenges but proved to be feasible.
Key implications for practice
  • Health system preparation and readiness is an important pre-requirement for integration of mental health into primary health care services. This is particularly significant in humanitarian settings in which the health system is fragile and struggling to keep services at a minimally acceptable level.
  • Capacity-building efforts alone cannot guarantee the success of the integration process, that is, adequate attention should be paid to communication with health policy and decision makers especially on facility and local level to foster the process of integration and support scaling up.
  • On-the-job supervision is a critical factor in mental health capacity building of non-specialist health providers. Without supportive clinical supervision, any plan for integration of mental health into primary care should be considered deficient and ineffective.
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Physical activity as a psychosocial intervention among Rohingya refugees in Bangladesh: a rapid ecological community assessment p. 140
Ruth Wells, Shaun Némorin, Zachary Steel, Meghna Guhathakurta, Simon Rosenbaum
DOI:10.4103/INTV.INTV_15_19  
Over 907,000 Rohingya refugees are currently living in mostly makeshift camps in Bangladesh with limited resources to address their psychosocial needs. Physical activity is a scalable, low-cost intervention effective for prevention and treatment of non-communicable diseases and mental health problems. Understanding community attitudes to physical activity and mental health is key to designing community endorsed and accessible interventions. We employed the ‘community readiness model’, a tool to assess community climate, needs and resources regarding physical activity as a community-driven psychosocial intervention. Fifteen Rohingya key informants were interviewed across multiple refugee camps in Cox’s Bazaar district in January 2019. Community readiness scores were calculated. Thematic analysis explored community-identified priorities. Community members strongly endorsed physical activity as an effective biopsychosocial strategy for relieving tension (a local idiom of distress). Despite leadership endorsement, space and resources to support community initiatives are extremely limited. For women, restrictions of movement were identified as barriers to participation. Physical activity is a feasible and acceptable community-identified strategy to promote psychosocial wellbeing among Rohingya refugees. Resources for physical activity programmes are extremely limited despite the identified social, mental and physical health benefits.
Key implications for practice
  • Physical activity was identified as a psychosocial strategy by Rohingya refugees living in Cox’s Bazar, Bangladesh, which can help to relieve tension, which is a local idiom of distress.
  • Resources (such as space and equipment) to support community-led physical activity initiatives are limited, despite support from community leadership.
  • Access to physical activity is limited for women, due to security fears and cultural attitudes, as well as for people with disabilities and older people, due to overcrowding and lack of accessibility planning.
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Contextual adaptation and piloting of Group Integrative Adapt Therapy (IAT-G) amongst Rohingya refugees living in Bangladesh p. 149
Mahmuda Mahmuda, Mohammad Abdul Awal Miah, Mohamed Elshazly, Sanjida Khan, Alvin Kuowei Tay, Peter Ventevogel
DOI:10.4103/INTV.INTV_48_19  
A main gap in the delivery of mental health and psychosocial (MHPSS) services to Rohingya refugees in Cox’s Bazar district in Bangladesh is the limited coverage of psychotherapeutic interventions. There is a shortage of mental health professionals who can provide culturally adapted and linguistically appropriate psychotherapeutic interventions that are congruent with the refugee experience. This article describes preliminary work on training Bangladeshi psychologists and para-professionals in applying a novel group-based psychological intervention for refugees, Group Integrative Adapt Therapy (IAT-G). This is a pragmatic, eclectic and transdiagnostic approach, based on the Adaptation and Development After Persecution and Trauma (ADAPT) model. It aims to help refugees to develop resilience and capacities for managing maladaptive reactions to trauma and post-migration living difficulties. This paper describes the key strategies and challenges during the first phase of the project. Activities included an extensive desk review, a one-week training workshop with competency assessments, cultural adaptation of the treatment manual and assessment measures, training on digital literacy and electronic data collection and a blended supervisory model (involving onsite and online sessions). It proved to be generally feasible but not easy to introduce IAT-G in this population. Key implications for practice
  • The introduction of a brief scalable psychological intervention within an acute and ongoing emergency was feasible, but faced considerable challenges including high staff turnover.
  • Implementation involves multiple components including stakeholder engagement, contextual adaptation of tools and materials, training and supervision and setting up a monitoring system.
  • Setting up a supervision is of critical importance but can be complicated in the context of an unfolding emergency.
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Supporting maternal mental health of Rohingya refugee women during the perinatal period to promote child health and wellbeing: a field study in Cox’s Bazar p. 160
Francesca Corna, Fahmida Tofail, Mita Rani Roy Chowdhury, Cécile Bizouerne
DOI:10.4103/INTV.INTV_28_19  
In humanitarian crises, such as the Rohingya situation in Bangladesh, maternal and child health may be strongly affected. Maternal mental health is a well-recognised key factor for child survival, development and health. Promoting maternal mental health during the perinatal period, especially in emergencies, contributes to the prevention of child mortality, morbidity and psychological distress. Despite this, few humanitarian psychosocial interventions have been evaluated to measure their effect on maternal mental health and child care. In 2012, Action Against Hunger in collaboration with the International Centre for Diarrhoeal Disease Research, Bangladesh, evaluated the effect of a psychosocial support groups intervention on 260 pregnant Rohingya women, living in the registered camps of Cox’s Bazar. A set of questionnaires (including MMSE, CES-D scale and Rosenberg’s Self-Esteem scale) was administered to participants to measure the improvement on mental health and childcare knowledge after a three-month psychosocial intervention. Maternal wellbeing and childcare knowledge improved significantly over the three months of intervention. Findings suggest psychosocial intervention can be effective despite the chronic stressful conditions of the refugees in the camps. This study reinforces the importance of community-based interventions promoting mental health in contexts of chronic crisis and contributes to the research discussion on the impact of maternal mental health and childcare promotion programming.
Key implications for practice
  • Supporting maternal mental health during the perinatal period has a positive impact on women's wellbeing and is also a key factor for good childcare, children's wellbeing and early childhood development. In an emergency situation such as the Rohingya crisis in Bangladesh, promoting maternal mental health is an effective way of preventing difficulties during the perinatal period that may aggravate family, maternal and children's wellbeing.
  • Psychosocial support groups appear to provide an effective methodology to work with refugees on mental health and childcare promotion, since refugees are often isolated, with disrupted social support and with limited access to external resources.
  • Reinforcing women's internal and external resources through group support helps to improve their self-esteem, which is a key factor for general wellbeing.
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Exploring host community attitudes towards Rohingya refugees in Bangladesh p. 169
Mst. Ismat Jerin, Muhammad Kamruzzaman Mozumder
DOI:10.4103/INTV.INTV_27_19  
Acceptance and assistance from the host community is crucial to ensure support for refugee populations. This article explores attitudes of the host community about Rohingya refugees in Bangladesh. In total, 202 respondents from Ukhiya in Cox’s Bazar participated in a questionnaire survey about their attitudes towards Rohingya refugees. Respondents from the host community demonstrated mixed attitudes. This article discusses these attitudes and their likely future impacts on the two populations. Findings may contribute to planning strategies towards preventing conflict escalation and increasing integration in the provision of assistance to the Rohingya in Bangladesh. Key implications for practice
  • The findings provide a baseline on host community attitudes and beliefs regarding the refugees, which may prove useful in tracking and understanding changes over time.
  • It orients the readers to the need to consider a host community perspective in providing refugee care.
  • This article calls for action to improve host–refugee relationships to avert possible conflict.
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Emotional distress among Rohingya refugees in Malaysia p. 174
Stacey A Shaw, Hamid Karim, Noelle Bellows, Veena Pillai
DOI:10.4103/INTV.INTV_8_19  
Malaysia hosts over 175,000 refugees or asylum seekers who are registered with the United Nations High Commissioner for Refugees, over half of whom are ethnically Rohingya. Economic, social and health challenges are common among refugees residing in countries of asylum such as Malaysia with limited legal rights and uncertainty regarding the future. This study examined emotional distress among a sample of 115 Rohingya refugees living in urban areas within Malaysia. We utilised both quantitative and qualitative methods to assess psychosocial wellbeing. After measuring emotional distress with the Refugee Health Screener-15, we examined socio-demographic and environmental characteristics associated with distress scores. We then examined open-ended responses to qualitative questions regarding perceptions of difficulties refugees experience in Malaysia as well as perspectives on needed assistance. Findings indicated that emotional distress was widespread among this sample. Age was associated with higher rates of distress, while gender, time in Malaysia, employment and other measured factors were not associated with distress. Qualitative themes emphasised challenges with income, documentation and concerns regarding global conflict. Findings point to the need for services that address economic needs as well as reducing distress, in addition to policy challenges that will enable stability and security for Rohingya refugees.
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Mental health of Rohingya refugees and asylum seekers: case studies from Malaysia p. 181
Xavier Pereira, Sharuna Verghis, Cheng Kah Hoe, Asma Binti Zahir Ahmed, Shasvini Naidu Nagiah, Leo Fernandez
DOI:10.4103/INTV.INTV_33_19  
Rohingya refugees are one of the oldest and largest asylum-seeking populations in Malaysia. Yet, there is a dearth of literature in relation to this population and their mental health. Through case studies, this paper seeks to add to the emerging body of knowledge on the Rohingya. These case studies highlight the unique factors which contribute to mental ill-health among them. It also seeks to identify mental health and psychosocial support strategies that are currently being implemented to address the mental health needs of the Rohingya in Malaysia, the challenges encountered and possible ways forward.
Key implications for practice
  • The importance of psychological and psychosocial interventions beyond pharmacotherapy.
  • The need for an multi-disciplinary approach.
  • The importance of cultural sensitivity and cross cultural communication.
  • The role of advocacy in complementing clinical interventions in developing sustainable solutions to addressing the mental health needs of the Rohingya.
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Intimate partner abuse among Rohingya in Malaysia: assessing stressors, mental health, social norms and help-seeking to inform interventions p. 187
Courtney Welton-Mitchell, Noor Arifah Bujang, Hasnah Hussin, Sharifah Husein, Fajar Santoadi, Leah Emily James
DOI:10.4103/INTV.INTV_18_19  
Intimate partner abuse (IPA) is one of the most common forms of gender-based violence worldwide. Risk for IPA can increase during periods of displacement, especially for refugees and other forced migrants. The current study explores patterns of IPA, its correlates and help-seeking behaviours among Rohingya refugees in Malaysia − a group that is particularly marginalised and vulnerable, being stateless and often unable to legally work or access various services. As part of a larger study, a multinational team collected information about IPA among displaced Rohingya in Malaysia through structured household interviews and focus groups, including women, men, community leaders and service providers (n = 75). Results indicated high rates of IPA. Respondents also reported numerous chronic stressors and suggested links between stressors, mental health and IPA. Social norms emphasising the acceptability of IPA and discouraging help-seeking were also common. These data have broad implications, including for development of a ‘healthy relationships’ intervention integrating social norms and mental health approaches to address IPA in Rohingya communities, with potential for scale-up within Malaysia and elsewhere.
Key implications for practice
  • Practitioners will better understand intimate partner abuse among Rohingya communities, including links with historical and chronic stressors, social norms and mental health.
  • Practitioners will better understand preferred sources of help-seeking and barriers to help-seeking for intimate partner abuse among Rohingya communities.
  • Practitioners will better understand how to develop interventions for intimate partner abuse, including healthy relationship workshops and public health messaging campaigns based on social norms.
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FIELD REPORTS Top

Challenges and opportunities for Rohingya mental health and psychosocial support programming p. 197
Mohamed Elshazly, Boris Budosan, A.N.M. Mahmudul Alam, Nabila Tarannum Khan, Peter Ventevogel
DOI:10.4103/INTV.INTV_49_19  
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.
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Strategic priorities for mental health and psychosocial support services for Rohingya refugees in Bangladesh: a field report p. 206
Sarah Harrison, Alex Ssimbwa, Mohamed Elshazly, Mahmuda Mahmuda, Mohamed Zahidul Islam, Hasna Akter Sumi, Olga Alexandra Rebolledo
DOI:10.4103/INTV.INTV_40_19  
In early January 2019, a participatory workshop took place in Cox’s Bazar, Bangladesh, with the mental health and psychosocial support working group (MHPSS WG) members. The principal purpose of the workshop was to develop the top ten strategic priorities that the MHPSS WG members wished to focus on over the next two years to improve the mental health and psychosocial wellbeing of the Rohingya registered and non-registered refugee camp populations. The strategic prioritisation areas also served as key advocacy messages that can be used in discussions with policy makers, government authorities and humanitarian donor agencies regarding the mental health and psychosocial needs of Rohingya refugee males, females, boys and girls residing in Cox’s Bazar, Bangladesh. The authors believe the strategic prioritisation process contributes to the functioning and purpose of a country-level MHPSS WG and therefore advocates for the approach in other humanitarian and refugee contexts.
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Field-level coordination of mental health and psychosocial support (MHPSS) services for Rohingya refugees in Cox’s Bazar p. 212
Mohamed Elshazly, A.N.M. Mahmudul Alam, Peter Ventevogel
DOI:10.4103/INTV.INTV_38_19  
The areas around Ukhiya and Teknaf in Cox’s Bazar district in Bangladesh are the location of some of the world’s largest and most congested refugee settlements. The refugees have myriads of needs, and hundreds of different organisations provide assistance in an enormously complex and at times chaotic humanitarian operation. The humanitarian community in Bangladesh has identified the provision of effective mental health and psychosocial support (MHPSS) services as a priority. However, the multi-sectoral nature of MHPSS can create challenges especially when it comes to coordination of services. A central coordination mechanism, the MHPSS working group, was established in December 2017. It is a sub-working group of the health sector and it has close ties with other sectors, mainly protection. This central MHPSS working group is attended mostly by mid-level and senior staff involved in policy and programming. We found that adding ‘field-level coordination’ with actors who work in the same geographical area helped to strengthen communication, cooperation and local coordination. It assists field-based staff to stay informed of each other’s work and can promote collaboration. For example, in the elaboration of the Emergency Preparedness and Response Plan to mitigate the effect of monsoon-related events in Cox’s Bazar, the field-level coordination mechanism proved very useful. Moreover, an area-based coordination mechanism can be a suitable platform to engage the affected communities in MHPSS coordination. This field report highlights the rationale, challenges and lessons learned from field-level coordination experience and argues that in large humanitarian settings establishing such area-based coordination mechanisms can have a clear added value and should be routinely considered.
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Psychological and psychiatric care for Rohingya refugees in Bangladesh p. 217
Geraldine M Dyer, Mukti Biswas
DOI:10.4103/INTV.INTV_30_19  
This field report outlines a mental health and psychosocial programme provided by Médecins Sans Frontières for Rohingya refugees in Cox’s Bazar, Bangladesh. This specialised programme focuses on the identification, assessment and management of moderate to severe mental health disorders whereas the majority of mental health and psychosocial support programmes within this context are providing focused non-specialised care. The activities provided by the programme include counselling, psychological intervention and treatment with psychotropic medication. An outreach model utilising volunteers from the refugee community is critical for case identification and community sensitisation. There were challenges with recruitment of appropriate human resources and adequate space for consultations. The most common presentations are psychotic disorders − many of the patients have long histories of untreated illness. Discussion considers cultural factors relating to mental health in the Rohingya community and comparisons with mental health and psychosocial support programmes in a number of humanitarian contexts.
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Community partnership with Rohingya refugees in Sydney, Australia: a systemic approach towards healing and recovery p. 225
Shaun Némorin, Shakeh Momartin, Mohammad Junaid
DOI:10.4103/INTV.INTV_31_19  
This field report highlights some modalities used in resettlement countries, such as Australia, which provide services to vulnerable Rohingya refugees. It encompasses both personal reflections coupled with an overview of the agency-based operational framework and evaluation which underpins the work of Service for the Treatment and Rehabilitation of Torture and Trauma Survivors and informs our community work towards the recovery of those impacted by war and systemic state-sponsored terrorism. Our aim is to further contribute to discourse about the ways in which service provision is accomplished, ensuring marginalised refugee groups are protected and supported. A background to the current Rohingya refugee context is provided, as well as the biopsychosocial systemic model informing our work. A brief overview of our agency’s various programmes, informed by community consultations and designed to foster healing Rohingya refugees, is presented. We describe our experience in evaluating services for improving efficacy when working with traumatised populations, including recommendations towards community self-determination and asset-based community development for Rohingya refugees.
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Child-centred, cross-sectoral mental health and psychosocial support interventions in the Rohingya response: a field report by Save the Children p. 231
Aladin Borja Jr., Ruma Khondaker, Jessica Durant, Beatriz Ochoa
DOI:10.4103/INTV.INTV_17_19  
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.
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The role of psychosocial support in coping with incidents of gender-based violence among Rohingya refugees Highly accessed article p. 238
Dhahabu Ibrahim Shair, Kazi Shahin Akhter, Anika Shama
DOI:10.4103/INTV.INTV_16_19  
Gender-based violence (GBV) remains a significant risk and everyday reality for Rohingya women and girls displaced in Cox’s Bazar district, Bangladesh. Women and girls face challenges in securing their safety, accessing information and services and negotiating decision-making. Restrictions on movement, cultural and social norms, low literacy and numeracy and reduced community and legal protections increase women and girls’ exposure to GBV. The current camp situation in combination with their experiences in Myanmar contribute to increased vulnerability to GBV. The aim of this paper is to highlight the role of psychosocial support in coping with incidents of GBV among the Rohingya refugees by exploring two particular cases. DanChurchAid (DCA) have found that useful approaches in this context have included the use of basic techniques for relaxation to help promote calmness in moments of anxiety and panic, plus reinforcement of positive coping strategies such as prayers, spending time with trusted people and engaging in productive activities (e.g., life skills training). This engagement has enabled Rohingya survivors of GBV to build relationships with other women, feel more relaxed and confident and able to respond effectively to issues affecting their lives.
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Implementing the Mental Health Gap Action Programme in Cox’s Bazar, Bangladesh p. 243
Hasina Momotaz, Helal Uddin Ahmed, M.M. Jalal Uddin, Rizwanul Karim, Maruf Ahmed Khan, Rajib Al-Amin, Nazneen Anwar, Tara Kessaram
DOI:10.4103/INTV.INTV_14_19  
In response to the overwhelming need for mental health and psychosocial support as a result of the humanitarian crisis in Cox’s Bazar, the Directorate General of Health Services, Ministry of Health and Family Welfare Bangladesh, in collaboration with the World Health Organization, the National Institute of Mental Health and the National Institute of Neurosciences, implemented the World Health Organization’s Mental Health Gap Action Programme in November 2017. Over the course of two trainings and supervision visits, general physicians, counsellors and other health professionals from both government facilities and nongovernmental organisations, working with both the host and Rohingya populations, have improved their capacity to assess and manage priority mental, neurological and substance use conditions using the Mental Health Gap Action Programme intervention guidelines. After the first training, over 75% of participants reported feeling confident to apply their learning to their work. Participants receiving the supervision visit valued this follow-up modality and demonstrated a high level of competency during an observed consultation. This was the first instance of the Mental Health Gap Action Programme implementation by the government of Bangladesh following a humanitarian crisis. Our findings suggest that trainees are providing better quality services to assess and manage mental health conditions and that mental health is being integrated into primary health care service delivery.
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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 p. 252
Joseph Sullivan, Natasha Thorn, Murad Amin, Kaitlin Mason, Noreen Lue, Muhammad Nawzir
DOI:10.4103/INTV.INTV_13_19  
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.
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Focus group discussions with Rohingya adolescents on current and future perceived needs and wants from two distinct cohorts in Bangladesh p. 259
Joel Montanez, Sanchary Prativa, Ilja Ormel, Mukta Jahan Banu, Nicolas Gulino, Cécile Bizouerne
DOI:10.4103/INTV.INTV_24_19  
Qualitative interviews were conducted with 24 single teenagers (aged 13–17) within gender-defined groups, 12 from Myanmar (arriving on or after the August 2017 influx) and 12 who were born in Bangladesh, to identify current and perceived future needs and wants of Rohingya adolescents. Participants reported that needs and wants were often associated with difficult lived experiences in Myanmar or Bangladesh. General results from both groups highlight the need to prioritise education and freedom of movement, as well as eradicating bullying and harassment. Other priorities that crossed cohorts included independence, citizenship, identity, restitution of land and property and access to nutritious and varied food. Myanmar-born females prioritised health, wellbeing, family and dignity-related needs, while Myanmar-born males highlighted needs involving restitution and both education and marriage for their siblings. Adolescents of both genders born in Bangladesh prioritised rights involving education, freedom and movement and reported a need to contribute to society beyond the Rohingya community. Female and male adolescents born in Myanmar expressed contrasting perceptions regarding the needs of the other gender. Unprompted answers suggested prioritising mental health management and community support to tackle the collective traumatic memories of the group of adolescents born in Myanmar. Overall findings would suggest tailoring interventions in accordance with the needs of distinct cohorts and genders, and to facilitate awareness among adolescents of the needs of other distinct groups.
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Implementing Integrative Adapt Therapy with Rohingya refugees in Malaysia: a training-implementation model involving lay counsellors p. 267
Alvin Kuowei Tay, Mohammad Abdul Awal Miah, Sanjida Khan, Mohammad Badrudduza, Rofique Alam, Susheela Balasundaram, Susan Rees, Karen Morgan, Derrick Silove
DOI:10.4103/INTV.INTV_45_19  
Contemporary scalable psychological interventions utilise task-shifting approaches that enable non-specialists such as social workers, nurses and lay persons to deliver structured interventions after a brief training and ongoing supervision by professionals. This field report describes a training-implementation approach we used to train lay counsellors to implement a psychological intervention, Integrative Adapt Therapy (IAT), with Rohingya Refugees in Malaysia. IAT is a theoretically guided programme based on the Adaptation and Development After Persecution and Trauma (ADAPT) model. Unlike existing cognitive behavioural treatment (CBT)-based interventions, IAT helps refugees trace their emotional and behavioural problems to the underlying psychosocial disruptions (reflected in the core ADAPT ‘Pillars’) they experience. We assessed implementation outcomes by conducting a focus group with the twelve lay IAT counsellors who completed a training workshop followed by six-month supervised implementation of the IAT programme with Rohingya refugees. The implementation outcomes focused on the value and benefits of the programme to the counsellors’ clients and broader community, implementation challenges, cultural acceptability, and recommendations for improvement in training. There was a strong agreement amongst the counsellors that both the clients and they themselves benefited from the programme. Furthermore, the general consensus was that the clients reported improvements in their relationships with people (ADAPT Pillar 2: Bonds and Networks), in having a more realistic view about their Roles and Identities (Pillar 4) and in gaining a sense of purpose and meaning in life (Pillar 5: Existential Meaning). In addition, the focus group agreed that the programme fitted well with the culture and values of the Rohingya people. Implementation challenges include ensuring that the intervention team reflects gender balance, that the programme is sustainable and refining strategies to facilitate programme attendance and adherence.
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Rituals and healing ceremonies help to promote psychosocial wellbeing by increasing sense of identity and community in Rohingya refugees in Bangladesh p. 278
Olga Rebolledo
DOI:10.4103/INTV.INTV_52_19  
In Myanmar, the Rohingya were prohibited from engaging in activities that preserved their cultural and religious identities. An assessment was conducted by the International Organization for Migration in 2018 with Rohingya refugees residing in Cox’s Bazar, Bangladesh, to identify key factors to promote psychosocial wellbeing. These factors were strengthening sense of identity, practising their faith and participating in group and community activities. It was also found that prayers, music and art were key aspects of coping mechanisms. The Healing Ceremonies programme was developed in 2018 to provide a space to reconnect with their memory as an ethnic group and to contribute to healing the collective wounds of the community. Three sessions of bi-weekly healing ceremonies were conducted in 10 refugee settlements in Cox’s Bazar, Bangladesh. The three sessions, each representing different elements of Rohingya culture, were held with 850 Rohingya refugees participating, ranging in age from 25 to 53 years and another group between 54 and 70+ years of age. Children were also invited to attend and to benefit from ceremonies and activities to reconnect them with a sense of protection from their community and primary caregivers. There were a total of 36 sessions held over the course of the programme, covering music, art and symbols of strength, followed by focus group discussions on the impacts of the sessions. The children did not participate in these discussions and, therefore, were not included in the group participant numbers. The discussions highlighted positive changes including a sense of calmness and joy from participating in the healing ceremonies that led to an increase in their sense of wellbeing, and that the focus on positive aspects led to feeling less hopeless. Further, it is expected, that by providing a safe space where community members can reconnect with their collective memory and identity, they will be supported in healing collective wounds resulting from a history of persecution and denial of their identity.
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Sports and physical activity in psychosocial interventions with adolescent groups of the Rohingya community in Bangladesh: potential, limitations and critical factors for success p. 284
Md. Salek Ahmed, Mahmuda Mahmuda, A. N. M Mahmudul Alam
DOI:10.4103/INTV.INTV_51_19  
The mental health and psychosocial needs of adolescent Rohingya refugees in Bangladesh are seriously underserved. There are few services and resources for them, and this population is hard to reach with conventional mental health and psychosocial support activities. Adolescent Rohingya refugees have very limited opportunities to express themselves and to engage in the community. This affects their mental health and psychosocial wellbeing negatively. This field report argues that the use of sports and physical activity could be a valuable means to provide psychosocial support to adolescent Rohingya refugees. A small number of research efforts and project evaluations have begun to help us understand the link between participation in sport and physical activity and mental health and psychosocial wellbeing. The data of this study were collected through focus group discussions and key informant interviews. The findings suggest that sports and physical activity may play a significant role in the psychosocial development and in strengthening positive social communication among adolescents. However, the development of sport activities in a humanitarian setting such as the Rohingya crisis is not easy. This field report explores challenges related to gender, local cultural context and community structure. Finally, some factors are discussed on how to design psychosocial programmes that include sport and physical activity and how to promote this with several stakeholders. *Both first authors contributed equally.
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Making psychosocial support programmes in emergencies inclusive: lessons learned from interventions in Rohingya camps p. 290
Sanem Ozen, Davide Ziveri
DOI:10.4103/INTV.INTV_29_19  
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.
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PERSONAL REFLECTIONS Top

The story of a Rohingya refugee: becoming a community psychosocial volunteer p. 296
Arafat Uddin, Hasna Sumi
DOI:10.4103/INTV.INTV_46_19  
Following violence in Arakan State in Myanmar in August 2017, many Rohingya refugees arrived in Bangladesh with tremendous mental trauma. They also arrived with health problems, along with psychosocial distress shaped by their experiences in Myanmar. Mental health conditions and psychosocial problems have made life more precarious than ever to them. To come to another country (Bangladesh) and to adjust here was a major change to their lives. However, people can also be resilient in the face of adversities and some are able to continue and thrive in the context of perspective hardship. In this personal reflection, the first author, Mr. Arafat Uddin, shares his experiences as a community psychosocial volunteer at the makeshift refugee camps in Bangladesh. He describes his own experience as a Rohingya refugee and shares his personal experience of becoming a psychosocial volunteer. He has also reflects on his role as a community psychosocial volunteer, discusses the challenges he faces, describes perceptions of the community around his work, and shares his future expectations. In the last part of this piece, Hasna Sumi, a female Bangladeshi psychologist with UNHCR, describes her experiences in training and supervising community psychosocial volunteers.
  • This personal reflection contains the life history of Arafat Uddin as told to Hasna Akter Sumi, Psychosocial Associate with UNHCR’s Mental Health and Psychosocial Support team in Cox’s Bazar. When the call for papers for this special issue was launched, Sumi had the idea to record a life story from the perspective of a Rohingya refugee. She works closely with a team of Rohingya psychosocial volunteers and asked who among them would volunteer to share their story. Arafat willingly came forward. Sumi and Arafat sat together on 29th April and 2nd May 2019 in camp 4 in Kutupalong Mega Camp. They spoke in the Rohingya language. Arafat told his story while Sumi wrote it down in an English version. The various drafts of this article were discussed with Arafat and he has given his consent to publish this story.
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The story of Salma and Sahar: a Rohingya mother and Bangladeshi baby who bridged two influxes and three family generations p. 301
Joel Montanez, Md. Salah Uddin, Fatema tuz Zohra, Ilja Ormel, Nicolas Gulino, Cécile Bizouerne
DOI:10.4103/INTV.INTV_23_19  
Sahar’s Bangladeshi mom had died during delivery and her daughter’s life was saved by Salma, a Rohingya woman. The 50,000 takas that Salma had saved from vegetable farming and raising chickens gave her the conviction that she could raise a dying child. Even if Salma’s husband and family-in-law did not agree with the adoption, Salma, who migrated to Cox’s Bazar in infancy, had seen in the camps how to sustain the survival of this dying and motherless child. Salma and Sahar’s story represents the interventions that resilient human beings put into effect with the support of key family members and internal resources. This is also an example signalling that in the current lingering crisis, we need to create bridges between earlier and newer Rohingya cohorts as well as to advocate for the Rohingya diaspora to be included in the process of caring for new lives. Ultimately, Salma and Sahar’s story is an illustration of the contribution of the Rohingya to Bangladeshi society.
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When resilience starts within the team: a case study of mental health and psychosocial support professionals during the Rohingya crisis in Myanmar p. 305
Pauline P Bubendorff
DOI:10.4103/INTV.INTV_20_19  
The author, a clinical psychologist who started her humanitarian experience in North Rakhine State, Myanmar ten years ago, coordinated mental health and psychosocial support (MHPSS) activities in Rakhine State during the latest crisis that led to mass displacement of Rohingya from Myanmar to Bangladesh. In this personal reflection, she describes how decisions related to technical management or coordination impacted team members and dynamics to such an extent that it seemed to contribute to team resilience. Based on her professional experience, field observations and team feedback, she proposes possible resilience building mechanisms which can be supported in any MHPSS humanitarian intervention. She hopes to confirm or open up perspectives on team support and staff care to humanitarian actors working with Rohingya communities around the world.
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Diasporic identity and transnational belonging: reflections from supporting mental health services in the Rohingya camps p. 310
Nargis Islam
DOI:10.4103/INTV.INTV_22_19  
Since August 2017, approximately one million Rohingya people from Myanmar have fled from genocide, gender-based violence and torture in northern Rakhine state, Myanmar to Cox’s Bazar in neighbouring Bangladesh. International and local humanitarian agencies are now attempting to support the health and mental health needs of over 1.3 million people who are dependent on aid, including the host communities. This reflection paper considers diasporic and transnational belonging issues emerging from being an international consultant who is also Bangladeshi by origin, and the cross-learning processes that emerged through working with local services. Given the recognition that historically western narratives are privileged over non-western knowledge and experiences, key learning around this interface and the necessity of reflective and ethical practice competencies are outlined. Working with local services in humanitarian settings involved a congruence with a personal–professional value base, and a humility, openness, self-awareness and reflexivity. The importance of reflective and ethical practice competencies is discussed in the context of delivering effective and culturally congruent, meaningful and useful interventions. The paper outlines key learning and reflections from supporting work in the Rohingya camps in Bangladesh, and how this learning might apply to clinical practice in humanitarian and development settings.
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How social constructs take precedence over religious beliefs in Rohingya refugees p. 316
Ayat Ajaz Shah
DOI:10.4103/INTV.INTV_21_19  
As a public health intern of UNHCR Bangladesh, I reflect on my learning from the story of 16-year-old Rohingya refugee, Husna,1 after she was sexually abused by a neighbour in the Rohingya refugee camp she resides in. Husna began to regularly visit a counselling centre which she found helpful, but she also said that her reliance on her faith of Islam had made the healing process easier. Taking note of this, in addition to other observations I had made during field visits, I was able to understand how religion plays a major role in the lives of the Rohingya people, and how they adopt practices in accordance with their interpretation of it. The example discussed in this personal reflection is that of Husna’s father, who maintained that although he knew it would be Islamically encouraged to engage in legal action against his daughter’s perpetrator (which would also promote his daughter’s safety and peace of mind), he feared that if word regarding her abuse became known to his community, his daughter’s future chances of receiving marriage proposals from potential suitors would be hampered. As per Rohingya culture, male members are responsible for making major decisions on behalf of their families. Husna’s father admitted that despite being a devout Muslim, he had certain reservations when it came to his family’s pride and social standing. Ultimately, I learned that the father was uncomfortable with following through with the legal process due to fears that Husna would not be desired as a spouse in the future. This exemplified that although religion does play an important role in the lives of the Rohingya people, cultural factors can cause social constructs to take precedence over religious beliefs.
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