|Year : 2021 | Volume
| Issue : 2 | Page : 224-232
Despair and Suicide-Related Behaviours in Palorinya Refugee Settlement, Moyo, Uganda
Moses Mukasa Bwesige1, Leslie Snider2
1 Mental Health and Psychosocial Support Specialist in Humanitarian Settings, Lutheran World Federation, Kampala, Uganda
2 Director, The MHPSS Collaborative, Save the Children, Copenhagen, Denmark
|Date of Submission||23-Feb-2021|
|Date of Decision||04-May-2021|
|Date of Acceptance||26-Aug-2021|
|Date of Web Publication||09-Sep-2021|
MSc Moses Mukasa Bwesige
Mental Health and Psychosocial Support Specialist in Humanitarian Settings, Room 2, 2nd Floor, Gulu Highway, Kampala
Source of Support: None, Conflict of Interest: None
This descriptive study illustrates the multitude of intertwining factors contributing to suicidal ideation and attempts, and deaths by suicide among South Sudanese refugees in Moyo/Obongi Palorinya settlements in northern Uganda. It was conducted from 2019 to 2020 due to escalating rates of suicide attempts and deaths by suicide noted in a rapid assessment by Lutheran World Federation mental health and psychosocial support (MHPSS) workers. This study aimed to better understand factors contributing to suicidal ideation and attempts among refugees, to tailor MHPSS interventions and prevent potential escalation of suicidality across the region, including nearby refugee hosting districts in Adjumani/Lamwo. Data collection techniques included key informant interviews, focus group discussions, case studies and review of the lead author’s therapy recovery notes. The findings highlighted the following factors contributing to escalating suicidality among the refugees: war stressors (experiencing and witnessing violent acts), daily stressors, social fragmentation, normalised violence, social isolation, lack of economic opportunities, loss of assets and loss of confidence and hope, among others. The assessment found that the spiking trend of increased suicidal behaviour is apparently unique to Moyo/Obongi, compared to neighbouring settlements, but emphasises the need for monitoring and preventive interventions in neighbouring districts. The psychosocial as well as economic impact of a reduction in funding for MHPSS programming is underlined, emphasising the need for long-term funding to consolidate programme effects and respond to realities on the ground. Community-based psychosocial support interventions provided by Lutheran World Federation are described that have subsequently helped to mitigate and respond to the escalating trend in suicidality and reflections given to strengthen the ongoing response with lessons learned for other contexts.
Keywords: MHPSS, suicide prevention, refugees, Uganda
|How to cite this article:|
Bwesige MM, Snider L. Despair and Suicide-Related Behaviours in Palorinya Refugee Settlement, Moyo, Uganda. Intervention 2021;19:224-32
| Background|| |
Few suicide prevention programmes exist in Uganda, despite significant rates of suicidal ideation. The number of suicide attempts and deaths by suicide among South Sudanese refugees in northern Uganda more than doubled in 2019, with 97 suicide attempts and 19 deaths, and up to 19% of refugee households reporting incidences of suicidal ideation (United Nations High Commissioner for Refugees (UNHCR, 2020).
Refugees in Palorinya refugee settlement (Moyo) constitute almost 80% of recorded suicide deaths among refugees in the northern part of the country (Nuri, 2020). Palorinya refugee settlement, adjacent to the Uganda-South Sudan boarders, was established in 2016. During the time of the study in 2019 as described in this field report, Palorinya had a total of 119,333 refugees. As summarised in [Table 1], of these just over half (52.8%) were females and 58.9% were children aged 0–17 years (Office of the Prime Minister (OPM) Population Summary by Settlement/Sex 31 March 2019). The total number of refugees increased in 2020 to 122,813 (UNHCR Palorinya Settlement Village Statistics, 31 May 2020).
|Table 1 Demographics of Refugees in Palorinya Refugee Settlement, Uganda, 2019|
Click here to view
Lutheran World Federation (LWF), supported by UNHCR, is the lead mental health and psychosocial support (MHPSS) and protection implementing partner in Moyo/Obongi refugee operation and provides one of the few MHPSS programmes addressing suicide prevention in northern Uganda. The programme provides community-based MHPSS services to refugees, aiming to help them manage negative thoughts, engage in social activities and reach out for help (UNHCR, 2020). The LWF-Moyo community-based psychosocial (CBPS) team, in collaboration with Medical Teams International (MTI) and UNHCR personnel, provided ongoing monitoring and assessment of the worrying trend of escalating suicide. A rapid assessment was triggered by a dramatic increase in attempted suicide and cases of apparent death by suicide among South Sudanese refugees in Palorinya, from less than 5 cases in 2017 and 2018 combined, to 15 suicide death cases and 29 attempts recorded in the first half of 2019. The details of gender, age and apparent contributing factors for completed and attempted suicides in Moyo in 2019 are summarised in [Table 2].
|Table 2 Demographics and Apparent Contributing Factors to Completed and Attempted Suicide Reported in Moyo 2019|
Click here to view
This field report summarises the findings of the rapid assessment, which was designed to explore the question: “What is new since 2018/2019 that could explain the seemingly dramatic shift in incidence of reported attempted suicide and suicide deaths in Palorinya refugee settlement?”
| Methodology|| |
The methodology adopted in this rapid assessment included a series of interviews and focus group discussions (FGDs) conducted with representatives of the OPM and LWF’s outreach para-counsellors who are members of the refugee population and know first-hand about the refugee experience. Interviews and FGDs were conducted by the LWF’s MHPSS team as well as selected outreach para-counsellors who were not also participants of interviews or FGDs. These selected para-counsellors were also enrolled as research assistants because of their particular insight into the suicidal behaviours being explored. Other interviews and FGDs were conducted with diverse groups such as religious actors, youth and women’s groups, refugee and host community leaders, members of an Alcohol Anonymous group and individuals who previously attempted suicide to gain a range of perspectives and deeper insight into the logic and factors contributing to suicidal behaviours. Interviews and FGDs were conducted in English, or in English with translation to Arabic Kuku/Bari provided by para-counsellors, and were recorded via note taking and recorders. The authors recognise potential sources of bias in the collection of data, including the use of para-counsellors who are also members of the refugee community as interviewers, the use of translators that could further interpret or misinterpret data and the fact that the study was conducted under the auspices of the organisation that provides services and that employs the lead author. Potential bias was mitigated through training and supervision of para-counsellors and translators, ensuring para-counsellors who were interviewed were not the same ones who served as interviewers or translators and through triangulation of information from varied sources and diverse participants.
[Table 3] describes the characteristics of participants for interviews and FGDs, by position/relevance to the study, gender and age group.
The lead author presented the findings of the assessment to LWF and MTI MHPSS teams, organisations working at different, complementary layers of the Inter Agency Standing Committee MHPSS intervention pyramid (IASC, 2007), to elicit further nuance to the problem analysis and possible solutions.
| Contributing Factors|| |
Various contributing factors were described as both causes and consequences of the escalating distress among the refugee population in Palorinya, and the consequent impact on suicidal ideation and attempts. The contributing factors are described below under the following themes:
- Compounding shocks from violence and daily life stressors
- Loss of assets, viable economic opportunities and agency
- Loss of hope for future peace
- Eroding social connectivity
- Alcohol misuse
- Failing to secure children’s education and wellbeing, and youth hopelessness
Compounding Shocks from Violence and Daily Life Stressors
Refugee respondents differentiate between two distinct types of distress they confront: one resulting from the impact of deadly violence and human rights abuses during the war, and new “shocks” stemming from daily stressors that characterise refugee life. Miller and Rasmussen (2014) indicate that daily stressors (e.g. parental divorce, sickness or loss of a family member) can be mediating factors between exposure to crisis-related stressors and psychological distress. These multiple stressors for refugees in Palorinya combine toxically, generating a sense of hopelessness that undermines the refugees’ self-confidence and capacity to effectively tackle the seemingly insurmountable challenges of forced displacement, and potentially increasing suicidal ideations and attempts. Of note, the refugees originated from a region that was not historically a focus of military violence in South Sudan, thus the war changed their lives dramatically in terms of social and economic stability, and they may have had fewer coping strategies to absorb both types of shocks.
In addition to exposure to violence and human rights abuses during the war, violence has become normalised in daily life of the refugees, contributing to the continued “shocks” occurring in lives of refugees, and worsening despair. Normalisation of violence may contribute to increased suicidal ideation and attempts through various means. Due to the near absence of a functioning judicial system in South Sudan, people tend to “take justice into their own hands”. Respondents described increasing risk of violent mob justice, brutal personalised violence and targeted “revenge” violence and killings of men (or their family members) accused of wartime activities. One Office of the Prime Minister (OPM) respondent explained that “these men commit suicide in order to avoid such attacks”. Conflict studies such as those of Annan et al. (2011) and Jimeno (2001) emphasise that exposure to ongoing deadly violence increases social fragmentation and isolation and changes social norms around the use of violence to solve even small disputes. Furthermore, the authors of this study suggest that if viewed as a form of violence directed at the self, suicide may be influenced by normalisation of interpersonal violence in society.
Loss of Assets, Viable Economic Opportunities and Agency
Loss of assets compound the stressful experiences of war for refugee respondents. As one refugee respondent stated: “People lost a lot, we had jobs, we had assets there; people saw their loved ones being killed”. Respondents noted that a number of refugees had arrived in the camps with some assets including livestock. However, over time, many of these assets were lost to disease and theft. In one case, a woman who had worked hard to earn money to pay her children’s secondary school fees reportedly attempted suicide after the money was stolen. Loss of remaining assets is a further shock can contribute to spiralling hopelessness and a sense that suicide is the only way out of desperate circumstances.
Lack of viable economic opportunities for the vast majority of refugees reportedly impacts both practical survival and their sense of self and agency to positively influence their circumstances. As described by Hobfoll and colleagues (2007), a sense of self and community efficacy − that the actions of an individual or group are likely to lead to generally positive outcomes − is one of five empirically derived intervention principles proposed for people exposed to mass trauma to achieve stress-resistant and resilient outcomes. But they go on to emphasise that interventions to build efficacy beliefs and behavioural skills can be doomed to failure in the situation of poverty of resources, and no clear path to regain personal, social and economic resources (Hobfoll et al., 2007, p. 13). Refugee respondents explained, “We had many things in South Sudan; we had things to do; here we are redundant”. In South Sudan, respondents noted they could do things for themselves, including sustainable agriculture; however, with the small plots of land currently allotted to them, they are unable to even ensure adequate food for their households. Respondents repeatedly called for vocational training and small inputs to kick-start sustainable self-reliance activities. In the absence of these, anxiety is increasing over the progressive reduction of World Food Programme (WFP) food rations, as few refugees have the independent capacity to augment the household food basket to compensate for the reductions. They also reported that NGO incentive jobs within the camp, the primary motor of the camp-based economic system, decreased by 30% in 2019.
Ellis et al. ((2015), p. 44) note that “while many refugees show great resilience and set up successful lives in their new homes, the structural challenges to creating a sense of belonging and contributing to society may leave some refugees particularly vulnerable to feelings of worthlessness and isolation”. Respondents, especially men, widely echoed this sentiment, one male respondent stating, “Now I am useless”. Respondents from Kajo-Keji, Yei and surrounding areas, particularly described themselves as having been “important” and “successful” prior to their forced displacement, and thus having “fallen far”. Male respondents feel women in their communities have been unable to adapt to the loss of their previous high standard of living and continue to hold men to expectations that they now cannot meet. Men report feeling harassed and turning to alcohol misuse and domestic violence.
A similar loss of sense of agency is evident among the youth, who frequently described themselves (and are described by adults) as “idle, bored and redundant”. They report feeling unable to reframe themselves as active and creative beings who can influence their own lives.
Loss of Hope for Future Peace
Many respondents talked about the loss of hope. One group of community FGD participants stressed, “People must have hope; they hope for many things like getting money to support their family; sending their children to school; and for going home”. But their hopes for peace and safety so that they can return home are repeatedly dashed with the failing peace process, and respondents state that consequently “people become mentally confused” and don’t know “how to move forward”.
As refugees in Moyo come from areas in South Sudan that were less affected previous wars, many expected they could return home within 2018. However, respondents recognise that, “Although there is a peace agreement, the war continues in South Sudan” and safe, sustainable returns are not possible. Prolonged life as refugees has fostered growing despair, as the national peace process misses established deadlines. Disappointment and uncertainty represent the “final straw” that pushes some people to consider suicide. Loss of hope also creates a toxic environment in which violence prevails and the space for humanity and compassion is progressively extinguished.
Eroding Social Connectivity
Social fracturing and erosion of social inter-connectedness were widely referenced as risks for suicide. Respondents highlighted that many women at risk of suicide are single heads of households, including young, unmarried woman who become pregnant and feel overwhelmed or shamed by their circumstances. Other alleged suicidal ideation or attempts were triggered by family break-ups, due to the man abandoning his family, or a woman fleeing domestic violence.
From another perspective, while extended families have taken in many separated children, some do so only to receive extra benefits, and children in these arrangements reportedly suffer disrupted access to education and forced early marriage. Social bonds and connections, critical factors in restoring wellbeing, thus continue to be eroded.
Women respondents acknowledged the critical value of “people coming together” to manage distress, but they also admit that the community does not proactively reach out to vulnerable, socially isolated or distressed people. They feel that the onus to engage rests with people who are distressed. Underscoring a sense of social isolation, one participant of a suicide recovery group could not identify a single person in the community (except her pastor and the LWF CBPS team) with whom she could share her worries. Thus, community-based MHPSS programming to mitigate social isolation and foster community outreach to vulnerable persons remains an important adjunct to focused MHPSS interventions.
Respondents also expressed concern for households that have experienced tragedy, such as suicide of a family member, but feel limited to help prevent the tragedy in the first place. Referring to the lack of material assets they used to have in South Sudan, one refugee respondent stated that “People have a lot of problems; you cannot help with words”. MHPSS programming helps to restore the value of community outreach to provide psychosocial support and “belonging”, empathy and compassion, even when material goods are scarce.
Alcohol misuse was noted as a growing concern and risk factor for suicide. OPM respondents stated that alcohol increases vulnerability of youth to suicide, because “alcohol makes them crazy; they can make quick decisions and just act”. Many refugee respondents suggested that “People drink because they are redundant, they have nothing to do, they have no jobs or salaries, they are frustrated” and alcohol helps them relax and forget their worries. Importantly the rate of alcohol abuse among refugee women is reportedly on the increase, as they tended to avoid alcohol use in South Sudan. One woman explained that drinking helps her to sleep, adding that “Without it, I am thinking too much”. Of note, alcohol-induced violence, especially among intimate partners, is escalating both in terms of prevalence and severity.
These risks are exacerbated by the fact that alcohol production and selling is one of the most viable income generating activities that women resort to within the camp. Alcohol is readily available, and some respondents pointed out that due to a lack of awareness, information and understanding, people drink excessively without recognising the consequences to their mental acuity, decision-making, behaviour, and physical and mental health. In their study on suicidal behaviour and alcohol abuse, Pompili et al. (2010, p. 1393) noted that, “Alcohol abuse may lead to suicidality through disinhibition, impulsiveness and impaired judgement”. Moreover, alcohol-abusing patients are more likely to have co-morbid psychiatric disorders that further increase their risk of suicide (Kraepelin, 1899, cited in Pompili et al., 2010). Greater community awareness of the cause-and-effect relationship between these elements may help generate some deterrence to substance misuse, with a consequent impact on suicide prevention or mitigating some causes of suicidal ideation and attempts, including domestic violence.
Failing to Secure Children’s Education and Wellbeing, and Youth Hopelessness
Women (especially those heading their households) are all too aware of what they term their “failures” towards their children’s welfare and education. One woman indicated that her perceived failure to take care of her children was a central contributing element to her own attempted suicide, explaining, “We can only watch our children suffer”. Lack of viable means to meet the daily needs of their children fuels a sense of hopelessness and loss of self. Respondents also noted that suicide of a parent carries stigma as it burdens others in the community, such as this quote from one refugee respondent: “Those who consider suicide are not thinking about their children; they are just thinking to leave the burden of raising them to the rest of the people”.
Decades of awareness-raising efforts by humanitarian and development partners have convinced young people and their caregivers of the importance of educating children as a source of hope for a better future. Respondents note that parents are now deeply distressed by their inability to pay school fees for secondary or advanced education. In addition, although primary education is free, most children are unable to access any education beyond primary grade 6 for other socioeconomic reasons. Youth expressed feeling especially devastated by this reality. In one interview, a young man aged 18 years was the image of despair explaining that since his father was killed in the war in South Sudan, his mother was now unable to pay his school fees to complete his secondary education. Forced to drop out of school and with no resources to advance his education through secondary or university level, he has no hope for his future. A number of both successful and attempted suicides reviewed by the author in 2019 among those aged 14–20 years were tied directly to this issue.
Limited opportunities for education are further compounded by the high prevalence of forced marriage for young women, including girls as young as 13 years old. Multiple young respondents stated they are forced into marriages because their guardians want to receive the dowry payment to offset the dire economic situation in those households. This is especially worrying, given that many girl children are hosted by people other than their biological parents, who may have less emotional ties to the girl and more incentive to force her into marriage. Youth respondents explained that the interruption of girls’ education combined with forced marriage have pushed some girls to suicide. Worsening economic conditions continue to fuel these challenges for girls and young women, further increasing their risk of suicide.
| Impact of Reduced MHPSS Funding|| |
LWF is by far the largest implementing agency in Moyo, and due to their CBPS approach, they have the closest engagement with the concerned population. During 2016–2018, intensive, participatory community-based activities were implemented that amplify inter-connectedness and social cohesion as the foundation for building refugee capabilities to support themselves and others. From 2017–2018, funding for CBPS doubled, allowing for a large increase in staff, including a cadre of community service workers and social workers across five zones.
However, the CBPS funding was reduced by two-thirds in 2019, with drastic cuts to staffing. Refugee respondents noted that this significant reduction in funding impacted community resilience programmes with immediate effects for the population. Effects included loss of opportunities for NGO incentive work − one of the few accessible and viable employment opportunities available to refugees − and a complete loss of incentivised workers dedicated to community services. The cadre of community service workers supporting family and community resilience strengthening in 2018 could no longer be engaged in 2019, and the number of social workers was also drastically reduced and eventually the positions cut entirely. Both refugees and programme staff respondents felt this reduction of support was premature because programme impact had not been adequately consolidated at community level.
The negative impacts reported by refugees and staffs due to reduced CBPS programme funds and activities underscores the importance of longer term funding for MHPSS programming in post-conflict settings to realise and sustain impact. Recovery from exposure to traumatic events, re-building wellbeing, functioning and social connections, and stimulating positive social change among crisis-affected communities are incremental processes that take time. The shock of forced displacement, loss of livelihoods and dependency on humanitarian aid undermine people’s confidence and sense of agency towards their own recovery and care for community members. During 2017–2018, the LWF team implemented community-based initiatives aimed at restoring calm, self-confidence and agency at individual level − elements essential for longer term recovery to shocks (Hobfoll et al., 2007) − and empathy, compassion and social responsibility at community level. These elements are foundational to fostering connectedness, restoring peaceful co-existence, encouraging people to engage positively in their community and to reach out to those most at risk.
Funding for social change processes should be driven by realities on the ground. Refugee respondents stressed that having become familiar with the value of psychosocial support, they are ever more aware of its absence when funding decreased, noting a broad regression in wellbeing. In particular, refugee respondents missed the community and family level structured MHPSS activities that were supporting social connectedness, collective resilience and group networking.
Nothing is static. Social change continues in the refugee settlements. However, without positive support and facilitation, such change may evolve in negative directions. One staff member reflecting on the findings of the study observed, “This context is very dynamic; people can easily regress to extreme levels of distress; this can be triggered by many things including an outburst of violence in their place of origin, a cut back of food aid, etc. − all of which is occurring”.
| Discussion|| |
Any successful suicide prevention strategy should hinge upon the important role affected communities can play, and rooting solutions and actions within communities themselves. LWF implemented the CBPS approach during the peak of escalating suicides in Palorinya settlement. Recognising and engaging affected communities as a resource, the lead author trained a team of 100 refugees as MHPSS “para-counsellors” who are now active across Moyo/Obongi and Adjumani/Lamwo districts. They were able to identify and refer 45 people with suicidal ideations for support in 2020. As a result, only 3 suicide deaths were recorded in 2020 compared to 19 in 2019, despite the social and economic challenges of the coronavirus disease 2019 pandemic.
Drawing upon lessons learned in this study, the following recommendations are offered for suicide prevention among refugees in Palorinya which may be useful for refugees in other regions too:
Anticipate and Prevent a Potentially Growing Trend
The multiple, contributing factors in Palorinya potentially apply to many South Sudanese refugees across the region. Thus, trends observed in Moyo could signal a wider trend across the region, as suicide-related behaviour becomes normalised in the current context. We should remain alert to this regional risk and pre-emptively implement prevention and response capacities.
Create Meaningful Opportunities for Education and Livelihoods
Meaningful and reliable opportunities for children and youth to access education are fundamental to their wellbeing and development, and the lack thereof is the prominent contributing factor in suicidal behaviour among children and youth in Palorinya. Furthermore, meaningful livelihoods are critical to enable refugees to rebuild and establish a quality of life beyond mere survival. Comprehensive implementation of education and livelihoods response (including early childhood, primary, secondary, tertiary education; vocational training; and adult literacy and numeracy training) is central to the Comprehensive Refugee Response Framework and Global Compact for Refugees. Global actors must move this commitment beyond rhetoric and enable implementing actors to make it a reality for the refugees in Palorinya. This is a critical advocacy issue, the shortfall of which costs lives.
Enhance Community-Based Psychosocial Efforts
This field report underlines the critical importance of LWF’s CBPS work and the profound, negative impact of the sudden reduction of this support before the community was able to carry such activities independently. CBPS work must also be implemented concurrently with, and integrated within, other key sectoral activities such as livelihoods and education to synergise impacts and promote sustainable social, psychological and economic recovery. A wide range of community duty bearers and rights holders, schools, workplaces, faith-based organisations, businesses, law enforcement, healthcare systems, and others can work together to deliver suicide prevention programs and services to high-risk groups at local level. Greater coordination among community and clinical service providers can synergise effects in preventing suicide and related health and mental health risk behaviours.
Foster Hope and Joy
A strong expression of positivity is essential to counter the increasingly toxic atmosphere of despair and hopelessness for refugees. In the spirit of solution-oriented programming, we need to develop a strategy that aims to prepare people to create a different kind of future by first helping them envision a different kind of future. Community centres can serve as places to foster hope and positivity and can help create a community-wide shift in attitudes of social connectivity and solidarity. Once grounded, community centres for hope can then be progressively extrapolated more widely. Furthermore, bringing community members together to promote play and joy at household and community level can be transformative itself. The LEGO Foundation, for example, emphasises that play supports children’s learning, wellbeing and healthy development and lays the foundation for lifelong learning (Zosh et al., 2017). Partnerships with organisations skilled in training youth in playful activities could generate important psychosocial impacts for children while engaging youth in constructive activities. Possibilities can be explored to prioritise, design and fund quarterly events that focus, settlement-wide in Palorinya, in supporting children and adults to re-engage with joy and laughter.
Changing Attitudes and Re-learning Peaceful Practices
Even when resources are scarce, it is critical to continue engaging refugees at the level of attitudes, beliefs and assumptions about peace, hope and their agency to influence their personal circumstances and environment positively. This includes creating opportunities for positive volunteerism and compassionate social responsibility (e.g. connecting youth in helping isolated elders) to counter feelings of boredom, idleness and redundancy. Furthermore, to counter the normalisation of violence in private and domestic spaces, people need to re-learn the value of social connectedness, peaceful co-existence, empathy and compassion. The CBPS approach in Palorinya helps rebuild social norms and connectivity through life skills that foster peace at individual, household and community levels − including support and protection for vulnerable children to counter a growing trend of child neglect, child marriage and other child rights abuses.
Work in a Sustained, Layered Manner to Strengthen Protective Community Networks
Complex social, psychological and economic issues faced by refugees must be tackled at multiple levels, from individual, family/household and community levels to the broader society (IASC, 2007). Positive change can be stimulated via community campaigns, through schools or existing youth and women’s groups, and together with opinion and religious leaders. Scholars like Hobfoll et al. (2007) note that the high degree of support characterising early emergency phases deteriorates with time and reduction of humanitarian aid, leading to a highly vulnerable period in later emergency and recovery phases − as true for Palorinya refugee settlement. Thus, at-risk individuals need long term support through direct programme engagement as well as community outreach to proactively draw them into social networks. The findings of this field report suggest that the community’s will and capacity to outreach to vulnerable people must be stimulated through CBPS programming and training to create progressively stronger and more sustainable socially protective networks.
Enhance Staff Capacity and Wellbeing
LWF and SCF MHPSS staff members identified the need for more intensive training and psychosocial support for themselves to engage more effectively with distressed refugee populations and equip them to better manage their own wellbeing in the process of this challenging work.
Enhance Inter-site Exchanges
Inter-site exchange among agencies and refugees themselves can help to share lessons learned, study methodologies, collective analyses and best practices for suicide prevention and response that can be adapted to specific contexts. Refugees in Palorinya often report that they are worse off than refugees in other settings and their distress is particular to them. Through exchanges, they can share experiences and coping strategies and find solidarity in managing the distressing situations they face within refugee settings.
| Conclusions|| |
The apparent increased rate of suicide in Palorinya settlement can be explained by social and emotional disconnection induced by an intersection of various factors that influence human rights and access to basic needs. Suicide-related behaviours among refugees in Palorinya seem to be an expression of layers of distressing experiences and prolonged stressful life circumstances that overwhelm refugees’ capacity to absorb shocks. This is further exacerbated by concurrent reduction in funding for MHPSS programmes that had previously provided both economic and social-emotional support, as well as failure of the peace process to progress that further undermines hope for the future and the ability to survive in the present.
Lessons learned from this study in Palorinya resonate with the literature on suicide prevention and response in neighbouring refugee settlements and add to the small but growing evidence base for improving prevention and response interventions. For example, Chiumento and colleagues (2020) found significant similarities among problems expressed by Congolese refugees in Rwanda and Uganda, rooted in diminished social cohesion. The authors further promote CBPS interventions to reinforce communities of support by harnessing the collective strengths and resources of refugee communities to promote mental health and psychosocial wellbeing. Further, the literature emphasises that this work must be done in concert with efforts to address the structural adversities that lead to forced migration in the first place and that contribute to the daily stresses of refugees, through programming that utilises multiple synergistic components (Haroz et al., 2020; Horn, 2009) and is rooted in the social ecology of the lives of refugees (Chiumento et al., 2020; Ingabire & Richters, 2020). The literature also emphasises the need for contextual and cultural understanding of how traumatic experience, loss, daily adversity, age and gender (including changes in gender roles; Baron, 2002), and how aid is delivered in situations of forced displacement impact suicidal ideation and attempts among refugees. For example, several studies corroborate the interconnected problems of lack of education and livelihoods, hopelessness, a sense of loss of agency and self-efficacy with substance abuse, domestic violence, early child marriage and adolescent pregnancy − all of which exacerbate suicidal ideation and attempts (Horn, 2009; Ingabire & Richters, 2020; Tankink et al., 2010; Vijayakumar, 2016).
More nuanced evidence is needed on the gendered aspects of the experiences of refugees with forced displacement, coping and recovery and with adaptations to new counter-cultural expectations enforced by how aid may be delivered. For example, respondents in several studies report that women are more likely to attempt suicide, but men are more likely to use lethal means. Better understanding of how these findings can be translated to effective prevention and response strategies for men and women, as well as strategies for different age groups and tailored for young people, is essential. Furthermore, one study emphasised that the efforts of humanitarian agencies to empower women by ensuring aid is delivered directly to female heads of households and promoting women’s and children’s rights, while having various benefits, can consequently increase marital strife and domestic violence as men’s roles as breadwinners and household authority figures may be undermined (Ingabire & Richters, 2020). This occurs concurrently with a lack of opportunities for many refugee men to access to dignified and meaningful livelihoods, and the ability to regain their productivity and self-esteem. CBPS programming can assist individuals, families and community leaders in better understanding these complexities in aid delivery and sociocultural dynamics to improve design of programmes and ensure their effectiveness in promoting mental health and wellbeing of community members of all ages, genders and abilities.
Finally, community-based MHPSS directly targets the issues that war, forced displacement and stresses of daily life in refugee settlements undermine − aiming to helping individuals better manage distress, and to rebuild community capacity to reconnect and collectively support those most vulnerable. Other studies corroborate the value that refugees place on community-based MHPSS interventions that promote family and community capacity to strengthen social cohesion, problem solving, basic psychosocial support skills and activities that promote recreation and emotional relief (Ingabire & Richters, 2020). But MHPSS programming requires long-term implementation to achieve these aims, that is, to ensure proactive engagement of individuals and communities in their own recovery, to build on capacities and resources within affected communities, and to stimulate a sense of agency and responsibility among the target population.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Annan J., Blattman C., Mazurana D., Carlson K. (2011). Civil war, reintegration, and gender in northern Uganda. Journal of Conflict Resolution
, 55(6), 877-908. https://doi.org/10.1177/0022002711408013
Baron N. (2002). Community based psychosocial and mental health services for southern Sudanese refugees in long term exile in Uganda. In De Jong J. (Ed.), Trauma, war, and violence: Public mental health in socio-cultural context
(pp. 157-203). Kluwer/Plenum.
Chiumento A., Rutayisire T., Sarabwe E., Hasan M. T., Kasujja R., Nabirinde R., Mugarura J., Kagabo D. M., Bangirana P., Jansen S., Ventevogel P., Robinson J., White R. G. (2020). Exploring the mental health and psychosocial problems of Congolese refugees living in refugee settings in Rwanda and Uganda: A rapid qualitative study. Conflict and Health
, 14(1), 77.
Ellis B. H., Lankau E. W., Ao T., Benson M. A., Miller A. B., Shetty S., Cardozo B. L., Geltman P. L., Cochran J. (2015). Understanding Bhutanese refugee suicide through the interpersonal- psychological theory of suicidal behavior. American Journal of Orthopsychiatry
, 85 (1), 43-55. https://doi.org/10.1037/ort0000028
Haroz E. E., Decker E., Lee C., Bolton P., Spiegel P., Ventevogel P. (2020). Evidence for suicide prevention strategies with populations in displacement: A systematic review. Intervention
, 18, 37-44.
Hobfoll S., Watson P., Bell C., Bryant R., Brymer M., Friedman M. J., Friedman M., Gersons B. P. R., de Jong J. T. V. M., Layne C. M., Maguen S., Neria Y., Norwood A. E., Pynoos R. S., Reissman D., Ruzek J. I., Shalev A. Y., Solomon Z., Steinberg A. M., Ursano R. J. (2007). Five essential elements of immediate and mid-term mass trauma intervention Empirical evidence. Psychiatry
, 70(4), 283-315.
Horn R. (2009). Coping with displacement: Problems and responses in camps for the internally displaced in Kitgum, northern Uganda. Intervention
, 7(2), 110-129.
Ingabire C. M., Richters A. (2020). Suicidal ideation and behavior among Congolese refugees in Rwanda: Contributing factors, consequences, and support mechanisms in the context of culture. Front Psychiatry
, 11, 299.
Inter-Agency Standing Committee (IASC) (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergencies
Miller K., Rasmussen A. (2014). War experiences, daily stressors and mental health five years on: Elaborations and future directions. Intervention
, 12(1), 33-42.
Pompili M., Serafini G., Innamorati M., Dominici G., Ferracuti S., Kotzalidis G. D., Serra G., Girardi P., Janiri L., Tatarelli R., Sher L., Lester D. (2010). Suicidal behavior and alcohol abuse. International Journal of Environmental Research and Public Health
, 7(4), 1392-1431. https://doi.org/10.3390/ijerph7041392
Tankink M., Ventevogel P., Ntiranyibagira L., Ndayisaba A., Ndayisaba H. (2010). Situation and needs assessment of mental health and psychosocial support in refugee camps in Tanzania, Rwanda and Burundi
. Unpublished report: HealthNet TPO; 2010.
United Nations High Commissioner for Refugees (UNHCR, 2020). Global trends forced displacement in 2019
. UNHCR: 6 June 2020.
Vijayakumar L. (2016). Suicide among refugees − a mockery of humanity. Crisis
, 37, 1-4.
Zosh J. M., Hopkins E. J., Jensen H., Liu C., Neale D., Hirsh-Pasek K., Solis S. L., Whitebrea D. (2017). Learning through play: A review of the evidence (white paper)
. The LEGO Foundation.
[Table 1], [Table 2], [Table 3]
|This article has been cited by|
||Refugee caregivers: Associations between psychosocial wellbeing and parenting in Uganda
| ||Melissa Meinhart, Patrick Onyango Mangen, Sabrina Hermosilla, Flora Cohen, Gary Samuel Agaba, Rehema Kajungu, Justin Knox, Grace Obalim, Lindsay Stark |
| ||Stress and Health. 2023; |
|[Pubmed] | [DOI]|
||Trauma Exposure, Social Networks, and Suicide Risk Among North Korean Refugee Women in South Korea
| ||Boyoung Nam, Ijun Hong |
| ||Violence Against Women. 2023; : 1077801223 |
|[Pubmed] | [DOI]|
||Adherence to Humanitarian Aid Principles and the Conditions for Refugee Settlements in Northern Uganda: Evidence from Humanitarian Aid Agencies in Adjumani District
| ||Kenneth Olido, Innocent Chandiga, Patrick Ocaya, Deogratias Mugaria, Clara Kansiime |
| ||Journal of Human Rights and Social Work. 2022; |
|[Pubmed] | [DOI]|