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Table of Contents
Year : 2021  |  Volume : 19  |  Issue : 2  |  Page : 242-248

Barriers, Attitudes, Confidence and Knowledge of Mental Health and Psychosocial Humanitarian Staff in Cox’s Bazar in Responding to Suicide Risk

1 Technical Specialist & Program Advisor, Friends in Village Development, Bangladesh, St. Louis, Missouri, USA
2 MHPSS Technical Specialist, Humanity & Inclusion, Bangladesh
3 Department of Clinical Psychology, University of Dhaka, Bangladesh
4 Consultant Psychiatrist, MHPSS consultant
5 School of Psychiatry, Faculty of Medicine, UNSW, Sydney, Australia

Date of Submission01-Dec-2020
Date of Decision27-Apr-2021
Date of Acceptance06-May-2021
Date of Web Publication09-Sep-2021

Correspondence Address:
MSW Lauren Fischer
Technical Specialist & Program Advisor, Friends in Village Development, St. Louis, Missouri 63110
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INTV.INTV_53_20

Rights and Permissions

Although suicide is a significant global health priority, it is underexamined in humanitarian crises. Over 850,000 Rohingya reside as refugees in Cox’s Bazar, Bangladesh; suicide risk may be high in this community by some indicators, but little is definitively known. Even less is known about humanitarian workers’ capacity to recognise and respond to suicide risk in affected communities. Participants were mental health and psychosocial support (30%), protection (31%), gender-based violence (17%) and others (22%) multisectoral humanitarian staff having weekly face-to-face contact with Rohingya refugees as part of their professional duties. We assessed barriers, attitudes, competence and knowledge regarding suicide-risk response. The survey was disseminated over 3 weeks in June 2020, engaging 181 respondents from multiple sectors of the coordinated response. Respondents who had prior training scored higher on the overall scale compared to those without (P ≤ 0.001), and there was a significant impact of prior training on attitudes (P = 0.005), confidence (P = 0.002) and knowledge (P ≤ 0.001). Humanitarian staff from multiple sectors reported low confidence or readiness to respond to suicide risk in the field. Training on suicide identification, intervention and response for such staff and related community gatekeepers is an urgent need in the Rohingya refugee response.

Keywords: confidence, mental health, MHPSS, Rohingya, staff training, suicide

How to cite this article:
Fischer L, Zarate A, Mozumder K, Elshazly M, Rosenbaum S. Barriers, Attitudes, Confidence and Knowledge of Mental Health and Psychosocial Humanitarian Staff in Cox’s Bazar in Responding to Suicide Risk. Intervention 2021;19:242-8

How to cite this URL:
Fischer L, Zarate A, Mozumder K, Elshazly M, Rosenbaum S. Barriers, Attitudes, Confidence and Knowledge of Mental Health and Psychosocial Humanitarian Staff in Cox’s Bazar in Responding to Suicide Risk. Intervention [serial online] 2021 [cited 2023 Mar 23];19:242-8. Available from: http://www.interventionjournal.org//text.asp?2021/19/2/242/325808

Key implications for practice

  • Formal training in suicide intervention is limited among humanitarian staff with routine contact with refugees creating a significant knowledge and intervention gap.
  • Suicide prevention training for humanitarian staff in Cox's Bazar is a strongly indicated need.
  • Monitoring and consistent evaluation of suicide intervention initiatives is recommended to scale effective approaches and inform other humanitarian contexts.

  Introduction Top

Suicide is a significant global health priority responsible for an estimated 800,000 deaths worldwide each year, 79% of which occur in low- and middle-income countries where the majority of the world’s population resides, including the majority of displaced persons globally (United Nations High Commissioner for Refugees, 2019; World Bank Group, 2020). Suicide is the second leading cause of death annually for people 15–29 years of age, although the true figure is likely to be higher due to notable underreporting (World Health Organization (WHO), 2019). While suicide has received attention as a significant global health concern, there is a need to further address suicide prevention with crisis-affected populations, particularly those displaced by disaster or conflict. The inception of a special thematic group in 2019 on ‘Addressing Suicide and Self-Harm in Humanitarian Settings’ by the Inter-Agency Standing Committee − the highest global forum for humanitarian coordination tasked with setting priorities and establishing standards for practice − speaks to this need. Refugee contexts typically present multiple stressors related to forced displacement, trauma exposure, loss of supports and opportunities and various forms of discrimination and abuse, which can impact mental health conditions − such as traumatic stress, depression and anxiety − known to be associated with suicide risk (Haroz et al., 2020). However, there is little consistent data to indicate the extent of suicidal behaviour among refugees, with some studies reporting estimated prevalence ranging from 3.4% to 34% (Tzeng & Lipson, 2004).

Bangladesh has recently made strides to address mental health needs and protect the rights of persons with various mental health conditions by enacting the Mental Health Act of 2018, but to date there has only been an ad hoc response to the issue of suicide in the country (Dey et al., 2019; Hossain et al., 2019). Bangladesh lacks a national suicide prevention strategy or national surveillance system, with much of the existing data extrapolated from media reports or sourced from law enforcement analyses (Arafat, 2017; Shah et al., 2018). While some researchers have explored alternative methods for assessing prevalence, they recognise the limitations of relying on media reports and household-level studies in such a populous country, and advocate for a national approach (Arafat et al., 2018; Mashreky et al., 2013). Furthermore, most media reports do not adhere to best practices for reporting, which may create challenges for future prevention efforts (Arafat, 2019). These efforts are often met with community reticence to disclose suicidality because of religious prohibition and stigma, with gendered consequences for the entire family system; these may be compounded by the National Penal Code, which makes suicide attempts or completions a punishable offence (Chapter XVI of Offences Affecting the Human Body, 1860; Soron, 2019). Such legal provisions have performed little to reduce incidence of suicide and may be reinforcing an adverse environment unconducive to seeking help or accessing social supports.

The Cox’s Bazar region of Bangladesh currently faces one of the largest humanitarian crises of modern times, hosting an estimated 860,500 Rohingya refugees who fled mass atrocities inflicted as part of a Burmese military campaign in 2017 against several Rohingya villages in Rakhine State of neighbouring Myanmar (UNHCR & Government of Bangladesh, 2020). The situation for the Rohingya in Bangladesh is changing from an acute crisis to protracted displacement as they “remain at serious risk of genocide under the terms of the Genocide Convention” (UN Human Rights Council − IIFFM in Myanmar, 2018). While experiencing restrictions of basic human rights, those living in refugee camps in Bangladesh, as in other humanitarian contexts, are also increasingly at risk of noncommunicable diseases, including cardiovascular disease and mental health issues (Aebischer et al., 2017). As rates of displacement continue to rise globally, the need to address the issue of suicide in humanitarian contexts is increasingly necessary (United Nations High Commissioner for Refugees, 2019). Rohingya refugees have experienced high rates of suicidal ideation (i.e. thoughts of dying by suicide) even before the recent mass displacements, which affected an estimated 13% of the refugee population present in Bangladesh before 2017 (Riley et al., 2017). More recently, anecdotal data from humanitarian medical response workers within the Suicide Prevention Subgroup indicated that hospitalisations for suicide attempts within the Bangladesh camps increased during the initial months of lockdown due to the coronavirus disease 2019 (COVID-19) pandemic in mid-2020 (Suicide Prevention Subgroup, 8 September 2020).

These figures may also be underestimates, as many Rohingya face faith-based hesitations around disclosure of suicidal ideation or attempts out of fear of judgement and shame, in addition to general stigma towards mental health issues (Tay et al., 2019). Especially in the light of the mass displacements of 2017, along with new, profound stressors such as catastrophic fires, relocations and restricted movement, a significant number of Rohingya refugees may still be experiencing unaddressed suicidal behaviours. Suicide is similarly an important issue in the Rohingya’s home country of Myanmar, which joins Bangladesh as one of only five countries globally where women die by suicide at a higher rate than men (WHO, 2019). The most recent data available estimates the suicide rate in Myanmar at 7.8 per 100,000, with 5.9 per 100,000 for males and 9.8 per 100,000 for females (WHO, 2019). Bangladesh has an estimated suicide rate of 6.8 per 100,000 for men and 8.7 per 100,000 for women (WHO, 2019). A recent study found that mental distress, interpersonal conflict and sexual abuse are significant drivers of suicidal behaviour and called for improved training to identify risk alongside support to increase coping mechanisms (Arafat et al., 2021). Similar findings have been echoed in the Rohingya response and contribute to motivations for the present study.

Generally, data related to suicide − including demographics, prevalence and intervention effectiveness − are lacking in the context of humanitarian sectors responding to global crises. However, subsectors of the humanitarian response framework such as gender-based violence (GBV) help to provide some insight through outreach to high-risk populations, such as female survivors of violence (Colucci & Montesinos, 2013). While some studies have shown that interventions such as the WHO-endorsed Brief Intervention and Contact (Fleischmann et al., 2008; Riblet et al., 2017) or the Contact and Safety Planning intervention (Vijayakumar et al., 2017) may reduce rates of suicide among refugees generally, there remains a paucity of data on successful interventions to address this growing need (Haroz et al., 2020). Many existing studies explore interventions with refugees in resettlement contexts generally, with fewer focusing on those practised in protracted situations of displacement (Haroz et al., 2020). Even less explored is the perspective and capacity of humanitarian staff themselves as they support displaced communities and may encounter people at risk of suicide. Understanding staff attitudes, confidence and knowledge regarding suicidality may help inform the design and delivery of training initiatives, and subsequently inform the response of the mental health and psychosocial support (MHPSS) community towards people at risk of suicide.

The primary aim of the current study was to assess suicide-risk-related barriers, attitudes, competence and knowledge of multisectoral humanitarian staff having face-to-face contact with Rohingya refugees in the Cox’s Bazar camps. Secondary aims were (i) to examine the relationship between the self-identified barriers, attitudes, confidence and knowledge and the level of formal training in responding to suicide risk, and (ii) to explore the possible impact of sex difference on response to suicide risk, given the strong cultural injunctions on gender relations in this context. Findings will support the development of a multisectoral suicide response strategy, including trainings, interventions and awareness, informed by the World Health Organization’s public health approach to suicide prevention and response (Saxena et al., 2014).

  Methods Top

The current project was reviewed and received ethical clearance from the Ethics Committee of the Department of Clinical Psychology at Dhaka University. A cross-sectional study design was utilised, with data collected over a 3-week period in June 2020. Data were collected through the Qualtrics online platform (Qualtrics, Provo, Utah, USA).

Participants and Procedure

Snowball sampling was used whereby potential participants were invited to respond by email invitations disseminated through multiple sector-level working groups including: MHPSS Working Group, Protection Working Group, GBV Sub-Sector, Child Protection Sub-Sector and the Health Sector. Emails were sent by the Suicide Prevention Subgroup chairs to Subgroup members and MHPSS Working Group chairs, who subsequently forwarded invitations to the Working Group at large and to the other sector leads for further dissemination. If contact was not established with a given sector during the 2-week period of the first round of sampling, one reminder email was sent to the corresponding group chairperson to follow up. The extended timeline and regular reminders made survey participation accessible to staff engaged in various aspects of the response. Sectors and Working Groups engaged for participation included: MHPSS; Child MHPSS; Protection; Child Protection; GBV; Gender in Humanitarian Action; Health; Site Management; Education; and Communication with Communities. Staff connected to these sectors were considered relatively more likely to encounter people at risk of suicide in the course of their daily work. No reimbursement was provided for participation.

Questionnaire Development

The survey tool was developed from items derived and modified from an existing assessment tool for mental health staff, the M-BACK (Watkins et al., 2017). Items were reviewed during Suicide Prevention Subgroup meetings with multisectoral participants consisting of supervisory-level Bangladeshi and international humanitarian staff representing national and international NGOs, as well as key UN agencies. Subgroup participants reviewed items to verify phrasing, utility and relevance to the study aim. Subgroup Co-Chairs integrated the selected list of items into a Qualtrics survey to anonymously collect and record an additional round of subgroup member feedback on each item. Feedback was solicited per item on (a) cultural appropriateness, (b) clarity, (c) translatability into Bangla language and (d) providing opportunity for additional, open-ended feedback. This feedback was compiled and documented, and items were adjusted accordingly. The draft tool was sent to an experienced researcher from Dhaka University Department of Clinical Psychology for review. Additional feedback was integrated prior to finalisation and use.


The Humanitarian-Barriers, Attitudes, Confidence, & Knowledge-Suicide (H-BACK-Suicide) survey was used. The tool was developed for the purposes of this study to assess the competencies of multisectoral humanitarian staff having face-to-face contact with refugees related to managing suicide risk, in terms of (i) barriers to providing effective intervention, (ii) staff attitudes about suicide and about their professional roles, (iii) staff confidence in conducting suicide-risk intervention and (iv) staff knowledge about suicide in general and about intervention strategies. The H-BACK-Suicide questionnaire consists of eight items ([Table 1]), each item as a five-point Likert type scale ranging from strongly disagree (scoring 1) to strongly agree (scoring 5). The tool is scored by summing all items, with items 3 and 5 reverse scored. Possible scores range from 8 to 40, with higher scores representing greater competence and comfort in professionally addressing suicide risk. Items and scoring for the four subscales are detailed below.
Table 1 H-BACK Suicide Questionnaire (n = 181)

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Domain 1: Barriers

Item 3 addresses barriers to suicide screening and intervention related to a lack of available services in the refugee response context. This question is reverse scored, with possible scores for this domain ranging from 1 to 5.

Domain 2: Attitudes

Items 1 and 4 reflect staff attitudes about suicide, including perceived pervasiveness of the issue and its relevance to their professional responsibilities. Possible scores for this domain range from 2 to 10.

Domain 3: Confidence

Items 6 and 7 assess respondents’ confidence in conducting suicide-risk assessments and safety plan interventions. Possible scores for this domain range from 2 to 10.

Domain 4: Knowledge

Items 2, 5 and 8 assess knowledge regarding suicidal ideation self-reporting, open discussion of suicide and services available for addressing suicide risk. Item 5 is reverse scored, and possible scores for this domain range from 3 to 15.

Demographic Variables

Demographic variables assessed included: sex; age; profession; highest level of education completed; sector of employment; years of employment experience in humanitarian contexts; experience of working with someone at risk of suicide (yes/no); if so, whether action was taken (took action/did not address suicidality); and current role and experience with formal suicide training (none, university coursework, other training, direct supervision or combination).

Statistical Analysis

Descriptive statistics were used to determine the proportion of participants agreeing or disagreeing with each statement. All the eight items were summed and means and standard deviation were calculated for all items and each of the four domains. For the secondary aims, independent samples t tests and Chi-squared analyses were used. The significance level was set at P < 0.05. SPSS 25.0 was used for data analysis (SPSS Inc., Chicago, Illinois, USA).

  Results Top


A total of n = 181 (n = 74, 41% females, mean age 32.1 ± 7.0 years) frontline humanitarian staff in Cox’s Bazar completed the survey. The most represented profession was social workers (n = 69, 38%) with most staff primarily working in MHPSS (n = 54, 30%). The majority of respondents had greater than 2 years work experience in humanitarian settings (n = 115, 64%), and the most commonly endorsed role was strengthening community or family supports (n = 76, 44%), followed by provision of individual general support (n = 48, 28%). Regarding the highest attained level of education, nearly half of participants held a bachelor’s degree (n = 81, 46%) and only slightly fewer held a master’s qualification (n = 74, 42%). All respondent demographics are summarised in [Table 2].
Table 2 Summary on Respondent Demographicsa

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Barriers, Attitudes, Confidence and Knowledge

The majority of respondents reported having no formal training, defined as university coursework, training or clinical supervision, for responding to suicide risk (n = 103, 58%).

One in five reported some training (n = 30, 20%) and only 8% (n = 14) reported completing a combination of university coursework and training and/or supervision. Of the entire sample, 29% (n = 52) had experience of working with someone at risk of suicide with further 18% (n = 33) unsure. Of those having direct experience (likely or confirmed) of working with someone at risk of suicide, 44% (n = 57) did not address the issue of suicide directly, whereas 56% (n = 74) took affirmative action including developing a safety plan, making a referral or providing direct care ([Table 1]). Nearly half of the sample agreed or strongly agreed with the statement that suicide was a problem in the community where they work (47%), yet only 13% of the sample agreed or strongly agreed that people will openly report thoughts of suicide if asked. In total, 36% of the sample agreed or strongly agreed that a lack of support services prevents them from discussing suicide, with 64% of the sample agreeing or strongly agreeing that asking about suicide was an important part of their role as a frontline worker. Regarding confidence, 63% of the sample was confident conducting a suicide-risk assessment and 71% were confident developing a safety plan. Less than half (44%) reported good knowledge of the local services available to support people thinking about suicide.

The mean H-BACK score for the entire sample with complete data (n = 175) was 25.6 ± 4.1, with scores ranging between 15 and 39. There were no significant differences between males and females (t(173) = 0.48, P = 0.63).

Impact of Prior Training and Work Experience

Those who had prior training (27.2 ± 3.7) scored higher on the overall H-BACK scale compared to those with no prior training (24.5 ± 4.1, t(171) = 4.4, P ≤ 0.001). Similarly, there was a significant difference between those who had prior training compared to those with no prior training for the attitudes (7.2 ± 1.7 versus 6.5 ± 1.7, t(174) = 2.9, P = 0.005), confidence (7.8 ± 1.4 versus 6.9 ± 1.8, t(175) = 3.5, P = 0.002) and knowledge (9.2 ± 1.7 versus 8.2 ± 1.8, t(172) = 3.8, P ≤ 0.001) subscales.

There was no significant difference between those with less than 2 years of work experience within humanitarian settings or those with more than 2 years’ experience for either the total H-BACK scores (P = 0.11) or any of the subscales (attitudes (P = 0.16), confidence (P = 0.21) and knowledge (P = 0.68)).

  Discussion Top

To the best of the authors’ knowledge, this is the first study to examine the barriers, attitudes, confidence and knowledge of humanitarian staff in Cox’s Bazar towards suicidal behaviours. We found that while respondents agreed that suicide was a problem, the majority had no formal training in suicide intervention. While roughly one-third of the sample had knowingly worked with a person at risk of suicide, we found relatively low levels of confidence among respondents, with only 63% reporting confidence in conducting a suicide-risk assessment. Together, these findings indicate an urgent need for training of humanitarian professionals having face-to-face contact with refugees in Cox’s Bazar regarding suicide-risk assessment and response.

Of all respondents, only 26% reported experience working with someone at risk of suicide, whereas a similar percentage disagreed with the statement that suicide was a problem in the community. These low rates of direct experience and conceptualisation of suicide as a community problem may be a consequence of decreased sensitivity to suicidal behaviour and suicide risks, stemming from a lack of training in how to identify and respond to these risks. Additionally, it is noteworthy that a majority of respondents (56%) indicated neutrality or agreement with the statement, “Talking about suicide can increase the risk”. The extent of participants’ agreement with this common misconception raises serious concern about their willingness to engage directly with people at risk of suicide, and likewise indicates an imperative for further training.

Within the extant academic literature, there are few suicide prevention initiatives specifically targeting refugees and other displaced population, with the majority of studies conducted in third-country resettlement contexts (Haroz et al., 2018). Even fewer initiatives are documented that address suicide among refugees and other displaced populations within camps or similarly tenuous situations (Haroz et al., 2018). However, more generalised training efforts, such as those equipping primary care physicians to address depression, have been effective in reducing suicide rates (Mann et al., 2005). Training staff who serve as points of contact for general health needs, among others, in a camp context for displaced communities may prove similarly effective. Numerous studies on suicide prevention strategies underscore the need for increased identification of persons at risk of or contemplating suicide as a component of a multidimensional prevention approach (Fleischmann et al., 2008; Mann et al., 2005; Riblet et al., 2017; Zalsman et al., 2016). Integration of suicide prevention training, by way of these gatekeeper staff providing general care, could provide an opportunity to do so in the Rohingya response context in Bangladesh.

Previous research has demonstrated that identifying and following up with people at risk is possible in displacement scenarios, with proper support of community and institutional service providers (Mann et al., 2005; Riblet et al., 2017; Zalsman et al., 2016). In the light of the limited available data on suicide prevention in humanitarian settings, and given our findings here, investing in such trainings should also be explored as a strategy within an ongoing multitiered approach to suicide prevention.

At the time of writing, face-to-face training opportunities within Cox’s Bazar are restricted to curb the spread of COVID-19 and are subject to ongoing local and national lockdowns. As such, structured virtual training presents the most readily available method for scalable, rapid instruction. As the rate of infection and death decreases alongside vaccine dissemination, in-person training will become more feasible, which remains the ideal instruction method when possible, given persistent limitations with online instruction. Furthermore, there is a clear need to identify or develop effective resources to support people at risk of suicide in the camp context. Such efforts must be carried out through close consultation and partnership with the Rohingya community to ensure services offered are sustainable and aligned with community needs, expectations and beliefs. Resources that are identified or developed must then be integrated into humanitarian workers’ methods of common practice and disseminated through existing networks of the multisector response, ensuring utilisation of resources that are available, effective and acceptable to the community at large.

Data from this study should be interpreted in the light of methodological limitations. This includes the use of snowball sampling and subsequent inability to determine the representativeness of the sample. It is also possible that those who elected to complete the survey constitute a more highly engaged or qualified group, resulting in selection bias. However, the authors find it unlikely that the need for suicide prevention training across all frontline workers, and specifically among MHPSS practitioners, is less than suggested by this sample. Participants may have demonstrated a social desirability bias in responding, due to potentially having received participation request emails from supervisors, although every effort was made to minimise this effect by underscoring the voluntary and confidential nature of the survey. Finally, the psychometric properties of the scale are unknown and future research should consider the reliability of individual items and the overall scale.

Future research should explore how cultural background, including religious views, impacts the use of professional knowledge and influences the overall approach to suicide prevention by multisectoral humanitarian staff having face-to-face contact with affected communities. This was not addressed here despite the widely recognised taboo status of suicide across sects of Islam, the general stigmatisation of suicide in Bangladesh and its criminalisation within the country. Furthermore, the impact of sector or occupational status was not accounted for, but may influence access to training and resources, or potential exposure to suicidal persons at a higher frequency and should be explored further. The scope and timeframe of the present study were limited by a desire to respond quickly to needs expressed by staff, volunteers and Rohingya refugees for more support to respond effectively to suicidal behaviours. Given the limited data available, the present study sought to first establish an understanding of the current extent of training across multiple sectors in the response. As such, many important areas for further exploration were not included in this study, which constitute important indicators for future assessments and training initiatives. The authors recognise the value of areas such as: clarification of the type of intervention used in response to suicidal behaviours; the source, frequency and time elapsed since last training; and the local resources to which refugees are referred for care. Additionally, further research should explore how cultural, educational and other personal contexts, including religious views, impact the use of professional knowledge and influences approach to suicide prevention. There should be a particular focus on health staff including doctors, nurses and aides given their proximity to suicidal behaviours within a medical setting.

Multisectoral humanitarian staff having regular face-to-face contact with refugees in Cox’s Bazar had generally low levels of confidence in responding to suicide risk. We recommend the development of training in suicide-risk identification, awareness and prevention across the humanitarian workforce, so relevant knowledge and skills may be widely available to multisectoral staff having face-to-face contact with refugees. Particular attention must be paid to ensure the safety of the affected population, upholding the Do No Harm principle. Further efforts to address the issue of suicide in displaced communities, including the Rohingya in Bangladesh, should be considered a public health imperative for humanitarian aid.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2]


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