|Year : 2021 | Volume
| Issue : 2 | Page : 255-260
International Organization for Migration Iraq Mental and Psychosocial Support Programme Suicide Prevention Activities
Hatem Alaa Marzouk
MRC Psych (UK), MSc Psychiatry, MBBCh, Mental Health and Psychosocial Support Programme Coordinator, The International Organization for Migration, (IOM), Erbil, Iraq
|Date of Submission||30-Jan-2021|
|Date of Decision||04-Apr-2021|
|Date of Acceptance||20-Jul-2021|
|Date of Web Publication||09-Sep-2021|
Hatem Alaa Marzouk
MRC Psych (UK), MSc Psychiatry, MBBCh, Mental Health and Psychosocial Support Programme Coordinator, The International Organization for Migration, (IOM), Erbil,
Source of Support: None, Conflict of Interest: None
Many Iraqis have experienced a multitude of stressors over the past four decades due to war, sanctions and civil conflict. Being closely associated with social cohesion and community stabilisation, suicide prevention activities have been an increasingly important component of the International Organization of Migration (IOM)’s Mental Health and Psychosocial Support Programme. This report introduces the aims and activities implemented throughout different locations in Iraq by IOM. Statistics from 2015 to 2016 indicated that the rate of suicide per 100,000 persons in Iraq was between 0.97 and 1.54, with the majority of the cases being 29 years of age or younger. Following a brief situation analysis of socioeconomic, cultural and political aspects related to the phenomenon of suicide in Iraq, the subsequent report outlines the steps IOM Iraq has taken to support the government of Iraq in developing the National Suicide Prevention Strategy. It also details the efforts done towards building community awareness about suicide and building the capacity of community gatekeepers.
Keywords: IOM Iraq, mental health and psychosocial support, national suicide prevention strategy, suicide prevention
|How to cite this article:|
Marzouk HA. International Organization for Migration Iraq Mental and Psychosocial Support Programme Suicide Prevention Activities. Intervention 2021;19:255-60
| Introduction|| |
In 2015, the Government of Iraq initiated a study in 13 (out of 18) governorates to better understand mortality associated with suicide. Elaborating on the findings of this study, Abbas et al. (2018) suggest that the suicide rate per 100,000 persons was found to be 1.09 (1.21 for males, 0.97 for females) in 2015 and 1.31 (1.54 for males and 1.07 for females) in 2016, with the majority (67.9%) under 30 years of age. As these figures seem to be well below the universal estimate (11.4 cases per 100,000), they are likely to be underestimated due to stigma, misclassification and consequent underreporting (World Health Organization (WHO), 2014). A more recent report presented by the Iraqi Ministry of Health (MoH) studying suicides in Iraq in 2019 indicated that 332 individuals died due to suicide and a total of 1112 individuals attempted to take their life (Abdul Razaq, 2020). Potential risk factors for suicide in Iraq include gender-based violence, inability to deal with stress and conflict (WHO, 2014), experiencing domestic violence (Hanna & Ahmad, 2009; Othman, 2011; Mohammad Amin et al., 2012), experiencing or witnessing political and sectarian violence and extremism (Hafez, 2006) and experiences of war-related psychological trauma (Abbas et al., 2018).
Acknowledging these potential factors, International Organization of Migration (IOM) Iraq’s Mental Health and Psychosocial Support (MHPSS) programme prioritised suicide prevention within its community stabilisation programming for two reasons: (I) suicide was reported as one of the top concerns in communities throughout Iraq and (II) the lack of available resources from governmental bodies and civil society to provide support in cases of suicidality. Previous research has found that suicidal ideation and attempts are prevalent among displaced populations around the world (e.g. Quosh et al., 2013; Akinyemi et al., 2015; Aoe et al., 2016). Therefore, suicide in Iraq needs to be addressed through comprehensive programmes and policies. In line with this, IOM supported the government of Iraq in developing the National Suicide Prevention Strategy which aims to integrate social, cultural and economic components in a more comprehensive framework of response.This report outlines IOM Iraq’s Suicide Prevention programme and its three key pillars together with the challenges faced in working on suicide awareness, preparedness and response in Iraq. The first pillar is advocacy and the support to the development of the Government of Iraq’s National Suicide Prevention Strategy, along with the strategy’s present stage of development. The second is the enhancement of community awareness about suicide. The third is IOM’s training and capacity-building activities provided to government institutions, NGOs and civil society bodies.
Supporting the Development of Iraq’s National Suicide Prevention Strategy
The presence of a robust national suicide prevention strategy in a country provides a framework for including different aspects of suicide prevention and reaffirms the government’s commitment to addressing the problem (WHO, 2012). Given the lack of resources at government level to instigate the process, IOM Iraq provided support to initiate concrete steps in partnership with the government of Iraq in 2019.
As a first step, IOM supported the government of Iraq and the MoH in organising a forum with all relevant mental health stakeholders to discuss the concerns voiced by the community and professionals about suicidality in Iraq. This forum organised in July 2019 was a chance to identify relevant stakeholders and plan for a situation analysis that was crucial to the development of the strategy. The MoH presented national suicide statistics as well as the challenges different governorates faced in tracking accurate figures on suicide due to a lack of an effective case surveillance system, denoting the discrepancy of figures provided by healthcare facilities, police authorities and the judiciary system due to the different sources of information that are not aligned. To support the MoH in suicide prevention efforts, a working committee on suicide was created under the National Technical MHPSS Working Group (TWG).
In the course of the situational analysis, it was clearer that there was a lack of representation of the individuals with suicidal experience and the families of both victims and survivors. As a result, IOM collaborated with local NGOs (e.g. Azhee1) to organise a national conference on suicide prevention in September 2019, with a key focus on bringing the community’s voice to the table. Therefore, it was agreed in this conference that policymakers, NGOs and members of the community should collectively participate in the design and implementation of a national suicide prevention strategy to ensure the effectiveness of the country’s response to suicide. Soon after this conference, IOM Iraq was invited to present its experience in suicide prevention in Iraq in a GIZ2 organised exchange on suicide prevention in October 2019 in Berlin, Germany. The exchange provided a platform for discussion between expert participants, who shared their experience in suicide prevention from the MENA region (Iraq, Lebanon, Jordan, Syria and Palestine) and Europe (Germany and the United Kingdom).
In November 2020, IOM Iraq worked with the MoH to finalise the draft for a national suicide prevention strategy and a workplan to guide its implementation. IOM and the General Secretariat of the Iraqi Council of Ministers (GSICM) organised a high-level intergovernmental conference on suicide prevention to (i) enable dialogue on suicide prevention between different ministries and explore how this fits within their respective ministerial programmes, (ii) provide recommendations to GSICM on steps needed to establish a framework facilitating collaboration between different ministries on suicide prevention and (iii) provide input to the draft national suicide prevention strategy and action plan. The conference brought together representatives of key stakeholders identified which were the Ministries of Health, Interior, Education, Higher Education, Justice, Labour and Social Affairs and Youth and Sports, as well as the Iraqi High Commission for Human Rights and the Supreme Judicial Council. IOM supported the incorporation of the input and recommendations from this conference into the draft strategy that is now pending the final endorsement by the Iraqi government.
Enhancement of Community Awareness About Suicide
As a part of the ongoing situation analysis that IOM instigated in Iraq, the programme management conducted several community assessments and consultations on suicide. IOM Iraq’s MHPSS team identified the lack of awareness and information on suicide to be one of the key elements contributing to the stigma attached to people with history of suicide or those who have lost someone to suicide. IOM subsequently developed an awareness-raising package, with materials tailored to different audiences such as healthcare workers, educators and families who lost someone to suicide. The content of the two leaflets (misconceptions about suicide and messages to bereaving families) is shared as an example in the following paragraphs (IOM-Iraq, 2020a,b,c,d). The misconceptions, messages and recommendations shared in the leaflets were prepared based on the evidence-based practical guides and suggestions offered by Wolfelt (2009), O’Sullivan et al. (2011), Centre for Addiction and Mental Health (2011) and Public Health Agency (2015). The leaflets, made in online and print formats, were made available in English, Arabic and Sorani and Badini dialects of Kurdish. The electronic version was circulated with all members of the MHPSS TWG. Further, IOM donated thousands of print copies to the MoH in Baghdad and Erbil in addition to other NGOs in targeted locations.
As misconceptions surrounding suicide significantly influence how individuals perceive and respond to those who have suicidal thoughts or attempt to take their life and to family members of those who died due to suicide, one of the leaflets focused on facts regarding these misconceptions (IOM-Iraq, 2020a). The eight misconceptions the leaflet covered included the following: (1) suicide is a rare phenomenon, (2) all suicide cases cannot be prevented, (3) people who talk about suicide only seek attention; (4) talking about suicide can incite someone to attempt suicide, (5) once a person is suicidal they will always be suicidal, (6) unsuccessful suicide attempts show the person was not serious, (7) suicide occurs more often among the rich or the poor and (8) suicide is inherited or genetically determined. The leaflet offered simplified, evidence-based information to dispel these misconceptions: Existing studies show that every year around 700,000 people die due to suicide and around 80% of suicides around the world occur in low- and middle-income countries (WHO, 2021). Suicides can be prevented and talking about suicide is one way to prevent it (Garfinkel, 1989; Vidal, 1989; WHO, 2021). Those who have suicidal thoughts give verbal warnings which may be a cry for help (Gordon, 1985; Hicks, 1990; Popenhagen and Qualley, 1998). Suicide may be observed in diverse contexts and among diverse populations, therefore not related to socioeconomic differences (Popenhagen and Qualley, 1998; Vidal, 1989) and finally, suicide is not inherited and may be an outcome of behavioural imitation or learning (Neuringer 1987-88)
([Figure 1] shows the cover of the English version of the leaflet.)
The leaflet for bereaved families who have lost a loved one to suicide included key messages to the families and surrounding community members who can offer their support (IOM-Iraq, 2020b). The five messages geared towards bereaved families aimed to bring awareness to their feelings, thoughts and behaviours after the suicide and included the following: (1) you may be overwhelmed with feelings of sadness, anger, shock, denial, guilt and shame, so notice your feelings and try to express them; 2) you may ask “why” and “what if” questions, although you may not readily have the answers, so notice your thoughts; (3) remember that grief is unique, so other family members may react differently; (4) take it one moment or day at a time, which will help you with focusing on the present moment and (5) it is not your fault, as you are not to blame for the choice made by others. The following messages listed some behavioural recommendations for their wellbeing and included the following: (6) call on your personal faith and values to help you through spiritual or religious rituals that you are accustomed to such as prayers, meditation or religious readings, as these may help you find comfort; (7) celebrate their lives by making opportunities to remember them, for example, doing activities you did together; (8) take care of yourself by eating, sleeping and staying hydrated; (9) supporting others can help you feel reassured; (10) give yourself permission to get professional help if you need extra support; (11) find a good listener with whom you can share your thoughts, feelings and concerns openly and (12) things get better over time so get back to the daily activities you are capable of doing and that help you find peace again. [Figure 2] shows the cover of the Arabic version of the leaflet.
As noted earlier, these leaflets were distributed in different locations to different organisations and institutions to make civilians, government employees and national and international NGOs familiar how they can contribute to suicide prevention in their networks. In line with this, five important messages were included in the leaflets to explain what one can do to help support a bereaved family. Mainly focusing on how they can express and promote solidarity with families, these messages included: (1) listen more than speak, attune to their needs and avoid making judgments or unsolicited advice; (2) offer practical help and support them in different ways such as doing grocery shopping and preparing meals; (3) tell them that they are in your thoughts by sending a text message or making a phone call; (4) encourage them to participate in group activities to help overcome the sense of isolation they may feel and (5) support them by fighting the stigma associated with suicide through avoiding negative language related to suicide as it adds to the suffering of the family by promoting a feeling of shame.
The leaflets established a clear connection between misconceptions surrounding suicide through tailored messages to different community groups on how everyone can contribute to suicide prevention. Strong messages dispelling misconceptions on suicide can be crucial in addressing the gaps in monitoring systems, community awareness and response and capacity to deal with suicidality countrywide. IOM Iraq, therefore, acknowledges how important it is to dispel the misconceptions through the distribution of awareness-raising materials. To ensure these messages are well received, IOM Iraq conducted extensive training activities throughout the country. The following section unpacks the purpose, content and outcomes of these activities.
Training and Capacity-Building Activities
The WHO’s global health observatory data repository (WHO, 2017) showed the deficiency of local specialised mental health service providers in Iraq with only 0.11 psychologists and 0.34 psychiatrists available per 100,000 population in the mental health sector. The figure for social workers was even lower at 0.089 per 100,000 population. As a result, IOM sought the training of different potential gatekeepers to start raising the community awareness about suicide and addressing the negative attitudes it is met with in the community.
The training package included a capacity-building component catering for trainees to help them better engage communities and bolster community-based support to suicide prevention through four basic aims. First, to provide participants with the necessary knowledge about suicide risk and protective factors, common misconceptions about suicide and culturally sensitive ways to speak out about suicide in the community. Second, to challenge negative attitudes or perceptions about individuals who attempt suicide and encourage the formation of stronger community networks to support them. Next, to support trainees in gaining the necessary skills to conduct community awareness activities to help foster an open dialogue about suicide. Finally, to deliver specific training modules to journalists and media personnel on responsible reporting and developing media content on suicide.
In total, around 200 individuals from different governmental entities and NGOs participated in suicide awareness raising. These trainings were offered to gatekeepers from nine governorates across Iraq between July 2019 and December 2020 (Dahuk, Diyala, Ninewa, Erbil, Najaf, Kerbala, Baghdad, Salah Al-Din and Kirkuk). Shorter versions of trainings were delivered remotely under coronavirus disease 2019 (COVID-19) restrictions and lockdown.
Considering the multitude of ethnicities and languages throughout Iraq and suicide being a cross cutting issue among different populations, trainings and capacity-building activities were made available in Arabic, English, Sorani and Badini dialects of Kurdish according to the local need. Case scenarios and exercises were also tailored to the local context. Moreover, to maximise the benefit of these activities, IOM supported some trainees from local NGOs to set up community awareness raising sessions in Sharya town, Shekhan camp and Qadia camp in Dahuk governorate. These sessions provided an opportunity for some trainees to practise their skills and knowledge on communicating with communities about suicide, with direct on-the-job supervision from IOM MHPSS team to ensure more effective learning (IOM, 2019). They also provided a space to test the awareness raising materials developed by IOM to ensure their appropriateness for local context.
Limitations and Challenges
The main challenge to the advocacy role IOM was playing to create a national suicide prevention strategy was the COVID-19 pandemic which has deprioritised suicide prevention from policymakers’ agenda and most stakeholders equally. In the lack of consensus around the strategy, IOM continued with the awareness raising and capacity-building components to keep the momentum created in 2019. Potential challenges following the prospective endorsement of the strategy nationally are the lack of governmental funding to different components, necessitating the contribution of different parties such as donors and international organisations to kick start the implementation until a more sustainable framework is established.
On the other hand, the majority of the capacity-building and training activities were held before COVID-19 was detected in Iraq and national restrictions were imposed. However, the pandemic has not only impacted the wellbeing of individuals on psychological and social levels, but also the delivery of MHPSS services to beneficiaries. Precautionary measures such as physical distancing and limitation of movement presented an additional challenge to delivering services in particularly underprivileged and underserviced areas. Further, as observed in IOM’s fieldwork and assessments, members of the targeted population had growing concerns about adequate access to services and maintaining their jobs and livelihoods. COVID-19 amplified the diversity of the stressors leading to fear, anger, sadness, frustration and anxiety which further complicated the context. Abiding by movement limitations and in continuing to ensure MHPSS as a key priority in crisis situations particularly among vulnerable groups such as internally displaced persons (IDPs), IOM Iraq’s MHPSS activities were adapted in accordance with local governments’ instructions and public health best practices.
| Conclusion|| |
IOM Iraq’s MHPSS programme interventions to bolster the government’s response to suicide are aimed at creating a more systematic approach to this issue in Iraq. IOM Iraq hopes this report contributes as an example of interventions aiming at strengthening multisectoral collaboration within a framework of evidence-based practice that is conscious of the local context and resources available. Stronger collaboration between different actors working on suicide prevention and response is needed to ensure that the community concerns about suicide are addressed.
The author acknowledges the general support and internal review of the report by Guglielmo Schinina, Head of IOM’s Mental Health, Psychosocial Response and Intercultural Communication Global section and IOM Iraq Community Stabilization Unit (CSU); Siobhan Simojoki, head of the unit; Yasin Duman, MHPSS Programme Officer and CSU reporting team. The author acknowledges We2 designs for the design of the IOM Iraq leaflets cited in this report.
Financial support and sponsorship
The suicide prevention programme activities of IOM Iraq were funded by the German Federal Foreign Office (GFFO), the Bureau of Humanitarian Assistance (BHA), USAID and the UK Foreign Commonwealth Office (FCO).
Conflicts of interest
There are no conflicts of interest.
1Azhee is a nonprofit nongovernmental organisation established in 2019 and is officially registered by the Kurdistan Regional Government in Iraq (KRI). http://azhee.org/
2GIZ is an acronym for Deutsche Gesellschaft für Internationale Zusammenarbeit (GmbH), (German Society for International Cooperation).
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[Figure 1], [Figure 2]