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Table of Contents
Year : 2022  |  Volume : 20  |  Issue : 1  |  Page : 114-118

Integration of Mental Health into Emergency Preparedness and Response Planning for the Monsoon Season in Bangladesh

1 MD, Mental Health and Psychosocial Support Consultant, Egypt
2 MSc, Mental Health and Psychosocial Support Programme Manager, International Organization of Migration, Colombia
3 PhD, Scienta Associate Professor, School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, Australia

Date of Submission22-Nov-2021
Date of Decision13-Mar-2022
Date of Acceptance14-Mar-2022
Date of Web Publication31-May-2022

Correspondence Address:
Mohamed Elshazly
Mental Health and Psychosocial Consultant (independent)
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/intv.intv_38_21

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The monsoon season in Bangladesh is an example of how climate-related events can have a significant impact on mental wellbeing of affected individuals and communities. In this field report, we reflect on the integration of mental health and psychosocial support (MHPSS) services into emergency preparedness efforts. The report aims to offer an understanding of the risk associated with the monsoon season on both refugees and host communities and how likely this risk could affect mental health and mental health services. The MHPSS working group in Cox's Bazar identified four major areas resulting from the impact of the monsoon season: increased incidence of mental health and psychosocial problems, relocation of individuals and families from high-risk areas to safer locations, disrupted provision of mental health and psychosocial services, and lack of self-care knowledge and practice for the humanitarian staff. To mitigate these impacts, an emergency preparedness and response plan was developed and included a wide range of activities aiming to better coordinate and scale up mental health services during the monsoon season.

Keywords: emergency preparedness, mental health, monsoon

How to cite this article:
Elshazly M, Rebolledo O, Rosenbaum S. Integration of Mental Health into Emergency Preparedness and Response Planning for the Monsoon Season in Bangladesh. Intervention 2022;20:114-8

How to cite this URL:
Elshazly M, Rebolledo O, Rosenbaum S. Integration of Mental Health into Emergency Preparedness and Response Planning for the Monsoon Season in Bangladesh. Intervention [serial online] 2022 [cited 2023 Jun 9];20:114-8. Available from: http://www.interventionjournal.org//text.asp?2022/20/1/114/346331

  Introduction Top

By mid-2021, Bangladesh was hosting more than 880,000 Rohingya refugees (also referred to as Forcibly Displaced Myanmar Nationals) in refugee settlement areas in the Cox's Bazar District in south-east Bangladesh (Hossain, 2021). Due to their rapid influx into Bangladesh, Rohingya have been living in overcrowded areas with fragile shelter and infrastructure set-up. Coastal areas in Bangladesh, including the district of Cox's Bazar, are affected by the monsoon season every year from April to October which is characterised by heavy rainfall, storms, cyclones, floods and landslides. The monsoon season is an added burden facing the humanitarian response in Bangladesh; it overstretches the available resources and increases the risks that refugees are facing, for example, in terms of loss of lives and properties, outbreaks of communicable diseases and interrupted access to basic services.

The Intersectoral Coordination Group has been actively coordinating the humanitarian response among all sectors in Cox's Bazar. The coordination efforts have extended to mitigate the impact of the monsoon season on refugees and host community through promoting emergency preparedness and response planning (EPRP). Mental health and psychosocial impacts of the humanitarian situation as a whole and of the monsoon-related events were a major concern for most sectors. The mental health and psychosocial support (MHPSS) working group (WG) under the health sector has been responsible for the intersectoral coordination of mental health and psychosocial services.

In response to the massive influx of Rohingya refugees, MHPSS services have progressively grown to meet the needs of affected populations. MHPSS services have been provided by the Government of Bangladesh and over 70 international and local nongovernmental organisations. Services have been provided mainly under the umbrella of both the health and protection sectors in an integrated fashion. They spanned all the layers of MHPSS interventions but focused to a large extent on community and family support, and nonspecialised services. Specialised mental health services, in particular, are limited to a public outpatient psychiatric clinic in Cox's Bazar hospital run by one national psychiatrist and a roving psychiatrist deployed by United Nations High Commissioner for Refugees (UNHCR) to support camp-based mental health services.

In 2019, the MHPSS WG was tasked by the health sector to develop, implement and monitor an EPRP in response to the anticipated events associated with the upcoming monsoon season. The plan aimed to focus on mental health and psychosocial issues aligned with other sectors' plans, ensuring the multisectoral approach to MHPSS.

  Emergency Preparedness and Response Planning Taskforce Top

The MHPSS WG launched a taskforce focusing on planning and monitoring of EPRP activities and including members from organisations that participated in the MHPSS WG. The taskforce met on a weekly basis to discuss the progress of activities and then share updates with the WG on a bi-weekly basis where challenges and possible solutions could be discussed. The taskforce was promoted as a functional intersectoral taskforce linking different sectors and subsectors providing mental health or psychosocial services.

Planning Workshop

During the first quarter of 2019, members of the MHPSS WG and members from other sectors and subsectors were invited to participate in a planning workshop. The objectives of the workshop were to (i) identify the potential risks associated with the upcoming monsoon season, (ii) identify the likely impact of these risks on both the mental health of affected populations and mental health services and (iii) determine the possible course of action to mitigate the potential impact.

The workshop included 31 participants from the Bangladesh government, United Nations agencies, international and local NGOs. Methodology included briefing the workshop participants about Interagency Standing Committee (IASC)-recommended emergency preparedness actions, and how they were linked to minimum MHPSS response. This was followed by dividing participants into groups and asking them to answer the following questions through group discussions: (a) What are the expected impacts of the monsoon and related events? (b) How do the monsoon and related events impact on mental health of affected populations and on mental health services? (c) What is the recommended course of action to mitigate against the potential impact of these events?

Following small group discussions, each group was asked to present their responses to the wider audience and engage in critical discussions regarding the identified needs and recommendations. Responses were thematically analysed and grouped under four problematic areas: (1) increased incidence of mental health and psychosocial problems, (2) relocation of individuals and families from high-risk areas (e.g. those susceptible to landslides and flooding) to safer locations, (3) disrupted provision of MHPSS services and (4) lack of knowledge regarding self-care and recommended measures. The following section includes a detailed description of the proposed activities under these areas.

Increased Incidence of Mental Health and Psychosocial Problems

The monsoon season is associated with stressful events including challenges in meeting basic needs, loss of shelter and property, physical injury, outbreak of communicable diseases, social disconnection through displacement and relocation, and loss of family members. These stressful events are major risk factors for affected individuals to experience poor mental health and wellbeing. They may lead to increased incidence of mental health problems especially among highly vulnerable groups including children, older persons, single mothers and persons with disabilities.

To mitigate against the risk of these events, there is a need to scale up the provision of psychological first aid (PFA), strengthen coordination of MHPSS activities and improve the referral process to MHPSS services. In line with this, the following activities were proposed and implemented by WG members:

  1. PFA: Provision of PFA by frontline workers during the events associated with the monsoon is an essential step to help affected individuals and communities to identify and address their needs (World Health Organization (WHO), 2011). The WG agreed to build the capacity of 50 PFA trainers through PFA training of trainers (ToT). These trainers would in turn train up to 1000 frontline workers (including field staff, mobile medical teams and shelter staff) over the course of the emergency preparedness period. Additionally, refresher PFA trainings were organised to include those who received PFA trainings in previous years.
  2. Mapping of mental health and psychosocial support services (4Ws mapping): Maintaining an updated “4Ws” (IASC, 2012) tool is essential to support the coordination of MHPSS services and strengthen the referral process. A dedicated team was established to hold regular meetings with partner organisations to update the 4Ws tool and share updates with the MHPSS WG on a monthly basis. With the anticipated interruption of some services during the monsoon season, the team identified that it was important to keep both service providers and the community informed regarding service interruptions and subsequent plans to mitigate risks associated with these interruptions.
  3. Emergency MHPSS focal persons: Referral to MHPSS services may be challenging during the monsoon season. A major challenge is a lack of knowledge of other sectors and subsectors about the services provided at each level of the MHPSS intervention pyramid and the different referral procedures applied by various actors. The WG members suggested to assign an MHPSS focal person in each camp. MHPSS focal persons would receive MHPSS referrals from different organisations and from the community to coordinate further referral to organisations based on their scope and service coverage. To strengthen the referral procedures, the WG shared information about MHPSS focal persons, their contact details and their roles were shared widely among various humanitarian actors, camp-based information points and call centres (hotlines). A WhatsApp group was created and included all focal persons so that group participants could reach out and seek support when needed, without sharing confidential information.
  4. Referral workshops: Camp-based referral workshops were facilitated to establish the link between different sectors and MHPSS service providers. It also helped ensure that different MHPSS service providers in the same location had adequate knowledge regarding each other's scope of work, the target population and the referral process.
  5. Persons with severe mental illness: Persons with severe mental illness are at high risk during the monsoon season. This could be attributed to potential service interruption, stressful events and the diminished social support associated with the relocation of families to safer locations. A guidance note for the management of persons with severe mental illness was developed and disseminated to different organisations providing services for this population. The guidance note included information about the frequency of dissemination of psychotropic medications, follow-up plans and the support provided by community health workers.
  6. Community engagement: Engaging affected communities in the humanitarian response is essential for strengthening community-based approaches and gaining the trust of communities in proposed activities (IASC, 2007). EPRP included the facilitation of community workshops and meetings to discuss the likely impact of the monsoon on mental wellbeing of individuals and ways to cope with that through community-based approaches. Recognising and strengthening the community response to these adverse situations and how the community should be actively involved in responding to them was placed at the centre of the humanitarian response.

Relocation of Individuals and Families from High-risk Areas to Safer Locations

Individuals and families living in areas at high risk for flooding or landslides in refugee camps are relocated to safer locations. Relocation may be a distressing experience as people may lose their social support networks (e.g. extended families and neighbours), lose established livelihood opportunities and face challenges in accessing basic services. Therefore, rapid response is needed through the provision of basic support by field staff involved in the relocation process, and through deployment of MHSS staff to relocation sites. Activities that were proposed and implemented by the WG members included:

  1. MHPSS human resources: MHPSS staff might be deployed to relocation sites to provide the necessary support to affected individuals and families. As part of the emergency preparedness, a guidance note was developed and disseminated to guide organisations planning for deployment of MHPSS human resources. It included information, for example, about the optimum number of community workers, counsellors and trained primary health care staff that should be mobilised to support a particular population size. While relocation was taking place, MHPSS staff were deployed to provide PFA, assess population needs and refer persons with complex needs to higher levels of mental health services.
  2. Rapid post relocation MHPSS assessment: Assessment of MHPSS needs and resources in relocation sites should take place as soon as the relocation starts. Terms of reference for the post-relocation assessment were developed and focused on the integration of MHPSS in the multisectoral assessment plans.

Disrupted Provision of Mental Health and Psychosocial Support Services

MHPSS services may be disrupted due to several reasons, for example, damage to service venues, challenges with accessibility (isolation of service venues due to flooding or landslides) and absence of the staff responsible for providing services. Service disruption will consequently affect service provision for both the new intakes and follow-up cases. Coordination of services, effective referral pathways and integration of mental health into other services can help to mitigate the impact of the anticipated service disruption. Activities that were proposed and implemented by WG members included:

  1. Field-level coordination of mental health and psychosocial services: Field-level coordination should help to inform local actors in the same location about the possible interruption in services and how to mobilise resources to address these gaps (Elshazly et al., 2019a, b). Hence, the MHPSS WG established field-level coordination of MHPSS services to complement the coordination efforts of actors.
  2. Establishing communication platforms: For example, site-specific WhatsApp groups were established as part of the EPRP. The purpose of these communication platforms was to share information among field staff about interruption of services, with possible deviation or modification of referral pathways for urgent cases.
  3. Integration of mental health services into camp-based primary healthcare units: The integration of mental health services into camp-based primary healthcare centres helps improve access to mental health services and ensures continuity of services in case of potential service disruption. Therefore, the WG suggested scaling up the ongoing mhGAP Humanitarian Intervention Guide (WHO, 2015) training that aimed to equip primary healthcare staff with the assessment and management of mental health priority conditions (Tarannum et al., 2019).

Lack of Self-care Knowledge and Practice for the Humanitarian Staff

Exposure to stressful events associated with the monsoon season, long working hours and demanding workloads may impact the mental health and wellbeing of humanitarian staff, especially frontline workers and volunteers from the Rohingya communities. There are limited existing programmes set up by humanitarian organisations to support their own staff. In addition, there is limited training for staff on self-care measures that may help to mitigate against the impact of this potential stressful experience. Activities that were proposed by WG members included:

  1. Development and dissemination of a guidance note on self-care: This was suggested for both humanitarian workers and their managers/supervisors (including peer support activities). Special attention was paid to rescue teams, dead body management teams, volunteers and witnesses.
  2. A one-day ToT workshop on self-care: The training aimed to train approximately 50 trainers who would in turn disseminate knowledge within their organisations through brief workshops and support groups.
  3. Peer support groups: Peer support groups were facilitated to promote a more supportive environment for helpers involved in the emergency response (Welton-Mitchell, 2013) when facing the response in the monsoon season.

[TAG:2]Discussion [/TAG:2]

This field report presents the EPRP that was developed by humanitarian actors in Bangladesh to address the mental health needs of populations affected by monsoon-related events. The plan was the first of its type and had a positive impact on mental health services' provision during the monsoon season. Although the IASC guidelines provide detailed recommendations for emergency preparedness, the current plan helped provide an adapted set of actions to fit the local context. It took into consideration the limited resources available, the existing MHPSS spectrum of services and the need to provide a timely response.

Following the planning phase, an implementation framework was developed. The framework included a breakdown of activities under each domain of action, which were assigned to various WG members based on their operational scope to expedite the implementation process. A specific timeframe for each activity was discussed with the respective organisation. The EPRP taskforce was responsible for following up implementation and reporting the progress to the MHPSS WG and the health sector. Any challenges encountered during implementation phase were discussed among working members and proper recommendations were shared.

The feedback that was received from the field staff was generally positive. They felt more confident in referring clients to services they needed, and felt more connected with staff providing MHPSS services under different sectors. They found that the EPRP was a helpful step in overcoming the fragmentation of mental health services commonly found in humanitarian response programmes. They could also identify an important role for themselves during the relocation of individuals and families to safer locations and could find an opportunity to engage communities in the coordination of services. Being in a network helped them to overcome service disruption and to respond quickly to people's needs.

However, the EPRP was developed within a tight time frame and the team faced several challenges during the planning and implementation phases. First, the plan relied on the effective coordination of mental health and psychosocial services which had been facing many challenges too, for example in terms of limited intersectoral communication around MHPSS services. Second, a cross-sectoral approach to mental health was not easily realised in such a large-scale emergency which led to some service duplication with the limited resources available for mental health programmes.

  Lessons Learned Top

Building on the experience from developing and implementing the EPRP plan in Bangladesh, we think there are some lessons learned that could help service providers and policy makers in other parts of the world when preparing to mitigate the impact of climate-related events on mental health and psychosocial support services. Firstly, mental health should be included from the earliest phases of emergency preparedness planning as a core component. To achieve this, MHPSS should be approached from a multisectoral perspective that integrates the views of various sectors and subsectors involved in the provision of mental health and psychosocial services. An active and functioning MHPSS coordination group helped in this aspect through bringing the various actors from these sectors to one platform to discuss and advocate for mental health from a comprehensive and integrated perspective. To that end, MHPSS emergency preparedness plans should be linked to and articulated with other sectors' plans. A standalone MHPSS plan is less likely to be implemented – but rather, a fully articulated plan will benefit from existing resources in other sectors to support mental health services.

Secondly, preparedness plans should be realistic in what may be achieved in the light of the usual limited resources available to support mental health services. Preparedness plans could be simply conceptualised as one step back from the minimum services that should be provided in response to the anticipated risks. The scope of involved organisations should be carefully examined and considered when suggesting new services or activities. Otherwise these services will be left unimplemented or implemented with low quality if they are outside the scope and the expertise of those organisations. Additionally, it is important to adapt any existing recommendations to the local context in terms of needs and resources and make sure that all parties agree on what is achievable rather than what is idealistic.

Thirdly, community engagement is a key to the success of any emergency preparedness plan. Community engagement ensures that community views about risks and mitigating measures are reflected in the preparedness plans. Additionally, community engagement helps orient the plan towards resilience factors, cultural sensitivity and strength factors, rather than being focused solely on risk and vulnerability. Community engagement should include discussions during the planning phase, but also extend towards involving members from the community in the implementation and evaluation phases too.

Fourthly, regular monitoring of the implementation of activities is a key aspect that should be considered from the start. The MHPSS coordination group or an EPRP subgroup could lead the responsibility for this monitoring part of the plan. Monitoring helps improve the outcome of the plan through identification of barriers facing the implementation and provision of practical solutions.

Last, but not least, an EPRP will benefit from cumulative experience built up and documented over the years. The MHPSS coordination group should therefore keep a record of all the documentation, discussions and decisions and factor them into subsequent versions of the plan that are designed over the following years. It is important to keep a reflexive attitude towards these plans and keep the discussion open about possible improvement in planning and implementation.

  Conclusion Top

A mental health EPRP was a helpful step forward in mitigating the risks associated with the monsoon season in Cox's Bazar. This was subject to later developments over the following 2 years. It served as a foundation for the later development of an EPRP in response to the coronavirus disease 2019 pandemic. It was clear that the cumulative institutional experience gained from responding to monsoon-related events had equipped the WG with knowledge and skills to plan for future emergency responses.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Elshazly, M., Alam, A. M., & Ventevogel, P. (2019a). Field-level coordination of mental health and psychosocial support (MHPSS) services for Rohingya refugees in Cox's Bazar. Intervention, 17(2), 212-216.  Back to cited text no. 1
Elshazly, M., Budosan, B., Alam, A. M., Khan, N. T., & Ventevogel, P. (2019b). Challenges and opportunities for Rohingya mental health and psychosocial support programming. Intervention, 17(2), 197-205.  Back to cited text no. 2
Hossain, A. N. M. (2021). Sustainable development and livelihoods of Rohingya refugees in Bangladesh: The effects of COVID-19. International Journal of Sustainable Development and Planning, 16(6), 1141-1152.  Back to cited text no. 3
IASC Reference Group for Mental Health and Psychosocial Support in Emergency Settings. (2012). Who is where, when, doing what (4Ws) in mental health and psychosocial support: Manual with activity codes (field test-version).  Back to cited text no. 4
Inter-Agency Standing Committee (IASC). (2007). IASC guidelines on mental health and psychosocial support in emergency settings.  Back to cited text no. 5
Tarannum, S., Elshazly, M., Harlass, S., & Ventevogel, P. (2019). Integrating mental health into primary health care in Rohingya refugee settings in Bangladesh: Experiences of UNHCR. Intervention, 17(2), 130-139.  Back to cited text no. 6
Welton-Mitchell, C. E. (2013). UNHCR's mental health and psychosocial support. UNHCR.  Back to cited text no. 7
World Health Organization (WHO). (2011). Psychological first aid: Guide for field workers.  Back to cited text no. 8
World Health Organization (WHO). (2015). mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies.  Back to cited text no. 9


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