Mental Health and Psychosocial Support during the COVID-19 Response: An Overview 1774912899, 9781774912898

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MENTAL HEALTH AND

PSYCHOSOCIAL SUPPORT DURING THE

COVID-19 RESPONSE An Overview

MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT DURING THE COVID-19 RESPONSE

An Overview

Edited by Joseph O. Prewitt Diaz, PhD

First edition published 2023 Apple Academic Press Inc. 1265 Goldenrod Circle, NE, Palm Bay, FL 32905 USA 760 Laurentian Drive, Unit 19, Burlington, ON L7N 0A4, CANADA

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© 2023 by Apple Academic Press, Inc. Apple Academic Press exclusively co-publishes with CRC Press, an imprint of Taylor & Francis Group, LLC Reasonable efforts have been made to publish reliable data and information, but the authors, editors, and publisher cannot assume responsibility for the validity of all materials or the consequences of their use. The authors, editors, and publishers have attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged, please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, access www.copyright.com or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. For works that are not available on CCC please contact [email protected] Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identification and explanation without intent to infringe. Library and Archives Canada Cataloguing in Publication Title: Mental health and psychosocial support during the COVID-19 response : an overview / edited by Joseph O. Prewitt Diaz, PhD. Names: Prewitt-Diaz, Joseph O., editor. Description: First edition. | Includes bibliographical references and index. Identifiers: Canadiana (print) 20230158420 | Canadiana (ebook) 20230158471 | ISBN 9781774912898 (hardcover) | ISBN 9781774912904 (softcover) | ISBN 9781003347620 (ebook) Subjects: LCSH: Community mental health services. | LCSH: Mental health services. | LCSH: COVID-19 Pandemic, 2020-—Psychological aspects. | LCSH: COVID-19 Pandemic, 2020-—Social aspects. Classification: LCC RA790 .M46 2023 | DDC 362.2—dc23 Library of Congress Cataloging-in-Publication Data

CIP data on file with US Library of Congress

ISBN: 978-1-77491-289-8 (hbk) ISBN: 978-1-77491-290-4 (pbk) ISBN: 978-1-00334-762-0 (ebk)

About the Editor Joseph O. Prewitt Diaz, PhD Former Professor, Pennsylvania State University, USA Joseph O. Prewitt Diaz, PhD, is a practitioner-scholar who began his career as a public health worker in the depressed villages of his native Puerto Rico. He soon learned from the wisdom of the people the value of listening, identifying common problems together, and devising ways to solve those community problems. Together with others, he developed the Puerto Rican Peace Corps: VESPRA. Soon thereafter, he migrated to the United States to pursue assisting migrant workers in the tobacco fields of Connecticut. Prewitt Diaz was an advocate for the poor, the linguistically diverse, and the underrepresented. He was a professor at the Pennsylvania State University, where he conducted research, taught, and trained community practitioners who would become leaders in the fields of school psychology and bilingual education. During his tenure, he received multiple awards and recognitions, including the W.K. Kellogg Fellowship and the Woodrow Wilson Hispanic Fellow­ ship, acknowledging his research and scholarly contributions. During this period, Dr. Prewitt Diaz and two collogues conducted a major national study of the effects of migration on children, and this study led to national changes in migrant education. From 1991 to 1998, Dr. Prewitt Diaz served as a mental health volunteer in some of the major disasters in the United States: Hurricane Andrew, the Oklahoma City Bombing, and the 9/11 United Recovery in Shanksville, PA. In 1998, Dr. Prewitt Diaz was assigned to the first international disaster where American Red Cross implemented a community psychosocial support program in the Americas, South Asia, and Africa. In 2008 he was the recipient of the APA International Humanitarian Award. He has continued in International Services as a volunteer to this day. Since 1998, Dr. Prewitt Diaz has been serving in international and domestic services with the American Red Cross. During his postings, he served as Program Coordinator for Central America in charge of Health, Water and Sanitation, and Community Engagement. He served the Mental Health Delegate during the 2002 El Salvador earthquake. He was transferred

vi

About the Editor

to India where he served as the Mental Health Delegate during the 2002 India Riots at Gujarat and earthquake response. By end of 2003, he oversaw the American Red Cross projects in the states of Gujarat, Orissa, and Tamil Nadu. In 2004 he was assigned to work at the Bhutanese Refugee Camps in Nepal as the Psychosocial Project Manager. In December of 2004, with the Southeast Asia Tsunami, he was tasked with the immediate response to the response and recovery in Maldives, Sri Lanka, Indonesia, and India. He returned to his native Puerto Rico where he developed a Disaster Law Center at the Law School of the University of Puerto Rico. By 2013, he had returned to the Washington, DC area, where he serves as a Red Cross volun­ teer focusing of the use of faith-based communities in disaster preparedness. He has been seconded to the IFRC for short assignments related to project development. In 2013, he supported the Ebola outbreak response in Western Africa; in 2016–2017, he supported the Zika response in Paraguay, Brazil, and Guatemala. From April 2020 to the present, he has been seconded from the American Red Cross to the IFRC, where serves as the Mental Health and Psychosocial Support Technical Expert for COVID-19. Among the many honors and awards, Dr. Prewitt Diaz received the Certificate of Merit for Lifesaving from the American Red Cross, the Meritorious Award from the Latin American Psychiatric Association for the Development of Mental Health and Psychosocial Support Programs in Central America, and the American Psychological Association International Humanitarian Award.

Contents

Contributors.............................................................................................................ix

Abbreviations ...........................................................................................................xi

In Memoriam..........................................................................................................xiii

Acknowledgment ..................................................................................................... xv

Foreword............................................................................................................... xvii

Preface ................................................................................................................... xix

PART I: Background of MHPSS ..........................................................................1

1.

Community-Based Mental Health and Psychosocial Support as a

Tool to Address the Societal Needs Raised by COVID-19...........................3

Joseph O. Prewitt Diaz

2.

Activating Community Resilience Through Community

Capitals After COVID-19.............................................................................15

Joseph O. Prewitt Diaz

3.

Community Engagement in Times of COVID-19 ......................................23

Anjana Dayal de Prewitt

PART II: Assessment of the Needs of the Most Vulnerable Population ..........27

4.

Community Engagement During COVID-19 and Beyond........................29

Joseph O. Prewitt Diaz

5.

Community-Based Psychosocial Support: A Process for the

Protection of Vulnerable Populations During COVID-19.........................47

Subhasis Bhadra

6.

Serving the Most Vulnerable: Psychosocial Support in

Indigenous Communities in Colombia, Costa Rica, Guatemala,

Ecuador, Mexico, and Peru ..........................................................................75

Joseph O. Prewitt Diaz

7.

Psychological Support Migration Appeal to the International

Federation of the Red Cross and Red Crescent in the

Americas Region ...........................................................................................95

Linda San Marcos

viii

8.

Contents

Mental Health and Psychosocial Support in Three African

Countries: Guinea, Liberia, and Sierra Leone......................................... 119

Joseph O. Prewitt Diaz

9.

Addressing Mental Health and Psychosocial Support Needs in

Cameroon, Kenya, Tanzania, and Uganda ...............................................139

Joseph O. Prewitt Diaz

PART III: Implementing Mental Health and Psychosocial Support.............161

10. An Examination of Mental Health and Psychosocial Support in

Four Low-Income Countries in South Asia ..............................................163

Joseph O. Prewitt Diaz

11. Developing a Universal Model of an MHPSS Regional Response..........185

Joseph O. Prewitt Diaz

12. Chronology of MHPSS Interventions in the Americas

During the Immediate and Early Recovery..............................................205

Greisy Massiel Trejo Rodríguez

13. Country-Level Mental Health and Psychosocial Support Programs:

Moving Forward After COVID-19............................................................239

Joseph O. Prewitt Diaz

14. Mental Health and Psychosocial Support During and After the

Pandemic: A Practical Response................................................................267

Joseph O. Prewitt Diaz

15. Monitoring and Evaluation of Mental Health and Psychosocial

Support*.......................................................................................................275

Joseph O. Prewitt Diaz

Index .....................................................................................................................297

Contributors

Subhasis Bhadra

Associate Professor and Head, Department of Sports Psychology, Central University of Rajasthan, Rajasthan, India

Joseph O. Prewitt Diaz

The Pennsylvania State University (Retd.), Pennsylvania, USA

Linda San Marcos

COVID-19 Recovery Program, International Federation of Red Cross and Red Crescent, Americas Region, Panama, C.A.

Anjana Dayal de Prewitt

American Red Cross, National Headquarters, Washington, D.C., USA

Greisy Massiel Trejo Rodríguez

Mental Health and Health in Emergencies Delegate, Americas Region, International Federation of the Red Cross, Panama, C.A.

Abbreviations

ANM CANPA CBPR CBPSS CBRN CE CEA CHD CHO CHW CTC DIP DMHP EOC GBV IASC ICG ICRC IEC IFRC INPI IT ITMS mhGAP MHPSS MoHP NGOs NRCS NSs PAHO PFA PGI PSP PSS

auxiliary nurse midwife Caribbean Association of Psychologists community-based participatory research community-based psychosocial support chemical, biological, radiological, and nuclear community engagement community engagement & accountability community healing dialog community health officers community health workers community treatment centers detailed implementation plans district mental health program emergency operation center gender-based violence interagency standing committee International Crisis Group International Committee of the Red Cross information, education, and communication International Federation of the Red Cross National Institute of Indigenous People information and technology Institute of Traditional Medicine Services mental health gap action program mental health and psychosocial support Ministry of Health and Population non-government organizations Nepal Red Cross Society National Societies Pan-American Health Organization psychological first aid protection, gender, and inclusion psychological support program psychosocial support systems

xii

R2 RBPSA RCRC SARS-CoV-2 SBP SDGs UIP UN UNFPA UNISDR URCS WHO

Abbreviations

resolution 2 resilience-based psychosocial assessment Red Cross and Red Crescent severe acute respiratory syndrome coronavirus 2 strength-based perspective sustainable development goals Interamerican University of Panama United Nations United Nations Population Fund United Nations Office for Disaster Risk Reduction Uganda Red Cross Society World Health Organization

In Memoriam

In loving memory of Mrs. Kanta Dayal (1949–2021) Kanta was a friend, a mother, and a grandmother. She was a Nurse by profes­ sion and served as a Nurse Supervisor in the Railway Hospital in New Delhi, India. She was a devout Christian. I recall the many times that we sang hymns of praise together. It was through her eyes that I began to learn about New Delhi and, once in a while, eat Indian food. When she came to visit us in Puerto Rico, she would always sing in church, and later in different churches here in Virginia. Kanta was elevated to eternity as a result of COVID-19 in April 2021. Kanta will always be in our thoughts and prayers and serves as an example and an inspiration to her children, grandson, and her friends. “Though you are no longer with us, you will never be forgotten. May your memory be forever held in the pages of this book.”

Acknowledgment

A number of people have had an input in the preparation of this book. We are grateful to all. However, there are a few individuals without whom the project would not have been completed. During the gestation stage for the book, three individuals provided inputs: Mr. Walter Cotte, Special Represen­ tative to the Secretary General of the IFRC for COVID-19, for his interest in learning how MHPSS fits into the societal recovery of the pandemic. I wish I had the foresight of a great Indian scholar, Dr. Srinivasa Murthy, Professor Emeritus of Psychiatry at the National Institute of Mental Health and Neuro­ sciences of India, and WHO representative for the MENA, who helped me to understand the importance of psychosocial support region for the most vulnerable, and who laid out the road map for the Indian Red Cross Mental Health and Psychosocial Support Project. Dr. Subhasis Bhatra, Director and Professor of the School of Social Work at the Central University of Rajasthan, India, is a practitioner-scholar who implemented the community-based program post-tsunami for the Indian Red Cross. I am particularly grateful to Dr. Gerald Jacobs, Professor Emeritus of Psychology and the Director for many years of the Disaster Institute at the University of South Dakota, who visited the projects in Gujarat, India, Sri Lanka, and Indonesia. I also want to acknowledge the hundreds of Red Cross volunteers who served in the teams in Central America after Hurricane Mitch, and the El Salvador Earthquake, and in South Asia, specifically the India Team who developed psychosocial support programs in Gujarat, Orissa, and Tamil Nadu. The field-based ideas of each member brought forth ideas and proto­ cols for training and project development that was linguistically, culturally, and contextually based intervention. You will find that the chapters of this book encapsulate your ideas and actions. I hope we have been able to project your actions into words. We are able and acknowledge the person that reviewed and corrected our English. Every chapter was processed through a two-step process: (i) is the chapter written clearly, and is it understandable in American English, and (ii) is the content technically and practically appropriate, and can it assist the field in developing community-based programming that meets the cultural, linguistic, social-emotional needs of the affected person in diverse parts of the world.

xvi

Acknowledgment

Making sure that we provided insights into the nuances of the program required that the Editor substantiate several parts, where he lacked their expertise. Each one of the contributors shared their wisdom in a specific area. Brito reported on a qualitative study with a selected group of youth, as they adjusted to the rigorous environment; Dayal de Prewitt focused on community engagement (CE), relying on her vast engagement with the subject for over 20 years in India, Sri Lanka, other parts of the world, Puerto Rico and most recently in diverse parts of the United States. Rodriguez Trejo brought the knowledge of the field as the architect of the initial response and recovery in the Americans and the Caribbean, and San Marcos brought years of experience working with migrant populations. All these pieces contributed to this written puzzle – Mental Health and Psychosocial Support during the of COVID-19 Response. We would be remised if we didn’t acknowledge Dr. Jono Anzalone, who directed and facilitated our work in the Americas and Caribbean countries. Last but not least, our three readers. Dr. Aida I. Rodriguez Roig, Rector of the University of Puerto Rico in Humacao, Dr. Irving Cotto, a faculty member at the Wesley Theological Seminary in Washington, D.C., and Dr. Glen Festinger, Marymount University.

Foreword

In early January 2020, I was on a mission to the International Federation of Red Cross Red Crescent Societies (IFRC) headquarters in Geneva, Switzerland. My regular round of unit briefings was underway, with a slight buzz around a virus popping up in Wuhan, China. The emergency operations center in Geneva was holding a series of briefings with the IFRC in Kuala Lumpur, a typical protocol for what appeared to be a typical public health incident. Then the Head of Disaster and Crisis for the Americas Region, based out of Panama called. I recall touching base with my team back in Panama via WhatsApp regarding the ongoing Hurricane Dorian Operation, concerns about drought in the northern triangle, as well as expansive migra­ tion crisis that had unfolded in the Americas. My Operations Lead, Felipe Del Cid, a seasoned disaster and crisis leader, posed the question, “when should we start scenario planning in case this virus begins to spread, similar to H1N1?” Just weeks later, on January 30, 2020, we saw bold action from the World Health Organization (WHO) International Regulations Emergency Committee, declaring the 2019-nCoV outbreak a public health emergency. WHO launched the Strategic Prepared and Response Plan just days later, alongside the initial IFRC appeal to mobilize resources. What followed in the days and months to come became part of the making of history. While not the worst global pandemic as of the writing of this foreword, compared to the smallpox pandemic of 1877, which killed an estimated 500 million people, the complexities and context of the COVID-19 pandemic is a black swan event. Like 1877, global pandemics have too often undervalued the mental health and psychosocial toll on those directly impacted by a public health pandemic and those indirectly affected. In the months leading up to March 3, 2020, WHO declaration of a global pandemic, millions of migrants were making their way along migratory routes from South America, the Carib­ bean, and Central America in search of safety, security, and property. The closure of borders, substantial restriction of movement within countries, and utter disruption of everyday transformation roots led to millions of migrants stranded in communities lacking infrastructure and social support systems.

xviii

Foreword

I recall firsthand seeing the small community near Las Peñita, a commu­ nity with an indigenous population of under 400 people, grow to over 2,500 due to stranded migrants from more than 13 countries across the globe. I recall the town council struggling to find sustainable ways to integrate those passing through on their migration journey, as social tension escalated. The emotional trauma that many migrants faced as they traversed the Darian gap on their route north surfaced psychosocial trauma due to the brutal terrain that the route poses, coupled with horrendous cases of human trafficking, exploitation, and abuse. These compounding complexities required bold focus, planning, and robust mental health and psychosocial support systems (PSS). This book is an essential read for both mental health and psychosocial support professionals, as well as disaster and crisis leaders and practitioners. Dr. Prewitt Diaz weaves together framing and subject matter expertise that builds on academic research pre-COVID-19 pandemic, emergent literature from 2020 and 2021, as well as key case studies. Most relevant, Dr. Prewitt played a key leadership role in the IFRC America’s COVID-19 operation, supporting the 35 countries that make up the region in designing and imple­ menting robust mental health and psychosocial support programming. To Dr. Prewitt Diaz and contributing authors as well as authors Anjana Dayal de Prewitt, Linda San Marcos, Greisy Massiel Trejo Rodríguez, and Subhasis Bathra, who I had the pleasure of working with as lead for the IFRC COVID-19 operation in the Americas, thank you for this vital contribution to the robust mental health and psychosocial support field! —Dr. Jono Anzalone Executive Director at The Climate Initiative, Portland, Maine, US

Preface

This book is written for planners and practitioners in the field of humanitarian assistance, funding agencies, decision-makers, influencers, and researchers. In addition, it informs policy and legal reforms in the regions under study. The book identifies the important need for Mental Health and Psychosocial Support (MHPSS) to be included as a holistic strategy by state governments to better serve all people. This book presents a holistic scenario of mental health and psychosocial support in 27 countries in three regions of the world. It looks at the need of the most vulnerable populations: (i) the native populations in the Americas; (ii) countries affected by the Ebola epidemic in Western Africa, as well as a group of sub-Saharan countries struggling to provide MHPSS to its popula­ tion; and (iii) poor Southeast Asian countries attempting to address a massive refugee crisis and political and socioeconomic turmoil while attempting to survive the disastrous impact of the pandemic. The reader is the conduit of more than 350 interviews with MHPSS administrators, volunteers, and technical staff in the ground-level personnel in these geographic areas. This book presents an existing reality; while there is MHPSS interna­ tional guidance, and some Humanitarian agencies are attempting strong measures to get states to recognize and write a policy that is inclusive, the problem in many states is the lack of services to the most vulnerable. So, this book is a call to action for cultural, linguistic, and contextual actions that inform inclusiveness of the most vulnerable, and unheard, communities. Four chapters were written by colleagues currently in the field, and who have been working closely with COVID-19/MHPSS-related programs. The content of this book consists of desk reviews from the most recent literature related to MHPSS during the pandemic, TEAMS, ZOOM, tele­ phone interviews, and emails with concerned experts in their respective countries, and it provides the analysis of a seasoned humanitarian worker, with over 30 years of direct experiences of the most vulnerable community in the countries covered in this book. The book is about the implementation of Mental Health and Psychoso­ cial Support during the COVID-19 pandemic internationally that has lasted over 18 months. For the last six months, the author has been looking at how language, culture, and context have affected vulnerable communities in three

xx

Preface

regions: Central and Americas, Western and Sun-Saharan African coun­ tries, and Southeast Asian countries. It highlights how the lack of trained personnel and mental health facilities has not reached the affected people, or how MHPSS has been contextualized so that the linguistically and culturally migrant and refugee people can benefit from this strategy. This book compiles reports and interviews with over 200 people in 37 countries, which provide inputs about the psychosocial needs of the popula­ tion. They help us frame COVID-19 as a systemic loss of protective factors, where the communities collapsed psychologically, socially, and economi­ cally. After the public health response, the major task is to re-establish resilience through mental health and psychosocial community-led programs. Mental Health and Psychosocial Support (MHPSS) was a theme that was operationalized by the IASC in 2007. It came about in recognition of the close relationship between mental health and psychosocial needs. Humanitarian workers have been using the strategy in whole or part in natural or man-made emergencies around the world. The COVID pandemic was different. It was happening all over the world, at a very quick pace. The response by the States was the same (physical distancing and quarantine), yet the response was the same; apply MHPSS. This book attempts to share with the reader the fact that MHPSS has not been a solution during the pandemic, not because of the method, but as a result of the duration of COVID-19, and the ground reality: lack of resources, lack of trained people, diversity of implementation of MHPSS, and the need to reach out to the most vulnerable. The book is a first look at MHPSS during the COVID-19 pandemic with the hope that it will tickle the readers’ imagination and generates action for future worldwide mental health and psychosocial support responses. The book is divided into three segments: the first segment addresses existing guidance for MHPSS from the viewpoint of the IFRC (the humani­ tarian organization where the author worked during COVID-19). It addresses resilience as an individual and collective activity and looks at how to engage the communities in times of COVID-19. The second part of the book consists of six chapters, which take the reader through selected countries in three regions: Central and South America, Western and Sub-Saharan Africa, and four countries in Southeastern Asia. The third part consists of five chapters and presents a theoretical and practical model for the implementation of MHPSS as part of a humanitarian response at the regional level. Most people have not traveled to many places in the world, and those that have adhered to the very focused nature of their tasks abroad. Mental Heal and Psychosocial Support encompasses clinical approaches with

Preface

xxi

community-based interventions. The reader has over 30 years of experience as a Humanitarian worker, doing direct interventions in clinics, and devel­ oping community-based interventions. It is through his optic that the book is presented. He takes you on an imaginary voyage to three regions of the world and introduces you to the ground conditions, the limited conditions, the lack of trained personnel, and the ground reality of the most vulnerable, looking at emotional human suffering as magic. We hope the reader becomes awake and invest this new learning into productive strategies.

PART I

Background of MHPSS

CHAPTER 1

Community-Based Mental Health and Psychosocial Support as a Tool to Address the Societal Needs Raised by COVID-19 JOSEPH O. PREWITT DIAZ

The Pennsylvania State University (Retd.), Pennsylvania, USA

ABSTRACT This chapter introduces mental health and psychosocial support as it is conducted at community levels. The chapter describes the development of the MHPSS, the tier for administrating the guidelines, and the adaptation of the guidance into the humanitarian sector. The chapter concludes with a description of the adaptation of MHPSS into the Red Cross Movement. 1.1 INTRODUCTION The early part of the 21st century has witnessed weather-related humani­ tarian crises and the recent COVID-19 pandemic. Humanitarian actors have scrambled to serve the emergent needs of the most vulnerable and under­ represented populations. The pandemic has created an emergency in health and mental health. From the outset, it has required community engagement (CE) to inform the public about quarantines, distancing, and wearing masks in public. Serafini et al. (2020) explored the psychological response of COVID-19 in the population. They found that the initial response was to prevent the Mental Health and Psychosocial Support during the COVID-19 Response: An Overview. Joseph O. Prewitt Diaz (Ed.) © 2023 Apple Academic Press, Inc. Co-published with CRC Press (Taylor & Francis)

4

Mental Health and Psychosocial Support during the COVID-19 Response

impacts of its contagiousness (Serafini et al., 2020). Soklardis and his colleagues (2020) concluded that after several months, professionals began to report issues regarding mental health and psychosocial support (MHPSS) related to the reactions to the pandemic (Soklaridis et al., 2020). The response to COVID-19 has exacerbated mental health and psychosocial issues for people with pre-existing conditions. Dickinson & Bangpan (2018), in their examination of facilitators and barriers in implementing MHPSS, found that various international organizations have sought to address social and psychological concerns by protecting children, women, the elderly, and other populations in their communities, while others groups have attempted to assist with services for mental health issues related to COVID-19, such as social anxiety, depression, fear, or other conditions (Dickson & Bangpan, 2018). This chapter explores the adaptation of MHPSS to the global pandemic response by one humanitarian agency: the Red Cross, as well as the Red Crescent community, and the proposed road map for its implementation throughout the world. The world wars during the 20th century, complex humanitarian events, and natural disasters gave birth to the study of mental health among affected populations throughout the world. Engel, in his study of creativity and move­ ment, found that while mental health treatment dates back to the beginning of time, the ancient Egyptians were the first to suggest that psychosocial activities such as recreational activities, music, dancing, and painting could alleviate symptoms and give patients some semblance of normalcy (Engel, 2008). Fuhrer and Keyes, in their study, found that mental health issues were not institutionalized until the 19th century with the emergence of talking therapies. It was not until the first half of the 20th century that person-centered approaches and cognitive approaches emerged. In Japan, an integrative socially oriented counseling method was devised, while in India, metaphysical and Ayurvedic systems were linked to European and Western methodologies to generate psychosocial support approaches to treatment (Fuhrer & Keyes, 2019). Natural disasters, humanitarian emergencies, and pandemics have continued to increase throughout the world. These events impact the community in such a way that thwarts people’s capacity to respond and impedes their capacity to move forward to recovery from the emotional turmoil that these emergencies cause (Makwana, 2019). Morganstein & Ursano (2020) suggest that, unlike physical injuries, adverse mental health outcomes may not be apparent because, in post-disaster settings, the affected population may experience new psychiatric disorders, exacerbations of

Community-Based Mental Health and Psychosocial Support

5

pre-existing psychopathology, or psychological distress related to the disaster (Morganstein & Ursano, 2020). By 2008, psychological first aid (PFA) had been recognized as an important tool to alleviate fear and stress among affected people. PFA and community activities, as well as psychoeducation, are generally accepted as important principles of the COVID response. 1.2 DEVELOPMENT OF MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT GUIDELINES Ubles et al. (2022) report that in 2007, the Inter-agency Committee on MHPSS achieved a consensus on a set of guidelines that address two issues: (i) the principle of “do no harm;” and (ii) the lack of coordination between agencies responsible for addressing immediate needs after disaster or emer­ gencies. A category that has emerged in MHPSS in humanitarian settings is a response based on psychological and social trauma (Ubles et al., 2022). Daggiel, Dua, Mahajan, & Chokhani (2020) clarify the role of the psychosocial approach as a tool to alleviate suffering and promote well-being during COVID-19. McDade & Harris (2018) suggests that the psychosocial approach involves the interplay of biological, psychological, and social dimensions within the social context of a family in communities and soci­ eties (McDade & Harris, 2018). Tol et al. (2015) define “psychosocial support” as any type of support that promotes psychosocial well-being and influences the psychosocial context and promoting health and well-being (Tol et al., 2015). Pedersen et al. (2015) propose two interventions to alleviate suffering after a disaster: (i) community-based approaches; and (ii) counseling to reduce traumatic stress (Pedersen, Kienzler, & Guzder, 2015). According to Greene, Jordans & Kohrt et al. (2017), MHPSS has become a common feature of many emergency humanitarian-response efforts (Greene et al., 2014). Many humanitarian aid workers believe that actions related to MHPSS interventions begin with CE and provide psychoeducation and PFA to alleviate the initial sequelae of COVID-19. Since its inception, MHPSS has accumulated information from the field regarding best practices in diverse crisis situations. MHPSS is providing valuable strategies for community-based activities that have been devel­ oped to address the mental health and psychosocial needs generated by the COVID-19 pandemic. MHPSS.net serves as a repository of materials developed in multiple languages.

6

Mental Health and Psychosocial Support during the COVID-19 Response

1.2.1 TWO EXTENSIVE ARTICLES ON THE PROGRESS OF MHPSS IN HUMANITARIAN EMERGENCIES

Dickson & Bangpan (2018) conducted a review of barriers and facilita­ tors with regard to implementation and suggested that CE is a key path to the implementation of MHPSS. Such programs are difficult to implement in resource-limited communities, however. Regardless of the setting or type of MHPSS intervention, it is important to consider contexts and how socially and culturally meaningful they may be for the target population. The intermingling of the community in planning, program development, and implementation will dictate the success of MHPSS-related programs. A desk review was conducted by Augustivicius et al. (2018) in regard to the terminology and focus of monitoring and evaluation of MHPSS programs in humanitarian settings to determine the best language to be used for program implementations (Augustinavicius et al., 2018). The findings suggested that standardized language and methods used to implement the MHPSS program would be beneficial for monitoring and evaluation. MHPSS is considered to be an important tool in the development of humanitarian response as its components fit into the general health response. It helps to identify the best tool for intervention and escalates the response from community-based psychoeducation and PFA to specialized services as needed. Furthermore, MHPSS ensures the treatment of clients with preexisting conditions. As the emergency response continues toward long-term recovery, MHPSS becomes a platform for community mental health clinics and supports psychosocial interventions remotely using communication and technological means. MHPSS developed a pyramid of services and recommended interven­ tions consisting of four tiers (Flynn & Sherman, 2017). In the first tier, at the base of the pyramid, there are social considerations, such as organizing rapid participatory approaches and conducting community-inclusive, focused groups, including marginalized people. In the case of COVID-19, common psychological reactions have been identified, such as fear, anxiety, confu­ sion, anger, and withdrawal. The second tier focuses on strengthening community and family support. The activities in this tier were recommended by the SPHERE (2018) stan­ dards and involved finding trained community actors offering PFA, identi­ fying community-based psychosocial strategies that foster mutual support, and preparing local information and recommendations for vulnerable at-risk groups. PFA must be made available to people exposed to potentially

Community-Based Mental Health and Psychosocial Support

7

traumatic events or who have witnessed deaths. It is non-intrusive and does not press people to talk about their distress. After a brief orientation, commu­ nity leaders, healthcare workers, and others involved in the humanitarian response can administer PFA. The third tier recommends providing focused, non-specialized support. Non-specialized healthcare workers can deliver psychological interven­ tions for mental health and psychosocial needs when they are well-trained, supervised, and supported. This includes cognitive behavior therapy or interpersonal therapy. The final tier recommends providing specialized mental health services, including remote care or the continuation of pre-existing treatments. The most frequent conditions presented to health services in emergencies are psychosis, depression, and a neurological condition, epilepsy. Maternal mental health is a specific concern because of its potential impact on care for children. To ensure the availability of specialized services, it is important to rely on strategies that the Ministries of Health have identified in affected areas. All volunteers must be briefed on available mental healthcare. In summary, MHPSS suggests some concrete steps for moving forward during the response and into recovery. MHPSS (2008) recommends the following concrete steps: (i) assessing the affected areas; (ii) prioritizing actions based on community needs; (iii) adapting messages and all forms of communication to different target groups; and (iv) exploring opportunities to develop community-based mental health services. 1.2.2 MHPSS ADAPTATION IN THE HUMANITARIAN SECTOR MHPSS has been adapted by UN agencies and multiple humanitarian actors, including the Red Cross movement. The Red Cross is the largest humani­ tarian volunteer movement in the world and includes 192 National Societies (NSs). The international structure has two components: the International Committee of the Red Cross (ICRC) and the International Federation of the Red Cross and Red Crescent (RCRC). 1.2.3 MHPSS GUIDELINES DEVELOPED BY THE INTERNATIONAL COMMITTEE OF THE RED CROSS (ICRC) IN 2018 In 2018, the ICRC developed guidelines to outline the organization’s approach to MHPSS. A needs-based publication was developed to provide a

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Mental Health and Psychosocial Support during the COVID-19 Response

programmatic overview of MHPSS and described program-specific needs, assessment methods, the main program activities and implementation strate­ gies, and the monitoring. The MHPSS interventions of the ICRC (2018) seek to take cultural considerations into account by engaging with key community members, including traditional and religious leaders, teachers, and health professionals. It is crucial to identify and strengthen these local resources in both govern­ ment and civil society. The ICRC does this through specific modes of action, such as raising awareness of responsibility and persuasion. As the ICRC’s health strategy indicates, all health programs must ensure a continuum of care. Mental health and psychosocial activities and programs were integrated into the health service framework. The ICRC’s designed continuum of care links first aid and prehospital care, primary healthcare, hospital, and rehabilitation services detention centers. 1.3 THE DEVELOPMENT OF AN INTERNATIONAL RED CROSS POLICY In December 2019, a council of delegates composed of representatives of the ICRC, International Federation of the Red Cross and Red Crescent Societies (IFRC), and the 197 NSs unveiled a policy addressing mental health and psychosocial support. The model was introduced by the movement resolu­ tion and published by the PS Center. The model is divided into a four-part pyramid: The IFRC developed a road map to help the 197 NSs over a threeyear period, which was published by the PS Center. By 2023, all volunteers and paid staff of all NSs are expected to be able to provide PFA and basic psychosocial support as part of the repertoire of response services. 1.4 BARRIERS AND FACILITATORS FOR SCALING UP MHPSS INTERVENTIONS One of the barriers is the recency of the documents explaining the guidelines. MHPSS has recently been adopted and published in the disaster field, and there are still discrepancies among practitioners with regard to the guidance as published in 2007 by the IASC. Furthermore, the most recent guidance was adopted in December 2020, so the COVID-19 pandemic is the first major disaster in which the Red Cross Movement has applied MHPSS as an integrated approach within its repertoire of services.

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It has been difficult for the Red Cross to adjust to the lower tiers of service of basic psychosocial support and focused psychosocial support, as articulated in the model presented above. The humanitarian workers in the field relied on the SPHERE guidelines as their primary tools. These tools included engaging community volunteers (teachers, health promoters, midwives, neighborhood leaders, and psychosocial volunteers) in providing initial social support to the affected people. The facilitators include the fact that COVID-19 was primarily a public health disaster, and as a result, the field was able to utilize pre-existing community mobilization tools. For people who have experienced death in their households or other traumatic, stressful events, they include a nonclinical intervention consisting of listening, assessing basic needs, ensuring those needs are met, and encouraging people to talk about the stressors and how to address them. This intervention is a first-order intervention referred to as PFA. The development of an MHPSS strategy to serve regional needs seemed to facilitate the development of long-term strategies to meet the psychosocial and emotional needs of the population. Prewitt Diaz developed a “spiral of recovery” based on MHPSS in 2020 that is widely used in Latin America and the Caribbean to explain the cycle of recovery from COVID-19, that proposes tasks that should be completed as part of the psychosocial evolu­ tion to recovery from COVID-19 (Diaz, 2020). 1.5 THE IMPACT OF THE PANDEMIC ON COMMUNITIES AND THE VALUE OF TRAINING VOLUNTEERS COVID-19 has had a catastrophic impact on physical and mental health worldwide. This section addresses the impact of the pandemic and the value of training Red Cross volunteers to provide community-based assistance in affected communities. The section briefly reviews the impact of COVID-19 on the psychosocial well-being of the community, the initial response, and the opportunity to reimagine MHPSS globally. 1.5.1 IMPACT OF COVID-19 ON PSYCHOSOCIAL WELLBEING The population-wide distress can be attributed to the spread of COVID-19, the effectiveness of containment strategies, and when and how everyday life will return to normalcy. These experiences have been augmented by

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Mental Health and Psychosocial Support during the COVID-19 Response

government measures for preventing the spread of the virus, including actions of containment and closures, economic response, and health systems’ community-wide interventions. Devising new ways to provide MHPSS and cope with the reduction in income and livelihood opportunities has had a devastating effect, and the most affected have been vulnerable populations. The pandemic’s effects on mental health can be observed in systemic social inequities across the demographic, economic, neighborhood, and sociocultural characteristics. Low educational levels, economic and social disadvantages, homelessness, unemployment, social isolation, and loneli­ ness are significant risk factors. COVID-19 has had a negative impact on long-term health. In addition, societal turmoil and violence have increased in larger urban centers. 1.5.2 RESPONSE TO MHPSS NEEDS It is important to assess implementation processes and outcomes to inform the mental health response to future public health emergencies, such as the extent to which the shift of care from in-person to remote delivery addresses individual clinical needs or MHPSS needs in communities, as reported by the IASC (2020); IFRC (2020); and WHO (2020). Three major initiatives were published in early 2020. In February 2020, the IASC issued a briefing note with MHPSS recommendations for COVID-19. The guidance suggested approaches for specific populations. The IFRC called for the widespread use of PFA, including remote delivery to people in quarantine, health workers, and groups with previous vulnerabilities. The International Organization for Migration developed guidelines for forced laborers and migrant populations. The WHO published materials to promote self-help, provide psychoedu­ cation, and promote community-based activities to alleviate stress, anxiety, and depression. One major initiative has been to build capacities among non-specialists to deliver psychological services through “Problem Manage­ ment Plus,” an intervention based on problem-solving therapy designed for delivery by a non-specialist. 1.5.3 REIMAGINING MHPSS Babel et al. (2020) recommend the identification and use of diverse resources in communities to face the pandemic and improve mental health and psycho­ social support. These efforts involve a shift to a broader care-gap perspective, increased recognition of the crucial contributions of local leadership, and

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action beyond the health sector to promote mental health (Bavel et al., 2020). Moving beyond these categories, we can recognize a diversity of resources, including financial sources that distinguish between global contexts and how they can be used to face crises and improve psychosocial support and mental health. For example, religious centers, community ties, family support structures, traditional healers, village leaders, and youth groups are all contextually varying resources that can be essential for overcoming mental and physical health threats, including those related to COVID-19. In order to assess the progress in MHPSS, strength-based assessment and context-free approaches may be two significant approaches. SPHERE (2018) recommends that to achieve good mental health as part of COVID-19 response efforts, the humanitarian community in the initial response must ensure that people’s basic needs are met and that human rights are protected. Shadmi et al. recommend that when social inequalities remain unaddressed, mental health interventions are less effective (Shadmi et al., 2020). 1.5.4 DEVELOPING MHPSS IN COMMUNITIES POST-COVID-19 The COVID-19 pandemic highlights the importance of resilient and respon­ sive mental health systems that take services to clients. To achieve this goal, the PS Center suggests supporting community-level psychosocial volunteers and community health workers (CHWs). Lehmann and Sanders define CHWs as selected members of communities who are accountable to those communities for their activities. During the pandemic, the Red Cross established a community-centric approach that facilitates proactive community-wide services that are consid­ ered crucial to slowing the spread of COVID-19. CHWs were crucial in providing psychosocial support to people during the pandemic. Volunteers in communities provided psychoeducation and other types of psychosocial support. Red Cross volunteers, other community-wide volunteers, and local healers were empowered to engage people in PFA, enhance literacy in local languages, and foster social support. 1.5.5 A CULTURE SHIFT: MOVING MHPSS FROM CLINICS TO THE COMMUNITY On June 10, 2021, the WHO announced community mental health services as an initiative that is person-centric and a rights-based approach. The initiative

12

Mental Health and Psychosocial Support during the COVID-19 Response

encouraged community volunteers to raise awareness in the community about MHPSS issues, identify distressed individuals, provide four to six sessions of PFA, and refer people who may have severe mental health conditions to public mental health services. In its road map to the implementation of MHPSS, the IFRC encourages staff and volunteers to develop the skills and competencies required to provide a basic level of psychosocial support relevant to their tasks and to identify segments of the population that are facing stigma, discrimination, and exclusion. As Red Cross volunteers work together with target communities, they will be able to train families so that at least one member of each household can administer PFA, as well as provide information on PFA in the community. We propose that for the RCRC movement, community groups and houses of faith should develop strategies that will allow target communities to conduct public information campaigns and contact tracing and provide PFA. The WHO suggests that in encouraging community mental health, schools must develop supportive environments where children can identify and develop protective behaviors that will foster resilience. By the same token, commu­ nities must identify their resources and develop cultural, ecological, and economic activities that will assist in the build-up of families and enhance communities’ well-being. 1.6 SUMMARY This chapter has examined the development of MHPSS to assist survivors of humanitarian or natural disasters or long-term pandemics. The chapter has explored the barriers and facilitators with regard to scaling up services during the COVID-19 pandemic in neighborhoods and communities using the Red Cross or Red Crescent as a community anchor. The response to the COVID-19 pandemic has been impacted by its magnitude, disruption of health facilities, erosion of emergency care systems, and reduction of medical personnel and supplies. Currently, vaccines to protect individuals from COVID-19 have limited availability. Following the guidelines of the United Nations (UN) and WHO will certainly provide a rights-based approach that will enhance community well-being.

Community-Based Mental Health and Psychosocial Support

KEYWORDS • •

community health workers COVID-19

• •

mental health and psychosocial support psychological first aid

13

REFERENCES Augustinavicius, J. L., Greene, M. C., Lakin, D. P., et al., (2018). Monitoring and evaluation of mental health and psychosocial support programs in humanitarian settings: A scoping review of terminology and focus. Confl. Health, 12, 9. https://doi.org/10.1186/s13031-018-0146-0. Bavel, J. J. V., Baicker, K., Boggio, P. S., et al., (2020). Using social and behavioral science to support COVID-19 pandemic response. Nat. Hum. Behav., 4, 460–471. https://doi. org/10.1038/s41562-020-0884-z. Diaz, J., (2020). The spiral of recovery: Mental health and psychosocial support during a COVID-19 environment in the Americas. Journal of Psychology & Behavior Research, 2, 13. 10.22158/jpbr.v2n2p13. Dickson, K., & Bangpan, M., (2018). What are the barriers to, and facilitators of, implementing and receiving MHPSS programs delivered to populations affected by humanitarian emergencies? A qualitative evidence synthesis. Global Mental Health (Cambridge, England), 5, e21. https://doi.org/10.1017/gmh.2018.12. Engel, J., (2008). American Therapy: A History of Psychotherapy in the United States. https:// www.penguinrandomhouse.com/books/301769/american-therapy-by-jonathan-engel/ (accessed on 27 October 2022). Flynn, B., & Sherman, R., (2017). Integrating Emergency Management and Disaster Behavioral Health: One Picture. (Chapter 3). Butterworth & Heinemann. Boston, Mass. Fuhrer, R., & Keyes, K. M., (2019). Population mental health in the 21st century: Time to act. American Journal of Public Health, 109(S3), S152, S153. https://doi.org/10.2105/ AJPH.2019.305200. Greene, M., Jordans, M. J. D., Kohrt, B. A., et al., (2014). Addressing culture and context in humanitarian response: Preparing desk reviews to inform mental health and psychosocial support. Confl. Health, 11, 2. https://doi.org/10.1186/s13031-017-0123-z. Greene, M., Jordans, M. J. D., Kohrt, B. A., et al., (2017). Addressing culture and context in humanitarian response: Preparing desk reviews to inform mental health and psychosocial support. Confl. Health, 11, 21. https://doi.org/10.1186/s13031-017-0123-z. Makwana, N., (2019). Disaster and its impact on mental health: A narrative review. Journal of Family Medicine and Primary Care, 8(10), 3090–3095. https://doi.org/10.4103/jfmpc. jfmpc_893_19.

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McDade, T. W., & Harris, K. M., (2018). The biosocial approach to human development, behavior, and health across the life course. The Russell Sage Foundation Journal of the Social Sciences: RSF, 4(4), 2–26. https://doi.org/10.7758/RSF.2018.4.4.01. Morganstein, J. C., & Ursano, R. J., (2020). Ecological disasters and mental health: Causes, consequences, and interventions. Front Psychiatry, 11, 1. doi: 10.3389/fpsyt.2020.00001. PMID: 32116830; PMCID: PMC7026686. Pedersen, D., Kienzler, H., & Guzder, J., (2015). Searching for best practices: A systematic inquiry into the nature of psychosocial interventions aimed at reducing the mental health burden in conflict and post-conflict settings. SAGE Open. https://doi. org/10.1177/2158244015615164. Serafini, G., Parmigiani, B., Amerio, A., Aguglia, A., Sher, L., & Amore, M., (2020). The psychological impact of COVID-19 on the mental health in the general population. QJM: Monthly Journal of the Association of Physicians, 113(8), 531–537. Advance online publication. https://doi.org/10.1093/qjmed/hcaa201. Shadmi, E., Chen, Y., Dourado, I., et al., (2020). Health equity and COVID-19: Global perspectives. Int. J. Equity Health, 19, 104. https://doi.org/10.1186/s12939-020-01218-z. Soklaridis, S., Lin, E., Lalani, Y., Rodak, T., & Sockalingam, S., (2020). Mental health interventions and supports during COVID- 19 and other medical pandemics: A rapid systematic review of the evidence. General Hospital Psychiatry, 66, 133–146. https://doi. org/10.1016/j.genhosppsych.2020.08.007. Tol, W. A., Purgato, M., Bass, J. K., Galappatti, A., & Eaton, W., (2015). Mental health and psychosocial support in humanitarian settings: A public mental health perspective. Epidemiology and Psychiatric Sciences, 24(6), 484–494. https://doi.org/10.1017/ S2045796015000827. Ubles, T., Kinsbergen, S., Tolsma, J., & Koch, D. J., (2022). The social outcomes of psychosocial support: A grey literature scoping review. SSM-Mental Health, 2, 100074. https://doi.org/10.1016/j.ssmmh.2022.100074.

CHAPTER 2

Activating Community Resilience Through Community Capitals After COVID-19 JOSEPH O. PREWITT DIAZ

The Pennsylvania State University (Retd.), Pennsylvania, USA

ABSTRACT This chapter explores the components of social structures. It describes how diverse groups become resilient and identifies the activities that lead to resilience in the population. An emphasis on social cohesion and how these activities lead to resilience among all groups. It concludes by providing an operational definition of community engagement. 2.1 INTRODUCTION This chapter explores the components of community social structure and identifies five community resilience parameters by discussing social cohesion engagement and community capital (Prewitt Diaz & Dayal, 2008; Prewitt Diaz, 2013). Both articles summarize practical experiences of engaging communities after the El Salvador Earthquake and the Southeastern Asia Tsunami. To identify the activities that lead to resilience in millions of people during recovery, the authors stumbled onto engagement and social capital as protective factors. The world’s population has had to face the consequences of COVID-19 at individual and community levels: Illness, losses, increased debt, and diversification of lifestyle have caused significant behavior changes within Mental Health and Psychosocial Support during the COVID-19 Response: An Overview. Joseph O. Prewitt Diaz (Ed.) © 2023 Apple Academic Press, Inc. Co-published with CRC Press (Taylor & Francis)

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Mental Health and Psychosocial Support during the COVID-19 Response

communities. Castiglioni & Gaj (2020) identified two actions characterizing the initial response to COVID-19: (i) At the pandemic’s outset, technology became key to reaching people who otherwise would have been unreach­ able; and (ii) affected people were overwhelmed by unexpected events that put a strain on everyday routines and usual meaning-making systems. Psychological and psychosocial interventions as coping strategies have been promoting an understanding of distressful events. People worldwide need to develop appropriate metaphors and promote a sense of coherence. The purpose of this chapter was threefold: (i) discuss early efforts to assist the population and provide meaning to COVID-19; (ii) provide a discussion concerning resilience; and (iii) introduce the concept of community engage­ ment (CE) as a conduit to enhance community resilience. 2.2 EARLY STRATEGIES TO PROVIDE INFORMATION AND MEANING More than one year later, the world is still trying to recover from the harmful effects of the pandemic. Middle- and low-income countries and the poor and marginalized have been most affected by this virus. One potential response is to increase patient-based resources, such as providing timely and accurate information, video messaging, and teleassistance. As a preventive measure, governments have mandated measures, such as wearing masks, distancing, quarantine, and vaccination. These measures seemed to have sufficed in reducing the spread of the virus. COVID-19 has induced high levels of stress that resulted in loneliness, and increased domestic violence caused quarantines. The challenge for humanitarian agencies and governments alike is understanding how to influence the emotional climate in neighborhoods and communities during this pandemic. One potential strategy is to design placebased outcomes to address social, cultural, and psychological disparities by developing: (i) defining what each community identifies as its strengths; and (ii) what are the most appropriate psychosocial tools. Change is required by re-inventing systems and enacting inclusive policies and information practices that address specific cultures, languages, traditions, and traits in communities that may define ways in which the population can identify its protective factors and transform fear into hope. Pietrabissa & Simpson (2020), in their article on the psychological conse­ quences of COVID-19, found that during the first year of the COVID-19

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17

response, community members referred to mental health needs that included attitudes toward the response, feelings of loneliness, and fear related to the unknown during the initial year of COVID-19. Williamson (2020), in his study on the early relationship, noticed common positive consequences such as an increased awareness of social connections among family members and neighbors. Furthermore, many people became aware of their neighbors and their reliance on them in hard times. Social interactions have been linked to protective factors that benefit mental health and psychosocial interactions. Morganstein & Ursano suggest that attributing meaning, severity, and impact on well-being as a result of COVID-19 affects a community’s outlook and shapes the mental health and psychosocial response. Protective factors such as hope and adaptability will dictate the forward vision and acceptance of the impact of COVID-19. 2.2.1 PSYCHOLOGICAL RESILIENCE DURING COVID-19 Blanc et al. (2021) defined psychological resilience as the capacity to adapt to a situation in the face of tragedy, trauma, adversity, hardship, and ongoing significant life stressors. One such example from this chapter is that at the pandemic’s peak, the main objective was to mitigate the devastating psycho­ logical impacts on populations that were struggling to cope with quarantines, social distancing, nighttime curfews, and states of emergency that were imposed worldwide. During the initial stages of the pandemic, the global economy receded and, as a result, created financial losses and psychological stress above and beyond the fear-provoking consequences of the virus itself. Researchers indicate (Blanc, Briggs, Azizi, et al., pp. 33–34) that an increase in protective factors, supportive neighbors, community activities, and religious beliefs to cope impacted. COVID-19-related distress has increased the sense of meaning/purpose of life since the early days of the pandemic. 2.2.2 SYSTEMIC RESILIENCE IN THE CONTEXT OF COVID-19 One social system cannot work without considering other ones. During COVID-19, humanitarian workers found interactions between such systems, which are interconnected within our physical and emotional well-being. Ungar et al. (2021) identified some factors that help people gather the strength needed to sustain themselves and transform fear into hope. The findings of

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Mental Health and Psychosocial Support during the COVID-19 Response

Ungar’s research suggest that resilience can be defined based on several parameters: (i) occurs in the context of adversity; (ii) is a systemic process; (iii) promotes connectivity; (iv) it is open, dynamic, and complex; and (v) includes diversity, redundancy, and participation. As a result, individuals and communities can transform during an adverse situation and identify protec­ tive factors and survive adverse conditions. Dubey et al. indicated that the onset of COVID-19 led to worldwide psychosocial consequences, including acute panic, anxiety, obsessive behaviors, paranoia, and depression, in addition to exacerbated physical conditions. The response to COVID has triggered survival behaviors that help people thrive under conditions of great stress. Adaptive strategies in individuals have increased to fight the fear of the pandemic and shift their emotional responses to hope. Ungar, Theron, Murthy, & Jefferies (2021) identified five processes that contribute to changes that make people more sustainable in the context of COVID: (i) Persistence or the practice of evolving within the environment and succeeding because you support existing traditions and the environment. As a result, a person can change their actions and habits and can successfully manage the pandemic’s social restrictions. (ii) Resistance is defined as not allowing yourself to become absorbed by the pandemic and the public outcry caused by death, quarantine, masks, and distancing. (iii) Recovery means bouncing back from the impact of COVID in your community and implies a return to a previous state. (iv) Adaptation is another way of handling the pandemic by learning new skills to address a specific threat. Adaptation implies that the person has developed the long-term capacity to accom­ modate COVID-related stress. And (v) transformation in which our bodies and our mind transform themselves to cope with the increasing psychosocial pressures caused by the pandemic. The learning of these five points is that affected and infected people construct meaning to determine if a change is advantageous to the new environment. Creating a shared understanding of adversities and strength is fundamental to developing pathways to healing and community resilience. 2.2.3 COMMUNITY RESILIENCE Patel, Rogers, & Rubin (2017) describe community resilience as a fluid and contextual concept (physical, social, and/or cultural). Within this defini­ tion, one must include three categories for the attainment of outcomes: (i)

Activating Community Resilience Through Community Capitals After COVID-19

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levels of congruence based on individual, family, and community levels that consider the propensity for adverse situations; (ii) a desire for maintaining healthy levels of psychological, social, and physical functioning; and (iii) communities and individuals harnessing local resources and expertise to recover from the negative impacts of the pandemic by looking at psychoso­ cial well-being and the existence of community health services. Based on the three categories of definitions above, nine common elements that appeared to be universally integral to the concept of community resilience: (a) local knowledge; (b) community networks and relationships; (c) communication; (d) health; (e) governance and leadership; (f) resources; (g) economic invest­ ment; (h) preparedness; and (i) mental outlook. Panzeri et al. (2021) define community resilience as a community’s degree of adaptability to changing circumstances and challenges as a result of COVID-19 and making services available. Community members individu­ ally and collectively respond to a pandemic and are restricted to resources that are made available and actionized at this scale. Communities can draw from collective individual resources and resources and opportunities avail­ able only to the cooperative organization. Community resilience is also a critical resource for humanitarian actors to consider while planning the recovery of mental health and psychosocial after COVID-19. 2.3 SOCIAL COHESION According to Jewett, Mah, Howeel, & Larsen (2021), social cohesion is the degree of social connectedness and solidarity between different community groups within a society and the level of trust and connectedness between individuals and across community groups. On the other hand, CE is a tool that assists in identifying priorities and solutions that are more likely to be appropriate, lasting, and supported by the affected community. Makriis and Wu have found that COVID-19 has affected social cohe­ sion in communities all over the world. Jewett et al. (2021) report that social cohesion, a likely a strong predictor of recovery after COVID-19. Marginalized communities are less likely to have access to opportunities and resources for social and economic recovery from pandemics as a result of less cohesion amongst its members, even when the social capital within these communities may be high. Makriis and Wu report that social capital, the degree of interpersonal relationships and connectedness within neighbor­ hoods and communities, has been dramatically hampered by the very nature of distancing measures required to slow the spread of COVID-19.

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Mental Health and Psychosocial Support during the COVID-19 Response

2.4 COMMUNITY ENGAGEMENT (CE)

Fedorowicz, Arena, & Burrowes (2020) describe CE as active planning, participation, and evaluation in a community activity that assists in deter­ mining the community’s needs and prioritizes its actions during COVID-19. The term CE often refers to a specific process facilitated by external part­ ners when planning a response to events such as COVID-19. The benefits of CE include the identification and development of psychosocial projects during COVID-19, including the opportunity to match community priorities, understanding diverse needs, attention to nuanced circumstances, commu­ nity buy-in and participation in policies, and improved appropriateness of interventions. Gilmore et al. (2021) proposed a five-step CE process: (i) understanding the community; (ii) providing relevant information in all sectors of the communities; (iii) feedback engagement; (iv) understanding changing needs; and (v) centering communities on leading and co-develop programs. 2.5 HUMAN AND COMMUNITY CAPITAL AS A CONDUIT TO REESTABLISH COMMUNITY AFTER THE PANDEMIC Prewitt Diaz & Dayal (2008) defined human capital as members of the community that has skills that can assist in making the COVID-19 response a success. This capital is an attribute of individuals that increases self-improve­ ment. Identifying community capital will assist humanitarian organizations in developing programs to address COVID-19 psychosocial needs unique to every targeted community. Even with the limitations of human capital in the community, other capital and collaborations can assist communities in understanding their needs, addressing them, and re-configure themselves. Mackridis & Wu (2021) proposed social capital, the interaction among people and organizations that help make things happen in the community, exists as a way to engage communities in their mental health and psychoso­ cial recovery after COVID-19. Social capital consists of three elements: (i) Trust includes people having faith in others, (ii) collective efficacy, and (iii) social networks that generate benefits for individuals and social groups. 2.6 DISCUSSION The present review describes how COVID-19 has affected systemic resil­ ience in individuals, families, and communities. It proposes that the goal is to achieve community resilience through CE by identifying and using

Activating Community Resilience Through Community Capitals After COVID-19

21

community capital to provide timely information, develop community support to combat COVID-19, and provide community identity after the pandemic. KEYWORDS • • • • • •

community engagement COVID-19 global economy humanitarian agencies social cohesion social structure

REFERENCES Blanc, J., Briggs, A. Q., Seixas, A. A., Reid, M., Jean-Louis, G., & Pandi-Perumal, S. R., (2021). Addressing psychological resilience during the coronavirus disease 2019 pandemic: A rapid review. Curr. Opin. Psychiatry, 34(1), 29–35. doi: 10.1097/YCO.0000000000000665. PMID: 33230041; PMCID: PMC7751836. Burrowes, K., Arena, O., & Fedorowicz, M., (2020). Community Engagement During the COVID-19 Pandemic and Beyond a Guide for Community-Based Organizations. Retrieved from: https://doi.org/10.13016/8grk-tvbd (accessed on 27 October 2022). Castiglioni, M., & Gaj, N., (2020). Fostering the reconstruction of meaning among the general population during the COVID-19 pandemic. Front Psychol., 11, 567419. doi: 10.3389/ fpsyg.2020.567419. PMID: 33192849; PMCID: PMC7655933. Coulombe, S., Pacheco, T., Cox, E., Khalil, C., Doucerain, M. M., Auger, E., & Meunier, S., (2020). Risk and resilience factors during the COVID-19 pandemic: A snapshot of the experiences of Canadian workers early on in the crisis. Front. Psychol., 11, 580702. doi: 10.3389/fpsyg.2020.580702. Dubey, S., Biswas, P., Ghosh, R., Chatterjee, S., Dubey, M. J., Chatterjee, S., Lahiri, D., & Lavie, C. J., (2020). Psychosocial impact of COVID-19. Diabetes & Metabolic Syndrome, 14(5), 779–788. https://doi.org/10.1016/j.dsx.2020.05.035. Gilmore, B., Ndejjo, R., Tchetchia, A., et al., (2020). Community engagement for COVID-19 prevention and control: A rapid evidence synthesis. BMJ Global Health, 5, e003188. Jewett, R. L., Mah, S. M., Howell, N., & Larsen, M. M., (2021). Social cohesion and community resilience during COVID-19 and pandemics: A rapid scoping review to inform the United Nations research roadmap for COVID-19 recovery. Int. J. Health Serv., 51(3), 325–336. doi: 10.1177/0020731421997092. Epub 2021 Apr 8. PMID: 33827308; PMCID: PMC8204038.

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Makridis, C. A., & Wu, C., (2021). Correction: How social capital helps communities weather the COVID-19 pandemic. PLoS One, 16(9), e0258021. https://doi.org/10.1371/journal. pone.0258021. Morganstein, J. C., & Ursano, R. J., (2020). Ecological disasters and mental health: Causes, consequences, and interventions. Frontiers in Psychiatry, 11, 1. https://doi.org/10.3389/ fpsyt.2020.00001. Panzeri, A., Bertamini, M., Butter, S., Levita, L., Gibson-Miller, J., Vidotto, G., et al., (2021). Factors impacting resilience as a result of exposure to COVID-19: The ecological resilience model. PLoS One, 16(8), e0256041. https://doi.org/10.1371/journal.pone.0256041. Patel, S. S., Rogers, M. B., Amlôt, R., & Rubin, G. J., (2017). What do we mean by ‘community resilience’? A systematic literature review of how it is defined in the literature. PLoS Curr., 9, ecurrents.dis.db775aff25efc5ac4f0660ad9c9f7db2. doi: 10.1371/currents. dis.db775aff25efc5ac4f0660ad9c9f7db2. PMID: 29188132; PMCID: PMC5693357. Perry, B. L., Aronson, B., & Pescosolido, B. A., (2021). Pandemic precarity: COVID-19 is exposing and exacerbating inequalities in the American heartland. Proc. Natl. Acad. Sci. U S A., 118(8), e2020685118. doi: 10.1073/pnas.2020685118. PMID: 33547252; PMCID: PMC7923675. Pietrabissa, G., & Simpson, S. G., (2020). Psychological consequences of social isolation during COVID-19 outbreak. Front. Psychol., 11, 2201. doi: 10.3389/fpsyg.2020.02201. Prewitt Diaz, J. O., & Dayal De, P. A., (2008). Sense of place: A model for community based psychosocial support programs. The Australasian Journal of Disaster and Trauma Studies, 1. Prewitt Diaz, J. O., (2013). Recovery: Re-establishing place and community resilience. Global Journal of Community Psychology Practice, 4(3). Ungar, M., Theron, L., Murphy, K., & Jefferies, P., (2021). Researching multisystemic resilience: A sample methodology. Front. Psychol., 11, 607994. doi: 10.3389/fpsyg.2020.607994. Williamson, H. C., (2020). Early effects of the COVID-19 pandemic on relationship satisfaction and attributions. Psychological Science, 31(12), 1479–1487. https://doi. org/10.1177/0956797620972688.

CHAPTER 3

Community Engagement in Times of COVID-19 ANJANA DAYAL DE PREWITT

American Red Cross, National Headquarters, Washington, D.C., USA

ABSTRACT This chapter briefly explores ways to engage communities during COVID19. The chapter defines the nature of the community and the importance of engaging them in their own process. A definition of challenges during COVID-19 is provided, and options are presented. 3.1 INTRODUCTION The basic principle of working with a community is to find ways to help community members understand why they want to work together. Commu­ nity engagement (CE) was recognized as a key component and catalyst of that transformation (Eder, Millay, & Cottler, 2021). The easiest way to identify needs, capacities, and wants is through community mapping and meetings among the stakeholders. In times of COVID-19, this is virtually an impossible task. The government mandates that all citizens musar quarantine and maintain social distancing. In the last 18 months, we have been exploring ways to engage communities so that they develop plans for recruitment and growth. In the next few pages, we would like to share with the reader some challenges, potential solutions, and options for the engagement of diverse segments of the communities.

Mental Health and Psychosocial Support during the COVID-19 Response: An Overview. Joseph O. Prewitt Diaz (Ed.) © 2023 Apple Academic Press, Inc. Co-published with CRC Press (Taylor & Francis)

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3.2 FUNCTIONAL DEFINITION OF COMMUNITY ENGAGEMENT (CE)

Community engagement (CE) is a way of working that recognizes and values community members as equal partners. It makes sure that the opinions of the target groups in the community under study are heard and used to design and guide the work of the Red Cross. There are three principles that inform CE within the Red Cross and Red Crescent (RCRC) movement: (i) an effective way of building trust within the target group and community by making sure that people always have the ability to engage with the RCRC, and to guarantee that we will act based on their feedback and needs; (ii) make sure that our clients are participants in their own recovery, and future post-COVID-19; and (iii) when communi­ ties play an active role in designing and managing their own processes, the outcomes are more effective and more sustainable (IFRC, 2019). In the American Red Cross, the doctrine of CE outlines the process of CE in at least four major tasks: (i) transparent selection process of the community where the region is going to work. (ii) Conduct community mapping (houseto-house survey) so that you can identify the problem(s) that the community wants to tackle, potential human capital (potential leaders), cultural capital (diverse cultures, languages, and context), and social capital (for example community-based organizations or faith-based in the community). (iii) Hold preliminary meetings with interested community members and identified leaders to rank order potential concerns and determine how to reach out to the broader community. And (iv) the community prioritizes a quick impact project to encourage support and mobilize local participation. 3.2.1 CHALLENGES DURING COVID-19 With social distancing and quarantining, the CE work is very challenging. There are gaps in conducting community meetings, celebrations, and other gatherings. The most vulnerable people in the community are left out of the information chain. They may not have the technology, may speak a different language, or maybe scared not only of the pandemic but of the authorities, who are trying to share timely and accurate information. Many of the most vulnerable in our communities depend on day-to-day jobs or travel outside of the community to work. Working females and heads of household are the most vulnerable to COVID-19 and cannot access information and identify their local support systems.

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The most vulnerable in the communities have existential problems that must be addressed through engagement activities, such as the need for daily medication, Cat pooling if transportation is not available, others may hold several part-time jobs, and yet single mothers may need childcare. 3.2.2 OPTIONS FOR COMMUNITY ENGAGEMENT (CE)

Human beings are nimble and can counter the challenge of COVID-19. Communities have been slowly devising a series of organic solutions depending on geography, infrastructure, and mobility. A COVID-19 plan for CE should consider the following: (i) community-led planning by the most vulnerable or more affected; (ii) use of two-way communication tech­ nology (WhatsApp, Facebook Live, Instagram, ZOOM, TEAMS or Smart Phones); (iii) organize community teams that will conduct in-person visits, while maintaining distancing, to the most vulnerable and harder to access community members. Attempt to better understand all segments of the community by conducting focus groups via phone or video conferencing, using key informant inter­ views via phone or other voice calls, or having a call-in community radio show with questions aired and the responses as well. Capture rumors and misinformation and disseminate accurate information through all sources available. Conduct orientation meetings about issues surrounding the pandemic. Hold by-weekly calls to touch base with vulnerable people in the community. Assist people in identifying hybrid solutions to their specific needs. Most importantly, engage people in activities of hope. 3.3 CONCLUSION The current pandemic has generated a difficult environment and set of situations that we must learn to manage. In an attempt to protect the total community, governments have proposed social distancing and quarantine. Human beings are nimble, capable of resolving existential problems, and accountable for one another. CE has to re-invent itself to provide hybrid solutions to everyday situations. Ultimately, we are members of one commu­ nity and must be engaged in solution-focused activities that will allow all of us to survive as one community.

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KEYWORDS • • • • • •

community engagement COVID-19 organize community pandemic red cross and red crescent social distancing

REFERENCES Eder, M. M., Millay, T. A., & Cottler, L. B., (2021). A compendium of community engagement responses to the COVID-19 pandemic. Journal of Clinical and Translational Science, 5(1), e133. https://doi.org/10.1017/cts.2021.800. IFRC, (2019). A Red Cross Red Crescent Guide to Community Engagement and Accountability (CEA). A 2019 Council of Delegates background paper supporting this resolution, and extensive consultations with and input from National Societies, the IFRC and the ICRC. https://rcrcconference.org/app/uploads/2019/10/CD19-DR6-Movementwide-commitments-for-CEA_en.pdf (accessed on 27 October 2022).

PART II

Assessment of the Needs of

the Most Vulnerable Population

CHAPTER 4

Community Engagement During COVID-19 and Beyond* JOSEPH O. PREWITT DIAZ

The Pennsylvania State University (Retd.), Pennsylvania, USA

ABSTRACT This chapter defines the concept of community engagement and further presents examples from the literature where community engagement has provided a platform for communities to recover from disasters. The chapter introduces the three drivers of community care, as well as five steps in community assessment. It concludes with the task of writing a plan to move forward. 4.1 INTRODUCTION Community engagement (CE) is the participation and involvement of indi­ viduals and groups within a community for planning, designing, and service delivery. CE is crucial to promote people-centered services and achieving

Note to the Reader: This chapter is an update for COVID-19 recovery based on original work and practice reported by the author and published in two papers: (1) Prewitt Diaz, J. O., & Dayal, A., (2008). Sense of place: A model for community-based psychosocial support programs. The Australian Journal of Disaster and Trauma Studies; (2) Prewitt Diaz, J. O., (2013). Recovery: Re-establishing place and community resilience. Global Journal of Community Psychology Practice; (3) Prewitt Diaz, J. O., (2010). Participatory Community Mapping. WebMed Central WMC00585. 2046-1690; and (4) Prewitt Diaz, J. O., (2018). Psychosocial support: A tool for empowering communities in Puerto Rico after a catastrophic event. Emergency Medicine Investigations, 3. doi: 10.29011/2475-5605.000079. Mental Health and Psychosocial Support during the COVID-19 Response: An Overview. Joseph O. Prewitt Diaz (Ed.) © 2023 Apple Academic Press, Inc. Co-published with CRC Press (Taylor & Francis)

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primary healthcare (Luisi & Hämel, 2021). CE is critical for creating context and locally specific solutions to limit the COVID-19 outbreak. This study describes community activities developed to limit the spread of COVID-19. The Red Cross and Red Crescent (RCRC) Movement approved Resolution 33, in which all National Societies (NSs) would prepare volunteers and paid staff to implement psychological first aid (PFA) services (RCRC, n.d.). By 2013, the RCRC mobilized the community to provide psychosocial support through community volunteers, peer support, and referrals. Holman, Thompson, Garfin, & Silver (2020) report that COVID-19 has unfolded a wide range of problems at the individual, family, community, and societal levels (Holman et al., 2020). The pandemic has eroded normal protective supports, has increased the diverse societal risks, and has amplified pre-existing problems of social injustice and inequality. The post-COVID-19 environments will force the RCRC to assist communities in dealing with preexisting social problems (poverty, underserved groups, or those belonging to diverse cultural and linguistic groups). Moreover, government measures to protect citizens, mandate people to wear a mask, maintain social distance, or implement quarantining have resulted in separation, disruption of social networks, and destruction of community resources and trust (Cetron & Land­ wirth, 2007). Without effective humanitarian responses, COVID-19 will continue to exacerbate grief, increase non-pathological distress, depression, and anxiety, and increase substance abuse and spousal and family abuse. The COVID-19 pandemic is deeply affecting people’s well-being glob­ ally. COVID-19 is particularly affecting migrants, asylum seekers, refugees, and internally displaced persons (Santillana, 2021). Moreover, the pandemic has affected disproportionally individuals owing to weakened social support structures, bleak socio-economic prospects, unequal access to health care and social services, precarious housing, tenuous living and working condi­ tions, vulnerability to misinformation, xenophobia, and risks of exploitation and gender-based violence (GBV) (IOM, 2020). Long-term social distancing and quarantine are likely to have psycho­ social, physical, and mental health impacts on societies. Saladino, Algeri & Auriemma (2020) that these restrictive policies will increase anxiety, panic, and fear, coupled with disruption to positive health habits and other routines, the threat of job and income losses, and a decrease in health care for those affected. Being confined indoors, without the opportunity to interact with neighbors and friends, may increase economic, social, and health challenges facing the total population (Saladino, Algeri, & Auriemma, 2020).

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In the last few months, the WHO has developed several social packages to implement psychosocial support and community-based approaches to address social problems associated with COVID-19. The WHO also proposes other treatment responses to serve the needs of the affected communities that, include psychological interventions and peer support to accelerate the support of person-centered recovery and rights-based approaches (WHO, 2021). The COVID-19 pandemic is having immediate effects on people’s anxiety and stress. The psychological impacts of social distancing and quarantining have shaped the household and individual circumstances (Rodríguez-Rey, Garrido-Hernansaiz, & Collado, 2020). Other drivers connected with COVID-19 are health conditions of the community, social connectedness, lack of trust in others, employment loss, and income loss, identified as poten­ tial risks in the current crisis. 4.2 THREE COMPONENTS OF COMMUNITY ENGAGEMENT (CE)

During the COVID-19 pandemic, communities have been: (i) primarily responsible for their care and changes applicable in all stages through the Mental Health and Psychosocial Support (MHPSS) responses; (ii) COVID-19 affected and infected many people, and active participants are responsible for improving individual and community well-being; and (iii) engaging families, groups, and communities to support and care for others in ways to encourage recovery and resilience. 4.2.1 DRIVERS OF COMMUNITY CARE Six drivers are used to care for and engage the communities: (i) focusing on the geographic location of where we live and recreate; (ii) access to food and transportation; (iii) health posts and schools; (iv) historical and social circles; (v) traditional healers and faith-based leaders; and (vi) access to jobs and informal sources of incomes. To understand the psychosocial impact of COVID-19, community mobilizers must understand and connect with the geographic locations to identify the following variables: impact of culture, the language of distress, health conditions, social inter-relations, trust in neighbors and community, and formal and informal employment (Shadmi et al., 2020).

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Population density and poor housing conditions play a role in spreading the virus, increasing mortality rates, and aggravating pre-existing health conditions may be for governments to develop a place-based approach to address COVID-19 sequelae (Shadmi et al., 2020). Vulnerable and under­ represented groups have been affected more severely. The affected groups are characterized by poor financial conditions and work as day laborers, and those employed are working in the lower wrung of our system (trash collec­ tors, maids, or babysitters). As the pandemic is progressing and has reached 18 months, it is time to build protective systems in our neighborhoods and communities to improve people’s well-being, which includes social connec­ tions, work-life balance, and environmental quality. 4.2.2 ENGAGING FAMILIES, NEIGHBORHOODS, AND COMMUNITIES TO BUILD RESILIENCE Community resilience is the ability of a community to use available resources to respond and recover from adverse conditions (Jewett et al., 2021). Community resilience uses the social capital, physical infrastructure, and culturally embedded patterns of interdependence to enhance dramatic change, sustain adaptability, support new growth, and integrate lessons learned during COVID-19. There is a relationship between the stressor a community experiences and the burden faced with disruption to daily lives and the capacity of all segments of the community to establish collaborative processes for achieving well-being. The CDC, in the late 90s, proposed a strategy called “Community engage­ ment,” as the process by which community members come together to reflect on and make decisions about the future of their community. The term CE often refers to a process that includes facilitated by community-based organi­ zations and faith-based or external actors to implement an impending action or necessary step (such as COVID-19 response) in the target communities (Principles of Community Engagement: First Edition, 1997). Engaging the neighborhood and the communities helps to visualize patterns related to the level of cultural competency, perceptions about mental illness, appropriate ways to address illness, and to reduce stigma. Engaging communities helps to understand the patterns and levels of stress caused to the diverse stratus and sectors of the community. This learning helps to understand the factors that hinder the community from coping with stress. Once these factors are identified, the community increases its protective

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33

factors and becomes resilient. Then, the community will re-invent them­ selves and possess the emotional tools to succeed. 4.2.3 CONDUCTING COMMUNITY ASSESSMENT

Community assessment is the process of identifying the assets, strengths, needs, and challenges of a community (Rosenbaum, 2013). The community assets attempt to identify social capital during COVID-19. Social capital is the behavior of social networks and relationships characterized by enhanced trust and reciprocity (Makridis & Wu, 2021). Precaution has been imple­ mented to protect capital from health authorities and the public. Wong (2020) suggests that, to this end, the dissemination of transparent and accurate public health information is crucial to enforce public health policy compli­ ance among political leaders (Wong & Kohler, 2020). In addition, policy consistency between domestic agencies and departments, as well as policy congruency with recognizing International Health, can enhance public faith in legitimizing national COVID-19 response. Exploring the potential mental health and consequences of social distancing necessitates psychosocial interventions for the international pandemic response. In this chapter, we group social capital into three distinct categories: bonding, bridging, and linking. 4.2.3.1 BONDING CAPITAL Leng, White, Hilton, et al. (2021) report that globally, social distancing policies have emerged as a central component of the COVID-19 response. Measures include post-exposure quarantining, shelter-in-place orders, and limits on the size of the social bubbles (Leng et al., 2021). These measures are credited with reducing the growth of new infections. However, measures also contributed to the dramatic disruption of physical, social, and psycho­ logical interactions in the communities (Sikali, 2020). As social distancing continues to limit access to customary channels of social support, communi­ ties are continuously being affected by COVID-19, thereby elevating mental health concerns (Pedrosa et al., 2020). Addressing the potential mental health consequences of social distance policy requires a conscious inclu­ sion of social and psychological interventions and community intervention (Pietrabissa & Simpson, 2020). Psychological interventions are particularly crucial for the elderly, those with underlying health conditions (asthma,

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Mental Health and Psychosocial Support during the COVID-19 Response

diabetes, high blood pressure, and marginalized people with no access to social distancing or health facilities. 4.2.3.2 BRIDGING CAPITAL

Containing the spread of COVID-19 requires a unified response using physical distancing or public mask-wearing. Psychosocial tolerance varies within diverse community groups. If one of the groups refuses to follow the rules, the efficacy of the preventive measures might be at risk. Thus, to make the entire community complies, the community health programs must target and make decisions on the population with the highest risks. Communities with weak bridging capital between high-risk and low-risk segments may find the requirements of social distancing and wearing masks an impossible task (Singu, Acharya, Challagundla, & Byrareddy, 2020). Initiatives to build social capital by fostering unity and understanding between diverse community groups are important for the COVID-19 response for the future management of COVID-19. 4.2.3.3 LINKING CAPITAL Most countries have embraced a pro-health social norm during the pandemic. Measures that protect linking capital between public health authorities and the public cannot be overlooked (Leach et al., 2021). The dissemination of transparent, timely, and accurate public health information generates public health policy compliance among community leaders and lead to the devel­ opment of consistent policy between health agencies, community leaders, and the national government. These actions ensure that the needs of vulner­ able groups are not ignored. Thus, individuals can access lifesaving health services during COVID-19 regardless of socio-economic status, legal status, cultural identity, or geographic location (IASC, 2020). 4.2.4 OBJECTIVES OF COMMUNITY ASSESSMENT The objective of a community assessment is to determine the needs of the total communities, which comprise the social, cultural, and psychological (self-efficacy, hope, optimism, and resiliency) capitals. The community volunteers and external assistance will conduct the assessment to identify:

Community Engagement During COVID-19 and Beyond

35

(i) groups at risk; (ii) interventions that have taken place (family, neighbor­ hood, and community); (iii) community capitals and how they can best serve the community; (iv) problem areas, priority concerns, and recommendations (Montiel et al., 2021). The impact of language will be addressed, and culture and distress manifested from language will be considered. An issue to consider is also the cultural perceptions about feelings expressed by neigh­ bors. In addition, the participants will be asked to identify the culture that impacts behaviors and protective factors that foster community resilience. 4.2.5 FIVE-STEP PROCESS OF COMMUNITY ASSESSMENT The five-step process is identified below. Prewitt Diaz (2018) explains that the gestation period involves external volunteers meeting with community members to address the need of the community based on the nature of COVID-19 (Prewitt Diaz, 2021). The preliminary assessment is to determine the geographic delimitations of the community, identify the representatives of community volunteers from all sectors, and assist the communities in defining their local needs related to COVID-19. The preliminary assessments also explore the available and needed resources to increase health care and protect psychosocial factors from facilitating community well-being. Prewitt Diaz (2021) explains the six stages in the participatory process are related to MHPSS: (i) entry into the community; (ii) community mapping; (iii) sharing of information gathered during community mapping and initial interviews with families; (iv) information review, confirmation to review themes and key informants in the community; (v) focused group interviews for selected MHPSS topics; and (vi) exit from the community (Prewitt Diaz, 2008). In all cases, these are cyclical processes implemented between one and three months (IASC, 2007). 4.2.5.1 ENTRY INTO THE COMMUNITY 1. This stage involves building the capacity of community volunteers using the PFA and the share your feelings’ (use of tri-folds and posters) methodology. During these initial sessions of capacity building, the volunteers learn that the immediate psychosocial needs of community members are for practical information such as the type of assistance available (PFA, peer-to-peer interaction, timely information related to MHPSS and COVID-19), how an affected

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Mental Health and Psychosocial Support during the COVID-19 Response

person receives assistance, what are difference of the assistance received from that of their neighbors, and what to do if they feel they need a referral for additional emotional help. 2. Then, volunteers visit the target village and disseminate non-verbal information in the form of tri-folds and posters to all the households and community. This is the initial step in data gathering. Two volun­ teers are on every team. The intervenor records all verbal interac­ tions with the family members and makes a verbatim copy. The volunteers ask if any member of the family is willing to facilitate the distribution of materials and interact with other families in the community (community members become community facilitators). The idea is to make a community facilitator responsible for reaching out to the 20 households. 3. The community facilitators are trained to use non-verbal tools, posters, and listening skills. They work with external NGO volun­ teers to gather data and learn about psychosocial losses caused by COVID-19 (stay-at-home, social distancing, job loss, or lack of access to psychoeducation). Rebuilding human communities requires focusing on social and emotional problems beyond the humanitarian effort. Reconnection leads to restoring natural networks effective for health, psychological competence, and everyday functioning.

4.2.5.2 PSYCHOSOCIAL SUPPORT AND GATHERING INITIAL INFORMATION Psychosocial support programs comprise a set of community-based activities that enhance resilience and improve community well-being (IASC/MHPSS, 2007). After the immediate response has stabilized the disaster-affected people, the next stage is to engage community members in studying their place, the elements that make their place, and their future goals. The conver­ sations that emerge are a form of therapy that allows people to share their COVID-19-related stories and allow the affected and infected people to set up the road map and re-establish their place. This initial exercise enhances resilience and well-being (IASC, 2007). Conceptually, this activity would be part of a humanitarian response in which the social and psychological needs of the affected people evolve from the loss of their ability to move around freely, interact with family and friends, and enjoy the outdoors as a result of the COVID restrictions. The

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37

next stage is to facilitate the re-establishment of a post-COVID community. The initial activity is to determine the current needs and protective require­ ments of the community. Three major assessment areas are (i) the needs and assets of an affected community, (ii) symptoms versus pandemic-generated problems, and (iii) the extent of stakeholder engagement. In psychosocial support, the primary intervention is to open a space where the affected and infected people share information (individually, in small groups, focus or interest groups, or larger community representative groups). Information is collected systematically, yielding an overview of the community’s history, livelihood, social support, emotional well-being, and spiritual and cultural practices. In most cases, key informants and indigenous leaders emerge and engage in conversations with external stakeholders (formal leaders, elected officials, and faith-based leadership) to draw up a plan and re-establish the community after the pandemic. 4.2.5.3 COMMUNITY PARTICIPATORY MAPPING This section is a revised version of an article published by the author (Prewitt Diaz, 2010). Community mobilization is the initial step toward recovery from COVID-19. The first step is to engage the affected people in understanding their losses. This chapter explores community mapping as a psychosocial intervention to identify the needs and suggest possible psychosocial activities. Drawing maps by local people is critical to developing a sense of place and identity and enhancing cultural knowledge traced back centuries. In the psychosocial support for humanitarian assistance, social and spatial mapping is designed as a participatory exercise and as a means of awareness creation (Prewitt Diaz, 2006). This process primarily focuses on the collective percep­ tion of the affected people, allowing the participants to document their move through different types of experiences in natural spaces, built spaces, and community participation (Prewitt Diaz, 2006). The data collection methods are visual, tangible, and conducted by a group representative. Community mapping is developed as a consensus of what the diverse neighborhood and representative groups have observed. The observations include physical structures, built facilities, community clinics, traditional health centers, and faith community meeting halls used by diverse groups from the community. In addition, services are also identified: local health workers, midwives, traditional healers, schoolteachers, counselors,

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Mental Health and Psychosocial Support during the COVID-19 Response

and service providers for the most vulnerable and unrepresented inhabitants of the community. Community participatory mapping is a versatile and powerful teaching tool, once underway, it is fun to implement, and the results provide valuable tools for psychosocial services needed that will result in feelings of wellbeing and increased psychosocial support. This interactive approach draws on local people’s knowledge, enabling participants to create visual and non-visual data as well exploring social problems, opportunities, and questions regarding the effects of a disaster or emergency. Participants work together to create a visual representation of their place using the tools and materials at their disposal, such as chalk or markers, construction paper, plastic cement, scissors, and tape. Prewitt Diaz (2010) observed that in the process of developing the community map, the group might deliberate on the best way to represent their place in question, share their observations, and tell personal stories and anec­ dotes. This is a valuable process in identifying the community’s risks, needs, resources, and protective factors. By the time the exercise is completed, the community members have a pretty idea of about the psychosocial activities and how they help them to reconstruct their community, plan and implement strategies, timelines and monitor devices and external resources needed to reconstruct the community, improve their resource, well-being, and to move forward (Prewitt Diaz, 2010). Dayal (2007) in her 18-month review of the Psychosocial Support program in Sri Lanka, found that participatory community mapping becomes a monitoring tool, and the process allows the outsider to observe different psychosocial community features and the interaction between the member of the community. For example, participatory mapping exercises are conducted twice a year during the project duration, revealing the physical changes that have occurred over time revealing the personal and collective experiences of residents, their attitudes, and perspectives on their place. These bi-annual maps reflect the community’s knowledge. Omissions and variations from one map to the next are indicative of the progress made during a project cycle, revealing the participation location, participants, how the participants are involved in their communities and beyond, and their reflections on the opportunities and barriers encountered during participation. The participa­ tion process reveals the perceptual changes that occur in a given community (Dayal, 2007) over time; in this case 18 months.

Community Engagement During COVID-19 and Beyond

4.2.5.3.1 Tri-Dimensional Models to Identify Community Vulnerabilities and Resources

39

Prewitt Diaz (2010) used participatory mapping as an initial psychosocial intervention that consists of inviting the affected communities to generate a tri-dimensional model for their neighborhood, community, and place. In addition, the method suggests how the affected communities would like their community to be reconstructed after a disaster. After the map is developed on the table, representatives from community groups prioritize the sugges­ tions provided by all the stakeholders and develop an action plan that serves as the community action, which could be used to request funds from external stakeholders and humanitarian agencies (Prewitt Diaz, 2010). 4.2.5.3.2 Maps Represent the Cultural, Physical, Psychological, and Social Geography of the Place A tangible outcome of community mapping is the development and produc­ tion of large paper and developed tabletop maps, indicating specific physical locations (built environment) or sites (natural environment) where people interact. Examples of leisure locations on the map are parks, the flame tree in the center of the community or schools, churches, businesses, and commu­ nity centers. Prewitt Diaz (2010) found that where several community groups (women, youth, and the elderly) are engaged, the maps were all quite different in appearance. Although these maps depicted the same places and included a number of the same landmarks, activities, and sites, some groups chose to create quite elaborate physical maps, which marked sites geographically. However, others created more conceptual maps that grouped sites themati­ cally, such as type of activity, type of organization, or group (Buddhist, Christian, or Muslim). In all cases, the finished maps included some details regarding the types of participation taking place, which gave the outsider a snapshot of some of the components of community life (Prewitt Diaz, 2010). The maps further highlighted the institutions, organizations, or groups that operated, managed, or controlled the sites and spaces of participation. Dayal (2007) reported that local maps included government bodies (schools, the police, local-authority-maintained parks/green spaces, hospitals), faithbased organizations (mosques, churches, or Hindu or Buddhist temples),

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Mental Health and Psychosocial Support during the COVID-19 Response

community centers, and informal gossip networks (often the interception of two paths or under a tree where you wait for the bus) (Dayal, 2007). 4.2.5.3.3 Mapping People’s Perceptions and Experiences

A paper map is limited in representing a place; however, participation within the place is dynamic. People’s conversation as they create the maps adds an important layer to the map’s interpretation and value. The meetings explaining the maps are a valuable source of information and help to identify common themes related to the perception of place, accessibility, and multipurpose sites (Foster et al., 2020). Often these discussions lead to planning and re-establishing a place: 1. Perceptions of Place and Community (Dayal, 2007): The conver­ sations during the map’s development revealed that the affected people had a strong sense of collective identity to their place of resi­ dents, based on common boundaries. For example, in Sri Lanka, the sense of identity in people’s place of residence affects community participation either within or beyond their immediate environment. The volunteer team can identify the participants based on the maps, outlining the boundaries of the communities. 2. Accessibility and Inclusion of Sites of Participation: Prewitt Diaz (2010) in his article entitled “Participatory Community Mapping: A Tool to Enhance Psychosocial Well-Being,” found that participants in the mapping exercises raised issues relating to the accessibility and inclusivity of local sites. Barriers to participation range from the practical programs that are conducted far away to an emotional feeling of discomfort that a member of a different caste or religious group receives when joining a group that does not welcome them (Prewitt Diaz, 2010). This segment of mapping was most important because it facilitated participation in diverse activities of represented or marginalized community members. 3. Multi-Purpose and Single-Use Sites: All communities identified hubs of participation to support a wide range of activities, events, and organizations through which diverse groups accessed opportuni­ ties. Common hubs included community centers, places of worship, schools, parks, natural community markers (the creek, the large rock), and green spaces.

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The visual method created in mapping encouraged the participant to dialog and developed the psychosocial support team’s relationship with the affected people. The visual method motivated the discussion and resulted in tangible local participation that the psychosocial support team has reflected on, analyzed, and used for the project development. The basic, self-created’ mapping technique helped the affected people to express their ideas and thoughts in an easily understandable and enjoyable manner. A blank slate approach Has been promoted to see how local people interpreted and constructed their local area concerning key landmarks and participatory spaces (Montiel et al., 2021). The final product varied, colorful, and rich visual representations of the neighborhood, community, and place, highlighting where participation happened. Mapping is a communitygenerated knowledge creation that facilitates dialog, individual reflection, and experiences. This exchange of ideas is generated during the map-making process. Participants’ comments and conversations were important because they took the process beyond a simple two-dimensional representation of the affected areas and invited exploration of people’s perceptions and experi­ ences (Di Cara et al., 2021). These conversations offered insights into the context and quality of participation in the local areas, bringing a broader interpretive dimension to the workshops. Participatory mapping was designed to overcome community-wide social boundaries by focusing on perceptual and informal information, which enabled participants to contribute ideas easily without physical informal pressure – people standing around a table contributing ideas rather than in a formal meeting setting. As such, mapping can involve the local community across the social spectrum, bringing in those who might often be excluded and encouraging collaboration, sharing, and relationship-building between groups who may not usually work together. 4.2.5.4 CHALLENGES TO COMMUNITY MAPPING Prewitt Diaz (2010) noticed that maps reflect the knowledge, worldview, and experience of the participants. While the community mapping activity is done through an open invitation, some groups with a particular participatory activity or interest can have the potential to influence the group dynamics during the map-making process, thereby unbalancing the content of the final map. The organizer of this activity should invite equal participation from all segments of the affected community.

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Prewitt Diaz (2010) further indicates that another factor that can influence map-making is the way the group negotiates map creation. Depending on the group facilitators, the maps do differ according to the individual knowledge, perceptions of participants, and the way the person/people draw a map, organize, and present information. Some maps are more conceptual; others are more spatial. Some used coding to demarcate the boundaries of the area, whereas others did not. Participants generate the data, and the role of the psychological support program (PSP) volunteer is to facilitate the process, allowing the participants to shape the mapping activity. The success of participatory mapping depends on the interests, motiva­ tions, and capabilities of the individual participants (Prewitt Diaz, 2010). However, disagreements can arise; misunderstandings can occur; an indi­ vidual’s perception of the boundary can be different from others. Thus, this is of high interest and part of the dialog prompted by the exercise. 4.2.5.5 RECORDING AND ANALYSIS The psychosocial support team ensured they fully captured the discussions in the map-making sessions to complement the visual data generated through map creation, digitally recording discussions, and taking notes. Two team members were present at each session. One team facilitates, and the second takes notes so that the digital recorders capture the discussion effectively. This approach worked well and was useful to back up the digital recordings to capture the notes of discussions, photos, and paper maps. With this informa­ tion, the team does not need to transcribe recordings of group conversations. Each PSP volunteered, with the assistance of the community members, and wrote a short note of each session, which included some key observations and themes, the main sites, and activities of each map. After this process, the project team met to collectively analyze the maps and identify key themes to be used in the development of the concept note. Thus, what emerged from the workshops of the mapping learning sessions are the initial ratio­ nale of choosing a method, the practicalities of recruitment and designing the sessions, and data capturing and reflection. Finally, the PSP team used participatory mapping as a fun activity, as the interesting and eye-catching introduction of community-based psychosocial support to local community members, which would help the community members to plan activities and re-establish their place.

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The framework, suggested by Prewitt Diaz (2013), will enhance the community planning process and offer power to the community in answering the following questions: 1. What do we have? Information from what happened in the past, what is currently happening, and what is expected to happen in the future are all part of identifying the protective factors of the commu­ nity and its members.

2. What do we want? Once the risks have been identified by the community, the next step is to identify opportunities and strategies to meet these challenges. The community members should identify activities to achieve these goals. 3. How do we get what we want with what we have? Community members decide the strategy to implement the project. They identify what items are needed to carry out the project, who will imple­ ment each activity, what are the roles of different members of the community, and what the timelines are to complete the project. The community develops a work plan and a budget timeline to help the trusted elders to monitor the work progress. 4. What happens when we get what we want? The community is ready to implement the project. As the project is being implemented, the community members start identifying the inner strengths and the community strengths (resilience, resourcefulness, cohesiveness, and social capital). The community attributes this to their overt efforts. These perceptions are pivotal to the recovery process and reconstruc­ tion and promote a sense of hope and psychosocial reintegration (Prewitt Diaz, 2013). The four questions provide responses to the protective factors of the individual, the family, and the community. The next section discusses how resilience evolves during the COVID-19 pandemic through these three groups (Prewitt Diaz, 2013). 4.3 CONCLUSION In conclusion, participatory mapping, as a tool for community-based psychosocial support, provided a range of principles and methods to be used as a platform for program development, inclusion, and resilience building.

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Psychosocial support uses this method at the initial stages of community interventions. The team developed a specific approach relevant to the project, the context, and the disaster-affected groups they were working with (Prewitt Diaz, 2010). The groups found that the participatory mapping provided real practical benefits at this stage of the project: helping to help disaster-affected people to work collaboratively, drawing on their local knowledge, motivating forward-thinking, plan reconstruction, increasing knowledge planning, and developing a psychosocial support project. The limitation of participatory mapping is that the data mapping generates and reflects only the views of the people who participate in the exercise and not. KEYWORDS • • • • • •

community engagement COVID-19 mapping mental health and psychosocial support psychological support program red cross and red crescent

REFERENCES Cetron, M., & Landwirth, J., (2007). Public Health and Ethical Considerations in Planning for Quarantine. Chapter 3. In Institute of Medicine (US) Forum on Microbial Threats. Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary. Washington (DC): National Academies Press (US). 3, Strategies for Disease Containment. Dayal, A., (2007). Psychosocial Support Program in Sri Lanka: Eighteen Months Report. Colombo, Sri Lanka. Di Cara, N., Song, J., Maggio, V., Moreno-Stokoe, C., Tanner, A., Woolf, B., Davis, O. S. P., & Davies, A., (2021). Mapping population vulnerability and community support during COVID-19: A case study from Wales. International Journal of Population Data Science, 5(4), 1409. https://doi.org/10.23889/IJPDS.V5I4.1409. Foster, S., Adams, E., Dunn, I. U., & Dent, A., (2020). The CDC Field Epidemiology Manual. Washington, D.C. https://www.cdc.gov/eis/field-epi-manual/chapters/GIS-data.html (accessed on 27 October 2022). Holman, E. A., Thompson, R. R., Garfin, D. R., & Silver, R. C., (2020). The unfolding COVID-19 pandemic: A probability-based, nationally representative study of mental health

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in the United States. Sci. Adv., 6(42), eabd5390. doi: 10.1126/sciadv.abd5390. PMID: 32948511; PMCID: PMC7556755. IASC, (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva. Interagency Standing Committee. IASC, (2020). Public Health and Social Measures for COVID-19 Preparedness and Response Operations in Low Capacity and Humanitarian Settings. Geneva. IASC. IOM, (2020). Mental Health Needs of Migrants and Displaced Persons Must Be Part of COVID-19 Response. https://www.iom.int/news/iom-reiterates-importance-addressingmental-health-impacts-covid-19-displaced-and-migrant-populations (accessed on 27 October 2022). Jewett, R. L., Mah, S. M., Howell, N., & Larsen, M. M., (2021). Social cohesion and community resilience during COVID-19 and pandemics: A rapid scoping review to inform the United Nations research roadmap for COVID-19 recovery. International Journal of Health Services, 51(3), 325–336. doi: 10.1177/0020731421997092. Leach, M., MacGregor, H., Scoones, I., & Wilkinson, A., (2021). Post-pandemic transformations: How and why COVID-19 requires us to rethink development. World Development, 138. https://doi.org/10.1016/j.worlddev.2020.105233. Leng, T., White, C., Hilton, J., et al., (2021). The effectiveness of social bubbles as part of a Covid-19 lockdown exit strategy, a modeling study. Wellcome Open Res., 5, 213 (https:// doi.org/10.12688/wellcomeopenres.16164.2). Luisi, D., & Hämel, K., (2021). Community participation and empowerment in primary health care in Emilia-Romagna: A document analysis study. Health Policy, 125(2), 177–184. doi: 10.1016/j.healthpol.2020.11.007. Epub 2020 Nov 17. PMID: 33248742. Makridis, C. A., & Wu, C., (2021). How social capital helps communities weather the COVID-19 pandemic. PLoS One, 16(1), e0245135. https://doi.org/10.1371/journal. pone.0245135 pmid:33513146. Montiel, C., Radziszewski, S., Prilleltensky, I., & Houle, J., (2021). Fostering positive communities: A scoping review of community-level positive psychology interventions. Frontiers in Psychology, 12, 720793. https://doi.org/10.3389/fpsyg.2021.720793. Pedrosa, A. L., Bitencourt, L., Fróes, A. C. F., Cazumbá, M. L. B., Campos, R. G. B., De Brito, S. B. C. S., & Simões, E. S. A. C., (2020). Emotional, behavioral, and psychological impact of the COVID-19 pandemic. Front. Psychol., 11, 566212. doi: 10.3389/fpsyg.2020.566212. Pietrabissa, G., & Simpson, S. G., (2020). Psychological consequences of social isolation during COVID-19 outbreak. Front. Psychol., 11, 2201. doi: 10.3389/fpsyg.2020.02201. Prewitt Diaz, J. O., (2006). Psychosocial Support Programs: From Theory to a Systematized Approach. New Delhi, India: Volunteers Health Association of India. Prewitt Diaz, J. O., (2008). Advances in Disaster Mental Health and Psychosocial Support. New Delhi, India. Voluntary Health Association in India. Prewitt Diaz, J. O., (2010). Participatory community mapping: A tool to enhance psychosocial well-being. Webmed Central Psychology, 1(9), WMC00585. Prewitt Diaz, J. O., (2013). Recovery: Re-establishing place and community resilience. Global Journal of Community Psychology Practice, 4(3), 1–10. Prewitt Diaz, J. O., (2021). Route map for the future: Psychosocial support program planning and development. In: Prewitt, D. J. O., (ed.), Disaster Recovery: Community Based Psychosocial Support in the Aftermath. Apple Academic Press. Principles of Community Engagement: First Edition, (1997). Centers for Disease Control and Prevention: CDC/ATSDR Committee on Community Engagement.

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Red Cross and Red Crescent Movement (RCRC). Resolution 2 – Addressing Mental Health and Psychosocial Needs of People Affected by Armed Conflicts, Natural Disasters and Other Emergencies. PS Center. Copenhagen. https://rcrcconference.org/about/reporting/33icresolution-2-addressing-mental-health-and-psychosocial-needs/ (accessed on 27 October 2022). Rodríguez-Rey, R., Garrido-Hernansaiz, H., & Collado, S., (2020). Psychological impact and associated factors during the initial stage of the coronavirus (COVID-19) pandemic among the general population in Spain. Front Psychol., 11, 1540. doi: 10.3389/fpsyg.2020.01540. PMID: 32655463; PMCID: PMC7325630. Rosenbaum, S., (2013). Principles to Consider for the Implementation of a Community Health Needs Assessment Process. The George Washington University. Washington, D.C. https:// nnphi.org/wp-content/uploads/2015/08/PrinciplesToConsiderForTheImplementation OfACHNAProcess_GWU_20130604.pdf (accessed on 27 October 2022). Saladino, V., Algeri, D., & Auriemma, V., (2020). The psychological and social impact of COVID-19: New perspectives of well-being. Front. Psychol., 11, 577684. doi: 10.3389/ fpsyg.2020.577684. Santillana, M., (2021). The Impact of COVID-19 on Migrants, Asylum Seekers and Refugees. IDEA. https://www.idea.int/news-media/news/impact-covid-19-migrants-asylum-seekersand-refugees (accessed on 27 October 2022). Shadmi, E., Chen, Y., Dourado, I., et al., (2020). Health equity and COVID-19: Global perspectives. Int. J. Equity Health, 19, 104. https://doi.org/10.1186/s12939-020-01218-z. Shadmi, E., Chen, Y., Dourado, I., Faran-Perach, I., Furler, J., Hangoma, P., Hanvoravongchai, P., et al., (2020). Health equity and COVID-19: Global perspectives. International Journal for Equity in Health, 19(1), 104. https://doi.org/10.1186/s12939-020-01218-z. Sikali, K., (2020). The dangers of social distancing: How COVID-19 can reshape our social experience. Journal of Community Psychology, 48(8), 2435–2438. https://doi.org/10.1002/ jcop.22430. Silva Caraballo, F., (2017). Identifying needs, resources, community response and recovery, and results reported in Prewitt Diaz, J. O. Psychosocial Support: A tool for empowering communities in Puerto Rico After a catastrophic event. Emerg Med. Inves., EMIG-179. doi: 10.29011/2475-5605. 000079. Singu, S., Acharya, A., Challagundla, K., & Byrareddy, S. N., (2020). Impact of social determinants of health on the emerging COVID-19 pandemic in the United States. Front. Public Health, 8, 406. doi: 10.3389/fpubh.2020.00406. WHO, (2021). Guidance on Community Mental Health Services: Promoting PersonCentered, and Right-Based Approaches: World Health Organization 2021. Guidance and technical packages on community mental health services, promoting person-centered and rights-based approaches. Wong, A. S., & Kohler, J. C., (2020). Social capital and public health: Responding to the COVID-19 pandemic. Global Health, 16, 88. https://doi.org/10.1186/s12992-020-00615-x.

CHAPTER 5

Community-Based Psychosocial Support: A Process for the Protection of Vulnerable Populations During COVID-19 SUBHASIS BHADRA

Associate Professor, Department of Social Work, and Head of Department of Sport Psychology Central University of Rajasthan, Rajasthan, India

ABSTRACT The chapter describes the most vulnerable and their living condition. The chapter then explains how disasters impact this population. It builds a case for existing international bodies that ensure the rights of the most vulnerable. It concludes with ways where those that live in extreme poverty are able to cope with the sequelae of huge disasters such as COVID-19. 5.1 INTRODUCTION Civilization is threatened by disasters over and again. Humanity is at crisis not just with deaths and destruction, but with the fear of death, scores of insecurities and problems to lead a healthy life that are outfall of a disaster, may even continue for years together. Disasters are becoming complex, critical, severe, and deadly. The understanding about the natural and manmade disaster is also changing rapidly, as the complex potentially harmful disastrous issues are emerging due to climate change and global warming that are outcome of exploitative and abuse of engagement of human with nature. The increased consumption and aggression of human Mental Health and Psychosocial Support during the COVID-19 Response: An Overview. Joseph O. Prewitt Diaz (Ed.) © 2023 Apple Academic Press, Inc. Co-published with CRC Press (Taylor & Francis)

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are the root cause of exploitative and abusive engagement with the nature. The world of consumerism created a number of artificial needs and the deviant economic and political interest increased the aggression, expressed in the form of conflict, terrorism, and war. Each of the disasters set the milestones of human sufferings, and the worse suffers are all the time the people who are marginalized, powerless, oppressed, and poor. Victimiza­ tions of the poor people are multifold, and they tend to suffer with the spiraling negative impact for longer period of time, while mechanism of supports for recovery are delayed, cripples or inadequate. The events of disaster and development are at race all the time, as civilization strives to bring development, but often increases the risk of disasters by compro­ mising with the natures’ ability to withstand the rupture made. Further, the threats of chemical, biological, radiological, and nuclear (CBRN) disasters are gradually increasing over the past few decades. The pandemic as biological disasters crippled the human life many a time, but the ability to fight with the same varied, as well the intensity of the impact thereby. But the bigger issue is the biological weapons in warfare that can destroy the generations and nature for centuries together. The chemical, radiological, and nuclear disasters are comparatively new with the development of industries and at the same time with the increasing incidences of industrial disasters that often lead to leakage of chemicals in the environment of exposure to radioactive substances. In that sequence, the Chernobyl nuclear power plant disaster (1986) in Russia and the Bhopal Gas leakage disaster (1984) of India showed the quantum of damage that can happen in the immediate and long term to the human, animal, plants, and nature. Even the use of chemical and nuclear weapon in war are the bigger threat looming on humanity. At this trajectory of CBRN disaster, the pandemic, COVID19, is one that took the World on hostage, and questioned the capacity of civilization to withstand and be resilient. While the mounting requirement of medical emergency was at the key focus, the socio-economic difficul­ ties, the survival challenges of common people increased and took a huge toll on mental and emotional well-being. Invariably everyone, became a survivor of the biological disaster pandemic COVID 19. The Carona virus pandemic also underscored the mental health pandemic and ruptured the psychosocial well-being. Therefore, psychosocial recovery and regaining well-being in the continuum of attending hope became a crucial need for all. With multiple factors of vulnerabilities, the marginalized, oppressed sections were in essential need for holistic support.

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5.2 THE VULNERABLE POPULATION IN COVID-19

49

Vulnerability is a situation determined by multiple factors that hinders the opportunities for development, abilities to perform, capacity to withstand adversities and ultimately lead a healthy life and well-being. The factors of vulnerabilities vary over time, situation, and also the intensity of such vulner­ able factors go higher during the time of crisis and disaster. Commonly the issues of vulnerable people or groups are always considered as an important matter in any disaster response program and intervention, yet the vulner­ able people are the groups and communities who fail to access the desired services and are often left unattended or inadequately supported. Therefore, the interventions and the resources for the vulnerable people and communi­ ties need to be consciously designed and delivered at the grass-roots level. The holistic support is most crucial for recovery, where the psychosocial support plays a cerebral role in the process of rehabilitation of the survivors and disasters. There are some common dimensions of vulnerabilities as well as the specific one that are pertinent to discuss in the context of COVID-19. There are a number of societal, economic, political, and systemic causes that increase the risk, susceptibility, and exposure of the different marginalized sections of the society toward pandemic. Thus, pandemic COVID-19 and its extent of impact is a reflection and also a symptom of the deeper societal inequalities (Ali, Asaria, & Stranges, 2020). 5.2.1 CHRONIC POVERTY AND THE POOR FAMILIES Poverty is a global issue and is the biggest hindrance to achieve the sustain­ able goals. Compromised living with experiences of abuse and human rights violations are the issues in daily life of the poor families. In the 21st century, while the global leadership is determined to protect human rights and promote social justice, the existence of poverty around the globe is the major backlog. The UNDP publication “illuminating inequalities” (UNDP-OPHI, 2019) indicated that 23.1% people in 101 countries are multidimensionally poor who are living with less than $1.90 a day. Two third of the poor live in middle-income countries, and half of these poor are less aged less than 18 years. Deprivation, malnutrition, lack of access to education, health facilities, safe drinking water, adequate housing are the associated features. Poverty is a systemic failure and by default it exists, as lack of political commitments, inefficient administrative strategies, issues of corruption in implementation

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of poverty alleviation program are often critical challenges (Bhadra, 2021). Poverty is marked by economic inequality and the poor people go hungry. The UNDP predicted the severity of the long-term impact of the pandemic and mentioned that in the next 10 years another 200 million more people will be pushed to extreme poverty all over the globe. Many of the poverty allevia­ tion programs that were taken up across the world according to the commit­ ment of MDGs and SDGs and the achievements which were made are fading away. Therefore, strong commitments towards attending the targets of SDGs would also be important for reducing the widening gender gap in poverty across the globe (UN News, 2020). The poor people are often vulnerable to abuse and exploitation that make them even more frill and psychologically perplexed to take decisions or to build self-confidence and resilience. Poverty increases the risk of mental health illness and mental health problem (Elliott, 2016). There are different complex socio-economic, cultural, personal, and other factors that shape the mental health outcome. Poor people always live in a stressful situation that contribute to vulnerability factors and risk of mental illness. During disasters the poor people experience higher nega­ tive impact and higher mental health issues. The recent disaster COVID-19 was not an exception in this row, as it caused severe impact on the poor, caused higher mental health sufferings and long-term consequences. The poor socio-economic status, unemployment, and low educational level is the major significant risk factor for developing mental illness, depression, and anxiety during the period of pandemic (Xiong, Lipsitz, & Nasri, 2020). 5.2.2 LIVING IN DIFFICULT TERRAIN AND REMOTE AREAS, IN URBAN SLUM The area of living is connected with the social support and facilities one enjoys that determines the level of well-being. Living in an area that is far away from main roads, inside the Jungle, on the hilly terrain, inside the desert land or in any other remote location causes a lot of issues or accessibility and availability of services and supports, be it medical, health care educa­ tion or otherwise. Even lack of financial services, lack of road connectivity, and issues in electronic communications cause a lot of issues that limit the opportunities and life chances for the people, leading to poor quality of life and fewer chances to grow with full potential. Similarly, living in an area characterized by pollution, unhygienic living conditions, lack of facilities of water sanitation, overcrowded living spaces in the urban slum cause a major

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threat to well-being. The people living in such areas are marginalized and usually from the developmental process to a large extent. During COVID-19 this vulnerability even become quite prominent. As the COVID-19 infection reach to such villages of remote location, people have very few chances to escape from the suffering. Often lack of knowledge, awareness, lack of adequate health infrastructure, healthcare professionals and medical facilities caused a serious crisis. Equally, some of the urban slum with high density of population experienced a very rate of spread of the diseases and fatalities too. In India, the Himalayan districts had witnessed the higher spread and higher rate of positive cases (IndiaSpend, 2021). 5.2.3 PERSONAL FACTORS There are a number of individual factors that impact the well-being and abilities to have coping and survival strategies. Similarly, there are a number of factors of vulnerabilities associated with the life of an individual that prevents him from attaining well-being. Such vulnerability factors are associated with the bio-psycho-social existence of an individual in a given situation and context. The bio-psychosocial model explains the interplay between the biological factors (bio-medical condition, genetic predisposi­ tion, etc.), psychological factors (behavior, emotions, personality traits, etc.) and social factors (socio-economic condition, culture, relationships, family-community life, etc.). The subjective experience of the person, relationships, and interactions with the social entities, ultimately contribute to the well-being or illness. There are different factors that contribute the factor of vulnerability, like advanced age, chronic illness, disabilities, and ailments cause a higher amount of vulnerabilities. Further, lack of acquired skills (skill training, educational attainment, professional qualifications) for healthy living contribute the vulnerabilities. During the period of pandemic and subsequently, such pattern of inabilities caused serious issues to maintain healthy living. Similarly, gender is a factor that was closely associated with the issues of higher vulnerabilities. The women were more vulnerable for psychological issues than men. In the informal sector due to COVID-19 lockdown job loss was much higher than the increased vulnerabilities of the women. In the informal sector, 94% of the employees are women, who became jobless (Bill & Melinda Gates Foundation, 2020; Herald, 2020). Thus, the low-income women in both the rural and urban areas faced major difficulties. It was not just an economic

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crisis, rather it pushed them towards higher social and emotional margin­ alization. The women faced an increased number of domestic violence and job loss during the period of a pandemic that increased the gender-based vulnerabilities of the women (UN Women, 2020; Bhadra, 2021). Even the sexual orientation of LGBTQI made them more vulnerable during the period of lockdown (Jaspal, 2021), as returning to their family home, they had fear about involuntary disclosure of their sexual identity, stigma associated with the same and often were under close watch. Geriatric populations are having number of factors of vulnerabilities in any disaster situation. The elderly people often suffer from a number of geriatric issues and dependent of regular medicine, care or different kind of supportive aid. In disaster the elderly people face a number of psycho­ logical abuse and trauma. Various studies around the world showed the elderly people experiences, PTSD, anxiety, and depression more (Adhikari et al., 2017; Jia, Tian, Liu, Cao, Yan, & Shun, 2010). They face a number of negative life events like deaths of young family members, injury, losses, illness, etc. Often the alteration in the life cycle became a source of severe stress (Bhadra, 2020). World Health Organization (WHO) in its bulletin in April 2020, has warned that “Older people are at highest risk from COVID19” and there must be special protective measures by the government and various authorities to ensure adequate support with dignity and respect. In the European region, it is reported by November 2020, that over 95% of the dead patients were above 60 years of age. Comorbid chronic medical condition like cardiovascular disease, hypertension, and diabetes, is also an important factor leading to higher death rates among the geriatric population (WHO Regional Office or Europe, 2020). Living with disabilities is a major limitations and factors of vulnerability if adequate support provisions are not provided consistently to facilitate opportunities and empowerment. Incidences of disaster make them further frill and vulnerable. It is reported that COVID-19 responses were largely disability exclusive and often they suffered from inaccessibility of public information, health care facilities, other survival needs, and social supports. Often the reasons are lack of understanding and appreciating the factors of vulnerabilities among the persons with disabilities (Mladenov & Brennan, 2021). WHO in its initial briefing urged for the special protection for the persons with disabilities during the outbreak of pandemic, as they have more health care needs and associated factors of vulnerabilities that make them more susceptible to the infection (WHO, 2020).

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Chronic illness usually takes a big toll on health and well-being. There are number of diseases or health-related issues that may cause to chronic illness, like, high blood sugar level, hypertension, living with HIV positive status, having tuberculosis, leprosy, etc. Chronic diseased condition requires persistent medical attention as well as special protective measures from the infection. The persons with chronic illness often face higher mental health issues and experience psychological distress during COVID-19 spread. Such chronic condition often reduces the overall life satisfaction and increase vulnerabilities (Blix, Birkeland, & Thoresen, 2021). 5.2.4 COMMUNITY SITUATIONAL FACTORS Existing social inequalities, wide discrimination, systemic oppression or certain communities based on race, ethnicity, caste or religion often cause major social disequilibrium and vulnerabilities among the people. Within the community the unequal power struggle often causes a major strain and disharmony that become an important source of stress and suffering for the people. Often the suppressed group face the higher negative impact of the disasters. During COVID-19 pandemic too, the impact was higher among the communities oppressed and marginalized communities (Kantamneni, 2020). There are many other vulnerable communities like the sex-workers, bar-dancers (Jangir & RajNat, 2020), baggers, ragpickers, manual scavengers who are associated with stigmatized professions and do not have much social security and social support mechanism. They became highly vulnerable during the period of pandemic and different forms of lock-down, cessation of working opportunity caused serious survival crisis (Azeez, Negi, Rani, & Kumar, 2021). 5.3 PROTECTION OF HUMAN RIGHTS AMONG THE SURVIVORS OF DISASTER AND PANDEMIC The 21st century is the era of realization of human rights, and the commitments of SDGs (sustainable development goals) are to end all forms of violence, and sufferings against the humanity that caused subjugation, dehumaniza­ tion, and endanger the whole world. The first milestone in the history of human rights is the Geneva Convention of 1864 that focused on the need of protection of the victims of armed conflict. Henry Dunant, the founder of the Red Cross Movement paved the way for care and protection of the wounded,

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sick military personnel without any discrimination and planted the seeds of protection of human rights as the essential need of civilization (United for Human Rights, 2016). Two World Wars in the first half of the 20th century were the ugly projection of human aggression, even till now continuing with eruption of violence across the globe. The birth of the League of Nations (10 January 1920) and further United Nations (UN) (24 October 1945) came as international agreements to maintain world peace for the protection of human lives on earth. The United Nations Charter was adopted in 1945 that further marked another milestone for international peace and security, inter­ national development and co-operation, protection, and respect for human rights and the rule of law. The adoption of UDHR-1948 (Universal Declara­ tion of Human Rights), in the general assembly of the UN considered as crucial landmark in the commitment for establishing human dignity. Around 15 years later, the General Secretary of UN Mr. Javier Perez de Cuellar mentioned Universal Declaration has become the basic international code of conduct by which performance in promoting and protecting human rights is to be measured. “The Declaration does not establish any difference in value or importance between economic, social, and cultural rights, on the one hand, and civil and political liberties, on the other. They are granted the same degree of protection” (Sekar, 2008; Human Rights and disaster: Psychosocial Support and Mental Health Services, p. 246). The important UN conventions that established the specific needs of protection for the vulnerable sections and people in general (UNOHCHR, 2016) are as bellow: i. International Convention on the Elimination of All Forms of Racial Discrimination, 21 December 1965. ii. International Covenant on Civil and Political Rights (1966). iii. International Covenant on Economic, Social, and Cultural Rights (1966). iv. Convention on the Elimination of All Forms of Discrimination against Women, 18 December 1979. v. Convention on the Rights of the Child, 20 November 1989. vi. International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families (1990). vii. Convention on the Rights of Persons with Disabilities, 13 December 2006. viii.Number of conventions are done for the protection of environment, animal, ecology, biodiversity that has important implication on human life on earth.

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These treaties provide important obligations to develop a human-rights based response for COVID-19 Pandemic. The right to health and other human rights are closely connected to each other for the protection of civil and political rights in relation to protect public health. These are the bindings on the Nation to design human right-centric COVID response. UNISDR (The United Nations Office for Disaster Risk Reduction) was established in 1999 to facilitate international strategy for disaster risk reduc­ tion and made considerable focus on the protection of different human rights for the survivors of disaster and for the vulnerable survivors. The major milestone was adopting The Hyogo Framework for Action (2005–2015): Building the Resilience of Nations and Communities to Disasters in 2005. Fourth Asian Ministerial Conference on Disaster Risk Reduction, held in Korea, in October 2010 specifically recognized “the need to protect women, children, and other vulnerable groups from the disproportionate impacts of disaster and to empower them to promote resiliency within their communities and workplaces” (UNISDR, 2010). Though many countries have initiated various mechanisms to protect and promote human rights yet after almost 8 decades of the UDHR, the situation of human rights is under criticism with increasing human sufferings all over the Globe. Beyond poverty and disease, natural and human made disasters, complex emergencies leading to huge refugee, displacement imposing challenges to protect human rights of the survivors. COVID-19 pandemic was a test for Global commitments for the protec­ tion of human rights. The human rights of the marginalized and vulnerable population were severely abused and threatened due to the spread of the pandemic. Assuming the upcoming challenges for the protection of human rights United Nations Human Rights Office of the High Commission, issued a number of directives from 2020 onwards. Public health emergency due to pandemic required many exceptional restrictions to impose that caused diffi­ culties in the life of the people. UN considered human rights are at the center of the pandemic response and recovery, thus stating – “Human rights are key in shaping the pandemic response, both for the public health emergency and the broader impact on people’s lives and livelihoods. Human rights put people center-stage. Responses that are shaped by and respect human rights result in better outcomes in beating the pandemic, ensuring healthcare for everyone and preserving human dignity. But they also focus our attention on who is suffering most, why, and what can be done about it. They prepare the ground now for emerging from this crisis with more equitable and sustain­ able societies, development, and peace” (UN, April 2020). This document

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also emphasized on the recovery on the path of “Build-Back-Better” keeping the environmental sustainability and protection at the center. The important recommendation that highlighted the protection principles are given below (UN, April 2020): • • • •

• • • • • • • • • •

Use maximum available resources to ensure availability, acces­ sibility, and quality of health care as a human right and right to life is protected. Provide stimulus packages to mitigate the economic impacts of the pandemic and support to those affected by the loss of their liveli­ hoods, without access to social safety nets. Ensure income security and targeted social assistance for the most marginalized or vulnerable. Ensure recovery plans for groups and individuals, including migrants, displaced persons and refugees, people living in poverty, persons with disabilities, women, older persons, LGBTI people, children, and those who faced disproportionate impact of a pandemic. take action against discrimination, hate speech, ageism, xenophobia, racism or violence arising from this pandemic. Participation of diverse civil society actors in decision-making processes on COVID-19 response. Ensure reliable, accurate information reaches all. Guarantee freedom of expression, including freedom of the press, thus disseminate scientific, evidence-based information without suppression, and counter misinformation. Ensure that any emergency measures are legal, non-discriminatory, have specific focus and duration. Ensure emergency powers are not used to quash dissent, silence human rights defenders or journalists or taking any steps not neces­ sary for managing the health situation. Safeguards the personal information. Ensure safeguards while new technologies are used for surveillance, treatment in response to COVID-19. Mitigate the impact of the crisis on women and girls, including on their access to sexual and reproductive health/rights, and protection from domestic violence, gender-based discrimination. Strengthen international cooperation and take steps towards the provision of universal health care, collaborate in developing a vaccine and treatment for the pandemic. Take measures to alleviate the situation of vulnerable groups.

Community-Based Psychosocial Support

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Take the lessons learned from this pandemic to refocus action on ending poverty and inequalities and addressing the underlying human rights concern to reduce vulnerabilities.

An effective community based psychosocial support (CBPSS) program can accommodate most of these recommendations that are recommended to implement at the grassroots level in the community to empower the people, ensure social justice, equality, protection of vulnerable population and encouraging to work on their strength, to overcome the difficulties and challenges. 5.4 LACK OF WELL-BEING CONTRIBUTE TOWARDS INCREASE OF VULNERABILITY Well-being and health are closely connected. Lack of well-being contribute towards increasing ill-health and vulnerabilities. The source of well-being is multi-dimensional and an outcome of complex phenomena. Within the WHO definition of health “mental, physical, and social well-being” (WHO, 1948) is highlighted and further the concept of well-being is elaborated by the WHO Regional Office for Europe (WHO, 2013). Well-being comprises both subjective and objective elements. The life experience of an individual in comparison to the existing social norms and values contribute to well­ being. The subjective point of view of well-being explains the level of satis­ faction, happiness, and being comfortable within the given circumstances. The subjective well-being may vary over the time according to the situation, thus an objective view of well-being is further explained through various indicators, like, demographic variables (like, age, gender, education, occupa­ tion, etc.), health status (like, presence of disease, perception of own health, satisfaction, etc.), social context (like, communication with family/peergroup/community, social environment, school environment, etc.), health-risk behavior (like, consumption/addiction of psychoactive substance, physical aggression, sexual behavior, etc.), and other variables which have impact on well-being according to the culture and context. Thus, well-being describes a “condition of an individual or group, with reference to social, economic, psychological, or medical attention” (Sfeatcu et al., 2014). High level of well-being contributes to positive experience and the vice-versa. Disasters and conflicts severely affect the well-being of the survivors. The well-being contributes towards attending the quality-of-life, which is a combination of living environment, physical, and mental health, education, recreation,

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social relationships, and communication. Thus, quality of life refers to the overall well-being of individuals from a society. In the context of disasters, the quality of life grossly deteriorates, as the environment suddenly becomes unsafe, threatening, absolutely uncomfortable, and adjustment becomes very challenging till further assistance is provided to the survivors. Thus, in the context of disaster psychosocial support is very crucial for recovery of the survivors that focuses on strengthening resilience and rebuilding well-being. In the context of COVID-19 pandemic the situation was quite difficult as the spread of the disease and threat engulfed the whole world, and everyone faced the trauma, suffering, and stress in some or other way. It is not just the disease rather the social factors, psychological issues, economic chal­ lenges as described earlier showed the worsening situation and increasing marginalization of the vulnerable groups or communities. Mental health impact of COVID-19 was enormous as difficulties in daily life, stress due to disease, threat of infection, being infected or loss of lives and job opportunities were common events across every nation. COVID-19 was termed as a parallel mental health pandemic. The job loss caused a huge amount of stress as mandatory closedown of work was common in every nation with the imposed lockdown that restricted all the economic activities. Many of the poor families with little savings in hands were out of basic survival requirements within a few days to weeks. At this time, they were worried about food than being infected with the virus. Subsequently, the government supports were of some help, but the situation was far off from normal. At this time, social issues like family violence, domestic disputes, and sexual harassment increased consistently lead to depression, hopelessness, anxiety, and number of psychosomatic issues. The slowdown of economic activity directly led to negative mental health consequences among the vulnerable groups. The women particularly faced higher amount of stress (Thibaut & Wijngaarden-Cremers, 2020), as in the informal sector, the job loss was quite high, and the women in the low and middle-income countries were largely dependent on the informal sector. Women also faced a very high amount of stress on the domestic front with increased demand of household course of activities, as the family members were at home throughout the day. The women lost their personal space and also faced higher sexual demands to fulfill. The family atmosphere was even more corrective while some of the family members got infected with COVID-19 or experienced death. A systematic review conducted by Xiong et al. (2020) reported relatively high rates of symptoms of anxiety, depression, post-traumatic stress disorder, psychological distress, and stress among the general population during the

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COVID-19 pandemic in China, Italy, Spain, Iran, Turkey, the US, Nepal, and Denmark. Risk factors of increasing mental health problem were associated with a number of factors of distress that included female gender, younger age group (≤ 40 years), higher family burden, presence of chronic/psychiatric and physical illnesses, unemployment, student status, and inability access the government of NGO supports. Decrease in physical activities and gross change in routine life leading to the risk factor of increasing stress and depression (Giuntella, Hyde, Saccardo, & Sadoffc, 2021). People affected by COVID-19 were having more mental health issues due to the fear and negative thoughts about the disease. Health workers were found to have a very higher level of mental health impact due to excessive pressure of work and inability to have break for self-care (Thibaut & Wijngaarden-Cremers, 2020). Increased engagement with the online activities, also created the risk of digital addiction with subsequent increase of online sexual activity, sexting, visiting pornographic site that caused mental health disturbances and issues in personal and familial life (Awan et al., 2020). Even overexposure to negative incidences, high exposure to social media news regarding the spread of COVID-19 infection caused higher amount of anxiety and depres­ sion (Xiong, Lipsitz, & Nasri, 2020). The psychological issues among the children and adolescents during the pandemic caused a concern about the future of the next generation. The close of school, cease of physical presence in the classroom, lack of contact with the peer groups, closer of the avenues of healthy entertain­ ment like playing in the park, playground caused major distress. Often, in the poor families, the school-going boys and girls discontinued education as the parents were unable to afford a digital devise for online engagement. Many times, the local schools and teachers were not equipped to conduct online classes, and the internet connection was too poor to have live-online engagement. It is found that many children across the globe, specially from the low and middle-income countries lost touch with academics and have grim chances to continue their education. Many of the adolescent girls are forced to marry quit education. All of a sudden, the demand of digital literacy exposed the wide digital divide between the rich and poor, educated and uneducated, rural and urban, across region, gender, and age groups. Beside the educational aspect, the children and adolescents have suffered a major psychological blow due to the illness of their caregivers/ parents in wort cases losing one or both the parents. Across the globe, the Carona pandemic (from 1 March, 2020, to 30 April, 2021) left estimated 1,134,000 children and adolescent orphan or semi-orphan (loss of primary

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Mental Health and Psychosocial Support during the COVID-19 Response

caregiver), who became dependent on their relatives or still waiting to have an effective support through government or civil society organization to get back to a secured, protected life. “Orphanhood and caregiver deaths are a hidden pandemic resulting from COVID-19-associated deaths” (Hillis, Unwin, & Chen, 2021). The biological disaster COVID-19 pandemic has exposed the complex realities and series of factors of vulnerabilities that require an effective inte­ grated interventions at the community level. Psychosocial support is a key component that must be initiated for the people to facilitate well-being and achieve normalcy, by strengthening individual initiatives, groups’-support and networking, family bonding, and supportive community cohesion. Thus, all the stakeholders require a compassionate engagement for effec­ tive policy making, implementation of program and allocation of resources for the Community-Based Psychosocial Support Program (CBPSS) that is process for promoting protective measures for the survivors of pandemic in a sustainable continuum. 5.5 CONCEPT OF CBPSS FOR DISASTER INTERVENTION (BHADRA, 2018) Protection as the central theme of human rights and social justice prin­ ciples are the driving force of the disaster interventions to respond to the humanitarian crisis is well recognized, worldwide. The most effective tool for the same is described here as CBPSS which is not limited within the outcome of resiliency, rather inbuilt within the process of recovery through community engagement (CE) based on the strength of the community and adaptive capacity which enhance capability and well-being of the survivors (Bhadra, 2018). The root of CBPSS can be traced within the dimensions of health and definition of mental health given by WHO. The physical, mental, and social dimension of health was added with spiritual health for a broader perspective of reaffirming holistic well-being (Larson, 1998; Dhar, Chaturvedi, & Nandan, 2011). Mental health is a “state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to contribute to his or her community” (WHO, 2001). In accordance with these understanding the PSS is a combination of psychological and social interventions (Hansen, Psychosocial Interventions A handbook, 2008), a process of facilitating resilience within individuals, families, and

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communities (International Federation of Red Cross, 2005) and a broad range of community-based interventions that promote the restoration of social cohesion and dignity of individuals and groups (Aarts, 2000). PSS is “any type of local or outside support that aims to protect or promote psycho­ social well-being and/or prevent or treat mental disorder” (Inter-Agency Standing Committee, 2007), and Sphere handbook (2011) mentioned “some of the greatest sources of vulnerability and suffering in disasters arise from the complex emotional, social, physical, and spiritual effects of disasters” that need to be supported with a structured PSS program. PSS is closely interlinked with the development of resiliency which is better conceptualized as ability or process rather than an outcome and focusing on adaptive capacity at individual and community levels than recovery (Norris, Stevens, Pfefferbaum, Wyche, & Pfefferbaum, 2008; Walker & Westley, 2011). Targeted intervention and CE is prime focuses of resiliency building that is built on the strength of the community, but it does not exclude the intervention by government or external agencies. The resiliency building is an empowering process considering the ‘strength­ based perspective’ (SBP) (Zastrow, 2010) of the affected community. Barker (2003) defined empowerment as “the process of helping individuals, families, groups, and communities to increase their personal, interpersonal, socio-economic, and political strength and to develop influence towards improving their circumstances” (p. 142). The principles of SBP explain, every individual, family, and community has strength; trauma, abuse, illness, and struggle can be injurious, but they also can be source of challenge and opportunity; there is an innate capacity of the community (survivors) to visualize the change and bring better develop­ mental opportunities for themselves; collaboration with the client to ensure an equal footage as a stakeholder in the process of intervention; and every environment is full of resources (Zastrow, 2010, p. 73). The CBPSS thrives its practice considering the capacity of the individual, family, and community that is mobilized through active participation, and allow the communities to take decision about the desired changes being an active stakeholder in the process through collaborative practice and strive to make best use of the available resources, opportunities. The process-oriented engagement in CBPSS may not pinpoint to a single outcome practically, but it is undoubtedly bringing a capability within the survivors that can holistically drive towards well-being. Capabilities are constitutive elements of well-being and capture the valuable doings and beings that individuals can achieve or become (e.g., being adequately

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nourished, and being sheltered, able to take decision, participate in enjoy­ able activity, engaged in meaningful livelihood, etc.). The capability approach propagated by Sen (1997); and Nussbaum (2011) in the field of development economic policy, brought a human-oriented approach in the development. There is evidence that a wide range of capabilities exhibit statistically significant relations to well-being (Anand, Hunter, & Smith, 2005). Thus, capability enhances resiliency among the survivors of disaster, specifically among the marginalized individuals and groups. Resiliency is understood in individual and community perspective. The individual perspective of resiliency explains two important dimensions; exposure to the adversity and ability, quality of adoption positively (Masten, 2001). In an adverse situation, the survivor will be able to deal with the same based on his/her capacity and resources available. “The ability to spring back from and successfully adapt to adversity is resiliency” (Henderson, 2012). “Resiliency is the capacity to transform oneself in a positive way after a difficult event” (Annan, Castelli, Devreux, & Locatelli, 2003) and in other words, resiliency is increased or enhanced ability to cope with difficult situations. A resilient community can cope with disturbances or changes and maintain adaptive behavior. For understanding community perspec­ tive of resilience, level of adoption at community and population wellness should be measured. This explains “high and non-disparate levels of mental and behavioral health, role functioning, and quality of life in constituent (i.e., disaster affected area) populations” (Norris et al., 2008; Potangaroa, Santosa, & Wilkinson, 2015). 5.6 COMMUNITY-BASED PSYCHOSOCIAL SUPPORT (PSS) AND COVID-19 PANDEMIC The pandemic causes a huge toll on human life in every dimension, health to well-being, social to economy, policies to action. The enormous stress in every aspect of life created a number of secondary weaves of pandemic, like weaves of death, weaves of loss, waves of sufferings and weaves of stressors with uncertain future among the common people, particularly the vulnerable sections with low capability, poor access to social security benefits, and weak social support. In such situation, CBPSS became an important intervention to ensure holistic care, facilitate adequate support, and strengthen effective action for social security through community-based strategies. The following activities are important for facilitating psychosocial well-being:

Community-Based Psychosocial Support

• •

• • • • • • • • •

63

Capacity building of the volunteers, and community leaders about COVID-19 pandemic, hygiene practice and PSS. Facilitating mental health services in the community through community workers/volunteers (teachers, Anganwadi workers, village health workers, self-help group members). Integration of public health care and mental health care in the community for the care of the people in quarantine and in-home care. Identification and care for the vulnerable population. Facilitating credible information through virtual medium, commu­ nity radio, other social and mass media. Demystifying the disease, fear, and adoption of scientific health measures, like quarantine, hospitalization, etc. Facilitating support for relief while job opportunities are stalled or hampered. Mental health care and support for the health care workers. Promotion of self-care strategies among the COVID front line workers, and community workers. Strengthening the local institutions. Accommodating the changes and adapting to the situation.

COVID-19 is also explained and understood as syndemic (Horton, 2020), that explained about the spread of the infection based on pre-existing vulnerabilities that are interacting and driven by larger economic, social, and political issues in a situation. This shows the wider factors of vulner­ ability is not just related to health, rather it is connected with the pre-existing problems in different interactive sphere of life. For CBPSS focusing on all the issues are essential for reducing vulnerabilities, controlling the disease and providing PSS to the people. Psychosocial supports are provided at three levels, namely individual, family or groups, and community level. 5.6.1 PSS AT INDIVIDUAL LEVEL The purpose of psychosocial support is to help an individual to develop his/ her abilities to cope with challenges and capabilities to maintain functional­ ities within the context before, during or after a disaster. The ability to cope with the problem is crucial for developing resiliency and empowering self with a commitment to lead a life with a healthy lifestyle.

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5.6.1.1 INTERVENTIONS FOR ALL

The social circumstances were stressful for many individuals during the period of strict lockdown. At this moment following a healthy lifestyle was most crucial to maintain positivity and be healthy. This included the habit of physical exercise, maintaining an active life at home, sharing the concerns and caring for all, talking to each other for seeking and giving support, and focusing on managing the day-to-day activities with a habit of plan­ ning for working out the best possible solution. Taking adequate sleep, rest, practicing yoga, hobbies, writing down feelings and emotions, and avoiding any kind of addictive substance were crucial to maintain a healthy life for well-being (Murthy, 2021). The pandemic has given a blow to the plans and aspirations and given a realization about the greater responsibility and morality that influenced the belief system, understanding about the universe and reconnected with superpower. Ultimately deriving strength from the spiritual resources were also important that talks about being grateful to upper power, being humid and drawing the spirit of compassion. Such posi­ tive behaviors and practices have no alternative to maintain a healthy life, yet many people belong to the vulnerable weaker sections of the society needed to be supported to adopt and maintain a healthy lifestyle, by assuring different social security measures for dealing with daily survival require­ ments. Thus, in such situation, community level holistic care provisions are equally crucial and essential to workout. 5.6.1.2 INTERVENTIONS FOR THE PEOPLE AT EXPOSURE WITH COVID-19 The person with exposure to COVID-19 or returned home from another area/ region often had to follow quarantine as a mandatory practice to prevent the spread of COVID-19 virus. In a family or neighborhood while someone detected with COVID-19; the isolation was essential for the patient as well for the primary contacts. In such situation, helping the family members to maintain a healthy life was most crucial. Thus, maintaining contact through tele-counselling, reaching to the doorstep to provide the basic household supplies, facilitating medical advice through distance mode (telephonic consultation) were practiced. Though this service was quite limited often as the caseload started increasing and there were less adequately trained mental health workers, or community level volunteers for such services. During the

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pandemic, the growth and use of tele-counselling emerged as a revolution. There was 10–12 folds increase of the use of tele-psychological helpline, brief training for the mental health workers to provide psychological support (through telephone), facilitate information delivery and there was also large development of manuals, professional materials for tele counselling (Pierce, Perrin, Tyler, McKee, & Watson, 2021). 5.6.2 PSS AT FAMILY LEVEL A healthy family life is always a source of strength to deal with the challenges and develop better family coping abilities. Maintaining a healthy family life is a practice and commitment by all the members, especially the adults. There were changes in leadership patterns, daily family routine, functions, family rituals, and other family situations with economic strain and health issues too. Performing the desired task as per the role and status and making a best effort to keep the communication open, sharing feelings, showing concerns, joint decision making at the face of difficult time, focusing on present situation than looking back or taking too many worries about future. Many of the families had suffered the job loss and difficulties in income with absolute economic halt that impacted production, marketing, transportation, consumption, and ultimately the livelihood and income opportunities. Thus, empowering the families to live a healthy life was very essential during the pandemic. 5.6.2.1 EMPOWERING THE FAMILIES Access to scientific information was most crucial to deal with healthy practice and maintain well-being. Unfortunately, during the pandemic, misleading information was a major challenge that often-caused serious issues and hindrance. Developing healthy open communication, sharing the household responsibilities, practicing alternate routine, supporting each other, managing with less, opting for the available job were crucial for leading healthy life. Such information was provided through a number of programs through mass media, social media, by the community volunteers, and through other community-based interventions. In India the District Mental Health Program (DMHP) that is implemented more than 600 districts provides specific mental health care and support services to the families living with mentally ill patients and also to the families in general to overcome the stress reactions

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and maintain well-being (NIMHANS, 2020, pp. 125–130). Psychosocial support for the family members having COVID positive patient was very crucial to reduce the immediate distress, encourage appropriate safe, hygiene practices, addressing the worries, encourage adopting constructive positive steps for solving problems, facilitate realistic hope and continuous supportive communication (ICMR, 2021). These interventions played a crucial role in demystifying the fear and have scientific information. 5.6.2.2 PSYCHOSOCIAL SUPPORT TO EASE STRESS IN PARENTING Parental stress impacts the well-being of their children. With closure of school children had disturbed routine and often at a huge stress as the parents were incapable to handle the difficulties of daily life and maintain their self-efficacy. The parental ill-health, distress, and family issues negatively impact the emotional and social well-being of the children and adolescents. During COVID-19, parental stress and compromised parenting often affected the children’s well-being and increase the chance of abuse (Brown et al., 2020; Morelli et al., 2020). In such a situation, empowering the parents with appropriate information regarding the emotional distress of the children, the behavior changes due to imposed restrictions, facilitating learning in a healthy family atmosphere, encouraging quality time with the children, and helping to be connected with others were most crucial. The community health volunteers, played an important role in different countries to reach out to the parents and children with adequate support and information. In India, the Anganwadi workers (child care personnel in the community under Integrated Child Development Scheme), ASHA (accredited social health activist, a community health worker under the program run by the Ministry of Health and Family Welfare, in community) and ANM (auxiliary nurse midwife, work in Health Sub-Center under Primary Health Care Center) played a role to provide supplementary nutrition, health care, and basic information, parental counselling at the community level. Psychosocial supports help in reducing the parental perceived stress, anxiety, and depression that helped in devel­ oping stimulating-nurturing supportive family atmosphere (Ahuja, 2021). 5.6.2.3 PSS AT COMMUNITY LEVEL Community situation, wider supportive networks, and opportunities to participate in community life significantly influence the family and

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individual well-being. A healthy community live is crucial to deal with the stress due to disaster. During pandemic it is seen, while the community people are together, community groups are active, community volunteers are in forefront, they come out as winner, and they can trumpet over the problem together by mobilizing their internal strength and resources. Communitydriven support and recovery are always an important aspect in disaster recovery. While many communities started community quarantine facilities, the local leaders, played an active role in providing support. Similarly, facili­ tated the care for the families with positive cases or the vulnerable families like the poor, women-headed households, aged people, families with no income opportunities, and others. World Bank Blog (Fallesen, Linneman, & Padua, 2021) reported a story “Strength in community: Tackling COVID-19 recovery in the Philippines through community-driven development” high­ lighted that disaster preparedness at the community can make a community better resilient and respond during the crisis. The psychosocial support and recovery from the pandemic are not an automatic process, rather the power of the community need to be activated, mobilized for this purpose. When­ ever such community mobilization and engagement has been stimulated effectively by the community leaders, the community become an effective source of psychosocial support and recovery during a pandemic. Following important engagements can play essential roles in a community context. 5.6.2.4 MULTI-STAKE HOLDERS’ ENGAGEMENT IN CARE AND RECOVERY The care, recovery, and well-being of the vulnerable population largely depend on the engagement of different stakeholders in developing and main­ taining a caring community. While many Civil Society organizations like, NGOs, CBOs, youth groups and religious organizations, joined to support the vulnerable groups, migrant population to provide the basic support for survival and displayed the compassion, it helped in husting the recovery and achieving better adjustment. Equally, many professional bodies, corpo­ rate groups, industrial houses joined hands to support the communities to develop facilities for COVID care as well as provided support to the vulner­ able families with supplies like, hygiene kit, daily rations or even cooked food. Like, other welfare-oriented nation, the government of India provided number of benefits for the poor vulnerable marginalized families across nation, like, job opportunities at the villages (through NREGA: National

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Rural Employment Guarantee Act-Scheme), food supplies through Public Distribution System, different scheme of Direct Cast Benefit, etc. (Bhadra, 2021). By these schemes, the local institutions were strengthened to ensure better protection services for the vulnerable populations. A number of addi­ tional schemes were designed to boost the morale of the service providers during the emergency as well. 5.6.2.5 USE OF INDIGENOUS KNOWLEDGE SYSTEM FOR HEALTH AND PSYCHOSOCIAL WELL-BEING Indigenous knowledge available to the communities and within the tradi­ tional sciences are the treasure of wisdom (Rathod & Dandekar, 2020). Such indigenous traditional knowledge in the community has been used to some extent yet require a systematic documentation for wider use. At the time of crisis, the use of indigenous knowledge in regards to prevention of health, promotion of community cohesion is most essential. 5.6.2.6 DATA INTEGRITY At the community level, effective data management was most crucial for facilitating psychosocial support. Tracking the spread of the disease, conducting systematic testing, providing medical and other support to the infected individual and families and providing social security measures to all vulnerable populations require a huge data tracking and management. During pandemic lack of data management at different level (in health system, in community for providing supplies, etc.) often caused problems. Thus, effective data management is essential for the protection and care of the vulnerable population. 5.7 CONCLUSION The psychosocial support during COVID-19 was conducted at an extent never before, but care for the vulnerable population was not at the center of focus. Hence, effective psychosocial support is most needed with specific targeted intervention for the vulnerable population to deal with the challenges due to disasters and pandemics. The pandemic showed the inadequacy of the healthcare system all over the globe. The long-term consequences are also

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going to be deep-rooted in the human mind as well as in the social condi­ tion. The widely practiced methods to stop the spread of virus-like, social distancing, isolation, work from home, restricted movement, ultimately increased anxiety, rumination, decreased physical activities that impact the mental health of the masses and also impacted the mental health status of the psychiatric patients, and other vulnerable groups. The whole situation highlighted the need of new mental health technology innovation (Figueroa & Aguilera, 2020) and wider use for maintaining well-being. KEYWORDS • • • • • •

chemical, biological, radiological, and nuclear community-based psychosocial support district mental health program psychosocial support strength-based perspective sustainable development goals

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Herald, (2020). More Women Lost Their Jobs During COVID-19 Lockdown Than Men: Report. Retrieved from Deccan Herald: https://www.deccanherald.com/national/morewomen-lost-their-jobs-during-covid-19-lockdown-than-men-report-887244.html (accessed on 27 October 2022). Hillis, S. D., Unwin, H., & Chen, Y., (2021). Global minimum estimates of children affected by COVID-19-associated orphanhood and deaths of caregivers: A modeling study. The Lancet, 398, 391–402. doi: https://doi.org/10.1016/S0140-6736(21)01253-8. Horton, R., (2020). Offline: COVID-19 is not a pandemic. The Lancet, 396, 874. doi: https:// doi.org/10.1016/S0140-6736(20)32000-6. ICMR, (2021). Guidance Document for Psychosocial Counselling for COVID-19 Positive Patients and Their Family Members. New Delhi: Indian Council of Medical Research. Retrieved from https://www.icmr.gov.in/pdf/covid/techdoc/PSC_COVID_patients_ v1_30042021.pdf. IndiaSpend, (2021). More than half of Districts with High COVID-19 Positivity are Himalayan. Retrieved from IndiaSpend: https://www.indiaspend.com/covid-19/himalayadistrict-positivity-rate-infections-testing-759064 (accessed on 27 October 2022). Inter-Agency Standing Committee. (2007). Guidelines on Mental Health and Psychosocial Support in Emergency Settings (MHPSS). Geneva: IASC. International Federation of Red Cross, (2005). Psychosocial Framework 2005–2007. Geneva: International Federation of Red Cross (IFRC). Jangir, H. P., & RajNat, V., (2020). Impact of pandemic on women engaged in bar dances and sex work: A case of Nat community in Rajasthan. Social Work with Groups, 1–5. doi: https://doi.org/10.1080/01609513.2020.1840192. Jaspal, R., (2021). Identity threat and coping among British South Asian gay men during the COVID-19 lockdown. Sexuality & Culture, 1–18. doi: 10.1007/s12119-021-09817-w. Kantamneni, N., (2020). The impact of the COVID-19 pandemic on marginalized populations in the United States: A research agenda. Journal of Vocational Behavior, 1119(3), 103439. doi: https://doi.org/10.1016/j.jvb.2020.103439. Larson, J. S., (1998). The world health organization’s definition of health: Social versus spiritual health. Social Indicators Research, 38(2), 181–192. Masten, A. S., (2001). Ordinary magic: Resilience processes in development. American Psychologist, 56(3), 227–238. Mladenov, T., & Brennan, C. S., (2021). Social vulnerability and the impact of policy responses to COVID-19 on disabled people. Sociology of Health and Illness. doi: https:// doi.org/10.1111/1467-9566.13379. Morelli, M., Cattelino, E., Baiocco, R., Trumello, C., Babore, A., Candelori, C., & Chirumbolo, A., (2020). Parents and children during the COVID-19 lockdown: The influence of parenting distress and parenting self-efficacy on children’s emotional well-being. Frontiers of Psychology, 11(3), 1–10. doi: 10.3389/fpsyg.2020.584645. Murthy, S. R., (2021). Pandemic blue: Community support and cohesion can mitigate the negative effects. The Hindu, 25, 7. Retrieved from: https://www.thehindu.com/opinion/ open-page/pandemic-blues/article34400607.ece (accessed on 27 October 2022). Nimhans, (2020). Mental Health in the Times of COVID-19 Pandemic Guidance for General Medical and Specialized Mental Health Care Settings. Bangalore: NIMHANS. Retrieved from https://www.mohfw.gov.in/pdf/COVID19Final2020ForOnline9July2020.pdf (accessed on 27 October 2022).

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Norris, F., Stevens, S., Pfefferbaum, B., Wyche, F., & Pfefferbaum, R., (2008). Community resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness. American Journal of Community Psychology, 41(1, 2), 127–150. Nussbaum, M., (2011). Creating Capabilities: The Human Development Approach. Cambridge, MA: Harvard University Press. Pierce, B. S., Perrin, P. B., Tyler, C. M., McKee, G. B., & Watson, J. D., (2021). The COVID-19 telepsychology revolution: A national study of pandemic-based changes in U.S. mental health care delivery. The American Psychologist, 76(1), 14–25. doi: 10.1037/amp0000722. Potangaroa, R., Santosa, H., & Wilkinson, S., (2015). Disaster management: Enabling resilience. In: Masys, A., (ed.), Lecture Notes in Social Networks: Disaster ManagementEnabling Resilience (pp. 227–266). New York: Springer. Rathod, N., & Dandekar, P., (2020). Fighting COVID-19 strength and challenges of community. International Journal of Research in Pharmaceutical Sciences, (11), 1416–1419. doi: https://doi.org/10.26452/ijrps.v11iSPL1.3674. Sekar, K., (2008). Human rights and disaster: Psychosocial support and mental health services. In: Nagaraja, D., & Murthy, P., (eds.), Mental Health Care and Human Rights (pp. 243–266). Bangalore: NHRC and NIMHANS. Sen, A. K., (1997). Distinguished guest lecture: From income inequality to economic inequality. Southern Economic Journal, 64(2), 384–402. Sfeatcu, R., Cernuşcă-Miţariu, M., Ionescu, C., Roman, M., Cernuşcă-Miţariu, S., Coldea, L., & Burcea, C. C., (2014). The concept of well-being in relation to health and quality of life. European Journal of Science and Theology, 10(4), 123–128. The Sphere Project, (2011). Humanitarian Charter and Minimum Standards in Humanitarian Response. United Kingdom: The Sphere Project. Thibaut, F., & Wijngaarden-Cremers, P. V., (2020). Women’s mental health in the time of COVID-19 pandemic. Frontiers of Global Women’s Health, 1(3), 1–7. doi: https://doi. org/10.3389/fgwh.2020.588372. UN News, (2020). COVID-19 Could See Over 200 Million More Pushed into Extreme Poverty, New UN Development Report Finds. Retrieved from: UN News Economic Development: https://news.un.org/en/story/2020/12/1079152 (accessed on 27 October 2022). UN Women, (2020). In Focus: Gender Equality Matters in COVID-19 Response. Retrieved from: UN Women: https://www.unwomen.org/en/news/in-focus/in-focus-gender-equalityin-covid-19-response?gclid=Cj0KCQjw8rT8BRCbARIsALWiOvSaLQZy92TgHU21p Du0wlaUZvdwnOpUaViZTuC12E6mJ9-lXnxjJQkaAmDdEALw_wcB (accessed on 27 October 2022). UN, (2020). COVID-19 and Human Rights We Are all in This Together. Geneva. Retrieved from https://www.un.org/victimsofterrorism/sites/www.un.org.victimsofterrorism/files/ un_-_human_rights_and_covid_april_2020.pdf (accessed on 27 October 2022). UNDP-OPHI, (2019). Global Multidimensional Poverty Index 2019- Illuminating Inequalities. New York: United Nations Development Program and Oxford Poverty and Human Development Initiative. UNISDR, (2010). Fourth Asian Ministerial Conference on Disaster Risk Reduction. Incheon, Korea: UNISDR. Retrieved from: http://www.unisdr.org/files/16172_ finalincheondeclarationdraftingcom1.pdf (accessed on 27 October 2022). United for Human Rights, (2016). History of Human Rights. Retrieved from: United for Human Rights: http://www.humanrights.com/what-are-human-rights/brief-history/ declaration-of-human-rights.html (accessed on 27 October 2022).

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UNOHCHR, (2016). The Core International Human Rights Instruments and their Monitoring Bodies. Retrieved from: United Nations Human Rights: http://www.ohchr.org/EN/ ProfessionalInterest/Pages/CoreInstruments.aspx (accessed on 27 October 2022). Walker, B., & Westley, F., (2011). Perspectives on resilience to disasters across sectors and cultures. Ecology and Society, 16(2), 1–4. WHO Regional Office or Europe, (2020). Supporting Older People During the COVID-19 Pandemic is Everyone’s Business. Retrieved from: http://www.euro.who.int/en/healthtopics/health-emergencies/coronavirus-covid-19/news/news/2020/4/supporting-olderpeople-during-the-covid-19-pandemic-is-everyones-business (accessed on 27 October 2022). WHO, (1948). Constitution of World Health Organization. Geneva: World Health Organization. WHO, (2001). Strengthening Mental Health Promotion (Fact sheet, No. 220). Geneva: World Health Organization. WHO, (2013). Measurement of and Target-Setting for Well-Being: An Initiative by the WHO Regional Office for Europe. Copenhagen: WHO Regional Office for Europe. WHO, (2020). COVID-19 Outbreak and Persons with Disabilities. Retrieved from: Department of Economic and Social Affairs: https://www.un.org/development/desa/ disabilities/covid-19.html (accessed on 27 October 2022). Xiong, J., Lipsitz, O., & Nasri, F., (2020). Impact of COVID-19 pandemic on mental health in the general population: A. Journal of Affective Disorders, 277(Special issue on Corona Virus), 55–64. doi: https://doi.org/10.1016/j.jad.2020.08.001. Zastrow, C. H., (2010). Evaluating Social Work Practice. New Delhi: Cengage Learning, India Edition.

CHAPTER 6

Serving the Most Vulnerable: Psychosocial Support in Indigenous Communities in Colombia, Costa Rica, Guatemala, Ecuador, Mexico, and Peru JOSEPH O. PREWITT DIAZ

The Pennsylvania State University (Retd.), Pennsylvania, USA

ABSTRACT This chapter addresses the distinct hygiene and medical needs and health solutions needed to address the specific needs of indigenous people in the Americas, as they attempt to address the sequelae of the COVID-19 pandemic. The chapter addresses the needs of the most vulnerable as the pandemic advanced throughout Latin America, the indigenous people were in need of: (i) protective gear; (ii) public health education about ways to contain the pandemic (quarantine, handwashing, and distancing); and (iii) access to treatment centers. 6.1 INTRODUCTION This chapter addresses the distinct hygiene and medical needs and health solutions needed to address the specific needs of indigenous people in the Americas, as they attempt to address the sequelae of the COVID-19 pandemic. As the pandemic advanced throughout Latin America, the indig­ enous people were in need of: (i) protective gear; (ii) public health educa­ tion about ways to contain the pandemic (quarantine, handwashing, and Mental Health and Psychosocial Support during the COVID-19 Response: An Overview. Joseph O. Prewitt Diaz (Ed.) © 2023 Apple Academic Press, Inc. Co-published with CRC Press (Taylor & Francis)

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distancing); and (iii) access to treatment centers. The Interagency Support Group on Indigenous Issues (2020) related to right-based approaches for pandemic response reported that amongst the indigenous population, there were issues related to access to: (a) appropriate cultural appropriate medical services; (b) traditional food systems; (c) water and sanitation; (d) culturally appropriate communication strategies and community engagement (CE); and (e) involvement of indigenous people in consultation process on the appro­ priateness of services. Tigre (2021), in her review, suggests that COVID‐19 has exacerbated the multiple crises Amazonia was already facing: (such as deforestation, the reduction of biodiversity and the lack of protection of the human rights of Indigenous people), and the measures taken by national governments and by regional and international groups responsible for the response to the pandemic have been insufficient and culturally inadequate. Barabas (2015), in her study on languages, culture, and context of indigenous people in the Americas, suggests that these people are distinct social and cultural groups. Fuentes (2017) reports on the conclusion of the Inter America Human Rights Court, which indicates that the indigenous population in the Americas share collective ancestral ties to the lands and natural resources where they live, occupies, or from which they have been displaced. Gonzalez et al., in their study of language as a cultural connector, indicate that any Indigenous people in Central and still maintain a language distinct from the official language or languages of the country or region in which they reside. ECLAC (2021) reports that the indigenous population in Latin America is estimated at 58 million, belonging to approximately 800 tribes, and about 9.8% of the total population (p. 23), with the greatest number of indigenous populations living in Bolivia, Colombia, Ecuador, Guatemala y Peru. According to the United Nations (ECLAC, 2021, p. 14). According to the World Food Program (2020), more than 86% of indigenous people work in the informal economy and are nearly three times as likely to be living in extreme poverty. Beltrami (2020) indicates that the indigenous population are more likely to suffer from malnutrition and often lack adequate social protection and economic resources. The COVID-19 pandemic has dispro­ portionately affected their lives, causing them to suffer even more from poverty, illness, and discrimination (Beltrami, 2020). Busso & Messina (2020) have concluded that the socio-economic condi­ tions of indigenous people in Latin America show that being indigenous is associated with being poor. Five countries have had a recent census, and the results highlight the extreme poverty of the indigenous people. These

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five countries are: Chile, Colombia, Guatemala, Mexico, and Peru. More than 8 million indigenous people have problems with domestic access to safe water, making frequent hand washing impossible in these five countries. Rosenthal (2020) reports for Human Rights Watch that the greater vulner­ ability of indigenous people is evident in all but Colombia, where half of the indigenous population does not have running water. Although the pandemic has been slower to spread to rural areas, the precarious living conditions and health care in these areas are a focus of concern. According to a report on the impact of the COVID-19 in the Americas, The Congressional Research Service (2022) indicates that pandemic is affecting the economies of Latin America and the Caribbean through external and domestic factors whose combined impact will lead to the most severe contraction that the region has experienced. Meneses-Navarro et al. have found Against the socio-psychological backdrop, the risk of indig­ enous people being overlooked both in pandemic mitigation efforts and the post-COVID-19 recovery process, particularly indigenous women, chil­ dren, and older persons, is growing exponentially, that include: (i) mistrust about the existence of the pandemic; (ii) disinformation and rumors about the origin of COVID-19; (iii) limited access to water; and (iv) widespread unemployment. Gutierrez, Martin & Nopo (2020) the challenges of COVID-19 for women and Latin America (2020), they found that as the pandemic progressed in Latin America, many voices were raised to address the emerging needs of the indigenous population. Among the many recommendations made were: (i) ensuring the availability of and access to culturally appropriate medical services, including access without discrimination to medical testing, emergency, and critical care, and providing self-care supplies and personal protective equipment to indigenous people. (ii) During the pandemic, more­ over, access to health services must be ensured in all areas, including mental health and sexual and reproductive health. (iii) Ensure a transformative gender approach to address the challenges that impact indigenous livelihood and ways of life. And (iv) create awareness and respond to the effects of the psychosocial crisis created by COVID-19. 6.2 IDENTIFICATION OF NEEDS THROUGH FOCUSED GROUPS Prewitt Diaz and Trejo Rodriguez had the opportunity to participate in community consultations with the native populations in Bolivia, Brazil,

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Colombia, Ecuador, Guatemala, and Peru. All of the respondents were members of indigenous groups, reinforced the need for primary care in their localities; most of the prevention fell on the shoulder of the Health Commu­ nity Promoter and midwives, who have been the closest to women and young children during the pandemic. The potential solution in fighting the impact of COVID was to provide health care practices that are community-planned and respect social, spiritual, and cultural aspects. Other concerns raised due to the COVID restrictions included food inse­ curity, water, and sanitation, economic difficulty resulting from not being able to work, lack of information and difficulty with social distancing since most people live near each other. These risks and impacts combined with pre-existing health conditions and psychosocial factors have increased the population’s vulnerability. COVID-19 has disrupted routines, generated feelings of insecurity over the effect of the virus and the impact of getting sick or making others sick. It has also impacted the living condition of many because of the physical distancing, and finally, many are feeling the impact of financial resources to provide for their families. Women and girls have been disproportionately burdened with multiple caregiving burdens, gender-based violence (GBV), and economic vulnerabilities. There are reports of mental health incidence that mainly affect indigenous youth, such as high rates of suicide recorded in the region. One potential intervention is to foster resilience utilizing cultural strengths. Overall, the participants supported community clinics where medical approaches (allopathic medicine) are practiced in conjunction with indig­ enous medicine, and the health staff is composed of indigenous clinical staff. There is a need to use traditional medicinal plants with preventive efforts, such as vaccination. Some psychosocial concerns included the value of indigenous lifestyles and the interaction with the natural environment, concerns for the loss of the elder and their collective wisdom, and high levels of self-medication and suicide amongst the youth. The indigenous people are the most vulnerable population in Latin America. They would benefit from a cultural, linguistic, and contextual approach psychosocial support program that embraces the principles of protection and human rights standards. Of concern to this writer were the stories of abuse of girls and young women and boys. We advocate for a psychosocial support program that works in tandem with traditional healers, midwives, and community health workers (CHWs) to improve the holistic well-being of this population during and post COVID-19.

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The importance of CE was present in all groups. Consultation, participa­ tion, and listening to the strategies and viewpoints of the community facili­ tated actions that would result in positive interactions in accepting a health/ mental health program that would lead to positive outcomes. In addition to the importance of elders and traditional healers, the groups supported other groups that influenced their communities, such as community networks and faith-based organizations. The question we raised was what are the factors that impact psychosocial well-being for your people. The findings from the focused groups can be divided into two areas of interest: (i) the psychological factors that affect the indigenous people are stigma, isolation, and loneliness; (ii) the social factors included community life, loss of income, lack of information, lockdown, or social exclusion. The factors that fostered resilience among the interviewees were positive thinking, spirituality, family support, and community support. The two Red Crossers that conducted these groups concluded that a person may have poor psychosocial adjustment as a result of the pandemic, become more resilient and experience improved mental health and psychosocial support, and in turn become a resource person for families belonging to their respective Indian group/nation. 6.3 VULNERABILITY OF INDIGENOUS PEOPLE Three elements put the indigenous people at risk of being affected by the pandemic: lack of clean water, poor sanitation, and overcrowding. The ECLAC (2021) Report indicates that the socio-cultural problems faced today and highlighted by the COVID-19 pandemic are the results of deep-rooted culture and may also be associated with reduced access by indigenous women and girls related education and sexual and reproductive health. This condition becomes a risk factor when dealing with the pandemic in contexts shaped by State policies specific to indigenous people that are makeshift, non-existent, or insensitive to the particular habitation patterns of their cultures. 6.3.1 VILLAGES AND FOREST AREAS Indigenous people continue to lead a rural way of life in villages in their ancestral territories. Since the coverage of formal social protection systems is very limited and not very relevant to indigenous people’s cultural and

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geographical specificities, they have developed their own community-based social protection mechanisms to address economic and social vulnerabilities. The pandemic has demonstrated the importance of community-based social protection mechanisms in addressing the needs of indigenous people, which has been done with some success. Balvedi Pimentel and Cabrera Ormaza (2020) explored the impact of COVID 19 on indigenous communities in Latin America. Among the find­ ings they addressed the limited access to markets and small stores during the pandemic that resulted in limited access to information and healthcare services in forest areas, making indigenous people particularly vulnerable. Often, mobility restrictions have made it impossible for them to sell their products and buy food, which in some cases has led to critical situations of food insecurity. Paralysis in the construction sector and the disappearance of tourism in these areas due to the pandemic have tremendously affected sales of forest products and tourism services. Indigenous people in voluntary isolation and a phase of initial contact are also a priority group in the context of rural areas, as they are in a particularly vulnerable situation. It is estimated that there are some 200 such groups, most of them in the Amazon and the Gran Chaco of Paraguay. Reduced public monitoring efforts in their territo­ ries leave them exposed to external threats from illegal miners and loggers since their immune systems have had no prior contact with coronavirus, and they have no access to any Western medical services. Therefore, this popula­ tion would benefit from health monitoring to prevent external access to their lands. 6.3.2 INDIGENOUS GIRLS AND WOMEN Bah et al. (2020) report that being born an indigenous woman or girl can be a life sentence of poverty, exclusion, and discrimination, largely rooted in historical circumstances of marginalization. Personal and situational circum­ stances of sex, race, ethnicity, disability, and location often place indigenous women and girls on the brink. Samuel et al. (2020) studied social inclusion and universal health in the Americas and concluded that when one or more of the factors overlap as is often the case the risk of social exclusion and marginalization is not only perpetuated but also acquires an enduring quality that can span over a lifetime and across generations. The pandemic is playing out in the context of widespread crisis. For indigenous girls and women, it goes beyond a health problem; it is a systemic

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structural, economic, migration, climate, and food crisis and one of science. COVID-19 was caused not only by physical and biological factors but also by social, psychological, and spiritual factors, so addressing the impact of the pandemic in girls’ women in indigenous communities requires a holistic view and approach. 6.3.3 INDIGENOUS CHILDREN, ADOLESCENTS, AND YOUTH In many countries in the region, indigenous children are in a situation of high vulnerability. The Pan-American Health Organization (PAHO, 2017) determined that special measures should be taken, in consultation and cooperation with indigenous people, to protect indigenous children from economic exploitation and work that is likely to be hazardous to their health or physical, mental, and spiritual development. During COVID-19, indigenous people are in greater deprivation, espe­ cially those living in traditional territories. In the particular case of indigenous girls and adolescents, the burden of domestic labor and care work assumed during the pandemic may affect their educational performance. Similarly, indigenous children, adolescents, and youth may also face differentiated obstacles in this area, as they must assume a more important role in the subsistence activities of traditional indigenous economies. There is a critical issue for adolescents and youth during the pandemic. For example, limited or no access to the internet; the increase for girls and young women of domestic labors and care work since the beginning of the pandemic lockdown measures; and reports of increased GBV and overreliance of indigenous youth in key roles in their communities fighting the pandemic. 6.3.4 INDIGENOUS PEOPLE IN BORDER AREAS Silva et al. (2021) studied the indigenous population of Brazil and hypoth­ esized that indigenous people are living in the border areas in in Colombia, Bolivia, and Peru. They found that this population lived in a situation of special vulnerability about their right to the territory since the politicaladministrative boundaries of the countries do not correspond to their ances­ tral territories. Silva et al. (2021) further reported that in addition, they are commonly affected by the presence of military and armed conflicts.

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Herbetta et al. (2021) studied the advance of the COVID-19 in Brazil and reported that existing vulnerabilities require the adoption of specific and harmonized legal and administrative frameworks between countries, which allow the free movement of these people, and guarantee their collective rights. For example, their right to use traditional natural resources (food and medicinal) needs to be guaranteed regardless of whether they lie on one side or the other of the current administrative boundaries. The pandemic also aggravates the dramatic situation of indigenous people who, because of their demographic fragility, territorial vulnerability factors, already faced a real risk of disappearance. Psychosocial interventions to mitigate the COVID-19. 6.4 THE ROLE OF TERRITORIALITY AND BORDERS Territorially and borders, in the context of Latin America considers existing geopolitical boundaries established by governments, and psychosocial boundaries established centuries ago that intertwines the cultural memory of the indigenous people (Barabas, 2006). This uncovers a challenge for external assistance from international agencies due to the fact that national territories, as identified by political treaties of the recent past 200 years, do not consider the ethnoterritories of indigenous people and therefore have not developed a road map to necessary serves needed to address pandemic, such as COVID-19. As a result of the discrepancy and understanding of the Government and Indigenous people has been detrimental in managing the health response to the pandemic. Below please find a brief description of how the target States have managed the pandemic response and the well­ being of the Indigenous people. 6.4.1 BOLIVIA According to the World Population Review (2021), Bolivia’ Amerindians indigenous population comprises about 55% of the total population. The four main groups are the Quechuas, Aymara’s, Chiquitano and the Guarani. Vargas Delgado (2020) addressed in his article the needs of indigenous people in Bolivia by pointing out that: (i) the Government didn’t take into the specific vulnerabilities of this population and making them leave their safe spaces to obtain the food rations, upon their return back to their lands they were carriers of COVID; (ii) soldiers and government agents that visited the Indigenous land became carriers of the pandemic, thus infecting the inhabit­ ants, without providing them the necessary tools to fight the pandemic.

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The COVID-19 pandemic has had a considerable impact on the psycho­ logical and social level of the population in Bolivia. The negative impact was greater in some population groups such as women, young people, indig­ enous population and those with a lower socioeconomic level, which may further increase inequities. The Health Ministry of Bolivia (2020) reported that during the quarantine, a series of communication handout, trifolds, and posters, were developed in native languages such as Quechua, Aymara, and Guarani. The Ministry of Health focused its efforts in producing materials: measures of prevention of COVID-19 focusing on: (i) the mental health of adolescents; and (ii) the skills of parents and children to better deal with confinement. Santa Cruz, located in the east of Bolivia, is one of the departments most affected by COVID-19 in the country. But that situation did not prevent the staff of the Departmental Mental Health Program from providing community psychological and psychiatric care, with emotional accompaniment through: (i) a call center; (ii) making home visits in the neighborhoods furthest from the capital, or in the rural municipalities adjacent to the big city. A call center allows us to attend to people, in the majority, actively listening to women and men, of all ages, who are going through anxiety and/ or depression because the pandemic impacted them: they have lost a family member, they are infected and afraid, or desperate because they do not have a job. However, not many members of the indigenous group members have access to phones or television, so the reported efforts by Government didn’t really address the COVID-19 health needs of a great number of indigenous people. Santa Cruz’s intervention strategy to address the mental health of its population affected by COVID-19 is comprehensive and community-based. The Departmental Health Service (SEDES), through its mental health program, applies face-to-face health care from the first level of care to the population that goes through more severe symptoms, reaching them at home, from a humanitarian intervention that helps overcome the gaps in mental health (mhGAP). The Pan American Health Organization prepared materials in Spanish and provided training to Bolivian professionals in mental health and psycho­ social support interventions in the community. They were provided guidance and psychoeducation during the COVID-19 pandemic, to help support the mental and general well-being of all people, especially those who might need additional support during these difficult times.

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The head of the Mental Health and Psychosocial support program, Iracema Justiniano reported that “participating in the mental health and psychosocial support program would encourage the participants to manage and prevent the repercussions of COVID-19 on emotional well-being from becoming chronic or pathological, and to prevent pre-existing mental health problems from worsening in the population that does not have access to specialized services” (Interview conducted by Prewitt Diaz, April 22, 2020). A recent study on the impact of COVID-19 in Bolivia (Indigenous Bolivians, Oct. 9, 2020) suggested that: (i) the overall emotional state of the participants in this interview is positive, as a result of compliance with the biosecurity measures provided by global organizations, and the Bolivian government; and (ii) psychosocial aspects have affected the emotional state negatively, such as the reduction in income, health problems, the expectation of future income and above all, death of a family member. The devastating effect of the loss of income by families, or the emotional impact in extreme case death of a member of the family or social group, are the aspects that have generated the greatest emotional mismatch. In summary, the pandemic itself has had a moderate effect on the emotional state of people, although there are factors, such as the losses of a family member, jobs or the reduction of income. These factors can be addressed through Community Mental Health Centers, and referral to hospitals as needed, and the organization of community resources to address economic needs in the affected households. In support of the indigenous population well-being the following activi­ ties went into effect six months after the Government announced National measures to control the pandemic: (i) increase epidemiological vigilance; (ii) improve health clinics in the target areas and disseminated relevant information about prevention in the native language of the indigenous population. Vargas Delgado (2020) in his article entitled “Entre el abandono y el Etno­ cidio: Pueblos indígenas y COVID-19 en Bolivia” has questioned whether the Government efforts have been sufficient to provide an integral health response to COVID-19 in the indigenous territories. According to Kaplan Benjamin, Trumble et al. (2020). These community-based actions involving the indigenous people has been acknowledged as a culturally appropriate measure. However, the Government has no plan after these interventions to support the health and wellbeing of the indigenous communities (Interview # 37—Bolivia – July 2, 2002, by Prewitt Diaz).

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According to the Travel Service Support (2022) the Indigenous people and minority Afro-Colombians. There are more than 8,00,000 indigenous people in Colombia, the largest groups of which include the Wayuu, the Paez, the Pastos, the Zenu and the Embera. There are 68 languages and dialects spoken in Colombia, but the official and most common language is Spanish. More than 99.2% of the people of Colombia speak Spanish. There are no specific strategies in mental health and psychosocial support proposed by any government agencies; however, we can highlight some peripheral efforts for this chapter. PAHO (2021) reported that in Colombia, the Ministry of Health and Social Protection, considering socio-cultural vulnerabilities, developed a clinical protocol that mandates adequacy of communication to ensure access to the indigenous population. The guidelines did not consider the cultural nuances of the management of dead bodies. The Ministry of Culture translated the measures to prevent infection in several local languages. There were unaddressed reactions from the indigenous people on the rules suspending in-person activities and proceedings, as well as mandatory preventive isolation. 6.4.3 COSTA RICA The Ministry of Health established technical guidelines that promoted people’s engagement in developing a community plan to promote informa­ tion and radio messages. Home visits and focused preventive education visits. The Indigenous World (2021) reported that in Costa Rica, based on four lines of action: (i) community participation, which made it possible to set up emergency committees in each indigenous territory; (ii) production of audiovisual and printed material in indigenous languages (Cabecar, Bribri, Ngabe, and Maleku); (iii) provision of humanitarian aid consisting of food and hygiene kits; and (iv) post-COVID-19 recovery, aimed at defining with local participation a comprehensive recovery plan for indigenous territories, with special attention to people and communities that have been granted precautionary measures by the IACHR due to the persistent violence resulting from the lack of guarantees for territorial rights (Teribe and Bribri indigenous people, p. 361).

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6.4.4 ECUADOR

The government developed a plan for health promotion and risk commu­ nication addressing the COVID-19 Pandemic among indigenous, Afrodescendant, and Montubio people and nationalities, which is currently being implemented and which promotes culturally appropriate practices for prevention, detection, and containment of the public health emergency. The initiatives developed a series of radio spots and booklets in indigenous languages. 6.4.5 GUATEMALA The Ministry of Health published a socio-cultural guide for prevention, containment, and management of COVID-19 cases at the community level for the Indigenous communities. It includes a set of integrated and continuous actions aimed at promoting changes in the behavior, attitudes, and mental patterns of the institutional staff of the official health system; in addition, the services will be aimed at promoting changes to respond to the culture of indigenous people. It develops the recognition, respect, and understanding of the socio-cultural differences of the indigenous people, their knowledge, and therapeutic elements in improving the population’s health. 6.4.6 MEXICO The National Institute of Indigenous People (INPI) developed an assis­ tance guide for indigenous and Afro-Mexican people and communities in the health emergency caused by COVID-19 in 51 versions to cater to the different indigenous languages spoken in the country. In addition, the Government has made available audiovisual materials in those languages containing information on preventing COVID-19 infection. In cooperation with PAHO, the Government also carries out information campaigns in indigenous languages via the 22 Indigenous Cultural Radio Network (SRCI) operated by INPI. In spite of the reported efforts of the Government, the Indigenous commu­ nities have faced many challenges. Cohen (2020) suggest several reason for the insufficient assistance of the Government during COVID-19 to the indigenous people: (i) the assistance from the concerned government agen­ cies have been limited or non-existent; (ii) the financial support, generated

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by external jobs has been non-existent as a result of government restrictions; and (iii) enhanced feelings of isolation. Camas (2020) have suggested that closing the borders of the Indigenous community in order of preventing outsiders from expanding the COVID-19 virus, has re-awakened self-sufficiency by increasing the production of internal agricultural products, and community-level labor projects. According to CDHMCM (2020), these actions have increased the communities’ resil­ ience. The downside has been the reduction of access for indigenous women to jobs, and medical care for women. 6.4.7 PERU Established measures for the protection of indigenous people in during COVID-19. The four action steps of the plan were: (i) guarantee compli­ ance with linguistic rights; (ii) promote the provision of public services in mother tongues, with particular emphasis on the indigenous or aboriginal population; (iii) ensure mechanisms for coordination with public entities that provide services to the indigenous or aboriginal population, based on criteria of appropriateness, cultural and gender appropriateness, timeliness, efficiency, and quality; and (iv) safeguard the life, health and integrity of indigenous or aboriginal people, paying special attention to those people in isolation. 6.5 INDIGENOUS PEOPLE’S RESPONSE Indigenous population in Latin America have suffered, as in past health crisis’s, as a result of previous pre-existing factors: (i) lack of representation in the Central government structures; (ii) isolation and poverty; and (iii) lack of adequate facilities and community health that considers cultural and religious believes, and is inclusive of traditional medicine and local healers (Rieger, 2021). In general, these initiatives involve the implementation of information and awareness campaigns on prevention of the virus; adoption of containment and mitigation measures such as health cordons, prohibition of access to communities, surveillance, community supervision, the estab­ lishment of protocols on movement, and isolation; use and promotion of traditional medicine; and adoption of measures to ensure food security. Many indigenous people decided to restrict or close the borders of their territories as one of the main measures to prevent transmission of the virus,

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particularly those groups that had already adopted similar measures during past epidemics. For indigenous communities, particularly those belonging to people with a small population, preventing the virus from spreading to their territory is a matter of life and death, not only for individuals but for people as a whole. Therefore, the closure of territorial borders is an extreme measure to avoid dramatic consequences, such as those that have already occurred in the past with other diseases. Such measures have been taken in all the region’s countries. In Ecuador, the Governing Council of the Kichwa Aboriginal People of Sarayaku arranged for groups of people from each of the seven communities to collect 30 medicinal plants and make a collection center to ensure the supply of these therapeutic resources for all of them. In Chile, the Mapu Express Mapuche Communication Collective launched a digital platform called Coronavirus mapping in Wallmapu, whose objective is to record and monitor the effects of the COVID-19 pandemic on families, communities, and natural ecosystems in Mapuche territories. This initiative aims to record the various actions taken by Mapuche communities to address the pandemic, as well as the threats experienced in the context of the health emergency in indigenous territories. The three pillars are: 1. Territorial Control: Actions and statements by the Mapuche communities of Wallmapu that strengthen or weaken territorial control in political, economic, health or cultural terms. 2. Spiritual Protection: Acts or statements by Mapuche communities concerning Mapuche spiritual practices or having regard to actions that help to confront, understand, and live through this pandemic (ceremonies, greetings, reflections). Includes: positive or negative effects on the spiritual values and practices of communities, fami­ lies, and individuals. 3. Ancestral Medicinal Heritage: Situations in which Mapuche communities, the State health network, organizations, families or individuals have used, defended, shared or disseminated traditional Mapuche medicinal practices and knowledge. In Honduras, with the support of the United Nations Population Fund (UNFPA) and PAHO, indigenous organizations were able to translate information on disease prevention into the Garifuna language, as well as Mosquito, Tawahka, and Chorti. Health workers and local radio stations use those materials to promote safe behavior.

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Indigenous communication networks and community radio stations have played a very important role in that regard in Brazil, Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Mexico, and Nicaragua, providing infor­ mation on self-care, government measures and local cases of COVID-19, as well as contributing to the organization of community responses to the crisis. 6.6 A PROPOSAL FOR COMMUNITY ENGAGEMENT (CE) WITH INDIGENOUS The United Nations (UN), World Health Organization (WHO), and other Humanitarian agencies acknowledge the harmful effect of COVID-19 and encourage community-based interventions to help the affected people cope with the stress and distress of the pandemic. The three recommendations; proposed by the United Nations 13 May 2020) in there Policy brief related to COVID-19 and its need for action in mental health proposed: (i) apply a whole-of-society approach to promote, protect, and care for mental health; (ii) ensure widespread availability of emergency mental health and psycho­ social support; and (iii) support recovery by building mental health services for the future (p. 3). The WHO (2021) proposed that to successfully integrate a personcentered, recovery-oriented, and rights-based approach in mental health; countries must change and broaden mindsets, address stigmatizing attitudes, and eliminate coercive practices (p. 22). In June 2021, they unveiled a series of steps, including community-based approaches to providing mental health and psychosocial support to the most vulnerable. The suggestions and examples are important because WHO is looking at the best way to reach out to the most vulnerable. One suggestion is espe­ cially important for this chapter. Mental health care begins in the home. Therefore, we must build structures to support the whole population, including the indigenous people. As part of the efforts, WHO and others develop guidance around MHPSS and propose a matrix of interventions to indigenous people. Figure 6.1 utilizes the IASC-MHPSS to develop a process whereby humanitarian organizations can address the psychoso­ cial support needs indigenous population. Based on the focused group interviews and reviews of activities in selected countries, we were able to learn that the indigenous people have begun to address their psychosocial needs by coordinating with the Ministries of Health in several countries, provided timely information through radio spots in several languages,

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initiated community mobilization, and identified human recourses (i.e., traditional healers, midwives, and elders).

FIGURE 6.1 A suggested structure for developing a humanitarian program by external humanitarian agencies following the guidance of MHPSS (IASC, 2007) and SPHERE Handbook (2018).

We propose that to initiate core mental health and psychosocial support, we activate the activities proposed above. We should be able to initiate interaction activities with the indigenous communities by conducting home visits, having group discussions, seeking information from key informants, interacting in community activities, and observing community dynamics. There are three key activities: develop a community committee, conduct a community mapping exercise, and mobilize all community segments. The process assures the participation of the community in determining their psychosocial needs, identifying potential interventions, such as Economic development projects, and determining how they will evaluate their success. Some actions steps include the dissemination of information to the total community. At the end of this phase, the indigenous communities will be able to plan, design, and implement a project, will ensure wide participation (everyone has a voice), coordinate with local authorities, and ensure funds from external sources, and finally achieve community ownership of their process and projects. International Federation of the Red Cross (IFRC) and Red Crescent personnel on the ground, have reported that COVID-19 has highlighted the

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increased need for mental health and psychosocial support for indigenous people in Latin America. The report continues to suggest the importance of working closely with the most vulnerable to understand their needs and find the most relevant and sustainable solutions and increase the invest­ ment of promoting good psychosocial health and address mental health problems generated by GBV, use and abuse of children and adolescents, and a sense of powerlessness and invisibility of the indigenous commu­ nities, by using activities related to Protection Gender and Inclusion activities. 6.7 SUMMARY This chapter identified psychosocial support needs within the indigenous communities in Latin America. Focused groups elicited information from indigenous people in six countries via interviews and literature reviews. A suggested schematic introduces the process of CE (assessment, planning, development, and evaluation). Furthermore, we suggest that Humanitarian organizations have a great responsibility to alleviate suffering amongst the most vulnerable. The indigenous population in the Americas comprise that segment of the population. It is that South American governments initiate appropriate MHPSS services it is recommended that: (i) countries must provide adequate resources for mental health and psychosocial support for indigenous populations; (ii) capacity building that includes consultation with indig­ enous communities and are inclusive of culture and context to meet the increased demand for MHPSS is recommended; (iii) recruitment of Nonspecialized health workers, including primary care providers, that can play an important role in delivering MHPSS in the indigenous communities, given the limited human resources; and (iv) use of telehealth strategies in local languages that may reach a larger portions of the affected indigenous population. Finally, In ensuring access to MHPSS for all during the pan-demic, countries must reach populations shown to be in greater need of mental health support, including but not limited to frontline and healthcare workers, children, and adolescents, women, people with pre-existing mental health conditions, racial, and ethnic minorities, and indigenous people as recom­ mended by Tausch et al. (2021).

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KEYWORDS

• • • • • •

COVID-19 National Institute of Indigenous People Pan-American Health Organization socio-economic united nations population fund World Health Organization

REFERENCES “Indigenous Bolivians Pray to Pachamama to End Pandemic” DW. https://www.dw.com/en/ indigenous Bolivians-pray-to-Pachamama-to-end-pandemic/av-54884160 (accessed on 27 October 2022). Baah, F. O., Teitelman, A. M., & Riegel, B., (2019). Marginalization: Conceptualizing patient vulnerabilities in the framework of social determinants of health-An integrative review. Nursing Inquiry, 26(1), e12268. https://doi.org/10.1111/nin.12268. Balvedi, P. G., & Cabrera, O. M. V., (2020). The Impact of COVID-19 on Indigenous Communities: Insights from the Indigenous Navigator. The International Work Group for Indigenous Affairs (IWGIA) and the International Labor Organization (ILO). ISBN: 978-87-93961-12-8. Barabas, A. M., (2006). Gifts, owners and saints: Essays on religions in Oaxaca. Mexico. Social Anthropology Notebooks, 26, 209–212. xmlui.dri2xhtml.METS-1.0.item-dc-subject: Reseña de Libros. Beltrami, S., (2020). Coronavirus Exacerbates Indigenous People Vulnerabilities. World Food Program. https://www.wfp.org/stories/coronavirus-exacerbates-indigenous-peopleshistoric-vulnerabilities (accessed on 27 October 2022). Busso, M., & Messina, J., (2020). The Inequality Crisis: Latin America and the Caribbean at the Crossroads. Washington, DC. Interamerican Development Bank. Camas, F., (2020). Zapatistas Sanction Those Who Enter Caracoles Without Authorization. 3 minutes reports. https://3minutosinforma.com/zapatistas-sancionaran-a-quienes-ingresensin-autorizacion-a-caracoles/ (accessed on 27 October 2022). Cohen, J. H., (2020). Indigenous Mexicans retreat to survive COVID-19 by isolating towns and producing food. The Conservation. Congressional Research Service, (2022). Latin America and the Caribbean: Impact of COVID-19. https://sgp.fas.org/crs/row/IF11581.pdf (accessed on 27 October 2022). Disasters Newsletter N.131. Strengthening the mental health response and psychosocial support in the COVID-19 pandemic. Washington, DC: Pan American Health Organization. https://www.paho.org/en/disasters-newsletter-n131-strengthening-mental-health-responseand-psychosocial-support-covid-19 (accessed on 27 October 2022).

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Economic Commission for Latin America and the Caribbean (ECLAC) and others, “The impact of COVID-19 on indigenous peoples in Latin America (Abya Yala): Between invisibility and collective resistance,” Project Documents (LC/TS.2020/171), Santiago, Economic Commission for Latin America and the Caribbean (ECLAC), 2021. Fuentes, A., (2017). Protection of indigenous peoples’ traditional lands and exploitation of natural resources: The inter-American court of human rights ‘safeguards. International Journal on Minority and Group Rights, 24(3), 229–253. https://www.jstor.org/ stable/26557865 (accessed on 27 October 2022). Gonzalez, M. B., Aronson, B. D., Kellar, S., Walls, M. L., & Greenfield, B. L., (2017). Language as a facilitator of cultural connection. Ab-Original: Journal of Indigenous Studies and First Nations’ and First Peoples’ Culture, 1(2), 176–194. https://doi.org/10.5325/ aboriginal.1.2.0176. Gutierrez, D., Martin, G., & Nopo, H., (2020). The Coronavirus and the Challenges for Women’s Work in Latin América. New York. UNDP Latin America and the Caribbean. UNDP LACX PDS No. 18. Herbetta, A., Pocuhto, T., Pimentel Da, S. Md. S., & Guajajara, C., (2021). Urgent considerations on the relationship between the advance of COVID-19 in indigenous territories in Brazil and the impacts of monoepistemic public policies. Front. Sociol., 6, 623656. doi: 10.3389/fsoc.2021.623656. Indigenous Peoples and COVID-19, (2020). A Guidance Note for the UN System Prepared by the UN Inter-Agency Support Group on Indigenous Issues. https://www.un.org/ development/desa/indigenouspeoples/wp-content/uploads/sites/19/2020/04/Indigenouspeoples-and-COVID_IASG_23.04.2020-EN.pdf (accessed on 27 October 2022). Inter-Agency Standing Committee (IASC), (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: IASC. Kaplan, H. S., Trumble, B. C., Stieglitz, J., Mamany, R. M., Cayuba, M. G., Moye, L. M., Alami, S., et al., (2020). Voluntary collective isolation as a best response to COVID-19 for indigenous populations? A case study and protocol from the Bolivian amazon. Lancet, 395(10238), 1727–1734. doi: 10.1016/S0140-6736(20)31104-1. Epub.: 2020 May 15. PMID: 32422124. Mamo, D., (2021). The Indigenous World 2021 (35th edn.). The International World Book in Indigenous Affairs (IWGIA). Meneses-Navarro, S., Freyermuth-Enciso, M. G., Pelcastre-Villafuerte, B. E., et al., (2020). The challenges facing indigenous communities in Latin America as they confront the COVID-19 pandemic. Int. J. Equity Health, 19, 63 https://doi.org/10.1186/s12939-020-01178-4. OECD, (2020). The Territorial Impact of COVID-19: Managing the Crisis Across Levels of Government: Contributing to a Global Effort. https://www.oecd.org/coronavirus/ policy-responses/the-territorial-impact-of-covid-19-managing-the-crisis-across-levels-ofgovernment-d3e314e1/ (accessed on 27 October 2022). PAHO, (2021). Protecting the Health of Indigenous Peoples from COVID-19 in the Americas. Washington, D.C. Pan American Health Organization, (2017). Health Plan for Indigenous Youth in Latin America and The Caribbean. Washington, D.C. Pan American Health Organization. Republic of Bolivia, (2021). Ministry of Health and Sport. https://www.minsalud.gob.bo (accessed on 27 October 2022).

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Rieger, I. A., (2021). COVID 19 and indigenous communities in Latin America: A comparative analysis of state public policy strategy in Mexico, Bolivia, and Colombia. Journal of Social Studies, 78, 36–55. Rosenthal, H., (2020). People of Resilience: Columbia Wayuu indigenous population. Human Rights Watch. https://www.hrw.org/video-photos/interactive/2020/08/13/people-resiliencecolombias-wayuu-indigenous-community (accessed on 27 October 2022). Samuel, J., Flores, W., & Frisancho, A., (2020). Social exclusion and universal health coverage: Health care rights and citizen-led accountability in Guatemala and Peru. Int. J. Equity Health, 19, 216. https://doi.org/10.1186/s12939-020-01308-y. Silva, L. L., Nascimento, P. E., Araújo, O. C. G., & Pereira, T. M. G., (2021). The articulation of the indigenous peoples of Brazil in facing the COVID- 19 pandemic. Front. Sociol., 6, 611336. doi: 10.3389/fsoc.2021.611336. Singleton, K., & Krause, E., (2009). Understanding cultural and linguistic barriers to health literacy. OJIN: The Online Journal of Issues in Nursing, 14(3), Manuscript 4. doi: 10.3912/ OJIN.Vol14No03Man04. Sphere Association, (2018). The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response (4th edn., pp. 374–379). Geneva. Tausch, A., et al., (2022). Strengthening mental health responses to COVID-19 in the Americas: A health policy analysis and recommendations. The Lancet Regional HealthAmericas, 5, 100118. doi: https://doi.org/10.1016/j.lana.2021.100118. Tigre, M. A., (2021). COVID-19 and Amazonia: Rights-based approaches for the pandemic response. Review of European, Comparative and International Environmental Law, 10.1111/reel.12396. Advance online publication. https://doi.org/10.1111/reel.12396. Travel Service Support, (2021). The Population in Colombia. https://travelservicesupport. com/colombia-population/ (accessed on 27 October 2022). UNICEF: Bolivia, (2020). Situational Report No. 2. https://www.unicef.org/media/85446/ file/Bolivia-COVID-19-SitRep-No.2-Oct-2020.pdf (accessed on 27 October 2022). United Nations, (2020). COVID-19 and the Need for Action in Mental Health: Recommended Action. New York. https://unsdg.un.org/sites/default/files/2020-05/UN-Policy-BriefCOVID-19-and-mental-health.pdf (accessed on 27 October 2022). Vargas, D. M., (2020). En tre el Abandono y el Etnocidio: Pueblos INDIGENAS y COVID-19 en Bolivia. https://www.iwgia.org/es/noticias-alerta/noticias-covid-19/3799debatesindigenas-abandono-etnocidio.html (accessed on 27 October 2022). Vargas, D. M., (2020). Entre el Abandono t el Etnocidio: Pueblos Indígenas y COVID-19 en Bolivia. https://www.debatesindigenas.org/notas/55-abandono-etnocidio.html (accessed on 27 October 2022). World Population Review, (2021). Bolivia Population 2022 Live. https://worldpopulationreview. com/countries/bolivia-population (accessed on 27 October 2022).

CHAPTER 7

Psychological Support Migration Appeal to the International Federation of the Red Cross and Red Crescent in the Americas Region LINDA SAN MARCOS

COVID-19 Recovery Program, International Federation of Red Cross and Red Crescent, Americas Region, Panama, C.A.

ABSTRACT This chapter mainly describes the development and response of the IFRC in the Americas in terms of MHPSS in migration as well as the response to the COVID-19 pandemic. The chapter is divided into seven sections. The first section gives an introduction to this chapter. The following two sections present the context of overall migration in the region and the way the move­ ment of the Red Cross in the Americas employed MHPSS to assist the migrant population. The fourth section describes the psychosocial response of the movement against COVID-19 during the emergency and recovery phases. The fifth section presents the challenges facing the need for assis­ tance and inclusion of migrants. The sixth and seventh sections are based on the lessons learned and the recommendations for future interventions in migration, respectively. 7.1 INTRODUCTION Migration has been part of humanity throughout history and is currently an increasing phenomenon that is in continual transformation. This is due to Mental Health and Psychosocial Support during the COVID-19 Response: An Overview. Joseph O. Prewitt Diaz (Ed.) © 2023 Apple Academic Press, Inc. Co-published with CRC Press (Taylor & Francis)

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economic, social, and cultural factors, which led us to consider how to address the needs of these migrants, especially their psychosocial needs. When it comes to providing care for people, the importance of including and addressing mental health and psychosocial support (MHPSS) in migration is evident. The International Federation of National Red Cross and Red Crescent Societies (IFRC) in the Americas had a quick response in adapting and including more precise and structured MHPSS interventions in response to migration and other factors such as the COVID-19 pandemic, which directly affected the region and migrants. Highlighting the areas of great importance and crucial elements in assisting migrants, this chapter presents and analyzes the imme­ diate response and adaptations according to the characteristics of each context. 7.2 MIGRATION AND MHPSS 7.2.1 MIGRATION IN THE AMERICAS Migration in the Americas consists of various flows, and the number of migrants has shown dramatic and progressive growth. In Venezuela, an estimated 5.5 million migrants and refugees have settled or are currently headed to other places in the world. The number of Venezuelans living in the countries of Latin America increased from 4 million in early 2020 to 4.6 million in October of the same year. These numbers are accompanied by a significant migrant population not only from the Caribbean and the Pacific, but also from Asia and Africa. While some settle permanently in Central and South American, others choose to travel north, crossing from Colombia to Panama through the Darién Gap on their way to North America. Migration from the south of the continent to the United States impacts countries from Central America and Mexico, unfortunately. With these massive displacements of people, a whole series of problematic events affect the condition of migrants: violence, drug trafficking, human trafficking, disappearances, and violations of human rights. According to the most recent report of the International Organization for Migration (IOM, 2019–2020), the following information is evident regarding the situation in South America, Central America, and the Caribbean. 7.2.1.1 SOUTH AMERICA Intra-regional migration is between nations recognized as part of the same space that share similarities, such as historical, cultural, and political

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parallels. Outside this area recognized as a region, the migratory movement is considered extra-regional (Cortez, 2016). Intra-regional migration is very important in South America, where the vast majority of international migrants move within the subregion. Most of the migrants who are in countries like Argentina (as countries with the highest international migration figures in South America in 2019) come from the same subregion. International migrants from Argentina were mainly from Paraguay, Bolivia, and Chile, while those from the Bolivarian Republic of Venezuela came mostly from Colombia. The foreign-born population residing in Chile is also mainly made up of migrants from South American countries such as Peru, Argentina, and the Plurinational State of Bolivia. In addition, due to conflicts and violence, the number of Venezuelans living abroad has increased, the vast majority to Latin American and Caribbean countries; this has become one of the main displacement crises in the world (IOM, 2019, p. 108). Emigration from South America is mostly related to work, and due to the economic and political crises in the countries of origin. The United States of America is the main destination country for South American migrants, with 3.4 million migrants. In addition to this, in some countries, conflict and violence are the main factors that contribute to migration. 7.2.1.2 CENTRAL AMERICA AND THE CARIBBEAN Northward migration continues to be the predominant trend in Central America, Mexico, and the Caribbean. It continues to be an important country of origin, with thousands of migrants making their way primarily to the United States every year. It is also a major transit country for migrants trav­ eling north to the southern border of the United States. Mexico is becoming a country of destination due to the restriction conditions at the borders of the USA (IOM, 2019, p. 110). The countries of the Central American region, with the exception of Panama, are characterized as having, for the most part, intra-regional immigrants. Currently, all the countries in the region operate as the origin, transit, and destination of migrants (Cortez, 2016). The main intra-regional migration corridors are those for Nicaraguans, Panamanians, and other Central Americans who move to Costa Rica for temporary or permanent jobs. In the Caribbean, one of the main intra-regional migration routes is that of Haitians who migrate to the Dominican Republic. In addition, there are growing numbers of migrants from other regions like Africa, who pass through Central America on their trips to the US (IOM, 2019, p. 110).

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The irregular migration flows in the subregion are dynamic and have become more complex and increasingly diverse. In recent years, the number of arrests of Central Americans from the “Northern Triangle” region (Guate­ mala, Honduras, and El Salvador) is higher than the number of Mexicans attempting to cross the borders to the United States (IOM, 2019, p. 110). One way to reach the frontier of Mexico and the USA is on the known “caravanas migrantes,” which began in Honduras in 2018, which thousands of migrants from countries like El Salvador and Guatemala joined. These caravans of migrants brought important political debates. Consequently, in early 2019, a caravan of Cubans and Haitians, including some Africans and Asians, entered Panama from Colombia and later arrived in Mexico. Within this migratory route, traffickers’ networks were seen, as well as situations of physical and sexual aggression, torture, and disappearance of migrants (IOM, 2019, p. 111). Emigration to the United States of America is an important characteristic of the Caribbean, and Caribbean immigrants are among the largest groups in that country. In 2017, 10% of immigrants living in the United States of America came from the Caribbean, and this country was the main destination for Caribbean migrants outside the subregion. Other important destinations are Canada, Spain, and the United Kingdom. In 2019, more than 65% of Caribbean immigrants to the United States of America came from just five countries (Haiti, Trinidad, and Tobago, Cuba, Jamaica, and the Dominican Republic), and the majority were Cubans (IOM, 2019, p. 112). Migration as a moving process occurred in which the exchange of mate­ rial elements, both emotionally and socially symbolic of the culture and identity, required care and protection of the basic needs of the population. In this process of migratory flow, such exchanges are found throughout the migratory cycle (country of destination, transit, and origin), whether it is a regular or irregular trip. In response to the increase in the number of migrants in the region, the International Movement of National Red Cross and Red Crescent Societies (IFRC) established a series of work commitments to address the humani­ tarian needs of migrants in the Americas through the Toluca declaration1. In order to protect the life and dignity of people in transit, in situations of vulnerability in the Americas, a plan of action of the Red Cross Movement on Migration in the Americas was developed. This was based on the IFRC 1. Toluca Declaration: The commitment to work with governments, civil society, host populations, and migrant communities to respond to humanitarian needs, especially of vulnerable groups, their families, and host communities.

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Global Strategy on Migration 2018–2022 and the Migration Policy of the International Federation (2009), taking into account that the Movement’s approach to migration is strictly humanitarian, and focuses on needs, vulner­ abilities, and potentialities, regardless of their legal status, type, or category. In addition, IFRC carries out humanitarian tasks through “Llamamiento Regional de Movilidad Poblacional” for the nine countries receiving migrants in order to provide humanitarian assistance to such countries as Argentina, Brazil, Chile, Ecuador, Guyana, Panama, Peru, Trinidad, and Tobago, and Uruguay. Emergency operations that prioritize vulnerable populations include the Emergency Appeal in Colombia, the Emergency Appeal in Venezuela, and the Program Mariposa Monarca in Guatemala, Honduras, El Salvador, Colombia, Venezuela, and Peru. These operations aim toward resilience in communities of transit, and in the return and recep­ tion of migrants. 7.3 MHPSS ON MIGRATION IN THE AMERICAS REGION Within the framework of the migration actions that are carried out in the Americas region, and as a response to the movement to provide support to migrant people in the different countries, interventions are available in accommodations, livelihoods, water and sanitation, protection, gender, and inclusion (PGI), migration, and health. This last area, specifically the compo­ nent of the mental health and psychosocial support, is a crucial element for planning, developing, and building the response to the migrant population in addressing their needs. The year 2020 unleashed changes and situations that necessitated adaptations in the interventions, as well as rethinking the significant impact that the COVID-19 pandemic brought to people. Migration is changing and cautions us every day to be attentive to the needs and dynamics that are growing in the population, requiring a continuous evaluation of the context. Since the response to migrants began, the Red Cross has developed support systems through their volunteers and staff to strengthen the resources of their services. These include construc­ tion materials and preparation and delivery of resources, in order to provide support in an empathic and appropriate way. In humanitarian interventions, it is important to help meet the basic needs of migrants, such as food, shelter, livelihood, and water. It is also important to provide psychosocial support and mental health care to all migrants: boys, girls, adolescents, mothers, adults, and other people who decide to

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undertake the search for well-being and quality of life in a different country. This implies risks, crisis situations, and a personal impact. It is here that we see the intervention to provide aid and begin with the psychosocial support. At the beginning of 2020, the actions in the region consisted of providing psychological first aid (PFA), discussions, emotional ventilation, friendly spaces for children, work in groups, individual interventions, workshops, and psychological consultation (IFRC, 2020). This reflects the effort of the Red Cross to accurately develop the best intervention for migrants. Such actions are performed at permanent and temporary moving checkpoints in the migration route; in places of transit, such as Darien in Panama or destina­ tions like Chile. From the monitoring of these actions performed in each country earlier this year, it became evident that there was a need to structure the use of the MHPSS, to create, build, and adapt materials for the population. In addition, it was necessary to strengthen the capacity of staff involved, improving the bases in order to continue providing care to the migrant population. Therefore, the creation of regional documents began. These included the Guide for Healthcare and Psychosocial Support for Migrants, which contained a specific chapter regarding MHPSS. In addition, the MHPSS care and intervention protocol was developed to provide general guidelines for approaching migration, as well as types of interventions aimed to be devel­ oped with migrants and the host community. Additionally, the care of the personnel involved was addressed. These documents were written based on the identification of needs of these communities and the staff involved from each Red Cross, as guidelines for the countries in order to accurately adapt to the needs of migrants. 7.3.1 MHPSS STRUCTURING Mental health and psychosocial support (MHPSS) involve various kinds of aid that are aimed at protecting and promoting the psychosocial well-being and mental health of the population. This is highly relevant for interventions in the context of migration, to provide security and protection, reinforce the capacity of decision making and resilience in the communities, and aid in the recovery from the negative effects of their situations. Therefore, as a framework to support or intervene holistically, approaches were developed, which involved psychosocial aspects, human rights, gender, interculturality, and participation, as well as the principles based on avoiding revictimization and harmful actions.

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In addition to this, areas of psychosocial attention focused on the following five areas: 1. Trust: Aiming for the person to strengthen self-confidence and confidence in other people to make the establishment of emotionally safe relationships possible in which the person can feel cared for, respected, and valued. 2. Identity: Consisting of the reassessment of some aspects that the person recognizes as roots (family, country, friends, wishes, learning, skills) through various strategies, such as storytelling, anecdotes, and experiences. In this way, they will be supported to strengthen their roots that have been disrupted by the experience of migrating. 3. Affection: Consisting in the recovery of ties that unite the migrant with those who are important to them in a symbolic way, essentially for the person to remain connected to the sense of being alive. 4. Coping: Reevaluating everything that the person has been able to do to stay alive despite the adversity they are facing. This will restore the person’s power over his own life and the ability to develop a personal sense of well-being. 5. Hope: Reestablishing the capacity to set new goals, dreams, wishes, and opportunities. The future is a time that is built with the memory of the past and the acts of the present. Therefore, when there is a feeling of losing everything in the present, the person must look ahead to the future to carry on. 7.3.2 IMPACT ON THE STAGES OF THE MIGRATION PROCESS The main problems faced by migrants, including the migration experience involve change, uncertainty, and personal risk when they feel separated from friends, family, customs, familiar places, and support networks. However, it is important to have a prior analysis and understanding of the specific protec­ tive or risk factors of migrants, in order to have an outline of the elements that influence migrants and according to their personal context. Protective and risk factors must be considered in relation to the specific characteristics of each stage of migration. Characteristics, such as age, sex, and gender that influence the different effects that can occur in the migratory

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process (Table 7.1) need to be considered and understood, which involve biological, psychological, social, and transcendental aspects. TABLE 7.1

Impacts on the Immigration Process

Biological Aspects Psychological Aspects Social Aspects

Aspects of Transcendence

Health problems, diseases on the road, nutritional disorders, including malnutrition, deterioration of physical health. Depression, anxiety, intensification of pre-existing mental conditions, lack of emotional control, risk of suicide and other self-harming behav­ iors, alcoholism, and addiction to psychoactive substances. Gender violence and abuse, unemployment, homicide, femicides, extortion, kidnapping, forced disappearances, drug trafficking, threats, xenophobia, and discrimination. In addition, poverty, lack of social and political guarantees, disruption of significant networks, neglect, vulner­ ability, lack of employment opportunities, lack of access to psychosocial services, medical care, legal advice, child protection services, etc. Loss of will to live, hopelessness, migratory grief, disappearance, lack of spiritual protection.

According to the effects identified in the immigration process, the impact at each stage of the process is described in subsections. 7.3.2.1 BEFORE MIGRATION OR DEPARTURE This is the start of a contradictory process where mixed situations experienced in the country of origin influence the decisions of achieving better conditions of life. This involves leaving friends, schools, customs, culture, and many significant people in their lives for the development of social skills. 7.3.2.2 DURING MIGRATION OR IN TRANSIT When saying goodbye to the place of origin, the migrant is separated from important elements that are part of the person’s identity. It can be said that whoever migrates faces migratory grief. This process is associated with the migratory experience and linked to language, family, and friends, culture (customs, religion, and values), social status, contact with the group to which they belong and the land. These generate changes in identity and are accompanied by feelings of ambivalence (Achotegui, 2009). Stress evolves from the lack of information, uncertainty, and changes in policies and migra­ tion routes, which is why at the time of transit the psychosocial impact is

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exacerbated. If migration occurs under irregular conditions, migrants are exposed to specific and critical vulnerabilities and possible risks. 7.3.2.3 AFTER MIGRATION – SETTLEMENT OR RETURN

The fate of migrants tends to be uncertain due to the characteristics and conditions that appear in the process. Situations occur that are not easy to anticipate, such as loss or transition of culture, language, difficulties of social and economic inclusion in destination countries, including discrimination and xenophobia. There is also stress related to asylum applications and other legal processes. Migration implies a redefinition of roles and, in some cases, of individual and collective values in addition to the determinant role of the environment in making the process either simpler or more complicated. Each person experiences a different process that can be evidenced through three phases of grief: (i) impact, which is related to the initial emotional shock and consists of emotions, such as sadness, nostalgia, fear, anger, and hope; (ii) confusion, which arises when facing unknown situations in the search that is potentially reduced by the aid of others; and (iii) adaptation, which occurs when the migrant overcomes those initial difficulties and adjusts his behavior to the new environment. That is when you can talk about integration. In all phases of the journey, migrants will feel stressed about having the means to meet their physical needs, as well as other psychosocial needs. Based on the effects mentioned previously, during and after the migration route, we can identify three key aspects that lead us to plan the following interventions: 1. Risk Factors for Migrants: These are related to the legal status (regular or irregular situation), socio-economic situation, habits, and traditions of their own country. These factors influence migrants, increasing the risk of vulnerability of the population, and the inability to cover their basic needs, such as housing, food, and health care. This is also related to the sustainability of their home or as a resource to continue their journey safely. Consequently, migrants in an irregular situation are at high risk of being left out of health responses, as well as other vulnerable groups, such as women, children, the elderly, and the LGBTIQ community. Exploitation and abuse, including violence, stigma, and discrimination are additional risk factors.

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2. Lack of Access to Health Services: Especially in psychosocial assistance, this requires personalized and individual attention, because they do not have access to short interventions focused on providing PFA and strengthening and promoting personal resources and coping with the life situation. 3. Lack of Information and Guidance: Migrants are unaware of information about psychosocial support when it comes to those that they can access. They are unaware of the areas where they can improve their personal capacity and access mechanisms that will help them adapt to the new society.

7.3.3 PSYCHOSOCIAL INTERVENTIONS Migration has generated changes and impacts at an emotional, psychological, and social level in migrants, which frames the responsibility to aim actions in these areas to restore, re-establish, and promote psychosocial well-being. Due to the problems faced by this population in the region, intervention is necessary from the standpoint of understanding the context and the needs of the specific population as well as the risk factors that are faced during the journey and at the final destination. These interventions contribute to strengthening the capacity and personal resources and are fundamental in dealing with situations that may arise and, thus, influence the psychosocial well-being of the migrant population. In addition to this, interventions promote social integration with the host community, allowing community cohesion. Many migrants face life-threatening situations during the journey and the length of their stay may vary according to their purpose and the conditions generated in the context or country in which they find themselves. However, any intervention that allows migrants to receive care, active listening, and information will contribute directly to their well-being Having these psycho­ logical interventions available to those in crisis, e.g., forced migration or a health emergency, requires psychosocial support to cope with appropriate and timely involvement. COVID-19 created significant changes that influ­ enced the interventions, and these changes will be explained later. In migration, two types of interventions have been proposed, depending on the identified needs or the context in which the people in crisis find them­ selves. The first intervention is PFA and the availability of listening areas. The second involves the formation of groups offering aid or support among

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peers (formed by people with similar circumstances who support each other according to their experience). Finally, psychoeducation is needed in which education and training in mental health and psychosocial support are provided to the community in general. In psychoeducation, large numbers of people with the aim of generating meaningful learning, attitudes, and behaviors were addressed. The selected topics must be associated with a participatory diagnosis, which can be developed through focus groups, social cartography, socio-drama, problem trees, and other techniques that contribute to the evaluation of psychosocial needs. The migrant population can address topics such as knowledge of the environment, self-consciousness, and self-esteem. These contribute to the recognition of abilities and qualities that allow migrants to know and recognize each other. In addition, PFA, control of stress and emotions, grief management, decision making to generate a sense of belonging, teamwork, and social projects can also result from group meetings (Figure 7.1).

FIGURE 7.1 A group intervention.

Group interventions can be approached in the context of migration to the host community, in which there are a diversity of people (different races, ethnicities, religions, and customs) that affect the relationships and coexis­ tence. In this complex scenario, the host community sometimes perceives migrants as a threat to their well-being and cultural identity. Therefore, it is important to design programs and interventions that work on this group conflict to improve integration and facilitate relationships and the construc­ tion of mutual cultural knowledge. In addition, the implementation of

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cooperative activities that promote interdependence and thus reduce preju­ dices is beneficial in these contexts. Other key interventions in this area include safe spaces, particularly spaces for children. These not only support the children, but they also indirectly support the parents by guiding them and using material for psychoeducation in psychosocial issues. There are psychosocial tool kits to work in the field, which can be basic or specific, including games, primers, and playful mate­ rials designed to provide information and generate an empathic bond with others. These are adapted according to context, language, culture, and age. The intervention process for psychosocial support must aim at the recovery of people in mobile conditions. Leaving one’s home and all belongings behind can mentally break people. This is why objects given by the community can be important in making migrants feel welcomed (Figure 7.2).

FIGURE 7.2 An intervention in a safe space.

Within the framework of these interventions offered by the IFRC, psychosocial care and interventions are taken into account through the levels of a pyramid proposed by the Inter-Agency Standing Committee (IASC, 2007), adopted in the Policy of the International Movement of the Red Cross and Red Crescent (RCRC) for psychosocial needs and mental health. This is designed on three levels: basic psychosocial support, specific psychoso­ cial support, and in some countries a third level of psychosocial support is applied which offers inter-institutional work for the referral process of cases that require specialized assistance.

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The COVID-19 pandemic has reached almost all countries in the world. Although the region of the Americas was not at the center of the outbreak, it remained vulnerable as the virus continued to spread globally. Since midMarch of 2020, the region had a significant increase in the number of cases and deaths, and the countries began to implement mobility restrictions and border closures. The measures adopted by the country affect all population movement and impact the journey of migrants between and within countries. This increased the risk of the migrant population being unable to meet their basic needs of housing, food, and health care. Unfortunately, migrants in an irregular situation run a high risk of being left out of health responses and are particularly vulnerable to situations of exploitation and abuse, including violence, stigma, and discrimination. The migrant population at great risk due to the geographical mobility, instability, informal or precarious income, poor sanitation, language barriers, religious and cultural differences, and access to healthcare. Although countries imposed strict measures, migration flow in the Americas has continued, which indicates that many migrants have chosen to migrate irregularly and face the difficulties, risks, and associated protection problems. In addition, some migrants may express the desire to return, and many of them have already returned to their countries of origin, as evidenced by the increase in returns in many countries. With the continuous spread of COVID-19 in the region and the expansion of response measures by countries to contain and confront the virus at a regional level, the impact and worsening situation of the refugee and migrant population and as well as the communities was evident. This has had an impact on the increase in vulnerabilities among this population. This has caused some changes in the profiles and migration flows, highlighting the consistent increase in returns to Venezuela. Many who return do so because they have no other alternative in the host or transit countries. This situa­ tion is worrisome considering the greater risks in which people could find themselves, especially if we consider protection and health issues. Below are some activities and measures taken by National Societies (NSs) in response to the emergency: • •

Activation of a contingency plan for the response to human mobility. Continuous monitoring and evaluation of the psychosocial needs of migrants.

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Use of all tools to notify, inform, and communicate to migrants who are destined to receive different steps to mitigate risks due to the closure of borders. Psychosocial support services and activities, as vital aspects to ensure that stress due to the disease is reduced in communities with high risk of contagion or where cases have been detected. Virtual means of response have been enabled to guarantee the safety of volunteers and staff, due to the closure of permanent and tempo­ rary checkpoints. Development of materials and strategies for prevention and aware­ ness on self-care toward COVID-19, in addition to adapting provided information so that it is understandable for the population, including children and other vulnerable groups.

In the pandemic, not only physical health is affected, but also mental health, and the well-being of entire societies have been seriously affected by the crisis; thus, it is a priority that must be urgently addressed. Unpredict­ able events, such as COVID-19, have different effects on people, such as the concern of becoming infected and infecting others, including loved ones and family, represent risk factors for mental health. Fear, anguish, anxiety, and stress can be expected reactions and are related to over-information or misinformation, lack of knowledge, and rumors. The Argentine Red Cross, through its humanitarian observatory, conducted a study on the impact of the pandemic on the migrant population in which it has investigated the emotional discomfort and stress that people experienced since the beginning of isolation. It highlighted that 77% (315) of the people interviewed reported having been in contact with this type of situ­ ation both for themselves and for those close to them. This high percentage can be considered in relation to the change in habits that social isolation poses for all people, in which the migrant population, due to the aggravated conditions of precariousness and labor instability, entails an increase in economic barriers in access to food and accommodations. In addition to this, the report on humanitarian needs and protection risks of migrants developed in the southern countries, revealed that although these countries host a lower proportion of Venezuelan migrants compared to other nations in the region, the needs, vulnerabilities, and risks of protecting migrants has increased considerably in the regions affected by COVID-19, which requires imme­ diate attention and response. In Chile, according to the Regional Migration Survey, the migrant popu­ lation that requires humanitarian assistance is made up mostly of family

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groups (62% are accompanied by children and adolescents). This was linked to the main needs identified in relation to livelihood, food, accommodation, health, migration regularization, protection, and mental care. As Brazil is the third country with the highest number of cases worldwide, notable psychological effects of COVID-19 were observed in the migrant popula­ tion, many of which reported fear, anxiety, stress, concern, and uncertainty about the future. Other worrisome protection risks included an increase in gender violence among migrants, cases of discrimination and xenophobia, labor exploitation, sexual abuse, and child abuse, among others. Finally, in Uruguay, despite that the number of migrants is relatively small, there are needs similar to those mentioned above, notably accentuated by the current pandemic. At this point, it was decided to pay more attention to the way the pandemic is addressed and the effects it can have, readapting the way care is provided. At the beginning of the emergency response and due to the loss of contact with the migrant population, it caused the suspension of activi­ ties and the need to respond in a way other than in person, using tools and technological means to offer remote or online services. The implementation of tele-assistance or telephone assistance was a challenge for the region. Although some countries such as Argentina had this system, most countries were not using it. This led us to adapt and build materials to guide this new way of intervention. The subsections describe cases of response to the COVID-19 pandemic in the care of migrant populations in the region and how the NSs responded by respecting security and protection measures, especially for the volunteers and staff who assist in these services. 7.4.1 PERU In Peru, a business WhatsApp line was implemented for COVID migra­ tion that provides remote assistance to migrants settled in the country or in transit with access to a mobile phone or internet. This provided information, medical guidance, and/or psychosocial care. Due to the high demand, this service was extended to the general population. Furthermore, a psychosocial attention protocol was generated to address questions that had to do with issues associated with psychosocial support. These questions were classified using a traffic light pattern (green, orange or red) in order to help the identifi­ cation of the degree of affectation of the person making contact. In this way,

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WhatsApp only addressed the consultations classified as green, that is, those who required a first level of help or advice, rather than complex attention. If a more complex case was identified, they were referred to specialized personnel through an appointment system. In four months, until mid-July, the line was attended remotely to users affected by COVID-19. Furthermore, 33% of the users who agreed to share their data identified themselves as migrants. 7.4.2 ECUADOR Serious problems that people in a situation of human mobility face are the psychological affectations, the separation from their families, the anxiety generated during quarantine, as well as the stigma and discrimination, which can have an emotional impact. In this sense, the Ecuadorian Red Cross has been working on the psychosocial support line through the tele-assistance service. Service is aimed at the entire community, including the migrant population. Mental health volunteers intervene, offering support from different parts of the country, in order to provide psychological assistance to people. The most known cases during the COVID-19 emergency can be classified as anxiety, stress, psychoeducation, and domestic violence. Ecuador was one of the countries in the region that had a major impact on the high number of infections and deaths. In March and April, hospitals were in a state of emergency due to the high demand of patients. The huge need for funeral services caused bodies to pile up in the streets and prompting families to bury loved ones in coffins made of cardboard, exacerbating their feelings of loss and grief. 7.4.3 CHILE In response to the pandemic, the Chilean Red Cross performed prevention activities through communication and awareness of self-care to COVID-19. The organization offered psychosocial support virtually in both home hosts in Santiago for personnel in charge and to the persons of interest. In addition to virtual assistance, this support also addressed volunteering in order to provide support, guidance, and management of emotional well-being against the crisis. Psychosocial tools were developed aimed at the migrant popula­ tion, which consisted of three guides: an orientation guide for volunteers and staff; a guide for parents and caregivers on the management of anguish,

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anxiety or stress in migrant girls, boys, and adolescents; and the orientation guide, “Looking for My Treasure to Know How to Find Myself Again.” These were directed at providing PFA to the life of each migrant. Validation of the tools was carried out in times of COVID-19 in one of the shelter homes, through focus groups directed at understanding, involvement, accep­ tance, and content. This initiative was developed in conjunction with the approach of Community Participation and Accountability to the Community and psychosocial support, highlighting the importance of continuing to work together and implementing actions. 7.4.4 EL SALVADOR As a result of COVID-19, the Salvadorean Red Cross implemented a system of telepsychology in order to provide psychological assistance to create a safe spot where the person can relieve grief or emotional burdens. This is directed toward people in containment centers, health professionals, popula­ tions in situation of vulnerability, communities in general, and Red Cross volunteers and staff. The telepsychology is a psychological service that allows communication from a distance, such as: telephone, mobile, email, and mobile apps. They developed interventions of psychoeducation in which projects were carried out through email and WhatsApp, as well as through the phone and teletherapy if necessary. Teletherapy is a brief process consisting of four sessions aimed at people with serious psychological issues or mental health deterioration. 7.4.5 STRENGTHENING IN THE REGION The region’s response to COVID-19 occurred quickly but ensured compre­ hensive and safe care and promoted mental health for the entire population. The previous and continuous needs assessment that was given has been a key element to adapting to the various situations that were generated during the year. Teamwork and communication between the leaders of each Red Cross in the region promoted by the regional office responded to contextual needs. During the response, constant monitoring was carried out, but various webinars and trainings were also developed on MHPSS issues that applied to migration and socialization. Faced with the need to strengthen capacity, the movement promoted the creation of a virtual course on psychosocial support in the IFRC virtual campus, aimed at all volunteers and personnel.

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The course consists of six modules and the content involves both the evalu­ ation of the context and the aspect of interculturality addressed in issues of childhood on the move, religious groups and ethnic populations on the move. It also highlights the transversality of psychosocial support with protection, gender and inclusion actions (PGI) and diversity issues, and psychosocial support for survivors of gender-based violence (GBV). 7.5 CHALLENGES IN ASSISTANCE In the region, the approach and response that was given in regard to the inclusion of psychosocial support to the migrant population in times of the COVID-19 pandemic was key (Figure 7.3). The actions, changes in interven­ tion, and in the forms of expression, such as hugging, seeing people’s expres­ sions, and providing face-to-face responses generated implications taking into account the diversity of countries, areas, and populations. Interventions in psychosocial support in response to crises will continue to face a series of risks and challenges, such as the following:

FIGURE 7.3 Attention in times of COVID-19.

•

Switching from face-to-face assistance to virtual assistance. The typical routine of providing assistance in person at the various

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•

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migrant care posts and in shelters providing assistance to migrants throughout the migratory route, including individual activities, group, and recreational activities in child-friendly spaces had to be adapted to meet the requirements of the pandemic. As soon as the virus began to spread, measures were taken by the countries, which led us to change and begin to generate and build protocols to continue serving those who needed it most. Virtual meetings and constant calls to coordinate, review, and evaluate risks and needs were gradually adapted to the care. In addition, there was only limited availability to migrants and community members to participate in activities, especially those that involved social interactions and group gatherings due to the social distancing restrictions of COVID19. A rapid and constant learning process to improve ‘telecare’ and remote assistance was implemented during the emergency and is still in effect, as the pandemic has not yet ended. The restrictions of the countries to open their borders to foreigners, the closing of borders, the reduction or prohibition of free transit within their territories and the establishment of general quarantines had a significant impact. That led to modifying or stopping face-toface actions; however, these measures collapsed at the borders and in-migrant shelters, increasing anxiety, stress, and uncertainty about continuing or traveling. This generated a high number of returns, especially Venezuelan migrants. As of August 10, 2020, more than 1,00,000 people had returned to Venezuela through the borders of Colombia. However, a significant flow of people traveling from Venezuela to Colombia and other countries in the region entered the countries through irregular border points. Therefore, the Red Cross in the region never ceased to provide assistance, according to the report of Venezuelans who returned in the month of October. They continued to provide psychosocial support to communities and migrants including for people who returned through their permanent and mobile checkpoints at the main transit frontiers in different countries such as Colombia, Ecuador, Peru, Bolivia, Argentina, Chile, and Uruguay, taking into account protection and security measures. The uncertainty of resuming “normality” in addition to the changes was also a great concern that remains in the new daily life. A move­ ment is necessary to guarantee the well-being and psychological and

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•

•

•

physical care of each of the volunteers and staff that are performing the interventions. This continues, while life slowly returns to normal. Discover new forms to reach migrants was obviously a big challenge. Ways in which to provide information and reduce stress and anxiety levels that generated not only from the migrant condition but also the effects of the pandemic were major concerns. Each of the coun­ tries in the region took on this creative means to attack these issues. Using technology, conducting webinars, trainings, key messages, campaigns, and adapting simple materials to different ages and populations were techniques that were employed. Teamwork with other organizations was implemented with the aim of linking and avoiding duplication of activities. This was a challenge in that some communities had no access to internet or mobile phones, which required great innovation. Attention and emotional support for humanitarian personnel was also a significant concern. This led the region to implement and generate support systems, listening, and psychosocial activities for the involved personnel. In many countries, individual attention was provided through the hotline established by each Red Cross, and they assisted through short sessions and assessments of emotional well-being. Likewise, emotional ventilation was performed in group formats to counteract professional burn-out and emotional manage­ ment in situations where volunteers and staff had to respond in many cases of grief and loss well as emotion management. A limited capacity of resources existed, both technical and financial, from responding to an unexpected pandemic that spread so quickly and remains unresolved. It generated a high demand for work and a lack of resources leading us to seek structures and take actions to find a response.

7.6 LESSONS LEARNED In general, the response has left us with great lessons to be learned in and improving our response to the migrant population and communities. The region showed great resilience during the emergency, facing uncertainty and acting in the most appropriate way while taking into account the needs and risks of a changing and diverse situation. They learned to implement vast digital platforms and social networks to continue psychoeducation and

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promote and assist the population in psychosocial support issues. Cope with the stress associated with COVID-19 and rebuilding hope in communities, listening and supporting migrants who may be quarantined, isolated or hospitalized, it was at times impossible for them to stay in touch via phone. The importance of psychosocial support and community activities to reduce stress and strengthen coping mechanisms must be adapted using gender and age factors. It is important to strengthen awareness to reduce stigma and discrimination against people of other nationalities, along with the identi­ fying and mitigating myths that lead to xenophobia. Lessons from the region can be summarized as follows: 1. Virtual Psychosocial Support: This is the technological means, which is the main method to provide psychosocial support to the migrant population and intervening personnel and address psycho­ social needs. In addition, it strengthens and manages the referral of cases to offer timely and more specialized care to people when necessary. This is in addition to group care, in which emotional ventilation opportunities and listening spaces are provided where people can express their discomfort and concerns and generate an exchange of experiences as a form of mutual support or support among peers. 2. Strategy of Psychoeducational and Key Messages: This includes developing materials, guides, and messages aimed at prevention and promotion of mental health. Awareness and information are provided according to the context changes that were generated. The usefulness of remote PFA applications and training during the COVID-19 emergency are part of this strategy. 3. Strengthening Capacity from a Distance: Despite the situation, we continued developing training, and one of the lessons learned was that when the capacity to approach was reached in the region, developing training for the psychosocial support referents in each country was enabled, also reaching out to volunteers from the region. This leads us to rethink how the usefulness of technological means can be an opportunity to continue improving. 4. Mainstreaming with the Areas: The task of connecting with different areas, such as protection, gender and inclusion (PGI), communications, community participation and account­ ability (CEA) and other areas in each Red Cross constitutes the

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mainstreaming. This is needed for the actions to have a significant impact and address various issues accurately.

5. Work in Network Coordination with Organizations: In psychosocial support, this action gives us a better understanding and sharing of experiences and best practices, with opportunities to increase access to psychosocial support services to the migrant population. This strengthens and coordinates joint actions focused on psychosocial support that respond to coordinated strategies. 7.7 RECOMMENDATIONS FOR FUTURE INTERVENTIONS Psychosocial support care for migrants should focus mainly on mental health care and prevention involving a psychosocial approach model. From this point of view, the relationship of the person in his/her context and the social dynamics that can influence psychosocial well-being, which is linked to identity, sense of belonging, roles, and social integration, must be taken into account. In this sense, mental health and psychosocial support professionals must coordinate activities in which communities are active agents of solu­ tions. Activities to provide psychosocial assistance must be designed for the specific context in which they will be carried out and that meet the needs of migrants. Therefore, it is recommended that the following elements for future interventions in the context of migration should be considered to guarantee the well-being and timely care of the populations. We must always be aware to carry out actions without harm: •

Evaluate community risk and needs and monitor actions to decide which activities are the most appropriate at any time. This involves a characterization of the general population and identifying major sociocultural characteristics, needs, and vulnerabilities of the popula­ tion (basic needs: housing, water, food, protection, and security. This includes the psychosocial needs: information, guidance, contact with family members, emotional support, protection, social and institu­ tional help, education, and care. We must identify the health services, particularly in mental health, and other complementary institutional offers, such as protection services for survivors of various situa­ tions of violence. Also, we should construct a map of individuals that includes the institutions and professionals. Additionally, an

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•

•

•

•

evaluation of the capacity of resources and personnel that is counted for the performing of actions and response must be considered. For any intervention, it is important not only to have a needs and context assessment but also to plan the interventions to be carried out. Define the type of intervention (individual or group) according to the characteristics of the population such as age, sex, gender, presence of functional limitations, cultural practices and languages (including literacy levels) of migrants. Be aware and consider the care and protection of the staff and the volunteers, both physically and emotionally as an important aspect. Provide tools and training in psychosocial support, e.g., the guide­ lines of caring for the caregiver, emotional ventilation, empathy skills communication, safety, and emotional support networks that contribute to self-care. Every interaction that staff and volunteers have with vulnerable migrants is an opportunity to strengthen psychosocial well-being, so make sure they are ready for the imparted training. It is also critical that training for the development of techniques for migrants in terms of psychosocial support be offered. Operate and monitor interventions aimed at the population. Assess their impact and understand the worldview of migrants about mental health and psychosocial care in relation to the context and crisis. There might be a cultural stigma attached to the concept, or people might not understand it and hesitate to avail themselves of the services that are provided.

KEYWORDS • • • • • •

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COVID-19 pandemic gender-based violence mental health and psychosocial support migration protection, gender, and inclusion psychological first aid

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REFERENCES

Achotegui, J., (2009). Migration and mental health. The Syndrome of the Immigrant with Chronic and Multiple Stress. https://dialnet.unirioja.es/servlet/articulo?codigo=3119470 (accessed on 27 October 2022). Cortez, C., (2016). Intra-Regional Migration Tendencies in Central America. https://www. revistas.una.ac.cr/index.php/derechoshumanos/article/view/9131/11166 (accessed on 27 October 2022). Cruz, R. A., (2020). Impact of the Pandemic on the Migrant Population in Argentina. https:// r4v.info/es/documents/details/78080 (accessed on 27 October 2022). Interagency Standing Committee, (2007). Guidelines for Mental Health and Psychosocial Support in Emergencies. Geneva: IASC. International Federation of Red Cross and Red Crescent Societies, (2009). International Federation Policy on Migration. http://prami.ibero.mx/wp-content/uploads/2012/03/CICR. pdf (accessed on 27 October 2022). International Federation of Red Cross and Red Crescent Societies, (2020). Report Venezuelans in Return. https://go.ifrc.org/emergencies/3122#reports (accessed on 27 October 2022). International Federation of Red Cross and Red Crescent Societies, (2020). Including Migrants and Displaced Populations in Preparedness and Response Activities to COVID-19: Guidance for Americas National Societies. https://reliefweb.int/report/colombia/includingmigrants-and-displaced-populations-preparedness-and-response-activities (accessed on 27 October 2022). International Federation of Red Cross and Red Crescent Societies, (2020). Human Mobility Report Adaptation in the COVID-19 Response. https://go.ifrc.org/emergencies/3122#reports (accessed on 27 October 2022). International Federation of Red Cross and Red Crescent Societies, (2020). Humanitarian Needs and Protection Risks of Migrants in the Southern Cone. https://prddsgofilestorage. blob.core.windows.net/api/sitreps/3122/Necesidades_humanitarias_en_Cono_Sur_IFRC. pdf (accessed on 27 October 2022). International Federation of Red Cross and Red Crescent Societies, (2017). Global Strategy on Migration 2018–2022. https://media.ifrc.org/ifrc/wp-content/uploads/sites/5/2017/12/ IFRC_StrategyOnMigration_EN_20171222.pdf (accessed on 27 October 2022). International Organization for Migration, (2019). World Migration Report 2020. https:// publications.iom.int/system/files/pdf/wmr_2020.pdf (accessed on 27 October 2022). Psychosocial Support IFRC, (2020). The Migration Project Venezuela. What is the Migrant Duel and How to Overcome it? https://migravenezuela.com/web/articulo/que-es-el-duelodel-migrante-y-como-superarlo/696 (accessed on 27 October 2022).

CHAPTER 8

Mental Health and Psychosocial Support in Three African Countries: Guinea, Liberia, and Sierra Leone JOSEPH O. PREWITT DIAZ

The Pennsylvania State University (Retd.), Pennsylvania, USA

ABSTRACT This chapter presents an overview of the COVID-19 response in three West African countries (Guinea, Liberia, and Sierra Leone). These countries have had a history of epidemics and have a wealth of experience in response. The findings of this review suggest challenges related to mental health and psychosocial support community programs. These barriers include: (i) a clear definition of cultural, spiritual, and mental health intervention; (ii) a lack of trained personnel; and (iii) limited implementation of mental health policies. WHO is working closely with the local Ministries of Health, and the IFRC is conducting basic psychological support training for its volunteers. 8.1 INTRODUCTION This chapter aims to provide an overview of Mental Health and Psychosocial support programs in three West African countries (Sierra Leone, Guinea, and Liberia). These three countries were affected by the Ebola virus, SARS, increased activity by child soldiers, and the impact of natural disasters. The chapter covers the period post-Ebola epidemic and looks at the early impact of COVID-19 services to the population. This chapter is a synopsis of focused groups, one in each country, and interviews with Mental Health Mental Health and Psychosocial Support during the COVID-19 Response: An Overview. Joseph O. Prewitt Diaz (Ed.) © 2023 Apple Academic Press, Inc. Co-published with CRC Press (Taylor & Francis)

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specialists from the Red Cross Societies and other professionals. The total number of participants was 31 through ZOOM and TEAMS, during the period of October 2020 to April 2021. In these countries, social and religious activities that increase community ties, have been critical in determining positive mental health and psycho­ social outcomes in the aftermath of the Sierra Leone and Liberia wars that spilled over into Guinea’s border. Castillo et al. (2019) explain in their research how communities have elaborated narratives that promoted healing by using different methods of psychosocial activities, and storytelling in describing the hardships they faced both on a collective and individual level and promoted positive coping. COVID-19 has had far-reaching consequences on the psychosocial health of individuals and communities. One of the assumptions of this activity, was that maybe we would gain some insights into the wisdom of survivors from the EBOLA virus, and the internal conflicts, that would help us identify individual and community tools that would alleviate suffering amongst the affected people during and in the immediate aftermath of the COVID-19 pandemic. Salim et al. (2021) have reported on the health and social conse­ quences of the pandemic: temporary and permanent layoffs, restrictions on informal income-generating activities, disruption of celebrations and other forms of public entertainment, and social distancing from relatives. All these restrictions and the uncertainty of an early vaccine and other cure for the detrimental physical effects leading to emotional deterioration, have increased feelings of stress and anxiety for many people and interrupted the livelihoods of Guinea, Liberia, and Sierra Leone (Salim et al., 2021). 8.2 EBOLA IN WESTERN AFRICA James et al. (2019) very eloquently helps the reader understand how the Ebola outbreak impacted Guinea, Liberia, and Sierra Leone. In their study on psychosocial experience and coping mechanisms that enhanced the coping mechanisms of the affected and infected people, taught some lessons that have been valuable in how to best address the mental and psychosocial impact of the current COVID-19 pandemic in families and communities. Rabelo et al. (2016) had conducted a quantitative study to try to understand the impact of EBOLA in Monrovia, Liberia. Some of the most prominent lessons indicated that survivors, caretakers, healthcare providers, and the affected communities experienced psychological effects due to the traumatic

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course of the infection, fear of death, and the experience of witnessing others dying (Rabelo et al., 2016). Rabelo et al. (2016) share with the reader that survivors from EBOLA had experienced psychosocial consequences due to feelings of shame or guilt, stigmatization, or blame from their communities. Van Bortel et al. (2016) reported similar findings in their research report in 2016. Jalloh (2019) studied cultural practices in his research in Sierra Leone and found some survivors were threatened, attacked, evicted, or left behind by or excluded from their families and communities because they were seen as tainted and dangerous. Fear and stigma of EBOLA were contributed to by cultural beliefs, widespread fears due to high infection risk, lack of information, and misinformation (Jalloh, 2019). Van Bortel et al. (2016) found that those infected with EBOLA also expe­ rienced stigmatization and isolation. In addition, survivors who witnessed the traumatic course of the infection in others, experienced traumatic stress manifesting itself in behaviors related to fear and anxiety about falling ill or dying themselves, in addition a significant number of participants in Van Bortel et al. study reported feelings of loss and grief from losing loved ones (Van Bortel et al., 2016). Since Ebola is transmitted through contact with bodily fluids, loved ones were often separated from the sick upon showing symptoms and could not be with them as they suffered or died. Montemurro (2020) studied the impact of COVID-19 in the early 2020, and he found that the increased feelings of grief, loss or distress, and guilt or helplessness for being unable to comfort or care for loved ones was significant. Montemurro indicated that the loss of support for affected and affected people, further limited the ability to cope and increased distress. Montemurro (2020) reported that the medical staff and healthcare workers experienced psychological effects. Another study, conducted by Sekowski et al. Witnessing the traumatic course of the infection and their patients’ death puts caretakers at risk of poor psychologic explored whether affected and infected people were at risk of developing post-traumatic stress as a result of working in the frontlines. The outcomes of their study suggested a strong probability of experiencing, anxiety, depression, and post-traumatic stress disorder in the aftermath of their experiences (Sekowski et al., 2021). Raven et al. (2018) hypothesized that given the high fatality rate and lack of treat­ ment for Ebola, caretakers felt burdened by guilt for not adequately looking after or saving the patients. Raven et al. found that specific factors affected the frontline workers: working long hours, overwhelming patient numbers, limited safety equipment, and a feeling of inability to provide adequate care

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for or heal, those infected can also result in frustration, anger, or feelings of helplessness for health workers. Radhakrishnan et al. (2021) found similar results in their study among survivors of the Nipah infection. Because of the severity of symptoms and high mortality rates, caretakers felt significant fear, anxiety, or helplessness related to their own risk of infection and death. These findings were congruent with the work reported by D’Ettore et al. with COVID-19 workers. They found that in some cases, healthcare workers and even their families suffered social consequences such as they were evicted, threatened, or attacked. At the community level, a cyclical pattern of fear occurs, with a loss of trust in health services and stigma, resulting in disruptions of community interactions and community fracturing (Van Bortel et al., 2016). A communal sense of grief can also be felt due to the significant loss of community members. This can have further psychosocial consequences as communities face shifting roles to adapt to the loss of parents, breadwinners, caretakers, teachers, and community leaders. Health systems in affected countries were severely disrupted and overstretched by the outbreak, and their capacities were significantly reduced as almost 900 healthcare workers were infected with Ebola, and more than 500 deaths were reported by Raven et al. (2018). 8.2.1 LESSONS LEARNED FROM EBOLA AND TRANSITION TO COVID-19 IN WESTERN AFRICA An examination of the literature conducted by Acharibasam, Chireh, & Menegesh (2021) on the Ebola outbreak between 2014 and 2016 identified similar types of mental health and psychosocial support sequelae: stress, grief, anxiety, depression, and symptoms of PTSD were reported at an individual level, as well as stigma, discrimination, and interruption of social networks at the community level. Hughes (2015) studied mental illnesses created by EBOLA in Sierra Leone. He found that some predictors of mental health problems, such as the inability of families to care for sick relatives coupled with the inability of family members to perform traditional and religious burial rituals for loved ones, caused significant psychosocial distress. Obande et al. (2021) looked at the current state of COVID-19 has spread all over Africa. The West African countries have experienced relatively low incidence and case-fatality rates. The COVID-19 incidence rate in West Africa is 14 times lower than the global incidence rate, and the rate case fatality rate is 1.7-times lower than globally (Obande et al., 2021). Obande et

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al. (2021) further has found extreme fear, anxiety, and fear-related behaviors during the COVID-19 pandemic form the most difficult barrier to preventive and curative measures and this uncertainty have led to an emotional crisis, especially amongst the tribal and indigenous population. The Ebola disease from 2014 to 2016 was associated with a spectrum of mental health problems among the general population and health workers, such as depression, anxiety, fear, post-traumatic stress disorder, and frus­ tration. Out et al. (2020) describes mental health problems associated with COVID-19 as a slow-motion disaster is very apt as psychological fallouts are likely to be widespread and persistent, it is as though having an elephant in the room Out et al. surmises. On the other hand, with lockdowns and physical distancing strategies being imposed in most African nations, people have turned to different media sources to get news updates on the pandemic; this strategy may cause more anxiety and fear because it may not be timely and correct for the specific country. Medeiros et al. (2015) have been studying the impact of the pandemic in Liberia. They have found that certain populations are more vulnerable to the negative social and economic effects of the COVID-19 pandemic due to underlying wealth inequality’s social discrimination, and social exclusion. Mothers and children, older adults, persons with disabilities, and individuals and families living in poverty are key groups who may face additional chal­ lenges in enduring the effects of the pandemic. Medeiros et al. conclude that one thing is certain: the management of the EBOLA outbreak in western Africa has played in the country’s response to managing COVID-19. 8.3 EFFECTS OF COVID-19 ON VULNERABLE POPULATIONS IN WEST AFRICA (GUINEA, LIBERIA, AND SIERRA LEONE) This section will provide an overview of MHPSS in three West-African countries: Sierra Leone, Guinea, and Liberia. These three countries were affected by the Ebola virus, SARS, and various natural and man-made disas­ ters. In these countries, social activities that foster community ties proved critical in determining positive mental health and psychosocial outcomes in the aftermath of the Sierra Leone and Liberia wars that spilled over into Guinea’s border. After the Ebola epidemic, communities that elaborated narratives that promoted healing by explicitly rejecting the hardships they faced demonstrated greater resistance to mental health problems both on a collective and individual level and promoted positive coping (O’Leary et al., 2018).

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COVID-19 has had far-reaching consequences on the psychosocial health of individuals and communities. Salim et al. (2021) have reported on the social impact of the pandemic. They suggest that illness and deaths due to COVID-19, temporary and permanent layoffs, restrictions on informal income-generating activities due to social distancing protocols, disruption of social celebrations and forms of entertainment, transitions to in-home learning for students, and social distancing from relatives have increased feelings of stress and anxiety for many people and interrupted the livelihoods of Guinea, Liberia, and Sierra Leone as reported by Salim and his collogues (2021). 8.3.1 GUINEA Medeiros et al. (2015) have described the health system and the available mental health facilities available for the population. The health system in Guinea is composed of Community Health Post, Regional Hospitals, and two specialized teaching hospitals. In Conakry, Guinea’s capital, there has been an indication that the population is complying with COVID-19 preven­ tion guidelines. According to Sow et al. there is an integration of mental health care in private not-for-profit health centers. Patients are responsible for mental health-related expenses. There are five psychiatrists in Donka Hospital-Conakry, and about 245 primary Health care physicians and nurses have been trained throughout the country by WHO, and an unknown number of persons trained in psychological first aid (PFA). The following paragraphs describe mental health and psychological support based on the experiences of wars and the Ebola epidemic as perceived by the population and reported in the existing literature. According to Medeiros, Orr, & Deventer (2015) family, social, and community bonds and obligations play an important role in the concep­ tualization of the self for many people and communities. Suppose others perceive one not to respect these bonds. In that case, one is likely to incur anger and resentment, occasionally even curses and sometimes suspicions of being a sorcerer. This suggests why the wider community may feel that they have a stake in the behavior of individuals. Thus, the self is commonly seen in relational terms to the family and community. While individual success may be valued, strong individualism may be discouraged (Medeiros, Orr, & Deventer, 2015).

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In Guinea, the determinants identified for mental health and psychosocial support would be determined by the degree to which one’s community acts as a solid support system during and after the crisis. And individual access to familial and parental support structures is critical in assuring positive mental health results in the face of the traumatic event and enhance resilience. In a review of social determinants associated with mental health, we found that WHO has identified the social determinants for mental health, several fixed characteristics include culture, race/ethnicity, nationality, and gender. Castillo et al. (2019) have studied social support and resilience to stress. They found that risk and protective factors concerning mental illness and disorders were deeply intertwined with the mediating process between communities and individuals as conduits for psychosocial resources that enabled the reconstruction of both the community and the individual in the aftermath of traumatic events. Castillo et al. (2019) suggest other protective factors have been identified, such as strong communal ties, familiar and kin networks, parental support structures, and community narratives that offer assistance to the effects of social crisis, internal conflict, and socioeconomic deprivation. Petherick (2015) reported that as the Ebola Epidemic continued to spread into Guinea, the World Health Organization (WHO) declared a public emergency in August 2014. Several steps actions were taken to try to bring the outbreak under control: isolation of affected patients; explanation and promotion of safe burial procedures; awareness-raising with communities; disease surveillance; tracing the contacts of those who became infected and putting in place policies that ensured health care and would control the Ebola transmission. Where psychosocial support needs were addressed during the epidemic, NGOs did it with limited coordination with the Guinea government. In May 2014, there was an effort to train health professionals to provide psychological care alongside fighting the Ebola virus disease. However, it was not approved by the government. A broader response to develop more attention in PFA awareness among healthcare staff and community workers was conducted. UNICEF supported psychosocial support for children by developing safe spaces and recreational activities, trained community leaders, and provided input in the development of a national strategy for MHPSS for children was more successful. According to Van Portel et al. (2016), the EBOLA virus had an impact on the development of psychosocial support. Some particular needs were: (i) During diagnosis and afterward, the affected individual and their family members might have to deal with fear, grief, and coping with stigma and

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marginalization within their communities; (ii) during the grieving process following bereavement, particularly in the light of the disruption caused by Ebola to customary grieving rituals, which ordinarily had helped adjustment; (iii) following recovery from the virus when stigma and fear of infection made it difficult to reintegrate into the community; (iv) the infection control teams and medical workers who came to the community also inspired fear (Van Portel et al., 2016). Medeiros et al. (2015) suggest that there were two lessons to be learned about the inclusion of MHPSS into the health system and the psychosocial nature of community assistance. The first addresses the intricacies of the population’s spiritual and social practices and worldviews, the need for meaningful and representative engagement with a broad cross-section of members of individual communities, and the practical difficulties related to social divisions and inequality the effect of violent conflict (Bayeh et al., 2021). The second is related to the implementation of MHPSS faced several challenges for the people related to their psychological and cultural wellbeing. The Ebola virus outbreak presented an unprecedented challenge to public health and two other internal and external resources and structures (Dickson et al., 2019). There were widespread suspicions of those in power or of outside agencies and spiritual and social practices and world views of the diverse segments of the population. Summarizing the post-Ebola period, practitioners need to realize that the people from Guinea had various perspectives to understand health, suffering, and ill-being. Their decisions may be influenced by the bonds they value with family, the wider community and the dead Manguvo & Mafuvadse (2015). God and the spirit world, as well as historical and contemporary experiences of oppression and marginalization. Guinea is culturally diverse, and clear generalizations about these issues cannot be made across the population Manguvo & Mafuvadse (2015). However, it is important to recognize that these are commonly key considerations for clients, although they may take different forms among different groups and sectors. In their work in working with this population, MHPSS practitioners must engage with and respect their importance if the outcomes they hope for are to be achieved. 8.3.2 LIBERIA In 2017, the Ministry of Health of Liberia put into effect legislation to address the severe shortage of mental health clinicians and social workers, train

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front-line workers to care for people with mental illness in the communi­ ties, and to prepare community health assistants in urban areas to recognize symptoms of mental illness, provide psychosocial support and make refer­ rals as appropriate. In addition, this legislation will work in tandem with the National Health and Social Welfare Policy and Plan 2011–2021. The goal is to develop a comprehensive basic community-based mental health system consistent with global mental health principles and accepted standards. 8.3.2.1 EXPLANATORY MODELS FOR MENTAL HEALTH AND PSYCHOSOCIAL PROBLEMS Gwaikolo et al. (2017) studied the health system preparation for integrating mental health and psychosocial support. Several mental illnesses and neuro­ logical disorders, like epilepsy, are highly stigmatized summons the people of Liberia, and untreated mentally ill persons are likely to suffer from extreme abuse. The WHO (2017) explored the interaction of culture and mental health in Liberia. They have concluded that mental illness continues to be regarded by many Liberians as a punishment or effect of having committed evil debts, like rape or murder, as evidence that one has been a victim of sorcery or witchcraft as a consequence of engaging in sorcery, or as a consequence of having violated religious totems and taboos (WHO, 2017). In many ways, like in other societies, traumatic stress poses an exception to the rule of the stigma towards mental illness. Hook et al. (2020) have conducted a systematic review of the literature on mental health in Liberia. They have concluded that the Liberian populations self-identify as needing trauma healing and counseling service in many contexts, and in a recent study of vulnerable youth, they actively appealed for counseling medication and, in some cases, institutionalization (Hook et al., 2020). Makwana (2019) reiterates that the cultural adoption of the concept of trauma is likely an outcome of long-term exposure to mental health and psychosocial public awareness campaigns during the war, national disasters and the Ebola epidemic (Makwana, 2019). 8.3.2.2 ROLE OF THE COMMUNITY AND NEIGHBORHOODS IN PSYCHOSOCIAL SUPPORT The WHO (2017) points out that Liberians are strongly rooted in family ties and community-based social networks. Social goods, like adequate finances

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for basic needs, language proficiency, social support networks, family cohe­ sion, cultural adherence, educational support, and faith and religious involve­ ment are all associated with the qualitative reports of positive psychosocial outcomes in Liberia. As a result, psycho-education, peer support, and PFA interventions may have a positive response within the communities. A lack of family and community support for persons experiencing mental health and psychosocial issues can undermine their ability to access healthcare, inhibit social acceptance, create poverty, and undermine economic their psychosocial well-being. This lack of support from family and community members violates basic rights and exposes the affected persons to extreme violence. Social pressures within communities, and lack of support from faith-based organizations, create significant psychological distress in the neighborhoods and communities. Kunzler et al. (2021) studied the mental health and psychosocial support strategies with people that have experienced COVID-19. The lessons of post-Ebola WHO community healing dialogs (CHDs) and more, as well as the results from the Kunzler et al. study as well as a decade post-conflict that a decade of post-conflict community-based reconciliation activities demonstrate that investments in improving commu­ nity relationships and understanding of mental health and psychosocial issues can have a positive effect in improving the well-being of individuals and communities. 8.3.2.3 RESPONSE TO THE COVID-19 PANDEMIC To ensure the psychosocial well-being of children and their caregivers, UNICEF is supporting the Mental Health and Psychosocial Support Pillar, which have provided services to the Observation Centers, Treatment Unit, and communities. As of the end of July 2020, 650 staff and social workers were provided with community-based psychosocial support. The Government of Liberia has included MHPSS as part of its plans to support Mental Health in the country. There is only one mental health hospital in the country, the E.S. Grant in Monrovia with 80 beds. At the time of writing, there was no information about how many health workers in local hospitals and community clinics have been trained or are using MHPSS methods in the positions. There is evidence that humanitarian organizations, the WHO, and faith-based groups are providing MHPSS, predominantly PFA, to survivors of violence, the Ebola epidemic, and currently the COVID-19 pandemic.

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Routine resources for youth and adults at risk of mental disorders have been underfunded in Liberia. Most of the services are found in Monrovia. However, a recent study assessing the needs of vulnerable youth in postconflict Liberia found that homeless children experiencing epilepsy and mental illness, former combatants, children of combatants need but do not have access to formal medical care treatment counseling or institutional assistance and support. The social sector seems to be providing psychosocial support through mobilization of community-based rehabilitation efforts, including psychosocial counseling, peacemaking, peacebuilding, and conflict resolution. For example, the Carter Center Mental Health Program has gradu­ ated over 249 clinicians to support children and adolescents (Cooper, 2018). In 2015, the WHO introduced CHDs. The objective of this program was to provide a community-wide activity that would encourage psychosocial well-being and promote community relationships of individuals affected by Ebola, support communities’ abilities to cope with conflict and distress and help restore social solidarity (WHO, 2016). According to Kohrt et al. (2018), the reports of the CHDs suggested that the community rehabilitation efforts helped improve coping skills and improve healthy and supportive relation­ ships within the community are accurate, and measurable. While some mental health and psychosocial worker training programs focus intensively on providing training and mental health counseling, there has been a lack of psychosocial resources in the community. Kienzler (2019) explored mental health systems reform in low to middle income countries. They have found that adaptation is a key feature in ensuring that MHPSS interventions are: (i) relevant and efficient in varying cultures and contexts; (ii) aligned with existing understandings of mental health and psychosocial support; and (iii) serving as a means to provide psychoeducation and PFA to alleviate fear in the communities (Kienzler, 2018). This review suggests that psychosocial counseling training and PFA in schools and communities would be beneficial during and after the COVID-19 pandemic. 8.3.3 SIERRA LEONE Sierra Leone has experienced traumatic events that are associated with nega­ tive mental health and poor psychosocial outcomes. These include a decadelong civil war, the 2014 Ebola outbreak, and multiple natural disasters. Fitts et al. (2020) have studied ways in which to strengthen the mental health services in Sierra Leone. They have found that the mental health system in

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Sierra Leone comprises all organizations and institutions that devote their activities to promote, restore, and maintain the mental health and psycho­ social well-being of the population (Fitts et al., 2020). These activities include formal health care, action by traditional practitioners, home care, and self-care public health activities such as health promotion and mental illness prevention and other health-enhancing interventions in communities and neighborhoods (Adams et al., 2020). Mental health problems in Sierra Leone are commonly attributed to spiritual or supernatural causes and are associated with help-seeking from traditional healers or religious institutions (Ofware, 1999). Horn et al. (2021) indicates that there are limited numbers of studies related to mental health in Sierra Leone. This small number of studies on helping person-seeking behaviors in relation to mental health and psychosocial issues in Sierra Leone indicate that individuals are managed in the homes of relatives, wher­ ever possible, with the most commonly assessed care being that provided by traditional healers or faith-based institutions (Horn et al., 2021). Bah et al. indicates that there has been an ongoing effort to treat mental health and psychosocial issues by mental health nurses (Bah et al., 2018). Horn et al. (2021) looked at factors that contributed to emotional distress in Sierra Leone. Horn and her colleagues found that reliance on informal healthcare is a result parts of the fact that public health services are difficult to access because they are far from where those in need actually live and the lack of healthcare staff trained to respond effectively to the mental health and psychosocial needs. Equally important are beliefs about mental health, costs associated with prognosis and treatment, stigma, discrimination, and shame amongst both the affected and their family (Horn et al., 2021). Traditional healing practices often allow for mental health and psychosocial issues to be addressed privately or even secretly between the healer and the patient, thus minimizing the risk of ostracizing and stick my inner community. The lack of communication and coordination between the formal system and a traditional system results in a lack of regulation and quality control and potentially harmful practices occurring at the community level. However, in the last five years, primary health workers have been receiving PFA training. 8.3.3.1 MENTAL HEALTH SERVICES According to Harris et al. (2020), the MH system in Sierra Leone comprises formal and informal structures to promote, restore, and maintain the MH of

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the population. However, these structures lack coordination, which limits the nation’s ability to treat mental health holistically. To reduce these problems, the Government of Sierra Leone has developed a Mental Health Policy 2019–2023, and the Mental Health Strategic Plan 2019–2023 indicates the prioritization of mental health and the efforts made since 2017 to develop mental health. The community mental health programs have been organized with Mental Health Nurses at the lead (Hopwood et al., 2021). The Ministry of Health developed a strategic plan for MH services that sought a multi-level coordinated approach to: (i) improve community aware­ ness; (ii) build demand for services; and (iii) improve service provision via specialized healthcare workers at the various levels of care from communities to tertiary hospitals. There is only one psychiatric hospital in Sierra Leone located in Freetown (Ministry of Health, 2017). The Ministry of Health established the CHDs at the district level; the CHD groups, which comprise 1,518 community members, help communi­ ties identify resources, suggest coping mechanisms, and offer mutual support for psychosocial problems. The groups, led by Community Health Officers (CHOs) and social workers, met weekly for a period of 12 weeks to discuss issues in their communities and how to build resilience. Community health workers (CHWs) have been trained in mental health and psychosocial support (Ministry of Health, 2017). WHO-Africa (2016) reported that within the public health care system, the Ministry of Health proposes to provide different levels of care for mental health and psychosocial support across communities’ primary, secondary, and tertiary levels. This recognizes the fact that people will respond differ­ ently to adversity, with the majority of the population being able to recover from difficult experiences over time, provided that they have access to basic services that are provided in a safe, dignified, and participatory way. Some people will need an addition to this assistance to strengthen the social networks and support that have been shown to play a crucial role in preventing and responding to mental health and psychosocial problems in their communities (Ministry of Health, 2017). 8.3.3.2 ROLE OF THE COMMUNITY In Sierra Leone, most care for individuals experiencing psychosocial distress, mental health problems, or psychosocial support needs takes place at the community level. Caregivers and service providers include family members, traditional healers, and religious leaders. Sijbrandij et al. (2020), suggests

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that Structured psychosocial support activities reach small proportions of affected persons compared to the informal support offered at the community level. Sijbrandij et al. (2020) recommend that the Ministry of Health acknowl­ edge and engage with psychosocial support activities at the community level. Counseling, psychoeducation, and peer-to-peer support can be beneficial for families who often bear overwhelming personal responsibility for the loved ones’ care with little support from the community level workers or the Mental Health nurses may engage in abusive practices due to their lack of understanding, lack of coping strategies, and/or the high levels of stress. Traditional healing can be helpful but can also involve overblown claims of what the healer can achieve and abusive practices. Faith-based healing activities in conjunction with active listening, sports or other activities and peer-to-peer support may be helpful (Sijbrandij et al., 2020). 8.3.3.3 COORDINATION OF MHPSS ACTIVITIES There are two coordination bodies for MHPSS in Sierra Leone: (i) the Mental Health Coalition; and (ii) the Mental Health Steering Committee, both based in the capital city of Freetown. The Mental Health Coalition advocate for the human rights and dignity of all those affected by and working to improve mental health. The coalition includes service users, their families, service providers, and traditional medicine practitioners. Local leaders are also being engaged to address the myth and stigma surrounding mental health and to promote community care. Through channels of already established community engagement (CE) programs, regional chapters and national mental health conferences are being organized by the coalition for diverse audiences. In addition to mental health, nurses often do community outreach and support the community service groups and caregivers. The Mental Health Steering Committee is chaired by the Ministry of Health Services, and members include all those bodies providing or supporting MHPSS services in Sierra Leone. 8.3.3.4 MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT DURING COVID-19 IN SUB-SAHARAN COUNTRIES Three factors affect the population in the Sub-Saharan region as a result of the direct impact of COVID-19. (i) The news of the heavy death rate in

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the communities has increased stress and fear, stigma, and discrimination among survivors’ families among survivors and healthcare workers at the community level. (ii) The disproportionately affected population amongst the healthcare workers, the COVID-19 survivors’ families and children who have lost loved ones to the disease and those with pre-existing mental health conditions are most in need of mental health and psychological support at the community level. (iii) There seems to be an inability to control the spread of the COVID-19 virus. The efforts of governments to restrict and limit physical interactions may have had an adverse social effect on the communities. (iv) The quarantine also created other problems, such as lack of social support structures and inadequate sources of food and medication, limited access to treatment for those experiencing mental health condi­ tions, and those with chronic physical conditions that, without appropriate care, have led to mental health issues. (v) The restrictions curtailed access to faith-based community organizations at the community level, and the limitation of social gatherings did not permit people to support and care for each other. Pedroza et al. (2020) observe that COVID-19 pandemic is harming the health, social, and material well-being of children worldwide, with the poorest children. Social distancing and confinement increase the risk of poor nutrition among children, their exposure to domestic violence, increase their anxiety and stress, and reduce access to vital family and care services. (vi) Finally, lack of access to support systems increased violence and other forms of abuse in their homes, with no forcible future, learned helplessness, negative emotions, and other psychosocial problems appeared. 8.4 SUMMARY There is a gap in understanding mental health and psychosocial support within the Sierra Leone society, culture, and context. It would be helpful to develop a study aimed at: (i) a systematic identification and validation of local idioms of distress; (ii) identification of mental disorders in Sierra Leone; and (iii) the appropriate training needed by MH nurses, psychoso­ cial counselors, and CHWs would be of great value. Sierra Leone would benefit from mental health and psychosocial support in conjunction with the community-based and clinical program that is called culturally and contextually appropriate for dealing with the distress cost by the COVID-19 pandemic.

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KEYWORDS • • • • • •

community healing dialog community health officers community health workers COVID-19 mental health and psychosocial support programs psychosocial health of individuals and communities

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Manguvo, A., & Mafuvadze, B., (2015). The impact of traditional and religious practices on the spread of Ebola in West Africa: Time for a strategic shift. The Pan African Medical Journal, 22(1), 9. Medeiros, E., Orr, D., & Deventer, J., (2015). Mental Health and Psychosocial Support in Guinea-Conakry. Ministry of Health Sierra Leone, (2017). Mental Health Policy and Strategic Plan. https:// extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/ sierra_leone/sierra_leone_nhssp_2017-21_final_sept2017.pdf (accessed on 27 October 2022). Montemurro, N., (2020). The emotional impact of COVID-19: From medical staff to common people. Brain, Behavior, and Immunity, 87, 23–24. https://doi.org/10.1016/j. bbi.2020.03.032. O’Leary, A., Jalloh, M. F., & Neria, Y., (2018). Fear and culture: Contextualizing mental health impact of the 2014–2016 Ebola epidemic in West Africa. BMJ Global Health, 3(3), e000924. https://doi.org/10.1136/bmjgh-2018-000924. Obande, G. A., Bagudo, A. I., Mohamad, S., Deris, Z. Z., Harun, A., Yean, C. Y., Aziah, I., & Banga, S. K. K., (2021). Current state of COVID-19 pandemic in Africa: Lessons for today and the future. International Journal of Environmental Research and Public Health, 18(19), 9968. https://doi.org/10.3390/ijerph18199968. Otu, A., Charles, C. H., & Yaya, S., (2020). Mental health and psychosocial well-being during the COVID-19 pandemic: The invisible elephant in the room. Int. J. Ment. Health Syst., 14, 38. https://doi.org/10.1186/s13033-020-00371-w. Pedrosa, A. L., Bitencourt, L., Fróes, A. C. F., Cazumbá, M. L. B., Campos, R. G. B., De Brito, S. B. C. S., & Simões, E. S. A. C., (2020). Emotional, behavioral, and psychological impact of the COVID-19 Pandemic. Front. Psychol., 11, 566212. doi: 10.3389/fpsyg.2020.566212. Peter Obonyo Ofware. (1999). Factors that influence the utilization of traditional and modern medicine among the Samia of Funyula Division, Busia District. Social Anthropology and Ethnology. dumas-01281364. Petherick, A., (2015). Ebola in west Africa: Learning the lessons. Lancet, 385(9968), 591, 592. doi: 10.1016/S0140-6736(15)60075-7. PMID: 25682526. Rabelo, I., Lee, V., Fallah, M. P., Massaquoi, M., Evlampidou, I., Crestani, R., Decroo, T., et al., (2016). Psychological distress among Ebola survivors discharged from an Ebola treatment unit in Monrovia, Liberia – a qualitative study. Front. Public Health, 4, 142. doi: 10.3389/fpubh.2016.00142. Radhakrishnan, C., Sankar, U. V., Rajendran, V. R., et al., (2021). Psychosocial impacts of quarantine among survivors of the Nipah virus infection: A qualitative study. Journal of Global Health Reports, 5, e2021092. doi:10.29392/001c.28993. Raven, J., Wurie, H., & Witter, S., (2018). Health workers’ experiences of coping with the Ebola epidemic in Sierra Leone’s health system: A qualitative study. BMC Health Serv. Res., 18(1), 251. doi: 10.1186/s12913-018-3072-3. PMID: 29622025; PMCID: PMC5887191. Rössler, W., (2016). The stigma of mental disorders: A millennia-long history of social exclusion and prejudices. EMBO Reports, 17(9), 1250–1253. https://doi.org/10.15252/ embr.201643041. Saalim, K., Sakyi, K. S., Fatema-Tuz-Zohra, Morrison, E., Owusu, P., et al., (2021). Reported health and social consequences of the COVID-19 pandemic on vulnerable populations and implemented solutions in six West African countries: A media content analysis. Plos One, 16(6), e0252890. https://doi.org/10.1371/journal.pone.0252890.

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Sekowski, M., Gambin, M., Hansen, K., Holas, P., Hyniewska, S., Wyszomirska, J., Pluta, A., Soban, ́ S. M., & Łojek, E., (2021). Risk of developing post-traumatic stress disorder in severe COVID-19 survivors, their families and frontline healthcare workers: What should mental health specialists prepare for? Front. Psychiatry, 12, 562899. doi: 10.3389/ fpsyt.2021.56289. Sijbrandij, M., Horn, R., Esliker, R., O’May, F., Reiffers, R., Ruttenberg, L., Stam, K., De Jong, J., & Ager, A., (2020). The effect of psychological first aid training on knowledge and understanding about psychosocial support principles: A cluster-randomized controlled trial. International Journal of Environmental Research and Public Health, 17(2), 484. https:// doi.org/10.3390/ijerph17020484. Singh, S., Roy, D., Sinha, K., Parveen, S., Sharma, G., & Joshi, G., (2020). Impact of COVID-19 and lockdown on mental health of children and adolescents: A narrative review with recommendations. Psychiatry Research, 293, 113429. https://doi.org/10.1016/j. psychres.2020.113429. Sow, A., De Man, J., De Spiegelaere, M., et al., (2020). Integration of mental health care in private not-for-profit health centers in Guinea, West Africa: A systemic entry point towards the delivery of more patient-centered care? BMC Health Serv. Res., 20, 61. https://doi. org/10.1186/s12913-020-4914-3. Strengthening Access to Mental Health Services in Sierra Leone. https://www. advancingpartners.org/sites/default/files/technical-briefs/apc_technical_brief_sierra_ leone_mental_health.pdf (accessed on 27 October 2022). Van, B. T., Basnayake, A., Wurie, F., Jambai, M., Koroma, A. S., Muana, A. T., Hann, K., et al., (2016). Psychosocial effects of an Ebola outbreak at individual, community and international levels. Bulletin of the World Health Organization, 94(3), 210–214. https://doi. org/10.2471/BLT.15.158543. Werner, M., & Acland, O., (2019). Toxic Stress’: Addressing Mental Health Needs in Sierra Leone. Aljaseera. https://www.aljazeera.com/gallery/2019/7/21/toxic-stress-addressingmental-health-needs-in-sierra-leone (accessed on 27 October 2022). WHO, (2016). Mental Health Services in Liberia: Building Back Better. https://www.who. int/newsroom/feature-stories/detail/mental-health-services-in-liberia-building-back-better (accessed on 27 October 2022). WHO, (2017). Culture and Mental Health in Liberia: A Primer. Geneva. World Health Organization. WHO–Africa, (2016). Improving Access to Mental Health Services in Sierra Leone. https:// www.afro.who.int/news/improving-access-mental-health-services-sierra-leone (accessed on 27 October 2022). World Health Organization and Calouste Gulbenkian Foundation, (2014). Social Determinants of Mental Health. Geneva, World Health Organization.

CHAPTER 9

Addressing Mental Health and Psychosocial Support Needs in Cameroon, Kenya, Tanzania, and Uganda JOSEPH O. PREWITT DIAZ

The Pennsylvania State University (Retd.), Pennsylvania, USA

ABSTRACT This chapter explores the impact of mental health and psychosocial support (MHPSS) in selected sub-Saharan countries. Concerns have risen in SubSaharan countries related to their capacity to identify behaviors congruent with a universal definition of mental illness related to the mental health and psychosocial support consequence of the pandemic. This is a report of the findings from 62 Zoom calls conducted between July to December 2020. 9.1 INTRODUCTION This chapter explores the impact of mental health and psychosocial support (MHPSS) in selected sub-Saharan countries. Concerns have risen in SubSaharan countries related to their capacity to identify behaviors congruent with a universal definition of mental illness related to the mental health and psychosocial support consequence of the pandemic. Here we review the literature and share in the table form the opinion of Ministry of Health staff from the target countries. The chapter is the result of focused groups with personnel from the local Red Cross Society, the Office of the Ministry of Health in each country, and the country Red Cross Society. A total of 62 persons participated in the Zoom calls. The author then reviewed existing literature to support the interviews comments. Mental Health and Psychosocial Support during the COVID-19 Response: An Overview. Joseph O. Prewitt Diaz (Ed.) © 2023 Apple Academic Press, Inc. Co-published with CRC Press (Taylor & Francis)

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The emergence of COVID-19 in sub-Saharan countries has raised fears due to high vulnerability and fragile public health and mental health capabili­ ties. Molebatsi, Musindo Ntlatsana, & Wambua (2021) report that many of the sub-Saharan countries are experiencing a pandemic with under-resourced mental health care systems, characterized by lack of a defined system that detect mental illness, inaccessible services for most of the population. There is a shortage of mental health and psychosocial support workers and limited funding. Mental health is constructed and defined by societies or cultures that spend time defining what is healthy and what is not and what are appropriate interventions to correct the behavior that does not match with the concept of health (Office of the Surgeon General of the United States, 2001). Logana­ than & Murthy (2008) define stigma as an expression of fear, avoidance, and anger to mental illness because of ignorance, religious beliefs and fear, and the inability to define “what is wrong” (p. 40). Amuyunzu-Nyamongo (2013) further suggests that in many societies’ stigma has a deleterious impact on the family (children, the elderly, chronically ill and women). Pedroza et al. (2020) suggest that there are three factors that come together to impact mental illness and psychosocial well-being: (i) The social environment in many African countries does not adequately define the concept of good mental health, in the context of culture, and existing religious and mystical traditions. (ii) Poverty is a major cause of mental illness. Since the great majority of the population in these countries live in poverty, they are more vulnerable to behaviors that are categorized as mental illness, while those with pre-existing mental illness are more likely to become trapped in poverty due to decreased capacity to function optimally. (iii) Inability of the person to appropriately express their needs (Pedroza et al., 2020). To better understand the perception of communities toward COVID-19, community engagement (CE) is very important. It has been considered a fundamental component of past outbreaks, such as Ebola. However, there is concern over the lack of involvement of communities and ‘bottom-up’ approaches used within COVID-19 responses thus far. Gilmore, Ndejjop, Tchetchia et al. (2020) identified how CE approaches that have been used in past epidemics may support more robust implementation within the COVID-19 response. Furthermore, Gilmore, Ndejjop, Tchetchia et al. (2020) identified COVID-19’s global presence and social transmission pathways required for social and community responses. That is important to (i) reach marginal­ ized populations; and (ii) support equity-informed responses that permit

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communities o play important and active roles in the prevention and control of the pandemic in the Sub-Saharan countries (Gilmore et al., 2020). The Africa Center for Disease Control and Prevention (May 19, 2020) developed and widely disseminated guidance addressing the steps to address MHPSS in African countries. WHO (2020) suggests key actions on mental health and psychosocial support (MHPSS) considerations in relation to the coronavirus disease 2019 (COVID-19) pandemic, as well as provides the guidance to provide MHPSS for the community, healthcare workers, care­ givers of vulnerable populations, and people in quarantine, isolation, or treat­ ment centers. Finally, WHO (2020) provided practical steps to reduce stress, anxiety, stigma, and psychological disorders associated with COVID-19 and to enhance overall mental health and well-being (WHO, 2020). The COVID-19 outbreak triggered serious psychosocial consequences at both the individual and community levels. Semo & Frissa (2020) in their analysis of the impact of COVID-19 in Sub-Sahara Africa suggest that fear of death, stress, grief, anxiety, and depression have been reported at the individual level. Semo & Frissa (2020) further hypothesized that stigma, discrimination, and interruption of social networks were observed in their research at the community level. The three factors that affect the population in the Sub-Saharan region as a result of COVID-19 are: (i) the direct impact of COVID-19; (ii) the Inability to control the spread of the COVID-19 virus; and (iii) loss of economic wherewithal. Mental health experts (Galea, Merchant, & Lurie 2020) suggest that the mental health of the communities is of concern during this pandemic. Anxiety heightened by the fear of contracting the virus and uncertainties due to poor information coming from governments and media. Extended lockdowns, curfews, and loss of work opportunities have impacted the economic livelihoods of many, thus influencing their mental health. According to Molebatssi, Musindo, Ntantsana, & Wambua (2021) the potential rise in persons needing mental health and psychosocial support in large urban areas and villages services has been an issue in the target countries addressed in this chapter countries due to a lack the human resource to cater to increased need of persons needing care. Meffert et al. (2021) after studying the impact of COVID-19, suggest that the pandemic may bring an opportunity to the Sub-Saharan countries to be leveraged to merge public health with mental health, foster togetherness, and reduce prejudice and stigma. Kenya and Cameroon have developed guide­ lines to address psychosocial issues. These guidelines focus on psychological first aid (PFA) as the primary tool to help people alleviate fear (Table 9.1).

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TABLE 9.1 An Encapsulated Summary of Focused Groups Conducted by the Author (Prewitt Diaz, between October 2020–March 2021)* Table for Source Country, Need and Challenge for MHPSS during COVID-19 Country Need Actions Taken to Curb Spread Lead Agency in the Field of COVID-19 Cameron Develop MH School closure, mandatory Red Cross providing infrastructure masks, restricted travel. Reliance psychological first aid and on Cameroon Red Cross is the accurate information and point for providing PSS to the referral in communities community and workers Kenya The COVID-19 (i) preparation of a formal mental Assist in screening, health response plan specific management, and providing response in MHPSS (psychological first Kenya has no to the COVID-19 pandemic; formal mental (ii) training; (iii) providing text aid services, information dissemination, and training health response message surveys. Lockdown, of community health plan. travel van between countries, mandatory quarantine. workers and midwives) Tanzania Mental health Provide mental health and Provide guidance on the psychosocial social; manage the implementation of PSS is a priority. Increase stress of staff and volunteers in during and after COVID-19 MHPSS action. Provide (i) information and education; (ii) training for resources. community volunteers; (iii) Limited atten­ tion the PSS engage communities in participa­ tory approaches. Uganda Need to Need financing to develop Foster healing, and enhance develop alternate MHPSS care models. resilience in the community community Training for community workers. by training and provide mental health psychological first aid *This table addresses the needs and challenges in four sub-Saharan countries for mental health

and psychosocial support. An analysis of this table suggests the need for mental health and psychosocial support for the most vulnerable, the poor, and the marginalized.

The mental health and psychosocial consequences of the Ebola outbreak persisted after the end of the epidemic. Semo & Fressa (2020) observe that while Ebola was deadlier and less contagious than COVID-19, the mental health and psychosocial consequences arising from the COVID-19 pandemic in sub-Saharan African countries are having similar mental health impacts and require psychosocial support and public responses. Out et al. (2020) report that the closure of schools, self-isolation, limits on people gathering in public places (e.g., weddings and burials) and visi­ tation of those in hospitals has been curtailed out of fear of transmitting the virus. These strategies have added additional stressors, such as the loss

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of loved ones due to COVID-19, economic anxiety from job losses, and financial instability, all constitute clear and present dangers. Isolation and physical, and an increase in issues, such as child abuse, internal, intimate partner violence, and suicide (Out et al., 2020). Out et al. (2020) further indicate that despite the aforementioned efforts, the mental health and psychosocial needs of the majority of the people are of concern during this pandemic but have not been given priority. Out et al. (2020) suggest that despite the provision of Mental Health and Psychosocial Support guidelines, gaps still exist, making them inadequate to meet the mental health needs of the communities with large numbers of COVID-19 cases. Molebatsi et al. (2021) compared the MHPSS in stable times and during COVID-19 and concluded that some of the mental health needs required at this time are different from what is needed in a stable environment. First, Molebatsi et al. (2021) felt that the mental well-being of individuals might be addressed by clear and consistent communication by the Ministries of Health and Welfare, geared toward assurance that taking the necessary measures they will be able to deal with the pandemic in the various countries. Secondly, Molebatsi et al. (2021) that by defining clear pathways for individuals to seek mental health and psychosocial support, the results would: (i) identify the need for more awareness on mental health needs that may arise because of the pandemic; (ii) a clear and structured referral systems that will help in the management of mental health needs; and (iii) alternative methods of support such as the use of telemedicine to interact with persons in need of psychosocial support Molebatsi et al. (2021). 9.2 CAMEROON Cameroon, a Low-Middle income country located in the Central African sub-region, was not spared by the COVID-19 pandemic. The WHO (2021) reported the first case of COVID on March 6th, 2020, community transmis­ sion was observed resulting in a cumulative 26,277 cases and 448 deaths as of December 31st, 2020. A nationwide observational study, conducted by Siewe, Musindo, Ntlantsana, & Wambua (2021) suggested that COVID-19 fear scores were highest at the beginning of June 2020, representing the first epidemic peak in Cameroon with thousands of cases confirmed on a weekly basis. During the latter months, schools were allowed to resume cautiously, and this brought about a semblance of normalcy in the daily routines of Cameroonians. These changes may have had repercussions on the overall

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psychosocial well-being of participants over time (Siewe, Musindo, Ntlant­ sana, & Wambua, 2021). Kannampallil, Goss, Evanoff, Strickland, McAlister, & Duncan (2020) found that the frequency of depression and high fear of COVID-19 was similar among participants who were workers/students in the healthcare sector and others not involved in healthcare. Indeed, increased exposure to COVID-19 cases has been shown to fuel stress, anxiety, and depression among healthcare providers. Reicher & Durry (2021) observed that during the COVID-19 outbreak in Cameroon, the affected people were more concerned about the health of their loved ones than their own health. This finding is relevant in the context of implementing public health measures such as mandatory quarantine and vaccination for COVID-19. Although adherence to preventive measures may depend more on their practicality (ease of implementation) than on the psychology of individuals (Reicher & Durry, 2021), one could still appeal to altruism by reminding the public about the community-wide benefits of such interventions. Mviena et al. (2020) reported that Cameroon was vulnerable to mental health problems related to COVID-19 due to the challenges of a weak healthcare system, inadequate mental health workforce, insufficient financing to pay for health care, lack of access to mental health medications, and the added complexity posed by ongoing humanitarian crises. In spite of efforts taken by the Cameroon’s Ministry of Public Health to increase the Mental health and psychosocial support availability in its hospitals and clinics, Diewe Fodjo et al. (2021) disagrees with this report, and indicates that the Cameroon healthcare system has not set up concrete measure of great magnitude to respond to mental health and psychosocial well-being, despite the growing needs and concerns of its population. Mari-Chntel et al. (2020) indicate that with the spread of COVID-19, some prominent factors are likely to generate a sense of vulnerability, on the one hand, and a plethora of psychological responses, on the other hand, the scarcity of frontline healthcare workers. Mviena et al. (2020) document how the Cameroon’s Ministry of Public Health has taken pragmatic steps towards ensuring that mental health is part of a core health systems approach. Pietrasbissa et al. (2020) found that some factors were not readily considered, such as: (i) understanding that travelers were not always psychologically prepared to spend 14 days or more in isola­ tion; (ii) considering the suggestions proposed by professionals on the ground related to the integration of psychological services into the national response against COVID-19, ranging from traveler arrivals to follow-up of positive cases in the community. Mviena and colleagues report that most recently

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health workers involved in the national response have received briefings and training from a team of psychiatrists on PFA, confidentiality, and stress management guidelines and procedures (Mviena et al., 2020). These training has been applied by teams using real-time integration of feedback into the response protocols. The IOM Cameroon Crisis Response Plan (2021) has integrated a strategy that promotes PFA as a first order intervention. During and in the immediate aftermath of COVID-19, using the PFA/WHO guide comfort and practical support, focusing on mental and psychosocial response were provided (World Health Organization (WHO), 2018). COVID-19 in Cameroon has triggered anxiety, stress, depression, trauma, and psychosocial issues, like stigmatization. PFA and psychoeducation were appropriate for preliminary intervention in the context of COVID-19. According to Moreno et al. (2020), the Ministry of Health established a toll-free number in collaboration with the Cameroo­ nian Red Cross for psychological support to support and sustain the affected and infected people after the pandemic is over. 9.2.1 THE ROLE OF THE CAMEROON RED CROSS The IFRC (July 2021) reports that Red Cross volunteers continue to respond to the outbreak, carrying out activities such as house and school disinfection and encouraging the population to practice handwashing and other protective measures, providing information and psychoeducation through community radio to reduce misinformation and rumors circulating in the community. Volunteers use the tools available to them as communication channels like megaphones, posters, social networks, and the radio to disseminate protec­ tion measures against COVID-19. According to the IFRC (2021), the National Society should strengthen the capacity of its volunteers and staff at headquarters and in branches. Over the past years, CRC’s leadership, management, and operational teams have discussed the importance of being prepared by assessing, measuring, and analyzing its strengths and gaps response system to take action (IFRC, 19 July 2021). 9.3 KENYA In Kenya, mental health and psychosocial support during the COVID-19 pandemic consisted of messaging from the Ministry of Health. This effort

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was followed by The Ministry of Health by providing awareness on mental health needs as a result of the pandemic; developing structured referral to manage mental health and psychosocial support needs, and enhancing the use of telemedicine to provide psychosocial support (IFRC, 2021). The Kenya Mental Health Policy 2015–2030 (Government of Kenya, 2020) provides for a framework on interventions for securing mental health systems reforms in Kenya. This policy highlights Mental Health as a key determinant of overall health and socioeconomic development. It influences individual and community outcomes, such as healthier lifestyles, better physical health, improved recovery from illness, fewer limitations in daily living, higher education attainment, greater productivity, employment, and earnings, better relationships with adults and with children, more social cohesion and engagement, and improved quality of life. COVID-19 mental health and psychosocial support response plan in Kenya has not been favorable for the population (Pinchoff et al., 2020). While guidelines for the management of mental health conditions during the COVID-19 pandemic have been prepared, implementation remains a major challenge due to a poorly resourced mental health system. According to Jaguna & Kwobah (2020), a surveillance system has been initiated, that will enhance the ability of the Ministry of Health to design mental health and psychosocial support evidence-based interventions. In their study, Kwobah et al. (2021) found that the levels of stress and anxiety, including worry, depression, anxiety, sleeping difficulties, and harmful alcohol and substance use, as well as manifestations of stigma and have increased the poor and marginalized population. The leading three issues reported by Kowbah et al. (2020) were fear of losing a loved one to COVID-19, infecting others, and getting infected with COVID-19 themselves. The respondents in the above study reported feelings of depression, the majority of respondents felt at higher risk as a result of pre-COVID-19, population-wide psychological and cultural factors. The cohort of younger health workers reported a higher degree of burnout and depression attributable to emotional exhaustion (Kowbah et al., 2020). 9.3.1 ROLE OF THE KENYA RED CROSS DURING COVID-19 The emergence of the COVID-19 outbreaks in Kenya, precipitated and recognized the importance of the critical role in the Kenya Red Cross’s mental health and psychosocial support provision. The Government of Kenya designated the Kenya Red Cross as their official partner in mental health

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and psychosocial support early in the pandemic, which gave the Kenya Red Cross a key role in coordinating and providing services to promote good mental health and to support those experiencing psychological distress. The volunteers worked in close partnership with the Government and other mental health and psychosocial support actors, but their partnerships with community volunteers across the country were key to reaching the more difficult-to-access sections of the population (IFRC, 2021). These efforts to strengthen community capacity paid dividends once the COVID-19 outbreak hit Kenya. Life in the informal settlements is precarious in normal times, but these communities have been particularly hard-hit by the social and economic effects of COVID-19. The Kenya Red Cross and its volunteers’ network played an important role in the government’s home-based care model for people who are asymp­ tomatic. When the COVID-19 outbreak began, they were quickly trained to offer emotional support, as well as pass messages designed to promote good mental health, to even those in the most remote areas (IFRC, 2020). The Community Health Volunteers, along with other Kenya Red Cross has built up strong community volunteer networks over many years, and these have been crucial in their efforts to address mental health and psychosocial issues during the COVID-19 pandemic. The volunteers had a deep understanding of and commitment to their communities, and a desire to enhance the psychosocial well-being of their fellow community members at the critical moments of COVID-19 (IFRC, 2021). Volunteers trained in PFA using materials that the Kenya Red Cross and the Ministry of Health worked together to adapt the PFA methodology to the Kenyan context and the COVID-19 situation. The Kenya Mental Health Policy recommended response during the early phases of the pandemic focused on the preparation of a mental health response plan to serve as a guide for actions to be taken during the pandemic (Ministry of Health of Kenya, 2020). The plan suggested that to manage the distress and anxiety often witnessed during pandemics, health care workers were trained on how to administer PFA during the early phases of the pandemic. At the beginning of the COVID-19 pandemic in Kenya, the healthcare workers used PFA as a guide via virtual platforms (Ministry of Health of Kenya, 2020). There have been reports (Muhorakeye & Biracyaza, 2021) of unmet needs in the community. A major challenge likely to be faced despite the guidelines is that the number of mental health facilities and mental health workers available in Kenya is scarce.

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Adepoju (2020) reported that using mobile phones and other technology to deliver mental health and psychosocial support services in Kenya during the current pandemic was a challenge as a result of limited infrastructure as well as ensure compliance with pandemic containment measures (Adepoju, 2020). Marangu et al. (2021) reported that there are fewer than 500 specialist mental health workers to serve Kenya’s population of over 50 million. The Mental Health Atlas (2017) series published by WHO provides the most comprehensive surveillance data and resources for mental health for affiliate countries and regions globally reported that there are three psychiatric hospitals. The Mental Health Atlas reports no information for community care or residential care, or prevalence rates for mental illness in Kenya. A recent study (Marangu et al., 2021) highlighted the need for interventions that can help to develop and enhance mental health knowledge and skills among primary healthcare workers to ensure adequate and effective response to the disease burden related to mental illness in Kenya. The most salient finding was the very low levels of diagnostic accuracy for mental illness among participants whose primary role includes assessment, diagnosis, and treatment of mental illness. Mwesiga et al. (2021) reported that with a surge of the pandemic in African countries, the need for isolated spaces and the alternative use of inpatient psychiatric beds for patients with COVID-19 are only expected to rise. An expected increase in the incidence of mental health-related complications will also pose a challenge because of the inadequate space; yet existing patients need ongoing care. Now rather than later, a discussion of community models of care for patients with mental illness need to be expedited. Since the outset of the pandemic, telehealth service providers have rapidly scaled offerings. Africans are opening up to telemedicine for mental health and are joining the rest of the world in using social messaging tools, such as WhatsApp, to provide telemedicine services. Currently, counseling is being conducted via mobile phone voice calls for persons in isolation and quarantine. There is, however, a lack of mobile mental health interventions targeting the general public. The government, through the Ministry of Information and Technology (IT), initiated the dissemination of information campaigns and public educa­ tion. The Ministry set up free telephone lines and hotlines for the public who called received information.

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According to Shah et al. (2020), the Ministry of Health provided training for community health workers (CHWs) and volunteers on PFA to enable access to psychological support for those in distress during the pandemic, particularly at the grassroots level. Many of these training opportunities were conducted remotely via video conferencing, given the good internet coverage and smartphone penetration rates in Kenya (Jaguga & Kwobah, 2020). However, Jaguga & Kwobah (2020) observed that community’s compliance with public health interventions to control the outbreak of the pandemic rely on individual understanding of risk, knowledge, and practice amongst the general population. 9.4 TANZANIA

According to Muhorakeye & Biracyaza (2021) in Tanzania, as in many resources poor countries, community-based mental health services are inad­ equate at all levels of the healthcare delivery system. The first contact with mental health care providers begins to happen mainly at the district level, where professional support is provided to facilitate recovery Iseselo et al. (2016). Mental health care and psychosocial support in Tanzania face a lack of social support, disruption of family functioning, stigma, and discrimina­ tion. All factors that intervene appropriate care for the population (Iseselo et al., 2016). The Ministry of Health, Community Development of Tanzania (2020) has declared that mental health is a priority during the COVID-19 pandemic. The immediate goal is to address coping with fear, through an information campaign related to COVID-19 sequelae. The Ministry of Health (2020) proposed the development of Mental and Psychosocial support Teams that were responsible for implementing the following actions: (i) reduce fear; (ii) dissemination of protective equipment; and (iii) use of social media to share timely information as well as conducting training and providing telehealth. Finally, capacity building about providing mental health and psychosocial support services for midwives, teachers, and other community volunteers enhances community sense of security and well-being (Ministry of Health, pp. 58–65). The guidance developed by the Tanzania Ministry of Health puts measures in place that guide the clinical and community delivery of mental health and psychosocial support interventions during and after the outbreak (Ministry of Health, Community development, gender, elderly, and children

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(2020). They highlight not only those prone to psychological deterioration during and after the COVID-19 outbreak but the whole society. The InterAgency Standing Committee used the MHPSS Briefing Note (2020) to unite a broad range of actors, underscoring the need for diverse, complementary approaches in the provision of appropriate support. It goes further to suggest that there are overarching principles to the MHPSS response. The Mental Health World Atlas (2020) suggest that the blind spot-on mental health is evidenced is evidenced by the lack of Mental Health facili­ ties and psychosocial support-related activities in communities conducted by health and CHWs. While Tanzania has included MHPSS as part of their COVID-19 response plan, the level of funding is greater for the geographic area with the more affluent population in urban areas. In Tanzania as well as other sub-Saharan countries, a cross-cultural approach that considers the needs, expectations, and human capital of every village, language and cultural group should be considered and incorporate both local practices and the local languages used to express individual and community mental health and psychosocial needs (Alegria et al., 2010). This can only be achieved if mental health and psychosocial support are promoted as a priority in the fight to support the total population during the COVID-19 pandemic. 9.4.1 THE ROLE OF TANZANIA RED CROSS In Tanzania, IFRC, in partnership with Radio Kwizera, one of the most popular Kiswahili radio stations in the Kigoma region, has been dissemi­ nating mental health messaging to promote positive coping mechanisms. The messaging uses jingles, educational dramas, and live interviews with psychologists and CHWs in local languages. TRCS The measures being taken to contain the spread of COVID-19 may hinder the ability of families to stay in touch. For instance, family members may not be able to visit relatives in health, isolation or quarantine centers and in detention facilities; people may also be prevented from entering, leaving or moving around IDP or refugee camps. Moreover, the situation exacerbates matters for families that have already been dispersed by conflict, migration, or natural disasters, and makes it difficult to continue work on behalf of the missing and their families. The Tanzania Red Cross is attempting to ensure that people – including children and older people separated from their caretakers, and migrants – can

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remain in contact with their relatives despite movement restrictions, while respecting infection prevention and control measures. Some 800 volunteers have been sharing accurate information about the pandemic and providing PFA in the villages, and refugee camps (IFRC, 2020). 9.5 UGANDA Uganda is the second-most populous country of Africa. Uganda has approximately 42 million inhabitants, and its capital is Kampala, where most medical facilities are located. Ainamani et al. (2020) reports that there were 39,314 COVID-19 cases in and around Kampala. According to Mugisha et al. (2019) the mental, neurological, and substance use disorders in Uganda are a major public health burden. Uganda’s mental health system receives the majority of cases with depressive disorders and anxiety disorders, and elevated stress levels are the most common, sometimes leading to suicide attempts (Miller, Kintu & Kiene, 2020). Most mental health referrals are sent to the Butabika Hospital in Kampala. Shah et al. (2017) report that the population living outside of Kampaqlka are seen Others are seen at one of the 28 community-based psychiatric inpatient units available in the country, with a total of 382 beds. Wadika, Okello, & Rukundo (2019) indicate that the transformation of psychiatric units into isolation centers in Uganda requires mental health providers to adopt new care models that do not involve these stand-alone units. Wadika et al. concluded that models for community mental health care in Uganda, such as integrating psychiatric care into everyday clinical practices, are crucial during this pandemic. To strengthen mental health and psychosocial support as part of the COVID-19 response, the health authorities in Uganda reported an increase in personnel and funding. WHO Africa (2020) reported that a team of 35 counselors has been deployed to the central region where their capital Kampala is located, and up to three mental health care workers are attached to every quarantine site (WHO-Africa (8 October 2020) Coping with Mental Health impact of COVID-https://www.afro.who.int/news/coping-mentalhealth-impact-covid-19). Around 230 psychosocial workers have been trained across the country to ensure that MHPSS services are operational (WHO-Africa (8 October 2020). Psychosocial support programs can be implemented and have an impact on communities long after the program is first initiated. Implementation

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strategies guided by implementing organizations and iteratively improved helped to maximize the effectiveness of programs within each community while being mindful of contextual factors and available resources. Cohen et al. (2021) indicate that in Uganda, psychosocial programming remains conceptually different from the treatment of mental disorders through mental health programming and includes a broad array of potential intervention approaches. A recent study (Chiumento et al., 2020) attempting to identify the causes and treatment of mental illness yielded the following results: (i) Extrinsic causes of mental illness (drugs, infectious disease, and seizures); External spiritual and emotional forces (mental health); Spirits, satanic powers, poor choices, curses, bewitchment; God, who has the power to inflict mental illness upon those who have acted wrongly; and poverty and family disharmony, and interpersonal conflicts (Kagaan, 2021). (ii) Intrinsic causes of mental illness are failures or weaknesses of an individual; people that cannot control their emotions (those who think too much, who lose their tempers or make poor choices). (iii) Treatment such as medical interventions centered on the idea of the hospital being the source for the treatment of psychiatric disease (Shah et al., 2017). Such interventions include prayer, resolution of family or personal conflicts, and the use of community-based witch doctors. A commonly held belief involved the need to tailor treatment of mental illness with a mix of spiritual and pharmacologic solutions (Chiumento et al., 2020). Wessells reports that armed conflict and conflict-related displacement have psychological and social consequences for individuals’ families and communities. Shah et al. reported that displacement can lead to disruption of traditional family and community structures that support mental health and psychosocial well-being. Although successful adaptation to adverse circumstances occurs for most people, others might develop mental health disorders and need psychosocial support activities to address the adjustment and well-being in the communities. 9.5.1 MENTAL HEALTH AND PSYCHOSOCIAL GUIDANCE BY THE MINISTRY OF HEALTH One of the mental health and psychosocial support issues Uganda has been dealing with are the South Sudanese refugees from northern Uganda. According to a study on mental health and psychosocial support needs (Adaku et al., 2016), the participants suggested that coping strategies for “thinking

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too much” and “ethnic conflict” center on connectedness with a social support system, such as seeking advice from elders and church leaders and coming together to resolve community problems. Community-based mental health services and community psychosocial support activities provide support for further education of community members and training of community health workers (CHWs) to address and integrate the above-stated beliefs regarding mental illness with techniques such as PFA (UNHCR, 2019). The pandemic has disrupted the already limited mental health services in many African countries, with patients avoiding seeking services in hospitals for fear of contracting the virus. Cancellation of elective medical services also saw the number of patients drop, while restricted movement hindered people from going to health facilities. Poudlowski (2020) In Uganda, like most African countries, mental healthcare was already weak before the epidemic. The country has only 47 psychiatrists, most of whom are based in Kampala, for a population of 42 million. Mental health services are mainly concentrated around the capital city. Furthermore, mental health units at the regional referral hospitals have been turned into isolation and treatment centers for COVID-19. To strengthen mental health and psychosocial support as part of COVID-19 response, health authorities in Uganda are increasing personnel and funding. A team of 35 psychiatrists have been deployed to the Central Region, where the capital Kampala is located, and up to three mental health care workers are attached to every quarantine site, says Dr Kenneth Kalani, head of the Mental Health and Psychosocial Support unit in the Ministry of Health’s COVID-19 task force. “Around 300 psychosocial workers have been trained across the country to ensure mental health and psychosocial support services are operational.” The MHPSS is managed by the Ministry of Health (Ministry of Health April 2020), that has developed a plan to provide psychological support and access to services that contribute to a sense of normalcy, foster the healing process and enhances resilience of the affected populations. This therefore means that the population should be supported to manage the stress, to prevent the negative psychological outcomes including anxiety, depression, panic attacks, and sleep disturbances (Ministry of Health of Uganda, 2020). Most of the suggestion are focused on the caregivers, rather than the population. The plan is divided into five sections. In addition of caring for front-line workers, and health facility managers, three sections provide instructions for: (i) care providers for children; (ii) caring for older adults, and people with underlying health conditions; and (iii) caretakers of people in isolation.

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Community mental health care needs to become the primary form of care for patients with psychiatric illness in Uganda both during and after the COVID-19 pandemic. With a surge of the pandemic in African countries, the need for isolated spaces and the alternative use of inpatient psychiatric beds for patients with COVID-19 are only expected to rise. An expected increase in the incidence of mental health-related complications will also pose a challenge because of the inadequate space; yet existing patients need ongoing care. According to Poudlowski (2020), Uganda was trying to address MHPSS during the pandemic by strengthening mental health and psychosocial support as part of COVID-19 response, health authorities in Uganda are increasing personnel and funding. 9.5.2 THE UGANDA RED CROSS SOCIETY (URCS) The Uganda Red Cross Society (URCS) put great emphasis on recruiting volunteers from local communities to carry out sensitive tasks such as risk communication Geiger, Harborthy, & Mugyisha (2020). This enabled them to speak about sensitive health-related issues and ensured a tailored approach of communication, which was well received. Such a community-based approach was instrumental to the successful change of healthcare practices such as hand washing, safe and dignified burials, or social distancing. The volunteers were trained to administer PFA, and CE. The lessons from the last 12 months working in communities in a COVID-19 environment are to varying degrees fundamental to the imme­ diate response to the current COVID-19 pandemic: (i) the pool of volunteers formed the front line of response to COVID-19; (ii) a second tier of volun­ teers provided support in risk communication and spread tailored messages that ensured compliant behaviors from the affected and infected community members; (iii) continuous training and recruitment of staff was challenging due to fear of infection and death; and (iv) establishment of peer-to-peer counseling for staff, PFA, was essential to reduce staff emotional exhaustion and burnout (Geiger, Harborth, & Mugyisha, 2020). 9.6 CONCLUSION This chapter summarizes the efforts of the National Governments, the Ministry of Health, and the local Red Cross Societies in attempting to

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manage the COVID-19 contingencies. A small group of Mental Health professionals, and community volunteers (midwives, nurses, teachers, coun­ selors, and social in each one of the countries under study have received guidance on MHPSS. However, there is greater need for additional support for the population in certain domains: (i) development of clear guidelines in a National Mental Health Plan to address COVID-19; (ii) recognize the values of community-based psychosocial support (CBPSS), and PFA; (iii) recruit and train traditional healers, and other persons in the community; and (iv) provide timely information to reduce fear and stigma. KEYWORDS • • • • • •

COVID-19 financial instability mental health and psychosocial support psychological first aid social environment Uganda Red Cross Society

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PART III

Implementing Mental Health and

Psychosocial Support

CHAPTER 10

An Examination of Mental Health and Psychosocial Support in Four LowIncome Countries in South Asia JOSEPH O. PREWITT DIAZ

The Pennsylvania State University (Retd.), Pennsylvania, USA

ABSTRACT The chapter examines the effects of COVID-19 on the mental health and psychosocial (MHPSS) well-being of inhabitants in four low-income countries in Southeast Asia (Nepal, Bhutan, Bangladesh, and Myanmar). It addresses the specific Mental Health and Psychosocial Support (MHPSS) needs of the Rohingya populations in Bangladesh and Myanmar. It describes the existing documentation addressing mental health in each of these countries. The results highlight the need for continuous assessment in the communities, the need for community mobilization and increased training for community-level health workers, and the development of a pathway for recovery. 10.1 INTRODUCTION The purpose of this chapter is to explore the impact of each of these countries (Bhutan, Bangladesh, Myanmar, and Nepal) located in the southeastern part of South Asia between India and China. In order to prepare this chapter, the author conducted six interviews via ZOOM that included 61 partici­ pants during the period of 1 October, 2020, to 31 March, 2021. We will explore what extant data on COVID-19 and mental health in these countries, Mental Health and Psychosocial Support during the COVID-19 Response: An Overview. Joseph O. Prewitt Diaz (Ed.) © 2023 Apple Academic Press, Inc. Co-published with CRC Press (Taylor & Francis)

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including current infection rates and ways in which the virus has impacted their populations. Furthermore, we will explore population movements that have affected the country, including individuals who are in exile from their countries of origin for non-COVID-19-related reasons and now must, in addition to the stresses of the pandemic, address the mental health and psychosocial support issues generated by displacement and consequent barriers with the local population’s language, culture, and political and socioeconomic context. 10.2 NEPAL According to the World Population Review (2022), Nepal has a population of approximately 29.9 million. The largest city of Nepal is Kathmandu, its capital, which has a population estimated at 1.5 million residents. Nepal has a multi-ethnic population composed of east Asians, Indo-Aryans, and Tibetans. The preferred language is Nepali, although a half-dozen other languages are spoken across diverse geographic areas. The two predominant religions in Nepal are Buddhism and Hinduism, with a small segment of the population identifying as Christians or Muslims. The Ministry of Health and Population (MoHP) is responsible for all health policies and plans and health activities and outcomes. Gyawali et al. indicate that the mental health programs in Nepal are operationalized by the Non-Communicable Disease and Mental Health Section. The country has only one mental health hospital located in Lagankhel, Lalitpur, with a 50-bed capacity. Rai et al. (2021) explored the mental health system in Nepal and found that mental health services are provided by the Psychiatry units of medical colleges, provincial government hospitals, and a few private hospi­ tals (about 500 beds). Mental health clinics have been initiated in different subspecialties, such as youth, attention, and memory, head trauma or pain, and addiction, as well as caring for the MHPSS of the population as a result of COVID-19. 10.2.1 MENTAL HEALTH LEGISLATION A comprehensive National Mental Health Policy was first formulated in 1996 and incorporated in the Ninth Five-Year National Plan by the Government of Nepal. However, the implementation of the policy was ineffective. The MoHP prepared a draft in 2018, which has undergone rigorous consultations

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with federal, provincial, and local government representatives in mental health and is planned to be endorsed by the Ministry of Health. Angdeme et al. in their situational analysis to develop community mental Health in Nepal reported that The Ministry of Health developed the Community Mental Health Care package in 2017 to facilitate implementation of the 1996 National Mental Health Policy. According to Spagnolo & Lai, the revision to the MH guidance was guided by the principles of integration of mental health into primary care and by the WHO mental health Gap Action Program (mhGAP). 10.2.2 TRAINING

Three-year postgraduate training in psychiatry (i.e., MD Psychiatry) started in 1997 and is now available in 16 institutions in Nepal. Although there are currently five post-graduate training programs, their training curricula and evaluation processes are not uniform. Currently, according to Singh et al. (2022), there are approximately 45 residents in psychiatry training. The undergraduate syllabus in Psychiatry is not nationally standardized; each university has its own version. 10.2.3 MENTAL HEALTH AND COUNSELLING According to Singh and colleagues (2022) in their article in the history of psychiatry in Nepal they report that Nepal (CMC Nepal) and the Transcul­ tural Psychosocial Organization Nepal (TPO Nepal) provided mental health and psychosocial care to the victims of civil conflict and of the Bhutanese refugee crisis. Non-government organizations (NGOs) have also contributed to the scaling up of community mental health programs, in collaboration with the Mental Health Policy. 10.2.4 CHALLENGES TO MENTAL HEALTH AND PSYCHOSOCIAL CARE Upadhaya et al. studied MHPSS services in primary health care in Nepal. They concluded that to ensure effective implementation of mental health and psychosocial care in primary care settings, the following are needed: (i) increase budget to ensure effective scaling up of community-based mental

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health programs throughout the country; (ii) formulation and implementa­ tion of awareness-raising and anti-stigma campaigns in communities; (iii) increase recruitment of psychologists, psychiatric nurses, psychosocial counselors, and community-based psychosocial workers; and (iv) increase clinical supervision of trained non-specialist service providers. 10.2.5 THE IMPACT OF COVID-19 ON MENTAL HEALTH AND PSYCHOSOCIAL NEEDS WHO (2020) suggested that lockdown, curfews, self-isolation, social distancing, and quarantines imposed by the COVID-19 pandemic have affected the overall physical, mental, spiritual, and social well-being of the Nepalese. Gupta et al. in their examination of pathways to mental health discovered that individuals suffering from pre-existing mental health condi­ tions are at a higher risk. Shrestha et al. (2021) in their study related to preparedness for COVID-19 found that the Government’s current attempt to integrate mental health services at the primary care level is encumbered by lack of infrastructure, intermittent medicine availability, and frequent change of trained healthcare providers. Sharma et al. (2021) explored the impact of government measures to curtail COVID-19, and found that the lockdown curfews, self-isolation, social distancing and quarantine have affected the overall physical, mental, spiritual, and social well-being of the Nepalese. Poudel & Subedi (2020) reported that in the beginning of lockdown, the government decided to shut down all cinema halls, gyms, health clubs and museums, as well as banned the gathering of people for cultural, social or religious activities, including temples, monasteries, churches, and mosques. According to Poudel & Subedi (2020) the action of the government of Nepal to close all educational institutions, postponing of all national level examinations and prohibiting the gathering of more than 25 people together led to an outflux of more than 3,00,000 people from Kathmandu in 3 days (Rising Nepal Daily, 2020). Perceiving the village environment as pure, free from germs and contamination, and unlikely to get coronavirus might have led to the surge in the outflux of people. The drastic increase in new infection rates, lesser tests, increased media reporting and death tolls have increased public anxiety. The absence of clear messages and the desire for facts have heightened fear among the public and propelled them to seek information from less reliable sources.

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In Nepal, contracting COVID-19 has led to an increased stigma and social discrimination among the population. Singh & Subedi (2020) found that cured patients upon returning home are socially avoided and discrimi­ nated against, leading to decrease in moral support. Divia et al. (2020) report that in Nepal, stigma has negatively affected clients searching for medical care at a time when they are at their most vulnerable stage. Stigma and social discrimination have led to hiding of symptoms and avoid seeking of medical care, making it tremendously difficult for healthcare professionals and the government to control the disease. Shrestha et al. (2020) conducted a survey to determine the impact of COVID-19 in Nepal; they found that This stigmatization has discouraged people from adopting healthy behaviors and can dramatically increase the suffering of people, leading to fatigue, stress, and other mental distress. Bhatt et al. (2020), as a result of their qualitative study concluded that by understanding the disease, building trust, showing empathy to those affected, and adopting effective practical measures, people can help to save their dear ones. According to a report from IOM (2020), Return migrants and persons (including youth and women) engaged in resource-dependent, informal economic sectors are facing uncertain times that are straining, threatening, and disrupting their livelihoods are part of the population at risk in Nepal. School closures also act as major social disrupters, cutting children and adolescent off from critical social networks. In addition to confronting heightened mental health and psychosocial risks, out of school children face decreased access to support services and increased exposure to householdlevel violence and abuse. Emotional and psychosocial distress and anxiety are rising among vulnerable groups, exacerbated by pre-pandemic social isolation. Suicide, a pre-existing public health issue, remains an issue of concern amid growing mental health and psychological well-being concerns, including among frontline service providers. Youth, adolescents, women, people living with disabilities and members of sexual and gender minorities face specific vulnerabilities. The COVID-19 pandemic has engendered tremendous psychological problems in various subpopulations; thus, there is an urgent need to priori­ tize strategies for mitigating mental health impacts on the public. Rai et al. (2021) reported that given the limited resources available for mental health care, providing education and training on psychosocial issues to healthcare leaders, first responders, and healthcare professionals may be key to addressing the current needs of the public. Furthermore, there is an urgent

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need to develop a mental health and emergency management committees tasked with identifying, developing, and disseminating evidence-based resources and interventions for mental health needs during this pandemic, especially in a developing nation such as Nepal. 10.2.6 COMMUNITY ENGAGEMENT (CE) Neupane et al. (2020) suggest that Nepal needs a strong: (i) national surveil­ lance system; (ii) capacity building of a critical mass of healthcare workers; (iii) implementation of participatory community engagement (CE) inter­ ventions; and (iv) a plan for a phased lockdown exit strategy for reducing transmission and enabling in resuming some parts of economic and social life. To prepare for the possible outbreak of COVID-19, information, educa­ tion, and communication (IEC) materials were developed and disseminated at strategic locations across the country as well as through Television and Radio. Napane et al. (2020) indicates that among the CE measures, communities were empowered, and the services planned and implemented based on the community’s feedback. Only with the support of motivated people from the community, can the Ministry of Health enhance our focus on critical func­ tions such as community education, supporting health workers, protecting vulnerable groups, case finding, contact tracing, and cooperation with physical distancing measures, hand hygiene and respiratory etiquette. An attempt is ongoing to understand the knowledge, attitude, perception, behaviors of the community and the proper channels and community-based networks to promote scientific and public health messages for an effective response to COVID-19 pandemic. Participatory CE interventions with accu­ rate information on risks of COVID-19, and the actions people can take to protect themselves. Neupane (2020) reports that the focus of the Ministry of Health was the displaced populations, migrants, and people residing in high-density and informal settlements, because they are at particularly high risk from the interruption of already limited health and social services. 10.2.7 THE NEPAL RED CROSS SOCIETY (NRCS) RESPONSE TO COVID-19 NRCS has continued its COVID-19 response in 2021, with the activation of the Emergency Operation Center (EOC) being led by the Health service

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department in coordination with NRCS executive members, senior manage­ ment team. The organization has continued to serve its 77 districts in Nepal. 10.2.8 MHPSS RESPONSE IN NEPAL

The MHPSS response in Nepal is being coordinated by UNICEF. Providing accessible MHPSS by working with existing helplines and setting up new ones; creating initiatives that use mobile phone technology around MHPSS services by exploring ways to engage the private sector and mobile phone operators to provide platforms to connect youth at risk with psychological first aid (PFA) and counselling services; and reaching out to children in critical areas such as wards in hospitals and in the community. WHO and the International Committee of the Red Cross (7 April 2021) are addressing the MHPSS needs of the Nepali people as well by training personnel, material development, and dissemination of information. As part of the intervention community health workers (CHWs) and Red Cross volunteers intervened in communities by dissemination of information and holding psychoeducation activities for children in schools. UNICEF identified safe spaces at youth clubs and other venues where health workers have increased value clarification sessions around psychoso­ cial needs arising from the COVID-19 pandemic. UNICEF has worked with the one service provider of mental health services based in Kathmandu to help them set up outreach services to other areas, including through capacity building and deployment of technical resources. The themes of the UNICEF program include: (i) peer-to-peer support groups with a specific focus on anxiety and distress to empower youth and enhance help-seeking behaviors; and (ii) an effort for neighbors helping to identify cases and provide support and referral information. 10.3 BHUTAN According to the CIA World Book, Bhutan, is located at the eastern edge of the Himalayas, with an approximate population of 7,82,000. The majority of the population live in small, scattered villages. In 2010, the King of Bhutan began measuring the Gross National Happi­ ness, which comprised nine domains. Psychological well-being is the first domain, mental health is encompassed within the fourth domain, and cultural diversity and resilience is the seventh domain.

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According to the Bhutan Ministry of Health (2021), there are 30 public hospitals and some 200 community clinics, which are called basic health units, and dispensaries. The World Health Organization (WHO, 2020) reports that in Bhutan the government supports the Institute of Traditional Medicine Services (ITMS), a separate network of facilities specializing in indigenous medicine. The ITMS includes a hospital, a training center, a pharmaceutical and research unit, and numerous clinics and dispensaries. In 2015, the Ministry of Health published a national strategy on mental health (2015–2023). This plan proposes a Mental Health Program. Psychi­ atric patients are admitted in the general ward with non-psychiatric patients. There is no dedicated psychiatric institution in which patients can be admitted for long-term care. Maleku et al. (2022) indicate that there are two major challenges in coordinating mental health services: (i) a geographically scat­ tered population with diverse cultural practices; and (ii) a national language which lacks dedicated words for mental health-related issues. Maddock et al. (2021) in their systematic analysis of psychosocial inter­ ventions found that Bhutan has made significant strides in mental health care. First, a three tier-network of mental illness treatment, rehabilitation, and prevention has been established. Second, treatment has begun with CHWs in rural communities, connected districts, subdistricts, and villages. Third, resources, such as community crisis and ambulatory centers and human resources have been identified in most communities. With the emergence OF COVID-19 pandemic, the government has encouraged humanitarian agen­ cies, and other NGOs, to establish community-based psychosocial support (CBPSS) services to support supplement the government efforts. According to BBS news (August 2020) despite the psychosocial, and economic growth and modernization in the country’s Health Services, anxiety and depression continue to be identified as the most common mental disorders. To address the mental health and psychosocial sequelae of the COVID-19 pandemic, Bhutan must: (i) increase the number of clinical mental health staff at the community hospitals; (ii) develop educational mate­ rials and mental health campaigns to inform the public and reduces stigma; (iii) encourage psychosocial support at the community level that involves traditional healers, midwives, CHWs, and teachers; and (iv) develop words that describe symptoms of mental illness in both allopathic medicine and traditional healing. COVID-19 cases have been rising rapidly in Bhutan. The first case was traced to a tourist in March 2020; by December 2020, the country recorded 671 positive cases. LeVine et al. (2020) studied the initial impact of COV

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ID-19 in Bhutan and reported that soon after the first case of COVID-19 was reported, Bhutan began preparing for the pandemic by publishing guidelines and standard operating procedures and by developing the capacity in critical care and services that included psychosocial support. However, the risk of further transmission was curtailed due to the high level of cooperation exhib­ ited by the Bhutanese people in adhering to the health advisories, including enduring travel restrictions and two nationwide lockdowns. 10.3.1 COMMUNITY ENGAGEMENT (CE) TO ADDRESS COVID-19 IN BHUTAN The Royal Government of Bhutan developed a National Preparedness and Response Plan for the Outbreak of COVID-19. UNICEF Bhutan was the lead agency on CE activities including community meetings to address prevention activities for COVID-19, dissemination of materials, and vaccination camps. Dorji (2020) explored how COVID-19 had impacted the people of Bhutan, specifically related to their level of happiness. He found that the pandemic caused disruption in socioeconomic activities, education, and other planned development activities. Dorji in a radio interview over the Bhutan Public Radio reported that A national mental health response team and sub-teams across the countries provided PFA and counseling to alleviate suffering as a result of COVID-19. IFRC (2021) reported that, in most communities in Bhutan community participation activities helped deliver non-health services such as timely information, infodemic, and developing community vaccination activities. Amitabha et al. (2019) that early and extensive contact tracing, extensive testing, effective communications, zoned travel restrictions, and adoption of physical distancing and hygiene measures were effective strategies to prevent COVID-19 transmissions within the country. 10.4 BANGLADESH Bangladesh, which gained independence from Pakistan in 1971, has a popu­ lation of approximately 166.7 million. The three largest cities are Dhaka (10.4 million), Chittagong (4 million inhabitants), and Khulna (1.3 million inhabitants). The most common religions in Bangladesh are Islam, Hinduism, and Buddhism, and approximately three-quarters of the population is literate. In the recent past, Bangladesh received approximately 1 million Rohingya people from Myanmar.

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10.4.1 THE ROHINGYA FORCED MIGRATION TO BANGLADESH

Faye (2021) indicated that systematic violation of human rights of the Rohingya as a result of the prevailing political situation in Myanmar forced thousands of Rohingya to flee the country, leaving thousands to live as refu­ gees, predominantly in Bangladesh. Seeking refugee status in Bangladesh did not mitigate the refugees’ suffering; some migrants were denied access to refugee camps, being forced to survive in extreme poverty in the villages or slums near Cox’s Bazar and Tekna. Rohingyas in Bangladesh are generally unwilling to return to their country of origin, due to their expected persecu­ tion by the authorities. Nevertheless, Bangladesh continues to see a rising number of COVID-19 cases, having recently surpassed 1.5 million cases. Moniruzzaman (2021) reported that of the approximate 8,50,000 Rohingyas in Bangladesh, more than half of whom are children, live in cramped bamboo and tarpaulin shelters that comprise the largest refugee camps in the world. Holloway & Fan (2018) studied the localization of Rohingya refugees to Bangladesh and found that: (i) high population; (ii) density increases; (iii) the chances of fast transmission rates; and (iv) limited sanitation and health facilities exacerbate the proximity to contagious deceases such as COVID. UNICEF (2021), and faith-based leaders have undertaken several activities to include: CE campaign, have enhanced community awareness activities in the camps to better inform the Rohingya children and their families about COVID-19 and can take preventative measures. According to Shoib, Arafat & Thuzar the report urgent need for MHPSS following the political conflict. Mental health services are supported by public and private sources. Both the government and NGOs have imple­ mented community-based psychosocial support interventions a model for the provision of psychosocial support in the country. Shoib, Arafat & Thuzar conclude that COVID-19-related mental health and psychosocial support has been exacerbated by the ongoing political conflict as an emergent humani­ tarian crisis. 10.4.2 SOCIOCULTURAL FACTORS AFFECTING MENTAL HEALTH AS A RESULT OF COVID-19 10.4.1.1 FAMILY IS A SOCIOCULTURAL FACTOR The most common family unit in Bangladesh is multi-generational and called the Barhi, typically composed of parents, their unmarried children, and their adult sons with wives and children. Paul et al. (2021) studied the WHO

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initiative for mental health and found that extended family networks are protective in that they provide additional opportunities for individuals with mental health disorders to socialize and grow their social support network. WHO (2021) in its special initiative on mental health have pointed out that family livelihood was impacted by COVID-19. Individuals living in poverty in Bangladesh were marginalized, thereby exacerbating their poverty. Lack of confirmed support from the local government and the COVID-19-related lockdown increased fear and anxiety among the country’s poor. Suicidal ideation and depression have emerged as major mental health concerns during the pandemic. A study conducted by Mamun et al. (2021) found that among a large cohort of citizens from every region of Bangladesh found a significant increase in reports of suicidal ideation or depression if participants were: (i) of younger age; (ii) female; (iii) current smokers and/or alcohol drinkers; (iv) less knowledgeable about COVID-19; (v) less engaged in preventive COVID behaviors; (vi) had greater fear of COVID-19; and (vii) had increased insomnia symptoms. These symptoms may be used to identify individuals most in need of psychosocial support. The public health system expanded its reach to the population by extending government, private, and NGO-sponsored health care providers. In the development of scalable models of mental health programming (Sandgol et al., 2021) to address the effects of traumatic stress within the population in Cox’s Bazar. 10.4.1.2 AVAILABILITY OF MENTAL HEALTH SERVICES Bangladesh’s largest specialty hospital, the National Institute of Mental Health and Treatment, a 500-bed facility located in the capital, Dhaka. A total of 56 public hospitals in Bangladesh have psychiatric outpatient facili­ ties, which encompass an estimated 260 psychiatrists, as well as 700 nurses who provide specialized mental health care, and 565 psychologists. General nurses trained in mental health are found only in the country’s two mental hospitals; there are no nurses who specialize in mental health. The Bangladesh Ministry of Health and Family Welfare has collaborated with members of the WHO Bangladesh and the National Institute of Mental Health by offering training to psychosocial support providers working with the population. To date, a total of 302 healthcare professionals working in the Cox’s Bazar area have been trained, including 120 government and 182 nongovernment affiliated personnel. In order to limit transmission of COVID-19, travel must be controlled, which requires measures such as slow lockdowns,

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self-isolation, and social distancing. For effective implementation of these measures in a densely populated country like Bangladesh, underprivileged people should be provided with essential government assistance, in addition to health and social services during this particularly challenging time. The absence of livelihood means greater fear of being infected by COVID-19, and insufficient government assistance has made their livelihood vulnerable and the life stressful. Islam et al. (2020) report that in Bangladesh had a total of 1,41,801 infected with the virus and 1,783 deaths from COVID-19 in the country as of 29 June 2020. Along with the fear of infection, fear of losing loved ones, the COVID-19 related misinformation spreading, the lack of medical treatment, and the shortage of properly equipped units to treat the patients, the lockdown-related issues are being sought to be associated with mental disorders like depression, anxiety, phobia, insomnia, and posttraumatic stress disorder. 10.4.2 COMMUNITY ENGAGEMENT (CE) AS A RESULT OF COVID-19 Following the COVID-19 outbreak, the public and private sectors initiated an extensive public health awareness campaign. The citizens were placed under lockdown, quarantine, or social distancing since March 2020; direct or indirect psychiatric disorders are anticipated to rise, directly or indirectly, are a result of COVID-19, which is already reflected in the rise of suicides in the country during the pandemic. A study by Pedroza et al. (2020) found that stress brought on by the pandemic impaired sleep quality, increased irritability, and introduced chaos into family life; some respondents also endorsed increased suicidal ideations. These authors also found that economic difficulties and food insecurity are significantly correlated. Identifying real from fictitious COVID-19 information helps reduce stress and helps the authorities better organize management efforts. Social activists, television and print media workers, social workers, and religious and political leaders are encouraged to come forward to help disseminate scientifically the accurate information on COVID-19 among the public in Bangladesh. The effort was to reach refugee communities. Anwar et al. (2021) reported that given the high level of illiteracy among the slum and village populations, the dissemination of COVID-19-related basic knowl­ edge is key to providing accurate and timely information.

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The challenge for CE included misconception, superstitions, and religious conservatism within the communities. Some, within the Muslim community believe, Muslims will not be affected by coronavirus, they just now need to cry at the mosque to avoid this crisis. 10.4.3 MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT (MHPSS) Kohrt et al. (2021) suggested the methods to achieve MHPSS key activities in Bangladesh as a result of a rapid assessment to address context and of culturally specific MHPSS issues amongst the population, effectively. They recommended that once the assessment is completed, culturally, linguisti­ cally, and contextually congruent activities should have taken place to conduct capacity building activities, conduct CE, and undertake CBPSS. 10.4.4 MENTAL HEALTH CARE FOR ROHINGYA REFUGEES IN BANGLADESH DURING COVID-19 While the mental health needs of refugees have increased, the available resources are usually grossly insufficient, particularly during the COVID-19 pandemic when local healthcare systems are overwhelmed and take some time to respond. This has been the case in the refugee camps in the Cox’s Bazar district of Bangladesh, where, as of 31 August 2021, some 2,893 posi­ tive cases and 30 deaths had been recorded since March 2020. The health status of individuals who arrived in the latter part of 2017 was appalling, with high levels of malnutrition, infectious diseases, and poor overall health, including exhaustion. Since the new wave of immigrants began arriving from Myanmar, mental health and psychosocial support and referrals have been implemented in the local hospital. However, there is no inpatient capacity for acute and severe mental health case management. The government of Bangladesh approved the provision of COVID-19 vaccines for the Rohingya, with over 80,000 vaccinations by the end of August 2021. While most of Bangladesh’s citizens reside in rural areas, special­ ized MHPSS services are concentrated in the highly populated urban centers. Government funds devoted to mental health prevention and care beyond hospital walls are minimal. Improvements are needed in access to community-based supports for persons with mental illness living in rural areas. Moving forward, Bangladesh should consider: (i) the development of a strong workforce, additional specialized services, and psychosocial

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services in rural areas; (ii) the establishment of teleassistance where people can obtain emergency assistance and follow-up; and (iii) increased dissemi­ nation of information to allow the public to be better informed about the pandemic and means of prevention. 10.5 MYANMAR Lat et al. (2016) in their study about healthcare in Myanmar reports that the country has an area of 6,80,000 Km. The International Crisis Group (ICG) (28 August 2020) reports that there are 135 different ethnic groups with their own languages and cultures dispersed over 14 states/regions. The popula­ tion is estimated at 54.8 million. Rangoon is the largest city and the capital, containing 4,477,638 residents. Mandalay, which is considered the country’s economic hub, comes in second with 1,208,099 inhabitants. The Bamar population accounts for approximately 68% of Myanmar’s population, with Buddhism being the predominant religion. 10.5.1 THE ROHINGYA POPULATION IN MYANMAR Faye (2020) has discussed the history of various groups including the Rohingyas, who originated from different ethnic groups that include Arabs, Moghuls, and Bengalis. Chowdary & Mohanty discuss in their book the citi­ zenship of the Rohingyas in Southern Asia, and report that the 1982 Citizen­ ship Act codified the legal omission of the Rohingya in spite of identifying 135 national races that qualify for citizenship. Dr. Kazi Abdul Mannan (2017) explains how the Rohingya exclusion denied the full benefits of citi­ zenship in what is described as nonindigenous ancestry. Albert & Maizland (2020) clarifies how exclusion from the Act affect the Rohingyas: “Under this Act, the Rohingya can only possess Foreign Registration Cards, which are rejected by many schools and employers, they are denied their right to own property, marry, and freedom of movement; these rights are guaranteed under international law.” 10.5.2 THE MINISTRY OF HEALTH IN MYANMAR Most COVID-19 patients in Myanmar are treated in Community Treatment Centers (CTC). Diagnosed patients were more likely to endorse psychological

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concerns, such as anxiety surrounding the unpredictability of the disease, fear of illness progression, disability, or premature death. Hum et al. (2021) conducted a study to determine the extent of identification of COVID-19 at risk of MHPSS symptoms, they reported that the personnel at the Centers (CTC) identified the extent of distress and other factors associated with a higher likelihood of developing psychological problems were crucial for providing behavioral guidelines and psychosocial support for COVID-19 patients. The treatment centers assumed the responsibility for psychosocial support, psychoeducation, enhancing social contact with family and friends, and using credible sources of information related to COVID-19 as part of the mental health services during the COVID-19 pandemic. Bodrud-Daza et al. (2020) studied the psychosocial and economic crisis in Myanmar as a result of COVID-19, they found that among those over 40 years old, possible explanations of psychosocial symptoms were concerns about the financial burden of the treatment, the impact of family responsibilities, lack of social connectedness with family members, as well as helplessness and isolation. 10.5.3 MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT (MHPSS)

COVID-19 had significant impact on the mental health and psychosocial condition of the people of Marzo et al. (2021) reported large number of the COVID-19 affected population that they are experiencing anxiety and stress associated with fear of infection, fear of death, social distancing, quarantine, misinformation, and uncertainty of the future. Htun et al. (2021) In addi­ tion, frontline responders who are involved in response efforts have also experienced physical, personal, social, and emotional stress in carrying out their duties over an extended period. Marzo et al. (2021) studied the factors associated with psychological distress in Myanmar they found that due to the significant impact of COVID-19 in Myanmar, on mental health and psychosocial aspects, people realized the importance of maintaining their emotional stability and mental well-being. The UNHCR in 2018 realizing the increasing needs for emotional support, PFA, counseling, psychotherapy, and psychoeducation develop a manual that focused on Culture, Context, and Mental Health of a segment of the population which has been put in use during the COVID-19 response.

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10.5.4 MENTAL HEALTH AFTER THE 2021 POLITICAL INSTABILITY

After the February 2021 coup, violent crackdowns have exerted, and will continue to exert, a significant impact on the mental well-being and psycho­ social needs of citizens. According to the WHO, conditions most frequently identified among people in the clinics were depression, anxiety, and posttraumatic stress disorder. Hopkins (2021) reports that thousands of new cases of COVID-19 have arisen since late May, including the Delta, Alpha, and Kappa variants. In mid-July, the junta-run health ministry reported nearly 35,000 cases and over 500 deaths nationwide. Low testing rates and the regime’s haphazard pandemic response mean that these figures only provide a partial picture. In trying to explain the MHPSS efforts in Myanmar, the author was challenged by the lack of gray literature or research on MHPSS. The most recent review of mental health interventions in Myanmar was conducted 2018 and found few interventions that would help us advance MHPSS. 10.6 CONCLUSIONS A desk review and a telephone interview were conducted to ascertain the extent to which mental health and psychosocial support was an intervention used by the four countries of Southeast Asia (Bangladesh, Bhutan, Myanmar, and Nepal). We attempted to document the MHPSS of the most at-need populations, namely, the refugees from Bhutan to Nepal and the Rohingya population that became refugees in Bangladesh. We acknowledge that there are also refugees from Myanmar near the border of Thailand; however, the exploration of this population was beyond the scope of this review. KEYWORDS • • • • • • •

emergency operation center information, education, and communication Institute of Traditional Medicine Services mental health and psychosocial Ministry of Health and Population Nepal Red Cross Society non-government organizations

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nepal-preparedness-and-response-plan-(nprp)-draft-April-9.pdf?sfvrsn=808a970a_2 (accessed on 27 October 2022). Upadhaya, N., Regmi, U., Gurung, D., et al., (2020). Mental health and psychosocial support services in primary health care in Nepal: Perceived facilitating factors, barriers and strategies for improvement. BMC Psychiatry, 20, 64. https://doi.org/10.1186/s12888-020-2476-x. WHO, (2020). Addressing the Mental Health Needs During COVID-19 Pandemic in Nepal. https://www.who.int/about/accountability/results/who-results-report-2020-mtr/countrystory/2020/nepal-mental-health (accessed on 27 October 2022). WHO, (2020). Traditional Medicine in the WHO South–East Asia Region. Review of progress (2014–2019). New Delhi: World Health Organization. Regional Office South Asia. WHO, (2021). Addressing the Mental Health Needs of the Nepali People During the COVID-19 Pandemic. https://www.who.int/nepal/news/detail/07-04-2021-addressing-themental-health-needs-of-the-nepali-people-during-the-covid-19-pandemic (accessed on 27 October 2022). WHO, (2021). Bangladesh WHO Special Initiative for Mental Health: Situational Assessment. https://www.who.int/docs/default-source/mental-health/special-initiative/who-specialinitiative-country-report---bangladesh---2020.pdf?sfvrsn=c2122a0e_2 (accessed on 27 October 2022). WHO-AIMS, (2006). WHO-AIMS Report on Mental Health System in Nepal. WHO and Ministry of Health, Kathmandu, Nepal. https://www.who.int/mental_health/evidence/ nepal_who_aims_report.pdf (accessed on 27 October 2022). Zam, N., (2018). The Mental State of the Happy Kingdom. The Diplomat.

CHAPTER 11

Developing a Universal Model of an MHPSS Regional Response JOSEPH O. PREWITT DIAZ

The Pennsylvania State University (Retd.), Pennsylvania, USA

ABSTRACT This chapter explores the psychosocial consequence of COVID-19 and how we as individuals and collectively have sought protective factors that help us find meaning, hope, and re-configure our lives. The chapter results from personal experiences, interviews with Red Cross frontline workers in the Americas and Caribbean Region, and a review of the emerging literature. We will look at the principles of community resilience. The chapter will conclude with suggestions on moving ahead. 11.1 INTRODUCTION During and in the immediate aftermath of the COVID-19 pandemic, social scientists and health professionals have begun to look at the impact of resilience on the recovery and re-invention of communities in the aftermath. This chapter serves as a review of the literature on individual and systemic resilience and the implications for developing individual and collective tools to alleviate suffering and enhance protective factors. The damages caused by COVID-19 worldwide include a high number of deaths, increased demands for treatment, lack of healthcare supplies, and very rapid research to find medicine and define behaviors that will reduce the harmful effect of the pandemic. The response of the governments around the world was to mandate: (i) wearing masks; (ii) social isolation; (iii) quarantine; Mental Health and Psychosocial Support during the COVID-19 Response: An Overview. Joseph O. Prewitt Diaz (Ed.) © 2023 Apple Academic Press, Inc. Co-published with CRC Press (Taylor & Francis)

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(iv) inaccurate crisis communication; and (v) uncertain cures fomented by the beliefs on traditional ways versus scientific research (Sheek-Hussein, Abu-Zidan, & Stip, 2021). The reality is that 2020 has brought about many changes in our society and our daily lives. Having to wear a mask whenever outside our home and keeping a six-foot distance from other people has become a new habitual norm. We will never look at the world the same. The coronavirus pandemic has changed the way we think about space in terms of spreading germs and sanitation; immediate changes resulting in loss of dear ones, jobs, lifestyles, and fear; and the sense of loss of place, the rhythm of life, recreation, and family, neighborhood, and community intimacy. People did not understand what was happening. For many, nothing had changed in early 2020; there was no damage to the physical infrastructure, the disaster was present, but no one could see COVID-19 (Pew Research Center, 2021). In those initial days, the news was just that, news from a faraway place. “COVID-19 will never reach here,” or “we have had other epidemics and have survived,” or “we should not overreact.” By the begin­ ning of April, the news was more ominous; COVID-19 deaths in the United States, Central America, and Brazil had increased significantly. Loss of place led to fear, anxiety, and depression. We were a wounded society, without much knowledge of how to survive. To heal the psycho­ social wounds, people needed to develop safe environments, learn helpful behaviors, and develop realistic plans to redefine our places. Our place (family or neighborhood) is a small group based on prox­ imity, language, culture, and context; the task of this group was to assist its members in manipulating and harmonizing personal relationships, reducing tensions, and achieve a feeling of safety and security amongst its members. Each community has its small groups and safe spaces that are representative of its diversity. To begin to address the losses created by the COVID-19 pandemic, psychosocial support arose as a conduit that helped the affected people to learn to manipulate and harmonize personal relationships in place to achieve feelings of safety and security. A community place is formed by many personal places (COVID-19 affected and infected people feel safe and secure at home and in their neighborhood and community). The objective was to have COVID-19 affected and infected people identify community tensions and develop some ideas about harmonizing those tensions. They identify what ecological modifications must take place so that the community feels wholistic calmness within. The guided activities envisioned by the psycho­ social support proponents was geared to have affected and infected people

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see for themselves what has taken place in their family, neighborhood, and community, and identify what the necessary recovery tasks are (What happened, How do we resolve the situation, Where do we get the resources, What will our place look like after we fix it). The affected people are encouraged to identify a “life space.” A life space may be the spot where two paths intersect, the soccer field, or a quiet place under a tree. This is a place within the community accessible to all the community members, places used for meetings with external stakeholders, to hold discussions amongst community members and reduce tension, and moments of large gatherings such as community cooking, religious ceremo­ nies, concert or plays. It is in these “life spaces” that the COVID-19 affected people identify the cultural and social capital within the community, what additional external resources are needed, and what the external stakeholders may provide. Helpful behaviors are those that facilitate the engagement of COVID-19 affected and infected people into small group processes. Psychosocial support begins its intervention by providing a space for affected people to understand themselves after having survived COVID-19 and the impact that verbal and non-verbal behavior has in their place. This approach uses psychological first aid (PFA) as a tool for group and individual learning, focusing on equality, inclusiveness, and protection. The group begins to identify helpful behaviors, inclusive behaviors and behaviors that impede group growth. Develop the capacity of volunteers and facilitators. Volunteers from humanitarian agencies and facilitators from the communities develop their skills of attending and managing small community groups. After completing their training phase, the facilitators increase self-awareness of behavior and interpersonal style in relation to others, learn to relate and communicate more effectively with others, develop abilities to give and receive feedback effectively, and develop the community. The facilitator encourages the affected and infected people to develop their autonomy by: (i) conducting orderly interventions and listening to others; (ii) problem-focused interaction (we/they relationships); and (iii) creative problem solving using a solutionfocused approach (Orkibi, 2021). Develop a realistic plan that achieves satisfaction. Achieving satisfac­ tion with place includes the interaction of four distinct factors. The first is the natural and built environment and the values and attitudes toward that environment. The second refers to the psychological connection to and dependence on the place, often separated into identity and dependence on the place. The third is connected to the social community as well as cultural

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context. The fourth dimension is composed of the behavioral reaction to the socio-cultural environment. i. The natural and built environment includes people’s contact with their neighborhood and communities, knowledge of the plants, trees, and green areas, and where to find shade, or fruits or the smell of flowers (Spence, 2020), and their relationship with the climatic conditions and geography of the place. ii. Psychology of the people. It is divided into an emotional and a func­ tional attachment. The length of residence allows the development of self-concept and interactions with others in their neighborhoods or communities. Participation in community activities allows a person to develop deep relationships with others and with the environment (Cantarero, Van, & Smoktunowicz, 2020). iii. The socio-cultural factor suggests that connection to place is rooted in social interactions within the neighborhood or community. Sense of place derives from people, experiences, and memories that allow sharing stories, celebrations, and commemorations (Zetterberg et al., 2021). The cultural component is related to the development and recognition of symbols that the community groups use to produce memories from the people connected to the place through relation­ ships that generate through lifestyle choice, familial history, and a sense of belonging. 11.2 THE PSYCHOSOCIAL IMPACT OF A PANDEMIC The response to various global infectious disease outbreaks, such as coro­ navirus (COVID-19), informs a response based on MHPSS responses to these events. It leads to appropriate pyramid-based interventions proposed by the IFRC (2020). Since the highly lethal influenza pandemic outbreak in 1918 (Crosby, 2004), there have been few global threats from infectious agents. The SARS outbreaks in Asia and Canada (Blendon et al., 2004) and H1N1, MERS, Ebola virus, and the Zika virus (Prewitt, 2017) have provided important lessons to inform preparedness and response. Like many crises, pandemics result in a predictable range of distress reac­ tions (insomnia, decreased perception of safety, anxiety), health risk behav­ iors (increased use of alcohol and tobacco, work/life imbalance manifested by extreme dedication in the workplace to relieve distress), and psychiatric

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disorders, such as posttraumatic stress disorder, depression, and anxiety, are common (Pedrosa et al., 2020). Infectious outbreaks have unique characteristics that increase fear and uncertainty due to the imperceptibility of the infectious agent, uncertainty about infection, and initial symptoms that are often easily confused with more known benign diseases (Prewitt, 2020). As a result, pandemics mani­ fest unique individual and community responses, such as scapegoats and guilt, fear of infection, and high levels of somatic (physical) symptoms. According to the IASC, the community’s response to outbreaks is governed by the perception of risk (not the actual risk) with various factors that affect community distress. This has been the case with COVID-19 (Prewitt, 2017). Effective public mental health measures will address numerous areas of possible distress and risky health behaviors, and psychiatric illness (Rajkumar, 2020). In anticipation of significant disruptions and losses, promoting healthprotective behaviors and health response behaviors will be imperative. Areas of special attention include: (i) the role of risk communication (Porat et al., 2020); (ii) psychological, emotional, and behavioral responses to public education, public health surveillance, and early detection efforts (Pedrosa et al., 2020); and (iii) psychological responses to community containment strategies (quarantine, movement restrictions, closing of schools/work/other communities) (Wissmath, Mast, Kraus, & Weibel, 2021). As the humanitarian world attempts to address the sequelae of the pandemic, community-based psychosocial support must focus on self-care activities, communication with others, enhanced reliance on meaningful rela­ tions, and prayer, as well as practicing mindfulness and stress management techniques, and when possible, calisthenics and other physical exercises (Chen & Bonano, 2020). 11.3 RESILIENCE Stress and tragedy, as a result of COVID-19, have become part of our daily living. Recent research has identified the importance of the ecological perspective of resilience. Resilience is defined as the critical interplay between individuals, communities, and cultures (Kaye-Kauderer et al., 2021). Ungar has placed culture as an important part of the interplay of psychological, environmental factors (Figure 11.1).

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FIGURE 11.1 The interaction of culture, resilience, and mental health (Panter-Brick & Eggerman, M. Understanding Culture, Resilience, and Mental Health: The production of hope). This illustration shows the interactions between the individual, family, neighborhood, and cultural milieu as interactors in resilience production (Panter-Brick & Eggerman, 2012).

Resilience has been viewed in individual terms. However, it is important to consider the influential actions that impact resilience. In the COVID-19 environment, psychosocial difficulties were overwhelming economic impediments to physical, social, and emotional well-being (Panter-Brick & Eggerman, n.d.). Ungar (2008) has operationalized resilience as follows “in the context of exposure to significant adversity, whether psychological, environmental or both, resilience is both the capacity of individuals to navigate their way to health-sustaining resources, including opportunities to experience feelings of well-being, and a condition of the individuals family, community, and culture to provide the health resources and experiences in culturally mean­ ingful ways” (Ungar, 2008). Culture provides communities with collective belief systems and accepted strategies for coping in the communities (Theron & Liebenberg, 2015). It provides guidelines to the community for actions and reactions to situations like the COVID-19 pandemic. Ungar proposes four culturally relevant interactions: (i) there are culturally and contextually specific aspects to young people’s lives that contribute to their resilience; (ii) aspects of resilience exert different amounts of influence on a child’s life depending on the specific culture and context in which resilience is realized; (iii) aspects

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of children’s lives that contribute to resilience are related to one another in patterns that reflect a child’s culture and context; and (iv) tensions between individuals and their cultures and contexts are resolved in ways that reflect specific relationships between aspects of resilience (Ungar, 2008). Ultimately, resilience is about embracing hope. Social hope comprised six fundamental values: family and community unity, helping others, sharing resources, and religious or spiritual practices. Access to education promotes social hope and leads to community resilience (Panter-Brick & Eggerman, 2012). 11.3.1 RESILIENCE ACROSS CULTURES In 2008, Ungar reported on the findings of a study of resilience across cultures (Ungar, 2008). His findings have summarized an explanation of the interac­ tion of culture, context, and levels of resilience. There are specific aspects of culture and context that contribute to resilience; these aspects of resilience excerpt a certain amount of influence based on setting or location; resilience components of development are reflected by the patterns of interaction that reflect culture and context; and their specific patterns of resilience reflect tensions in a persons’ behavior (Ungar, 2008). Resilience research suggests a connection between (Panzeri et al., 2021) patterns of positive adaptation in the context of risk or adverse behavior. The interaction between individuals and social ecology will determine the degree of positive outcomes (Ungar, 2008). Since a family or community must be resilient, if a child is to be resilient, it makes sense to look to those communities to define for themselves what they determine to be signs of healthy development. There are both universal and culturally specific indicators of resiliency throughout the world (Ungar, 2008). During the COVID-19, the relationship of resilience as context-depen­ dent is highlighted irrespective of context or culture; the result will be the same, that is, the development of protective behaviors. The context will determine: (i) sense of belonging; (ii) personal meaning of an interaction; (iii) the experience of self-efficacy; (iv) development of life skills; and (v) cultural identity (Ungar, 2018). While these components may be found in all cultures, the importance of each in one culture may be different. Ungar defined resilience in the context of exposure to adversity, whether psychological, environmental, or both: (i) the capacity of individuals to

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navigate their way to health-sustaining resources, including opportunities to experience feelings of well-being; and (ii) the condition of the individual’s family, community, and culture to provide these health resources and experi­ ences in culturally meaningful ways. Resilience is, therefore, both a process of navigation towards and the capacity of individuals to negotiate for healthy resources on their terms (Ungar, 2008). 11.3.2 RESILIENCE APPROACH TO PSYCHOSOCIAL ASSESSMENT A psychosocial assessment is a process of collecting, organizing, and analyzing information about a community. A resilience approach to psycho­ social assessment (Veer et al., 2021) can be used to understand a community’s vulnerabilities, resources, and adaptive capacities that drive its response to change. The resilience approach identifies the resources and adaptive capacity that a community can utilize to overcome the problems that may result from the change (Massaro et al., 2018). The approach builds upon the inherent capacities, rather than only relying on external interventions to overcome vulnerabilities. A resilience approach accepts that change is inevitable and unpredictable (Luthar & Cicchetti, 2000). The resilience approach identifies the resources and adaptive capacities that a community can utilize to overcome any problems resulting from the change (Hynes, Trump, Love, & Linkov, 2020). A crucial difference is that rather than relying on external interventions to overcome vulnerabilities, a resilience approach builds upon the capacities (resources, flexibility) already established within a community. This focus on resources and capacities does not ignore the components of a community that may be vulnerable to a particular change. The resilience approach is balanced in that it includes both the vulnerabilities within a community (rather than labeling an entire community as ‘vulnerable’) and the resources and adaptive capacities that enable the community to over­ come these vulnerabilities and positively manage change (Patel et al., 2017). A resilience perspective enables an adaptive form of governance, which encourages the use of environmental and social resources in a sustainable way. A resilience-based psychosocial assessment recognizes the inherent complexities and interactions between a community’s resilience, vulner­ ability, and adaptive capacity (Burger, Kennedy, & Crooks, 2021). The community perceptions fluctuate based on the stage of recovery after a

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disaster. The assessment process will be contingent on: (i) the phase and type of the emergency; (ii) the information that is already available (identified through key informant interviews, and historical/ecological data available from government/church and community records; and (iii) the type of infor­ mation sought will depend on the interest of the survivors in their recovery process and the priorities that they have established. 11.4 COMMUNITY ENGAGEMENT (CE) Community engagement (CE) is considered a fundamental component during outbreaks and is important to ensure contextually appropriate interventions (Questa et al., 2020). It presents the experience and insights gained by involving the community in identifying immediate and long-term needs; CE is a process-oriented strategy that allows COVID 19 related survivors and affected people to take control of their future (Gilmore et al., 2020). Psycho­ social support programs are based on the premise that well-implemented CE strategies can be used to design interventions, build trust and community entry, social and behavioral change communication, risk communication, surveillance, and contact tracing to support COVID-19 prevention and control responses (Independent Panel for Pandemic Preparedness and Response, 2021). The major causes of stressors in the population during COVID-19 are the loss of attachment, familiarity, and identity. The displacement caused by quarantine and staying at home has caused physical, social, and psycholog­ ical impacts (Saladino, Algeri, & Auriemma, 2020). The secondary impact of COVID-19 in many communities has led to nostalgia disorientation and alienation (Zhu et al., 2021). These are sub-clinical areas often overlooked by those conducting mental health surveillance. In fact, the psychosocial personnel consistently report that survivors (affected and infected people) from COVID-19 and other affected people may not identify psychological stress as a priority need, the reason being that the survivors and other affected people may be more concerned with practical issues such as housing, water, food, getting back to work, or staying healthy (American Psychological Association (APA), 2020). COVID-19, in the last two years, has led communities to recognize and acknowledge the importance of community-based psychosocial support. Two important lessons were learned: (i) COVID-19 affected communities may not identify psychological stress as a priority need, as they are more

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concerned with their practical social needs; and (ii) affected and infected people should be directly and actively involved in their recovery from COVID-19. Psychosocial support practices include several steps to engage the communities, beginning with assistance to the communities to identify their perceived and felt needs. Over time we have learned that the community is the main actor in their recovery. The initial activity includes: (i). eliciting input from all community members through community mapping exercises and the development of community resilience indicators (Rodríguez-Rey, Garrido-Hernansaiz, & Collado, 2020); (ii) systematize information to assist the community in prioritizing its perceived needs; (iii) identify community resources and human and social capitals; and (iv) assure the involvement of community members as executors of their process (planning, develop­ ment, monitoring, and reporting) community activities (Fedowicz, Arena, & Burrowes, 2020). Community inputs are obtained through community mapping exercises and by preparing community facilitators responsible for assisting diverse community groups in the process of developing a community-driven agenda during and after the COVID-19 pandemic. Communities develop their capaci­ ties based on their recognized strengths, weaknesses, and bonds. Equity and respect for human rights are central to the recovery process from COVID 19; preparing volunteers and community facilitators and understanding the language and context of the stress of the community is the preparation (International Recovery Platform, 2020). The way of enhancing the capacity of the community is to provide the space so that community members can look at themselves through commu­ nity mapping. The psychosocial community committee was comprised of traditional healers, trusted early elderly, and underrepresented groups. The committee participated in a physical walkthrough of the community and drew a map of the area. The map includes communal facilities, buildings, roads, utilities, human and social capital, and environmental strengths and risk. After the map had been drawn, the community facilitators and a small, diverse group (women, children, adolescents, the elderly, and vulnerable and at-risk population) developed separate maps. Under continuous threat from COVID-19, communal threats such as the management of ongoing racial and social conflicts in the immediate response period and during recovery take on additional importance (OECD, 2021). Stigma is a great challenge and further contributes to the distress caused in this situation. Stigma is faced by those who have become ill, their relatives,

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health care workers, frontline professionals, and survivors (Bhanot et al., 2021). In addition, individuals and the community have to overcome the grief of losing their loved ones and the anguish of many that undergo finan­ cial losses. In these circumstances, psychosocial support may be useful or necessary to help individual recovery. Stigma and discrimination can marginalize and isolate certain groups preventing recovery and should be an integral part of any psychosocial program during COVID-19 (Rahman et al., 2021). Next, all the small groups prepared a large three-dimensional map combining and synthesizing what is included in all the small group maps. This map showed the perspectives of the participants and revealed much about local knowledge and wisdom of resources, land use settlement patterns, and household characteristics. Community mapping is a dynamic process and reflects the world view and focused objective of exercising their force. It must be reviewed quarterly in an integrated program. It is essential that different groups address the focus objective and then utilize photography and tabletop laid out to interpose layers. While mapping the community, the community volunteers must empha­ size identifying someone who may assume the role of community facilitator and introduce double and tears to a small circle of family, friends, and acquaintances. These networks are used for initial interviews and observa­ tion since, since everyone knows many other people, the volunteers and community facilitators work their way through social groups, finding more and more people to talk to and being allowed into more and more homes. Communities are the drivers of self-care and change. Participatory plan­ ning is a process-oriented strategy that allows their COVID-19 affected people to take control of their future, and it is based on the premise that participatory methodologies are a key tool in establishing a sense of belonging, a plan, that will undo the psychological damage that has been caused by the 30 months of COVID-19 in their respective communities. Each person has a space to “make” our place in the world. The most altruistic action that we should include in our community plan is attending to the most vulnerable. 11.5 MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT INTERVENTIONS (PREWITT & DAYAL, N.D.) This section originally appeared in 2018 and modified for this chapter. See citation below. Mental health and psychosocial support problems (MHPSS) are prevalent in all segments in humanitarian settings. The situation is no different

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with COVID-19. The extreme stressors associated with COVID-19 increase the risk of experiencing social, behavioral, psychological, and psychiatric conditions. MHPSS comprise multi-sectoral actions, and the mental health disorders and the functional disabilities that accompany them (WHO, 2021). Efforts to increase health-protective behaviors and response behaviors are important. People under stress will need reminders to take care of their health and limit potentially harmful behaviors. This includes taking medica­ tions, giving medications to the elderly and children, infection prevention measures, and when to get vaccinated. The current COVID-19 response has impacted the approach to the community from a person-to-person approach to one that relies on technology to convey messages to the population. There­ fore, clear, precise, and timely information is critical (Reddy & Gupta, 2020). Risk communication should be based on risk communication principles. The media can promote a collaborative approach. Interactions with the media will be critical and challenging (Hyland-Wood et al., 2021). 11.5.1 CAPACITY BUILDING The initial effort to train MHPSS community workers begins with a 2-day operational training of all the staff and volunteers who will interact with the community members. The two major topics were: (i) basics of psychological support; and (ii) PFA for facilitators. The second part of the training for volunteers includes PFA, community assessment, self-care, and resilience. Once the program began to develop, the capacity-building continuum continued with several tiers of training such as Facilitation Skills in Schools and Communities, Crisis Intervention Technicians, Specialists, and Professionals. All the training included follow-up sessions and supervision by experts in the field. Capacity-building activities were not limited to the Red Cross staff but extended to the community leaders, schoolteachers, government officials, social workers, and faith-based leaders. The purpose was to enhance the skills of community members to understand their responsibility toward the psychosocial well-being of the community. The goal of the community is to be better prepared to plan, respond, and survive with their existing resources. 11.5.2 FACILITATING COMMUNITY ACTIVITIES While psychosocial support is a transversal theme in all areas of disaster response and recovery, the SPHERE Project (Sphere Association, 2018)

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recommends four major sectors for MHPSS (IASC, 2020) interventions: (i) self-help and support in the community; (ii) psychological first aid (PFA); (iii) psychological interventions; and (iv) specialized mental health care. Table for Facilitation of Community-Led Efforts (Prewitt & Dayal De, 2018) Organizing community needs and direct action towards tangible goals will help build the community’s inherent resistance to recovery using evidence-based principles of psychological first aid. • Establish security and identify safe areas and behaviors. •

Provide accurate and up-to-date information.

•

Maximize people’s ability to care for themselves and their families and provide measures that allow individuals and families to succeed in their efforts.

•

Teach calming skills and maintenance of natural body rhythms (e.g., nutrition, sleep, rest, and exercise). Limit exposure to traditional and social media as increased use increases distress.

•

Maximize and facilitate connection to family and other social supports as much as possible (this may require electronic rather than physical presence).

•

Promote hope and optimism without denying risk. Encourage activities that restore a sense of normality.

11.5.2.1 SELF-HELP AND SUPPORT IN THE COMMUNITY Emotional support begins at the neighborhood, school, faith community, or community level. Community social support, both formal and informal, is of great importance. Psychosocial support on a personal level may be hampered by the need to limit movement or contact due to contagion concerns. Virtual contact via phone, web, and other remote resources will be particularly important at this time. At other times, local gathering places (places of worship, schools, post offices, and grocery stores) could be access points for education, training, and distribution. Insofar as it allows, instilling a sense of normality could be effective in building resilience. In addition, observing rituals and participating in regular activities (such as school and work) could control distress and adverse behaviors in the community and organization. Providing tasks for community psychosocial support can complement neces­ sary work resources, increase effectiveness, and instill optimism. Main­ taining and organizing to keep families and community members together is important (especially in relocation).

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11.5.2.2 PSYCHOLOGICAL FIRST AID (PFA)

First aid is necessary for people exposed to episodes in traumatic spaces. These include physical violence, sexual violence, witnessing deaths among family members, or have suffered serious trauma. It is not about clinical interventions but a basic, humane, and supportive response to our neigh­ bors who are suffering for what they have seen and/or suffered. The PAP steps include: (i) careful listening; (ii) evaluate; (iii) guarantee basic needs; (iv) foster psychosocial support; and (v) protect against further harm. It is not intrusive, and it does not pressure people to talk about their discomfort. After a brief orientation, volunteers can administer PAP to the affected community. One session allows the affected person to let off steam briefly but systematically recounting their perceptions, thoughts, and emotional reactions during a stressful episode. A part of PFA is to conduct activities for all sectors of the population that address basic needs: (i) safe spaces; (ii) work activities that generate access to food, shelter, and a secure environment. 11.5.2.3 PSYCHOLOGICAL INTERVENTIONS With proper clinical supervision, volunteers who have the proper preparation and licensure can perform psychological interventions related to depression, anxiety, and traumatic stress disorders (De Sousa, Mohandas, & Javed, 2020). 11.5.2.4 SPECIALIZED MENTAL HEALTH CARE Specialized mental health and neurology services must be identified in the location where the national society is located. Protocols must train providers based on ICD-10 and/or DSM-V (WHO/PAHO, 2015). If possible, all national society clinics should have a psychiatric nurse. Maternal mental health is especially worrying because after COVID-19, affected and infected people will need a calming environment that will offer them trusting rela­ tionships with each other; reintegration with the physical and psychological community; and recovery of neighborhood faith-based relationships and community-wide friendships. The initial period of immediate response has changed from a personto-person approach to the use of information and technology (IT)

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strategies to reach affected and infected people. Webinars and other media sources, like WhatsApp and Instagram, are used for linking, consulting, and sharing tools. They can also provide a virtual safe space to reach children, the elderly, and marginalized populations. PFA is rarely done in person but rather via telecommunication. Teleconsultation between a psychologist and the affected population has taken over the role of community-level PFA. Referrals for short-term sessions are being done from specialized call centers of National Societies (NSs), the Red Cross, or local governments. There are three lessons learned from practitioners at this early stage of recovery. First, the “one size fits all” toolbox no longer applies. COVID-19 has brought much loss and tragedies to be affected and infected people. Most survivors will be distressed because COVID-19 has led to a loss of neigh­ borhood and communities, bonds, familiarity, and attachments (individually and collectively). The community will have to create new ways to express their language of distress and devise potential interventions to resolve postCOVID-19 related stress (TISS, 2021). Second, retooling volunteers with PFA skills that promote calming, exploration of ritual that promotes hope, and leads survivors to a new place. Third, MHPSS is a simple paradigm easily institutionalized by NSs, the Red Cross, and local governments. The ultimate goal is to provide a sense of safety, security, calmness, and promote hope. Neighborhoods and communities will never be the same. The role of the volunteer becomes crucial in psychosocial support at the community level. People will continue to mourn their physical, spiritual, and emotional losses. Letting go of rituals from life before COVID-19 and embracing the new reality must occur in long-term recovery to foster psychological rebuilding based on hope for a brighter and safer future. Calmness and stability allow people to develop knowledge for this new lifestyle. This can lead to trusting relationships with new neighbors or re-establishing trust with old neighbors (Brenner & Moses, 2010). The immediate response to COVID-19 has changed from a person-toperson approach to the use of IT strategies to reach affected and infected people (Budd et al., 2020). PFA is rarely done in person but rather via telecommunication. Webinars and other media sources, like WhatsApp and Instagram, are used for linking, consulting, and sharing tools. They can also provide a virtual safe space to reach children, the elderly, and marginalized populations.

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11.6 CONCLUSION

COVID-19 is novel to everyone, and the life changes during the COVID-19 pandemic have been unprecedented (Zhang et al., 2021). In this specific time, willingness to embrace change is important for people to be less psycho­ logically impacted, making openness a characteristic resource. People that became engaged in psychosocial support activities in their communities may have become less fearful and more accepting of life changes and be less mentally impacted by the pandemic. COVID-19 has forced people to adapt to new lifestyles. People who have used their protective tools to succeed, despite the prevailing situation with the pandemic, have become more dependable, capable of planning ahead and immersing themselves in the workforce and meaningful community activities. Social distancing practices and stay-at-home orders may have threatened the need for connectedness among people in the neighborhood. Social connectedness was important during the pandemic (Wolf et al., 2020). Family connectedness buffered the negative psychological impact of the pandemic. During the pandemic, family connectedness could fulfill a need for related­ ness, making people feel more emotionally supported and less isolated and, therefore, buffer the psychological influence of the pandemic. Finally, People who were high in family connectedness also talked more about relaxing things, such as going to the park, cooking their favorite plate, and connecting with neighbors and friends, thereby maintaining the protocols. They were able to engage in relaxing activities and therefore be more hopeful and more resistant to the mental and psychosocial impact of COVID-19. KEYWORDS • • • • • •

COVID-19 inaccurate crisis communication mental health and psychosocial support psychological connection psychological first aid social isolation

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TISS, (2021). Psychosocial Support During the COVID-19 Pandemic. A Training Manual for Counselors. https://tiss.edu/uploads/files/RAHBAR__NDMA-manual1_compressed1.pdf (accessed on 27 October 2022). Ungar, M., (2008). Resilience across cultures. British Journal of Social Work, 38, 218–235. Ungar, M., (2018). Systemic resilience: Principles and processes for a science of change in contexts of adversity. Ecology and Society, 23(4), 34. https://doi.org/10.5751/ ES-10385-230434. Veer, I. M., Riepenhausen, A., Zerban, M., Wackerhagen, C., et al., (2021). Psycho-social factors associated with mental resilience in the Corona lockdown. Translational Psychiatry, 11, 67. https://doi.org/10.1038/s41398-020-01150-4. WHO, (2021). Providing Mental Health Support in Humanitarian Emergencies: An Opportunity to Integrate Care in a Sustainable Way. https://www.who.int/news-room/ feature-stories/detail/providing-mental-health-support-in-humanitarian-emergencies-anopportunity-to-integrate-care-in-a-sustainable-way (accessed on 27 October 2022). WHO/PAHO, (2015). mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies. Geneva: World Health Organization. ISBN 978 92 4 154892 2. Wissmath, B., Mast, F. W., Kraus, F., & Weibel, D., (2021). Understanding the psychological impact of the COVID-19 pandemic and containment measures: An empirical model of stress. PLoS One, 16(7), e0254883. https://doi.org/10.1371/journal. pone.0254883. Wolf, L., Haddock, G., Manstead, A. S. R., & Miao, G. R., (2020). The importance of shared human values for containing COVID-19 pandemic. British Journal of Social Psychology, 59, 618–627. https://doi.org/10.1111/bjso.12401. Zetterberg, L., Santosa, A., Ng, N., Karlsson, M., & Eriksson, M., (2021). Impact of COVID-19 on neighborhood social support and social interactions in Umeå Municipality, Sweden. Front. Sustain. Cities, 3, 685737. doi: 10.3389/frsc.2021.685737. Zhang, X., Wang, Y., Lyu, H., Zhang, Y., Liu, Y., & Luo, J., (2021). The influence of COVID-19 on the well-being of people: Big data methods for capturing the well-being of working adults and protective factors nationwide. Front. Psychol., 12, 681091. doi: 10.3389/fpsyg.2021.681091. Zhu, Y., Zhang, L., Zhou, X., Li, C., & Yang, D., (2021). The impact of social distancing during COVID-19: A conditional process model of negative emotions, alienation, affective disorders, and post-traumatic stress disorder. Journal of Affective Disorders, 281, 131–137. https://doi.org/10.1016/j.jad.2020.12.004.

CHAPTER 12

Chronology of MHPSS Interventions in the Americas During the Immediate and Early Recovery GREISY MASSIEL TREJO RODRÍGUEZ

Health Delegate, Americas Region, International Federation of the Red Cross, Panama, C.A.

“The pandemic has allowed us to make a mental health culture possible; therefore, we must ensure that everything we are doing now in MHPSS, lasts when times without masks return. Otherwise, we will expose ourselves to suffer a pandemic of social and moral failure.” —Greisy Trejo

ABSTRACT This chapter describes how the support of the International Federation of the Red Cross (IFRC) was organized to assist the National Societies (NSs) of the Americas and the Caribbean to provide mental health and psychosocial support (MHPSS) during the COVID-19 pandemic. The chapter provides a brief chronological review of some key actions during the pandemic, then some specific short-term actions taken to mitigate the emotional suffering that is now affecting most of the globe. Finally, this chapter describes how the IFRC MHPSS response in the Americas was organized. 12.1 INTRODUCTION The International Federation of the Red Cross (IFRC) response was orga­ nized to help the National Societies (NSs) of the Americas and the Carib­ bean in the aftermath of the COVID-19 pandemic. In order to alleviate fear Mental Health and Psychosocial Support during the COVID-19 Response: An Overview. Joseph O. Prewitt Diaz (Ed.) © 2023 Apple Academic Press, Inc. Co-published with CRC Press (Taylor & Francis)

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and the stress of the population, one of the specific programs developed was to provide mental health and psychosocial support (MHPSS) during the COVID-19 pandemic. This first part of the chapter will be present, through a psychosocial filter, the impact of the announcements (distancing, masks, and quarantine) government tools that changed the social dynamics and, therefore, developed a collective series of stressors that have contributed to the increase in the level of uncertainty, hopelessness, and anxiety of the population in the face of an unprecedented situation. Also, we note specific actions taken to mitigate the emotional suffering that is now affecting most of the Americas as a result of COVID-19. Finally, the chapter describes how the IFRC MHPSS response in the Americas has been organized. 12.2 CHRONOLOGY OF THE PANDEMIC ADVISORIES AND THE EMOTIONAL REACTIONS IN THE POPULATION The initial chronology for the pandemic response was guided by the World Health Organization (WHO). Below please find the sequence of guidance that led to the COVID-19 response by States and Humanitarian organiza­ tions. Some of the suggested actions had a negative impact in the community by promulgating fear, increased anxiety, and abuse. 12.2.1 DECEMBER 2019: EXPECTATIONS In December 2019, the WHO in the People’s Republic of China received a statement from the Wuhan Municipal Health Commission on cases of atypical “viral pneumonia” (WHO, 2021). In response to this notification, WHO and others, activated their mechanisms to determine the causative agent of these cases, publishing on January 9 that the cause is a novel coro­ navirus. At this moment, it can be said that a questioning phase is being initiated mainly by the scientific community, with questions such as what do we do now? What is it? How is it? Why? How is it transmitted? And behind all these questions and doubts, there is an increase in uncertainty and fear about what might result from the studies. There was no social impact per se, but there was an impact within the scientific community. 12.2.2 JANUARY 2020: VULNERABILITY AND DOUBT Around 13 days after this announcement by the Chinese authorities, the first imported Coronavirus case was reported in Thailand (January 21, 2020), then in the Americas in the United States. By January 30, 2020, there were 98 cases

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with no fatalities in 18 countries outside China (Germany, Japan, the United States, and Vietnam). A common social concern had arisen from the evidence that the virus had spread beyond its place of origin. Stress levels increased because of the risk of being affected. Also, at the end of January, the WHO announced recommendations for using masks in community spaces and caring for people with respiratory symptoms. At this time, there was much debate and mixed messages about masks, creating confusion and doubt amongst the population. The Chinese were already entering lockdown, with an apparent significant loss of human life, exposing the population to great suffering. 12.2.3 FEBRUARY 2020: LOSS OF TRADITIONAL SOCIALIZATION AND FREEDOM The WHO announced quarantine recommendations. Around 78 countries in all continents implement measures to restrict the mobility of people. Which, at the social level, marked the beginning of an abrupt change in the daily forms and dynamics of life, ways of relating to each other, and customs and traditions. A sensation of loss of control in autonomy, independence, and decision started to increase when mobility was restricted, thus increasing fear and anxiety in the population. 12.2.4 MARCH 2020: GENERALIZED INCREASE IN CONCERN On March 11, 2020 (Ioannidis, 2021), the WHO declared COVID-19 as a global pandemic. The health authorities reported feeling “deeply concerned by the alarming levels of spread, severity, and levels of inaction, a call to countries to adopt urgent and aggressive measures” (Wan, 2020). This exposed everyone globally to higher levels of stress and induced mass hysteria. Italy, and Spain became the countries with the most cases and deaths, and Europe was declared the epicenter of the pandemic (Schnirring, 2020). The global community began to receive reports of large numbers of COVID fatalities. Feelings of insecurity and fear were fostered by losing loved ones and vulnerability to the virus, regardless of the country’s development or financial resources. The WHO (2020); UNICEF (2020); and the IFRC (2020) published guidelines outlining the most important considerations for keeping schools safe, with practical checklists and tips for parents, caregivers, and children and students. Children and adolescents were exposed to a radical change in their daily routine by dropping out of school and changing to a virtual online

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system. This target population was exposed to various limitations that inter­ fered or allowed them to attend the virtual lesson linked with situations, such as a no internet connection or having device situations that expose young people to exclusion and isolation from not finishing their studies. 12.2.5 APRIL: THE IMPACT OF VERBS ASSOCIATED WITH PHYSICAL DISTANCING RESTRICTIONS

On April 16, 2020, the WHO published guidance on considerations related to adjustments to public health and social measures in the context of COVID-19, such as restrictions on large-scale mobility, commonly referred to as “confinement” or “isolation” (WHO, 2020). The emission of messages or communications in the media using verbs that usually have a negative connotation, such as “confinement,” influenced people’s perception of these preventive measures as a punishment rather than a beneficial measure to the community. 12.2.6 JUNE 2020: INFODEMIC In June, the term “infodemic” began to be used, defined by health authorities as “the overabundance of information, which can be good or bad (WHO, 2020).” The scientific community recognizes the negative impact of the saturation of COVID-19 information. Information was being produced so fast that there was no time for people to assimilate it, creating confusion and mental fatigue. Three months later, the WHO published a joint state­ ment with other United Nations (UN) partners and IFRC calling for action to manage the COVID-19 “infodemic,” both online and offline (IFRC, 2021). The Americas become the epicenter of the pandemic. The United States has the most cases, followed by Brazil. 12.2.7 OCTOBER 2020: PANDEMIC FATIGUE The term “pandemic fatigue” began to be used, which was defined by the WHO as “demotivation to follow the recommendations for protecting behaviors, gradually emerging over time and affected by a series of emotions, experiences, and perceptions” (WHO, 2020). It was estimated that 60% of the population was suffering from pandemic fatigue. This was also associated with a false perception of security (when case numbers fall) and a longing to return to the social dynamics of the past.

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12.2.8 DECEMBER 2020: HOPE VS. MISTRUST

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With the arrival of COVID-19 vaccines and vaccination of the vulnerable, many are hopeful that the pandemic is coming to an end. On the other hand, rumors and misinformation have created fear and mistrust, creating renewed uncertainty. It has been reported that the vaccines are safe, thereby increasing the proportion of people in favor of vaccination (OECD, 2021). The arrival of vaccines was also accompanied by a less stringent following of prevention measures (associated with a collective fantasy of the end of the pandemic). 12.3 DEVELOPING THE IFRC RESPONSE FOR THE AMERICAS AND THE CARIBBEAN This section provides a chronological synapse to explain the actions orga­ nized by the IFRC to support the 35 NSs in Latin America and the Caribbean (see Appendix A). The NSs have been able to immediately identify people’s psychosocial needs and the importance of implementing different actions to reduce the impact on the psychological and mental spectrum. This was possible because of the efforts made over the last 20 years to strengthen capacities in Psychosocial Support (PSS) as an essential and fundamental part of the Red Cross programs, projects, and humanitarian responses (IFRC, 2020). In the context of this pandemic, more than ever, it has been possible to visualize the impact of events on psychological well-being at a personal and social level, and the importance of support for those affected (Calbi et al., 2021). The actions carried out, beginning in April, keeping in mind that in the Americas the pandemic became the epicenter of the pandemic in June 2020. As of December 2020, the specialists affirmed that the Americas have not emerged from the “first wave” due to the lack of control of community trans­ mission by health systems, a situation that can be largely associated with the historical weakness of these systems and the low budget allocated to health (McKinsey & Co., 2020). Thus, the region has been trapped in a sustained situation, plunging the population into prolonged measures of social isolation and greater uncertainty. This implies that the NSs have had to continually maintain a high level and rhythm of activity to continue to meet the needs of the population, exposing volunteers to high-stress levels. Therefore, it is of the utmost importance to ensure their psychosocial stability and provide support systems for those who care for others.

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12.3.1 DEVELOPING THE TEAM

At the Regional Office of the Americas located in Panama, in mid-March, after the launch of the COVID-19 appeal, the Health Unit formed a multidisciplinary team with water and sanitation (WASH), health, mental health, and psychoso­ cial support (MHPSS) professionals to provide technical support and guidance to the NSs. The response to the COVID-19 was the first time that mental health and psychosocial support has been included within the structure of the Health Unit of the International Federation of Red Cross and Red Crescent (IFRC). 12.3.2 IDENTIFYING THE MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT (MHPSS) HUMAN CAPITAL The principal tasks of the MHPSS coordinator were: (i) To analyze the suitable amount of MHPSS delegates needed to provide technical support to the 35 NSs of the region; (ii) to identify and contact the NSs’ MHPSS focal point; and (iii) to establish an MHPSS communication network for the Americas and Caribbean. Next, through the IFRC surge system, it was possible to support a specialist from the American Red Cross, and a delegate from the Costa Rican Red Cross. Three MHPSS delegates were identified and joined the team. From April to June, the regional MHPSS team consisted of six professionals that were distributed per country cluster (CCST): one MHPSS Team Leader for the Colombia-Latin Caribe; one MHPSS specialist for the English-Dutch Carib­ bean; one MHPSS delegate for Central America; one MHPSS delegate for the Country Cluster in Lima (Perú, Ecuador, and, Bolivia); one MHPSS delegate for the southern cone (Brazil, Chile, Argentina, Paraguay, and Uruguay) the IFRC MHPSS migration interventions of the Monark Butterfly and regional migration appeals; and one MHPSS delegate that already was in the Country office of Venezuela supporting the humanitarian responses implemented there. In most of the NSs in Latin America had MHPSS focal points (volunteer or paid staff). In the Caribbean, Trinidad, and Tobago, Jamaica, and the Bahamas had MHPSS focal points, and the other NSs had a health focal person who covered WASH, health, and PSS. A total of 20 MHPSS focal points were identified. A WhatsApp group was developed for each sub-region to facilitate and maintain faster and more fluid communication. The representatives preferred this source of communication since the connectivity in some countries was compromised. Through this channel, the information could be streamlined in real-time to address rumors, provide guidance and protocols, exchange experiences, and share awareness-raising materials for the population.

Chronology of MHPSS Interventions in the Americas

12.3.3 DEVELOPING TIES AND ASSESSING THE NEEDS

211

To establish a relationship of trust and mutual support, at the end of March, the MHPSS Regional team identified the best way to serve the Caribbean and Latin America. It is necessary to clarify that the division was done because of language differences. Language was a major challenge for communica­ tion. In the region, Portuguese, English, Creole, and Spanish were used by most of the people. In some sectors in the Amazonia, Peru, and Guatemala, traditional languages were used. In the case of the Spanish-speaking NSs, a monthly technical workshop was set up with the NSs’ MHPSS focal points; in the Caribbean, it was worked through personalized telephone calls. To establish the relationships and develop a common working plan that NSs felt identified with them, a needs assessment was carried out through an online survey-type instrument shared with the 35 NSs. In the survey carried out in April, the goal was to know the type of support that they expect from the regional MHPSS, the principal action that they were carrying out to respond to the pandemic, and their perception of the principal MHPSS issues that were affecting the population. In terms of their expectations, the principal support requested was MHPSS training, followed by providing materials and guidelines and technical support. About the actions that NSs were already carrying out, the main actions were awareness and transmission of messages to reduce stress or reduce rumors and telephone assistance through helplines (at the beginning of the epidemic, 12 NSs installed MHPSS helplines). Based on the NSs’ daily activities and being in the front line and in contact with people, the NSs perceived anxiety and fear of being infected or infecting their at-risk family members as the main problems among the population. After obtaining this information and carrying out the need’s analysis, it was possible to proceed to elaborate the work plan to support and work side by side with the NSs. Also, this information was crucial to develop the Action Plan for the COVID-19 Appeal for the Americas. 12.4 LAYING THE FOUNDATIONS OF THE MHPSS RESPONSE BASED ON RESOLUTION 2 (R2) After the needs analysis, the work plan of the technical team was prepared in a way that could meet the real needs of the NSs, and this was aligned with the eight statements of the movement’s resolution 2 (R2) adopted at the 33rd International Conference of the RCRC Movement in December 2019

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(IFRC, 2019). It should be noted that the COVID-19 pandemic is the first level-global catastrophic event to occur after the approval of R2. The main aspects analyzed and included in the work plan were and continue to be: •

• •

•

Strengthening of capacities through developing, organizing, and training; promoting peer-to-peer work; and producing or gathering materials as guidelines. It is important that this strengthening is done bidirectionally, since it is an extraordinary situation, we all must learn together. Technical support for inquiries from National Societies and the Regional Clusters. Internal and external advocacy on the commitment to R2 to guar­ antee the inclusion of MHPSS actions in all emergency responses and establish permanent programs and guarantee the presence of MHPSS systems for the NSs’ volunteers and staff. Serve as a liaison with other actors and resources to combine efforts and resources.

12.4.1 A STRATEGY OF HOPE (IFRC-LAC, 2020) Hand in hand with laying the foundations for the intervention, the regional team focused on developing a guiding framework that would help NSs to: Visualize that the identity and spirit of the psychosocial support of the move­ ment are based on community-based interventions; and identify the most effective and relevant evidence-based interventions. The strategy aimed at: (i) assessing the regional capacities of the NSs in terms of MHPSS to direct efforts towards areas that require strengthening. (ii) Develop and strengthen the capacities of the NSs in mental health and psychosocial support through the implementation of training and technical advice adapted to the specific needs of each context, thus ensuring impartial access to MHPSS and prioritize prevention and early response, as well as ensuring its implementation. (iii) Increase awareness internally and exter­ nally about the importance of implementing MHPSS interventions during the pandemic response for both affected and infected populations as well as the responders. (iv) Recognize the resilience, participation, and diversity of the total population of the region of the Americas, with greater atten­ tion to afro-descendant, aboriginal, and native populations, in psychosocial activities; thus, promoting participation, community empowerment, and advocacy for the rights of these population groups. (v) Include basic psycho­ logical support (psychological first aid (PFA) and basic psychoeducation) as

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compulsory training for all volunteers and personnel of the movement. (vi) Integrate basic psychosocial support into other key services: first aid, shelter, water, and sanitation, nutrition, livelihoods, education, and protection. The implementation of this strategy is based on four large blocks linked to the pyramid of psychosocial intervention (PS Center, 2021).

Source: Courtesy of The IFRC Reference Centre for Psychosocial Support . https://pscen­ tre.org/?resource=the-iasc-mhpss-pyramid-vs-the-international-red-cross-and-red-crescentmovement-framework&selected=single-resource

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12.4.2 BASIC PSYCHOSOCIAL SUPPORT

Ensure that volunteers are trained and can implement activities that promote social connection and cohesion, self-care, community participation, and support networks between community members and volunteers. Interaction between volunteers, communities, and their community leaders is sought to develop inclusive strategies where all community members (neighbor­ hood, community, including marginalized people, communities of faith, and/or community traditions) improve self-help and psychosocial support. Activities can include safe spaces for different sectors and/or community activities that foster dialog in the community. Communities are encouraged to empower themselves and take ownership of psychosocial interventions, including psychosocial support sessions and social support groups. All of this follows community assessment, mobilization, and collaboration supported by community participation and accountability (CEA). 12.4.3 FOCUSED PSYCHOSOCIAL SUPPORT WITH AN EMPHASIS ON PSYCHOLOGICAL FIRST AID (PFA) Psychological first aid (PFA) was provided to people affected by COVID-19 to improve their mood or reduce or eliminate any sequela that might impact on life, such as exposure to physical, psychological, and/or sexual violence, the loss of a loved one, witnessing death, or having deaths among family members, or some other need related to loss, grief, and emotional recovery. PFA is not a clinical intervention, but a basic, humane, and supportive response to people affected by what they have seen and/or suffered, including health workers, first responders, and volunteers. The five steps of the PFA are: (i) listen carefully; (ii) evaluate; (iii) guarantee basic needs; (iv) encourage psychosocial support; and (v) protect against further harm. It is not an intrusive technique or action, and it is not about pressuring people to talk about their ailments. To ensure accessibility to specialized services for people with more complex needs detected during the provision of PFA, referral mechanisms must be established both inter­ nally, within the NS, and externally to others. PFA is an important tool with proven positive impact and benefits that all Movement members and first responders need to know and be trained. 12.4.4 PSYCHOLOGICAL SUPPORT NSs with specialist volunteers, such as Counselors, Social and Community psychologists, teachers, and community mobilizers, and others were able

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to provide psychological support interventions for people in need. These interventions detected the need to address mental health problems, such as depression, anxiety, and traumatic stress disorders, to ensure their referral to government services for timely follow-up, treatment, and rehabilitation. 12.4.5 SPECIALIZED MENTAL HEALTH CARE

The IFRC and NSs developed established relations with the Pan American Health Organization and identified local Mental Health facilities as well as local psychiatrist for referrals. The International Federation (IFRC) assessed the needs in the countries most affected by COVID-19 to support and provided technical assistance to the NSs in the development of action plans, coordination, and training that facilitate meeting the mental health needs of the communities during the different emergency phases (immediate, recovery or long-term). The IFRC supported the organizational development and sustainability of MHPSS programs in the NSs by including developing their capacity to provide increased psychosocial activities in selected opera­ tional contexts. The actions of the regional team revolved around carrying out activities that would help strengthen the NSs and effectively and efficiently carry out the four pillars. The official launch was carried out in October 2020 with the IFRC regional heads’ support, who called on both the Regional Clusters and the NSs to reaffirm their commitment to the IFRC Psychosocial Support policies. 12.4.6 RESPONDING TO THE NEEDS OF THE NATIONAL SOCIETIES (NSS) The IFRC-MHPSS Technical Unit in Panama provided the following specific activities in support of the NSs: •

Around 25 virtual training sessions were held by the MHPSS regional team, where 450 people were trained in topics such as PFA, PFA for loss and grief, PFA for children and adolescents, and community psychosocial support. When the material produced by the Psycho­ social Support Center of the IFRC RC was translated to Spanish, a PFA pilot was carried out to ensure that the content was culturally and linguistically adapted to the region. The NSs that participated in

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•

•

the pilot were Chile, Bolivia, Costa Rica, the Dominican Republic, and Venezuela. Around 18 online webinars were held on relevant topics, such as the importance of self-care aimed at volunteers and the staff, emotional intelligence, resilience, a culture of mental health after COVID-19, and the impact of using personal protective equipment in the physical and mental well-being of the participants. For these events, different specialists and NSs participated, such as the Magen David Adom, Mexican, Canadian, American, Spanish, Costa Rica, Panamanian, Ecuador, Trinidad, and Tobago, Jamaica, and the IFRC Psychosocial Support Center. Around 11 workshops were held with the MHPSS LA focal point, addressing self-care, the importance of implementing protection systems and self-care for volunteers and staff, special considerations to implement PSS helplines, R2 and the roadmap 2020–2023, community mental health programs, and PAHO Community mhGAP. The NSs were also invited to share their COVID-19 interventions to promote lessons learned, and good practices among peers: the NSs of Colombia, Bolivia, Argentina, Costa Rica, Honduras, Chile, and the Dominican Republic shared their experiences.

In terms of providing technical guides (42), different documents were produced, such as the MHPSS minimum actions guide to be carried out during COVID-19 or the MHPSS Regional COVID-19 Strategy. Addition­ ally, the technical team made great efforts in translating (in real-time) 12 guides and training documents into Spanish. 12.5 EARLY RECOVERY (JUNE–DECEMBER 2020) During the response (March-June 2020), an attempt was made to follow the disaster response model and temporalize the response phases, such as emer­ gency, early recovery, long-term interventions, and preparation, and to plan activities based on these phases. The team had made the following timing for the work plan: emergency phase, March to July (4 months); early recovery phase, August to January 2021 (6 months); and long-term recovery, January to December 2021 (11 months). In the context of COVID-19, situations arose that prolonged or delayed the timing of the traditional disaster cycle phases. As mentioned above, in June, the Americas was declared the epicenter of the pandemic, and since

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then, most countries have maintained a constant response level and restric­ tions. Therefore, the NSs have maintained a constant and tireless work rate to continue accompanying and supporting the population. It can be said that a constant cycle has been maintained between emer­ gency and early recovery. In January 2021, a rebound and increase in cases were observed in most of the countries of the region, associated with multiple factors, such as family reunions and trips due to December celebrations, and pandemic fatigue, which again collapsed the health services, with govern­ ments implementing restrictive measures. During September, an analysis was made of all the NSs of the region to identify which would require greater support from the technical team. The analysis was carried out following research criteria and using relevant demo­ graphic, social, and epidemiological data and NSs capacity and resources in MHPSS. The criteria included the total population of each country, the number of COVID-19 cases, the number of COVID-19 deaths, the proportion of the population considered vulnerable indigenous people (https://www. bancomundial.org/es/region/lac/brief/indigenous-latin-america-in-thetwenty-first-century-brief-report-page; https://www.paho.org/es/historias/ protegiendo-comunidades-indigenas-covid-19), the presence of migrants, the capacities and resources of the NS (human, material, and economic). Based on this information, a work plan was developed consisting (in the first phase) of building the capacity of the National Society MHPSS focal point. The second phase built the capacity of PSS national teams to be able to develop action communities through a model based on PSS mobile units. The third phase aimed to support the MHPSS National Society focal point in the planning and implementing actions at the community level, with special attention given to actions in schools. In December, with the arrival of the roadmap 2020–2023 (PSCenter, 2020) of R2, those NSs will be accompanied in the process to achieve the objectives of the focus areas based on the docu­ ment. It is a commitment of the IFRC to support the NSs to re-strengthen themselves, thereby being best able to respond to the needs of the affected population. 12.5.1 SUPPORTING THE IDENTIFIED NSS The analysis identified Peru, Bolivia, Honduras, Guatemala, Uruguay, Para­ guay, and Belize. An interview was arranged with each NS to comment on

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the findings and ask them if they would be interested in being part of a tech­ nical assessment process to strengthen their MHPSS capacities. Following these meetings, Bolivia, Chile, Honduras, Guatemala, and Uruguay began to receive initial training in the community psychosocial support programs. Based on the dynamic cycle of constant change that occurs, continuous monitoring was carried out with the NSs to identify new trends or situations that were appearing. Throughout the response, it was possible to receive information from the field. As already mentioned, in April, the user expresses fear of becoming infected or infecting their loved ones. By September, the new worries expressed by the user were physical and mental exhaustion in the face of the pandemic, difficulties in combining teleworking and raising and attending to their children’s school activities, fear, and uncertainty about the future due to having lost their livelihoods, increased domestic violence, suicidal ideation, increased anxiety, and symptoms leading to depression. In October, the movement presents the report “The greatest need was to be listened to: The importance of mental health and psychosocial support during COVID-19,” where representative data is evidenced, such as that 51% of the adults interviewed in the seven study countries reported that the pandemic had negatively affected their mental health (https://www.icrc.org/ es/document/una-crisis-dentro-de-una-crisis-mental-health-distress-risesdue-covid-19). Based on these data, the regional team, together with the NSs, visualized the latent needs of society and planned actions and direct efforts towards those priority issues. 12.5.2 TOGETHER, WE ARE MORE The regional team has focused on joining efforts and strengthening ties, cooperation, and collaboration (both internally and externally), with the ultimate goal of reaching the emotional and existential needs of more people. At movement level, communication, protection, gender, and inclusion (PGI) and community engagement (CEA) were fundamentals area of collabora­ tion for MHPSS to guarantee the awareness of the importance of the mental health, stigma reduction, community participation, empowerment, and the gender inclusion and protection approach in each MHPSS intervention. Externally, ties have been strengthened with the MHPSS sections of other agencies, such as PAHO and UNICEF, as well as with other actors, such as the Caribbean Association of Psychologists (CANPA) and John Hopkins University, School of Public Health.

Chronology of MHPSS Interventions in the Americas

12.5.3 CHALLENGES

219

12.5.3.1 RECOGNIZING THE IMPORTANCE OF MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT SYSTEMS (PSS) Although the COVID-19 pandemic has put mental health needs in the spot­ light, showing how people have been affected by emotional stressors. One of the great challenges was (and continues to be) raising awareness (especially internally within the movement) about the importance and impact of MHPSS interventions. The inferred situation is mainly associated with ignorance or confusion about the concept of what health is, a culture of “blocking and hiding feelings” (Western thinking); and a lack of knowledge of scientific methodologies for approaching psychosocial problems. Therefore, the task has been arduous, and it has been recognized that: there is no health without mental health, and the impact of COVID-19 has put mental health in the spotlight. In April 2019, the Secretary of the United Nations, António Guterres (2020) made a declaration and called for governments, health authorities, civil society, and collaborating organizations to urgently focus on the pandemic’s mental health impacts. Confinements and quarantines should not discriminate against those whose mental health is affected. There have been calls to change the perception of mental health and to internalize that there is no health without mental health. It is difficult to continue teaching society that we have the right to express our feelings and suffering. Also, it is normal to ask for help to cope with those emotional situations that we cannot face on our own. 12.5.3.2 REINVENTING ONESELF TO MEET THE POPULATION’S MHPSS NEEDS Psychosocial and mental health interventions have traditionally been done face-to-face. Besides, face-to-face interventions are a key part of psychoso­ cial support, fostering openness and trust in people. COVID-19 has changed “the traditional rules of the game.” All professionals and organizations have had to reinvent the way they conduct their interventions, to remain close to people and meet their needs while also complying with regulations and restrictions to reduce contacts and maintain distancing. For this reason, the NSs recognized that new technologies would help to remain emotionally connected, being able to provide PSS through helplines.

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Similarly, we should note that despite technological advances and the popu­ larization of access to the Internet or smartphones, many communities still do not have access to these tools, such as indigenous communities. For that, the Movement needs to continue looking for the best ways to reach everyone in every corner. 12.5.3.3 KEEP A SPACE IN THE RESPONSE

MHPSS is an area that has put a great effort to ensure that its contributions, ideas, objectives, and activities are included in the interventions, programs, and projects. When ideas, contributions, and recommendations are devel­ oped, the sector is also exposed to a reduction and even elimination of these because it is not considered important or because those who make the deci­ sions lack knowledge of the impact of these interventions. Another situation that the sector must deal with is the tendency for budget funds to be moved from MHPSS to other lines that are considered “greater priority.” To change this reality, It crucial to work in the sensitization of the decision makers to understand better that MHPSS intervention are an essential part of the soul of the Movement, to understand clearly that at the end of the day, all the sector in somehow are doing MHPSS actions all together we are working to reduce the suffering. 12.5.3.4 CHANGE LABELS OR PERCEPTIONS OF MHPSS INTERVENTIONS For as long as I have belonged to the movement, I have observed that the MHPSS sector has been pigeonholed and labeled as “the entertainers who paint faces.” I thought that this perception was linked to ignorance of the scientifically proven positive impacts of MHPSS interventions. During the COVID-19 response, it was necessary to make it understood that MHPSS is not only a sector of entertainment for the population, but an imminent serious response during a pandemic. Hence, it is also important that sufficient funds be assigned to research the impact of MHPSS interventions. COVID-19 has allowed us to better understand the impact of the interventions non a pandemic. An example of this is the hotlines provided to the population, which reduces uncertainty and stress.

Chronology of MHPSS Interventions in the Americas

12.5.3.5 PROVIDE NSS OF THE AMERICAS TO HAVE ACCESS TO MATERIAL IN REAL-TIME

221

During the pandemic, MHPSS courses, guides, protocols, and materials of various kinds were produced (both by the movement and other actors), many of them in the English language. For this reason, it was a priority for the MHPSS regional team to ensure that Spanish-speaking NSs could access these materials. The challenge in this regard was that there were no funds to carry out the translations, either from the authors or from the movement. Therefore, the MHPSS regional team rapidly carried out numerous transla­ tions, and in parallel with the daily commitments of each of its members. Valuable time was spent in translation undertaken by the technical staff. 12.5.3.6 NO ONE LEFT BEHIND Another challenge of the operation has been to ensure that the interventions were accessible to those who live in more isolated areas or do not have access to communication systems. Attending to the psychosocial needs of indigenous people has been challenging because the material that have been produced and the recommendations are elaborated from a conception of the norms of “westernized” societies, creating barriers in indigenous people’s understanding and appropriation of these recommendations, thereby increasing their risk of becoming infected and mental pathologies (https:// iris.paho.org/handle/10665.2/28416). The challenge is also associated with the fact that historically indigenous people have been exposed to greater vulnerability. This has long been associated with a failure to understand and adapt health practices to their customs. COVID-19 pandemic has worsened this situation: PAHO has reported that the indigenous people of South America have experienced a greater number of cases and deaths from COVID-19 linked to the chal­ lenges of access to health services (https://www.paho.org/es/historias/ protegiendo-comunidades-indigenas-covid-19). In Bolivia, since the confirmation of the first cases of COVID-19 in the country, and until July 6, 2020, 31,249 cases were confirmed, including 1,135 deaths. Indigenous populations are facing fear because they have not received information adapted to their understanding, culture, belief, and perspective of indigenous or Afro-descendant people, and this exposed them to be contagious and face a representative number of deaths that

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leave behind a deeper loss and grief. Apart from that, the majority of the MHPSS interventions, protocols, and tools are not adapted to cover their emotional needs situation that exposed more the indigenous community to suffer psychological and mental health problems. For these reasons, work was carried out to raise awareness of the importance of adapting resources and materials to the languages of indigenous people. The Colombian Red Cross has carried out campaigns in the native languages of some indigenous communities. It has also been a challenge for the NSs to reach the most isolated commu­ nities that do not have access to the Internet or even radio. It is important to highlight that the pandemic has further exposed social inequalities. Not only the most isolated communities have had problems accessing available resources, but also in urban areas, many families do not have access to the Internet or have a telephone to be able to access helplines. This situation worsens among migrants, people living on the street, and there is a great concern for women, girls, and boys who are victims of domestic violence and subjected to a higher level of stress and suffering, now coupled with the uncertainty of the pandemic (https://www.un.org/es/coro­ navirus/articles/un-supporting-trapped-domestic-violence-victims-duringcovid-19-pandemic). For this last situation, the IFRC MHPSS team worked with the NSs to strengthen knowledge for the management of telephone lines, including knowledge on detection of victims of gender violence and referral systems with the support of the PGI sector. It has been a challenge to have resources adapted to people who have a visual or auditory limitation, or both, which puts this group at risk of exclusion. 12.5.3.7 BREAKING MHPSS PARADIGMS Based on the Pyramid of Intervention introduced by the IFRC, most of the NSs in the Americas address the first, second, and third levels; they mainly carry out psychosocial support interventions with an emphasis on estab­ lishing a robust reference system at the fourth level. Nevertheless, there are specific cases of NSs that provide care at the four levels (because they have clinical services with mental health specialists). The essence of MHPSS in the movement is based on a community approach that seeks to promote and prevent psychological problems or mental pathologies, counting on the capital, social, and ecological resources of people and communities with the premise to not harm.

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Where the empowerment and resilience of people are sought from seeing them as possessors of resources that will help them overcome specific situa­ tions with support, and not as victims. During the response, we have noticed a tendency to make an approach via the clinical psychologist; therefore, there was a mismatch between international guidance and the services provided by NSs. In this sense, the NSs MHPSS referents were supported with training on community interventions so that they could replicate it with their team, emphasizing the premise of not harming and that the main responsibility for the treatment and monitoring of people who need specialized care lies in the health services of each country; our role is supportive and auxiliary to the public powers. 12.5.3.8 ESTABLISHING PERMANENT COMMUNITY MHPSS PROGRAMS WITHIN NS STRUCTURES The pandemic has targeted mental health and revealed the need for perma­ nent psychosocial support services that meet the needs of vulnerable people, the community in general, and of the volunteer and staff of the NSs. The challenge in this regard is to ensure that, based on field experience and the existing policies and guidance, the NSs should permanently include in their structure, the community MHPSS programs that go parallel with the programs of community health. This is of great importance, in addition to be a resource that will be of great value to the community and opportunities to strengthen relationships with the ministries of health; since the region has a significant lack of systems and trained psychosocial personnel to support the community (https://iris.paho.org/handle/10665.2/49664). 12.5.3.9 ADAPTATION OF TRAINING RESOURCES AND MATERIALS TO A VIRTUAL FORMAT Much of the pre-existing material and courses had to be rapidly adapted to the virtual format, requiring significant time and effort for technical staff to translate to Spanish, and little to no translation in the native languages of native population in Peru, Bolivia, and Guatemala. Also, the trainers had to adapt to a different way of rolling out the training (that had traditionally been given in person). Thus, going forward, courses and materials should be adapted for both in-person and virtual delivery.

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12.6 LESSONS LEARNED

12.6.1 THE USEFULNESS OF NEW TECHNOLOGIES Technologies have been especially useful during the pandemic, with four key roles. At the beginning of the pandemic, 16 NSs have used new technologies to remain close to people in times of mobility restrictions, providing PSS services through telephone lines and instant messaging services. Second, video calls have been used to follow up regular users of the programs and services offered by NSs. The NSs conducted training especially for users not familiar with new technologies. Third, all 35 NSs have used social networks to deliver awareness messages about the importance of mental health care, stress management, coping with loss and grief, and resilience. Fourth, the NSs and the IFRC’s regional MHPSS team have used virtual platforms to provide training on topics to help implement actions during the response. This has enabled a greater number of people to be trained. Reduced cost is one benefit of having used this virtual route. In this way, technical teams have been able to meet frequently to share challenges, ideas, and experi­ ences. It has been possible to demonstrate that new technologies are useful tools when used responsibly and ethically. 12.6.2 THE EFFECTIVENESS OF PEER SUPPORT SYSTEMS During the pandemic, the MHPSS teams of the NSs have been tirelessly providing frontline emotional support. Peer support has been promoted, including the twinning of NSs (e.g., Ecuador, Costa Rica and Argentina, and Bolivia). The participating NSs have reported that twinning has been very positive and should be maintained. 12.6.3 INVESTING IN MHPSS HAS AN EXPONENTIAL IMPACT ON COMMUNITY HEALTH AND WELL-BEING The fact that PSS services previously existed in most of the NSs has made it possible to respond to the emotional needs of the population from the beginning of the emergency. Also, it has been possible to protect volunteers and the work­ force. However, efforts and funds must be invested in establishing permanent PSS community-based programs and services to support people’s emotional needs during crises. All member of the Movement needs to work together to achieve the commitments of the MHPSS policy, resolution and roadmap and support government providing robust MHPSS community programs.

Chronology of MHPSS Interventions in the Americas

12.7 RECOMMENDATIONS

225

Based on our experiences, we propose 12 key recommendations: • • • • • • • • • • • •

Ensure the prioritization of MHPSS as a focus area in the institu­ tional structures and strategies of NSs, with support for the IFRC and ICRC. Promote investment in mental health, especially in PSS, with a community approach. Encourage implementing school PSS programs to promote a culture of well-being, mental health, peace, and inclusion from an early age. Do not underestimate the mental impact that the social imbalance, caused by the pandemic, is generating on people of all ages. Seek and assign more resources for research on the mental health impact of COVID-19 and MHPSS interventions. Include “to eradicate the stigma around psychological problems and mental illnesses” as an objective of the Red Cross and Red Crescent movement. Support the NSs (at the managerial and operational levels) to achieve the 2020–2023 roadmap objectives. Ensure that the IFRC Clusters and regional office teams include MHPSS specialists. This is an important exercise to align with the commitments and focus areas of the policy and R2. Include children and adolescents in the design and process of emer­ gency response or programs. Ensure that they have a voice and vote in all processes and express their needs and opinions. Consider expanding the list of vulnerable groups (e.g., to include young people who are facing major problems of exclusion due to not having access to educational or work opportunities). Sep up MHPSS training for the decision makers and managers to understand the importance of including in each response and program this sector. Promote a basic initial training package for all volunteers who start activities in the movement, including basic knowledge about the movement, first aid, protection, gender, and inclusion (PGI), community engagement & accountability (CEA), and psychosocial support (PSS).

We hope that these lessons learned will improve practices and guarantee quality interventions by and for the well-being of people and communities.

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KEYWORDS • • • • • •

community participation and accountability International Federation of the Red Cross mental health and psychosocial support national societies psychological first aid psychosocial support

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Ioannidis, J. P. A., (2021). Infection fatality rate of COVID-19 inferred from seroprevalence data. Bull World Health Organ, 99(1), 19–33F. doi: 10.2471/BLT.20.265892. https:// pubmed.ncbi.nlm.nih.gov/33716331/ (accessed on 27 October 2022). McKinsey & Co., (2020). The Path to the Next Normal: Leading with Resolve Through the Coronavirus Pandemic. Washington, D.C. https://www.mckinsey.com/~/media/McKinsey/ Featured%20Insights/Navigating%20the%20coronavirus%20crisis%20collected%20 works/Path-to-the-next-normal-collection.pdf (accessed on 27 October 2022). OECD, (2021). Enhancing Public Trust in COVID-19 Vaccination: The Role of Governments. OECD. https://read.oecd-ilibrary.org/view/?ref=1094_1094290a0n03doefx&title=Enhancing-public-trust-in-COVID-19-vaccination-The-role-ofgovernments&_ga=2.216357462.1712306151.1627662099-761298958.1627662099 (accessed on 27 October 2022). PSCenter, (2021). The IASC MHPSS Pyramid Vs. The International Red Cross Red Crescent Movement Framework. Copenhagen. PS Center. https://pscenter.org/wp-content/ uploads/2021/07/iasc_rcrc_pyramid-2.pdf (accessed on 27 October 2022). PSCenter, (2020). A Roadmap for Implementation Commitments on Addressing 2020 – 2023 Mental Health and Psychosocial Needs: A Roadmap for Implementation 2020–2023. Copenhagen. PSCenter. https://pscenter.org/wp-content/uploads/2020/06/MHPSSroadmap-2020-2023.pdf (accessed on 27 October 2022). Schnirring, L., (2020). WHO: Europe Now World’s COVID-19 Epicenter. CIDRAP News. https://www.cidrap.umn.edu/news-perspective/2020/03/who-europe-now-worlds-covid19-epicenter (accessed on 27 October 2022). UNICEF, (2020). Interim Guidance for COVID-19 Prevention and Control in Schools. https://www.unicef.org/reports/key-messages-and-actions-coronavirus-disease-covid-19prevention-and-control-schools (accessed on 27 October 2022). United Nations, (2020). United Nations Comprehensive Response to COVID-19: Saving Lives, Protecting Societies, Recovering Better. New York. https://www.un.org/sites/un2. un.org/files/un-comprehensive-response-to-covid-19.pdf (accessed on 27 October 2022). Wan, W., (2020). WHO Declares A Pandemic of Coronavirus Disease COVID-19. The Washington Post. https://www.washingtonpost.com/health/2020/03/11/who-declarespandemic-coronavirus-disease-covid-19/ (accessed on 27 October 2022). WHO, (2020). Considerations for Implementing and Adjusting Public Health and Social Measures in the Context of COVID-19 (Interim Guidance). WHO-2019-nCoV-AdjustingPH-measures-2021.1-eng.pdf. https://www.who.int/publications/i/item/considerations-inadjusting-public-health-and-social-measures-in-the-context-of-covid-19-interim-guidance (accessed on 27 October 2022). WHO, (2020). Infodemic. https://www.who.int/health-topics/infodemic#tab=tab_1 (accessed on 27 October 2022). WHO, (2020). Pandemic Fatigue – Reinvigorating the Public to Prevent COVID-19. Policy framework for supporting pandemic prevention and management. Copenhagen: WHO Regional Office for Europe. https://apps.who.int/iris/bitstream/handle/10665/335820/ WHO-EURO-2020-1160-40906-55390-eng.pdf (accessed on 27 October 2022). WHO, (2020). Protect Yourself and Others from COVID-19. https://www.who.int/ emergencies/diseases/novel-coronavirus-2019/advice-for-public (accessed on 27 October 2022). WHO, (2021). COVID-19 Response Timeline. https://www.who.int/es/news/item/29-062020-covidtimeline (accessed on 27 October 2022).

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APPENDIX A

IFRC1 Strategy for the Development of a Mental Health and

Psychosocial Support Strategy for the Americas Region2

Joseph O. Prewitt Diaz, Greisy Trejo Rodriguez, Andrya Spyridou,

Linda Sanmarco, and Tatiana Pasos

A.1 BACKGROUND The COVID-19 pandemic is the first major global disaster that humanity has faced since the approval in the Council of Delegates held in Geneva in December 2019 of Resolution 33: Policy of the International Movement of the Red Cross and the Red Crescent on the attention to needs of Mental Health and Psychosocial Support that mandates the inclusion of Mental Health and Psychosocial Support in the repertoire of services to be offered in any humanitarian response3. From the Health Unit and MHPSS team of the Americas Region, since the beginning of the pandemic, it began to articu­ late what this new modality of intervention would look like in the Mental Health and Psychosocial Support response in the emergency and immediate recovery response. For this reason, the strategy presented below has been developed, the result of which is the guidelines to implement interventions and actions for Mental Health and Psychosocial Support in the Americas. These guidelines can contribute to reducing the impact of COVID-19 on well-being and health, mental health in the community in general, and mental health among the most vulnerable. This strategy operationalizes the spirit of the resolution into a comprehensive tool for the Americas. This strategy is in line with the 1 International Federation of the Red Cross and Red Crescent. 2. © International Federation of Red Cross and Red Crescent Societies, Geneva. All or part

of the content of this publication is authorized for non-commercial purposes, provided the source is clearly stated. The International Federation would appreciate receiving details about its use. Requests for the commercial reproduction of this publication should be addressed to the International Federation at the address: [email protected]. P.O. Box CH-1211 Geneva 19 Switzerland. Telephone: +41-22-730-4222, Telefax: +41-22-7330395, E-mail: [email protected]. 3. IFRC, (2019). A Roadmap for Addressing Mental Health and Psychosocial Needs: A Roadmap for IMPLEMENTATION 2020-2023. Geneva. International Federation of Red Cross and Red Crescent.

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IFRC’s Global and Regional Health Strategy and the International Red Cross and Red Crescent (RCRC) Movement’s Policy and Resolution on Mental Health Care and Psychosocial Support (MHPSS) adopted in December 2019 during the 33rd International Conference of the RCRC. A.2 INTRODUCTION During disasters, pandemics, or any other complex event that puts the life, physical, and mental health of individuals and communities at risk, the Inter­ national Red Cross Red Crescent Federation, through National Societies (NSs), will promote a culture of care and well-being. This culture will enable affected people to reduce suffering, achieve the highest health level, and ensure access to psychosocial support systems (PSS) and specialized mental health services for the most vulnerable and affected. Resolution 33 proposes three priority items priority areas: (i) guarantees a basic level of psychosocial support and integrates mental health and psychosocial support across sectors; (ii) develop a holistic MHPSS4 approach between movement components and in collaboration with other actors; and (iii) protect and promote the mental health and psychosocial well-being of staff and volunteers5. COVID-19 has been identified as a pandemic. In times of a pandemic, it is common for people to feel stressed and worried. Common responses by those affected (both directly and indirectly) may include: (i) fear of becoming infected; (ii) fear of losing their livelihood, not being able to work during isolation and being fired from work; (iii) fear of being socially excluded/ quarantined because of association with the disease; (iv) feeling powerless to protect loved ones and fear of losing them to the virus; (v) fear of being separated from loved ones and caregivers due to the quarantine regime; and (vi) refusal to care for unaccompanied or separated children, persons with disabilities or the elderly due to fear of infection because parents or caregivers have been institutionalized or quarantined. Emergencies are always traumatic, but at the time of the COVID-19 pandemic, there have been very specific stressors due to governments’ public health and social measures. These stressors include: (i) caregivers may be increasingly concerned that their children will be home alone (due to school closures) without adequate care and support; (ii) women are carrying out a dual role of care as caregivers and teachers plus fulfilling their role as 4. Mental Health and Psychosocial Support. 5. IFRC, (2020). A Roadmap for Implementation 2020-2023. Geneva. IFRC.

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workers. Both roles are unpaid and limit their employment and economic opportunities; and (iii) a higher level of deterioration in vulnerable people’s physical and mental health. For example, the elderly and persons with disabilities are often left alone because their caregivers are quarantined or because there is no alternative care and support mechanism to address their needs if they are quarantined. The IFRC and the NSs of the Americas and the Caribbean have identi­ fied the need and relevance of implementing an MHPSS strategy to reduce the impact of COVID-19 on people’s physical and mental well-being and to promote hope among vulnerable groups such as indigenous populations, migrant Afro-descendants, and people traditionally underserved by govern­ ment health services. It is expected that by the conclusion of the recovery phase, the expected response include: (i) all NSs in the Region will have a basic level functional psychosocial support program; (ii) MHPSS consider­ ations are integrated into other humanitarian services; and (iii) a supportive and caring working environment amongst volunteer and paid staff is achieved and sustained across the region. In the early stages of the pandemic (April 2020), there was much atten­ tion focused on the consequences that the COVID-19 could have on the mental health and psychosocial well-being of the general population6 and the healthcare workers at the frontline of the response. The historical deficit of investment in mental health care in the Americas region where the average intended allocated by sub-region reported in 2013 was South America 2.05%, Central America 0.9% and, Anglo Caribbean 3.5% (minimum recommended by WHO of 10%)7 and limited PSS plus the problems and limitations that the essential health care and social services are facing during the COVID-19 pandemic are factors that can contribute to decreasing psychological or mental health impact during COVID-19 situation. The IFRC, together with the NSs in the Americas Region (Central, South America, and the Caribbean) aligned with the movement approved MHPSS Resolution 33 (4–12 Dec. 2019), will breach the gap of inadequate services by mentoring, supervising, developing institutional structures and strategies. 6. Clara González-Sanguino, Berta, A., Miguel, Á. C., Jesús, S., López-Gómez, A., Carolina,

U., & Manuel, M., (2020). Mental health consequences during the initial stage of the 2020 Coronavirus pandemic (COVID-19) in Spain. Brain, Behavior, and Immunity, 87, 172–176, ISSN 0889-1591, https://doi.org/10.1016/j.bbi.2020.05.040. 7. PAHO Report on mental health systems in Latin America and the Caribbean 2013 https:// www.paho.org/per/images/stories/ftpage/2013/who-aims.pdf (accessed on 27 October 2022).

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231

As an immediate response to COVID-19, the NSs have established different Psychosocial Support Services through Tele-assistance in more than 12 NSs of the region and systems to protect the psychological and mental well-being of volunteers and staff in the 35 NSs of the region. Also, they provide support to partners such as ministries of health for psychosocial support for health workers and migrants (Figure A.1). Since the beginning of the epidemic in December 2019 in the Asian continent, by June 2020, according to the statistics issued by the WHO, the Americas is the region with the highest number of confirmed cases (10.447.261), with the United States the country with the highest number of confirmed cases of COVID-19 (4.836.930). Since mid-March, the Americas region has seen an increase in the number of cases and deaths. Added to this is a problem of deficient epidemiological surveillance that could be causing underreporting of both cases and deaths, making it difficult to anticipate the speed of transmission and the impact on health systems, which have historically had extensive structural deficiencies. Statistical data from the WHO Situation Report 202 of 9th of August 2020 and statement of the COVID-19 Regional Action Plan.

FIGURE A.1

Chronological evolution of the COVID-19 outbreak Americas region8.

8. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports

(accessed on 27 October 2022).

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A.3 SITUATION ANALYSIS

Timeline of the evolution of the Pandemic COVID-19, WHO. With the sudden appearance of the new viral agent SARS-CoV-2 in December 2019, the world’s scientific community has joined forces to study and understand the virus’s behavior to find ways to contain its spread and/or eradicate it. Today, there is still no specific treatment, cure, and/or vaccine available. The COVID-19 epidemic has spread worldwide and has caused serious disruption to physical health and daily life. The unprecedented implementa­ tion of measures to contain the spread of the disease, such as quarantine, physical distancing, and self-isolation, has affected people’s daily lives, routines, and livelihoods. Also, COVID-19 and the factors that will exac­ erbate the stressors of the pandemic have triggered a wide range of mental health problems. Previous experiences indicate that loneliness, depression, harmful use of alcohol and drugs, and self-harm or suicidal behavior can increase after a disaster, and this is currently happening with COVID-19. The COVID-19 pandemic picture is rapidly changing in neighborhoods and communities in terms of isolation, sense of fear, loss, and control over the future, and will also do so for groups of people who were most at risk of developing mental health problems and psychosocial issues pre-disaster. There are significant experiences that pandemic is having a significant negative impact on the psychosocial well-being of the population. Loss of income, isolation, or separation from loved ones are consequences of quar­ antine measures that have affected mental health. The extent to which health services have been disrupted is unknown, as are the levels of social and psychological distress and the mental health needs of society. Additionally, the impact on people with mental health pathologies and preconditions can lead to depression, obsessive-compulsive disorder, and self-medication. NSs in the Americas, which are in the front line of meeting people’s needs on the ground, report that as a result of all these measures (social isolation, quarantine, job losses, restricted mobility, physical distance), plus previous situations of social, linguistic, cultural, and contextual shortcomings in the countries of the region. The population has had to deal with stress due to: (i) the impossibility of being with loved ones who have fallen ill; (ii) not being able to conduct funeral rites to the dead; (iii) facing increased unemployment; (iv) limited or no access to health care; (v) school closures; and (vi) lack of access to new technologies. Consequently, there has been an interruption of children and

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young people’s in-person schooling, overloading with teleworking, risks of other infections, stigmatization of health staff and first responders (such as volunteers and staff from the NSs). All these situations have increased the demand for psychosocial support to manage the pain, hopelessness, frus­ tration, fear, and stress affecting the population’s psychosocial and mental well-being. A.4 RESPONSE

The IFRC and the NSs in the region should guarantee the basic level of psychosocial support, assess needs, refer and advocate external partners as needed. Since IFRC and the NSs are the closest to the affected and infected population, it follows that integrating MHPSS across sectors will allow components to reach more people and ensure that referral to specialized external partners. To help reduce the impact of COVID-19 on the well-being and mental health of the population volunteers from NSs in the Americas have been carrying out crucial MHPSS interventions, especially for those who are isolated, who have lost loved ones, who report loneliness, anxiety, and depression. The groups with the greatest needs are NS volunteers and staff who are on the front line of response and are under constant stress due to the risk of infection and the stigma of society, groups with less access to essential services such as migrants, indigenous communities, women, children living in situations of violence, older people, and all those in society who may lack psychosocial support networks due to their social or economic conditions. The role of the IFRC will be to support the strengthening and capacity building of NSs to implement MHPSS interventions by adapting technical guidelines, facilitating learning and knowledge sharing through the use of new technologies such as telecare, PHC for volunteers, staff, health, and community promoters (non-specialists) generating community MHPSS approach tools, psychological first aid (PFA), and other psychological interventions. IFRC-MHPSS will select the most impacted NSs to improve services that reach out to the total community by identifying and implementing other measures such as prevention, promotion, protection, and coordination between and within the movement and with external partners. The NSs throughout their MHPSS sectors will protect and promote the mental health and psychosocial well-being of staff and volunteers. Finally, the IFRC will ensure accountability.

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The crucial interventions that have been implemented are in line with those recommended in the WHO mhGAP-C9 Community Guide, as mentioned below: • • •

•

Supporting affected people by conducting rapid assessments and recommending implementation of innovative actions. Implementing psychoeducation actions through the development of awareness materials to promote well-being, hope, inclusion, and reduce stigma. Work on “normalization” so that people understand that the problems they manifest are completely normal about their experience and are attended to through Tele assistance services, bereavement support groups, PSS for volunteers and staff of the NS to reduce stress. Support to all National Societies in the region with MHPSS during the COVID-19 response, the IFRC’s regional health unit has devel­ oped an MHPSS strategy to facilitate and guide the implementation, monitoring, and evaluation of effective, efficient, and relevant inter­ ventions that contribute to the well-being of the population.

The strategy is intended to: • •

• •

Assess the regional capacities of National Society in terms of MHPSS to direct efforts towards areas requiring strengthening. To develop and strengthen the capacities of the Clusters in South America in terms of mental health and PSS through the implementa­ tion of training and technical advice adapted to the specific needs of each context. This will ensure impartial access to MHPSS and help prioritize prevention and early response and ensure the implementa­ tion of MHPSS. Raise awareness internally and externally of the importance of implementing MHPSS interventions in any humanitarian response for affected populations and responders. Recognize the resilience, participation, and diversity of the total population of the Region of the Americas and with greater attention to the populations of African descendants, aborigines, and native populations of people in psychosocial activities promoting commu­ nity participation and empowerment and advocacy for the rights of these population groups.

9. https://www.who.int/publications/i/item/the-mhgap-community-toolkit-field-test-version

(accessed on 27 October 2022).

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Include PFA (psychological first aid and basic psychoeducation) and integrate basic psychosocial support into other key services: first aid, shelter, water and sanitation, food, livelihoods, education, and protection.

A.5 MENTAL HEALTH AND PSYCHOLOGICAL SUPPORT STRATEGY 1. Psychological First Aid (PFA): PFA is used for people affected and/ or infected by COVID-19 to reduce their stress levels or any other life-long consequences such as exposure to physical, psychological, and/or sexual violence, loss of a loved one, witnessing death or dying among family members, or any other need related to lose, grief, and emotional recovery. These are not clinical interventions but a basic, humane, and supportive response to our neighbors affected by what they have seen and/or suffered. The steps of PFA include: (i) listening carefully; (ii) assessing; (iii) ensuring basic needs; (iv) promoting psychosocial support; and (v) protecting against further harm. It is not an intrusive technique or action and is not about pres­ suring people to talk about their discomfort. After a brief orientation, volunteers can administer PFA to the affected community. A session allows the affected person to vent by briefly but systematically relating their perceptions, thoughts, and emotional reactions during a stressful episode. This can be done through telecare and, referrals will be made for the more complex cases. In the same way, care for health workers and first responders such as volunteers is included to reduce the emotional impact/stress by implementing MHPSS interventions and training. Develop MHPSS in selected NSs: IFRC will assess the needs in the most affected countries by COVID-19. We will select a few operational contexts in target NSs, develop action plans, coordinate training, and provide technical assistance. The IFRC will support the organizational development and sustainability of the NSs by including the development of their capacity to provide an increase of psychosocial activities in selected operational contexts. 2. Other Psychosocial Interventions: Volunteers who have the appro­ priate professional preparation and training and licensing can perform psychological interventions to alleviate more complex or structured situations, such as depression, anxiety, and traumatic stress disorders, always under proper clinical supervision (Figure A.2).

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FIGURE A.2

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Infographic MHPSS strategy actions COVID-19.

A.6 LOGICAL FRAMEWORK “Reduce the impact of COVID-19 on people’s mental health and well-being and promote resilience in the Americas.”

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Chilean Red Cross MHPSS Intervention for the Passenger of fly company Jet Smart

BRCS volunteer provides PSS Kits, water, and breakfast items to the collective shelter Bahamas Academy, in Nassau. This collective shelter is housing families who lost their homes after Hurricane Dorian.

CHAPTER 13

Country-Level Mental Health and Psychosocial Support Programs: Moving Forward After COVID-19 JOSEPH O. PREWITT DIAZ

The Pennsylvania State University (Retd.), Pennsylvania, USA

ABSTRACT After a brief definition of community psychosocial competence, and psychosocial support, the chapter provides a framework for a program in the communities and in schools. Immediately, it encourages active community participation, and defines the component of each segment at the organizational level (in this case, a Local Red Cross-National Society), a local level (Red Cross and community working together), and community engagement activities that foster communications amongst all sectors. The chapter concludes with a sample scorecard for community involvement and a scorecard for school involvement. 13.1 INTRODUCTION Human beings are a part of the natural world and, as such, are the products of their nature, circumstances, and experiences. Human beings use their individual experiences to construct their lives, identities, and relationships to their context (Venuleo, Marinacci, Gennaro, & Palmieri, 2020). A person’s private experiences occur in a context with a meaning that is somewhat socially constituted, so they also have a social as well as an individual char­ acter. Psychosocial competence is contextual in the sense that communities have an active part in defining their needs and determining when those needs Mental Health and Psychosocial Support during the COVID-19 Response: An Overview. Joseph O. Prewitt Diaz (Ed.) © 2023 Apple Academic Press, Inc. Co-published with CRC Press (Taylor & Francis)

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are met (Martela & Riekki, 2018). Thus, broadly, all human experiences are psychosocial. Based on my field experience in developing, implementing, and evalu­ ating disaster mental health and psychosocial support for the last 17 years in Central America and South and Southeast Asia, I offer a retrospective discussion on the context of the American Red Cross-supported psychoso­ cial support program. 13.2 THE NATURE OF PSYCHOSOCIAL SUPPORT The definition of the psychosocial support program (PSP) has been a longdiscussed issue between academics and practitioners alike. Psychosocial is a term used to refer to interventions that consider a person’s view of self and the influences that a society, the environment, economy, biological make-up and a host of other external factors that influence the development of the way they see the world and react to everyday occurrences (Swim, 2011). Psychosocial support intervention as an intervention using primarily psychological or social methods for the substantial reduction of psychosocial distress (Dubey et al., 2020). IASC guidance include counseling, activities with families, psycho-educational activities, the provision of social support, rehabilitation activities (e.g., leisure and socializing activities, interper­ sonal and social skill training, occupational activities, vocational training, and sheltered employment activities) (Inter-Agency Standing Committee (IASC), 2007). The Mental Health and Psychosocial Support (MHPSS) is an important area of intervention in COVID-19 recovery. In the short history of PSP, staff alike has offered several interpretations and operational definitions. Some important points are: •

•

•

Mental Health Psychosocial Support is an internationally used term that involves any program that helps to rebuild the individual’s, families’ and communities’ capacities to function normally. It first recognizes and validates the losses and then builds on people’s innate strengths to guide them to self-motivating actions. Both the psychosocial workers and the beneficiaries focus on losses but on the actions and resources that can be utilized in rebuilding communities. It recognizes that recovery and resilience come from within the affected groups; it cannot be imposed from outside. Non-professionals can be educated about stress and the impact of grief and loss. They can be trained to give psychosocial support to

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disaster-affected individuals and families and to build on the indi­ vidual’s and communities’ resources (IFRC, 2020). Finally, the role of psychosocial support is to study, understand, conceptualize, and carefully intervene in the process by which communities enhance the community members’ psychological well-being.

The psychosocial support program was formulated based on existing standards such as the SPHERE Project (Sphere Association, 2018), and the standards of IASC Task Force MHPSS (Inter-Agency Standing Committee, 2007). With the development of the SPHERE guidelines to engage communi­ ties in planning, developing, and evaluating psychosocial support activities, humanitarian organizations have been challenged to develop an integrated participatory model in PSP. The Interagency Standing Committee (IASC) on Mental Health and Psychosocial Support (IASC/MHPSS) Standards suggest the inclusion of both qualitative and quantitative measures to monitor and evaluate signs of distress, community planning, program implementation, and to define the language of psychosocial well-being. 13.3 THE EFFECT OF ADVERSE EVENTS ON INDIVIDUAL AND COMMUNITY PSYCHOSOCIAL COMPETENCE Adverse events such as crises, emergencies, and disasters affect communi­ ties and can produce such human and material losses that the resources of the community are overwhelmed and, therefore, the usual social mechanisms to cope with emergencies are insufficient (SAMSHA, 2021). A pandemic, as evidenced by reports of COVID-19 in popular press reports total break­ down of everyday functioning; normal social functioning disappears; there is loss of the trusted elderly; and the community leadership, the health and emergency systems are overwhelmed in a way that survivors do not know how to receive help. Emergencies are situations that threaten the lives and well-being of large numbers of a population and extraordinary actions are required to ensure the survival, care, and protection of those affected. Emer­ gencies include natural crises such as hurricanes, droughts, earthquakes, and floods as well as pandemics. Crises are individual events that tax the capacity of individuals to respond. One way to explain the social and psychological disruption is to see loss of place as a by-product of the reaction to COVID-19 over the last 20 months. The pandemic has caused the survivors to lose their sense of place, which

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is the actual or perceived loss of social networks, governmental systems, and individual indicators of control that lead to individual and community psychosocial competence. It may take many more months before the persons affected by an adverse event can re-establish their sense of place and for the individual to feel comfortable in a new environment when the systems begin to work once more; health and welfare is re-established; schools are back in session; livelihood activities have been initiated; and the social networks become functional once more. Once the person begins to function normally within a community, it is said that resilience is enhanced, and the survivors become stronger and realize that they have the capacity to survive. 13.3.1 PSYCHOSOCIAL COMPETENCE Psychosocial competence provides a guide for understanding and contrib­ uting to a variety of ways to the well-being of individuals, communities, and their interactions. It suggests that there may be ways for attaining particularly facilitative psychosocial attributes that can be developed for psychological well-being and that there may also be a range beyond which psychosocial attributes cannot vary without producing detrimental personal and social effects. Identification of these limits and possibilities can benefit individuals and communities experiencing pandemic-related stressors and help them to realize their inner strengths and to establish supportive environments. Two types of psychological competence are identified in the study of stressful life events: individual and community psychosocial competence. Individual psychosocial competence refers to levels by which survivors are able to guide and take charge of their lives, moving beyond the trauma. It consists of a number of factors, which include a sense of control and a sense of being an active part of family and community networks, of engaging in active planning, and a sense of being able to manage the physical and psychological support and threat. Each individual becomes a product as well as a contributor to the culture and its relationships to other cultures (Mariam, 2018). Operationally defined, community psychosocial competence is the integration and transformation of knowledge about persons and community networks, about patterns of behaviors, relationships, values, practices, and attitudes within a specific context that allows planning, implementation, and evaluation of community activities and projects that foster a sense of place and psychosocial well-being (Gopalkrishnan, 2018).

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13.3.2 COMPONENTS OF A PSYCHOSOCIAL SUPPORT PROGRAM

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The psychological support program (PSP) proposed for adoption by a National Society is predicated on industry-approved guiding principles (SPHERE, IASC/MHPSS, and WHO). Evaluation of these programs will depend entirely on the critical event for which psychosocial support is needed, such as COVID-19. The impact evaluation should reflect that PSP embraces the five following strategies: • • • • •

Uses a community-based approach; Implements interventions that are contextually and culturally and linguistically appropriate; Empowers affected people; Encourages community participation; and Encourages active involvement.

13.3.3 COMMUNITY-BASED APPROACH Past experience has shown that community-based approaches are best when implementing PSPs. Building on local resources, providing training, and upgrading local structures and institutions are critical to the programs’ success. This approach allows trained volunteers to share their knowledge with fellow community members. Since the majority of emotions experi­ enced (e.g., distress and sorrow) do not require professional treatment, local volunteers often become instrumental in providing successful emotional relief. A larger number of people are reached by working in groups through which community networks are strengthened, making it more likely to bring forth a culturally appropriate response. The international arena where most PSP programs are implemented presents the challenge of encountering language, culture, and religious beliefs that are not frequently understood by the outsider. Culture exercises a great influence on the way in which people view the world. Building the capacity of community volunteers ensures that they may be able to provide culturally appropriate assistance to the affected population. Trained personnel from the community affected by the disaster can react immediately in times of crisis and can assist with the provision of longterm support to the survivors. They have easy access to and the confidence of the disaster survivors.

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13.3.4 EMPOWERMENT

A PSP in a National society conceptually operates under the premise that high-quality psychosocial assistance is based on helping others to regain self-respect and autonomy. It focuses as much attention on the abilities and strengths of the recipients as on their problems and weaknesses. A high degree of community participation is generally accepted as one way to encourage the empowerment of the people (IFRC, 2021). 13.3.5 COMMUNITY PARTICIPATION Basing projects on ideas developed by concerned people themselves, as a result of community engagement (CE) activities, will promote empower­ ment and local ownership and help facilitate and consolidate a long-term capacity for problem solving. Through participation, people gain an increase in control over their lives as well as the life of the community. Participation in collective decision making about their needs, as well as in the development and implementation of strategies, is based on acknowledging their collective strengths to meet those needs. 13.3.6 ACTIVE INVOLVEMENT A National Society PSP program focuses on individual strengths, the promotion of protective factors, and provides a space for community members to enhance their resilience. The program is built on existing resources, coping mechanisms, and resiliencies. The objectives of the interventions then become: (i) identifying and strengthening internal coping mechanisms; (ii) actively involving people in the community in mapping and identifying problems and resources; and (iii) recognizing people’s skills and competence. 13.3.7 ACTIVITIES IN A PSYCHOSOCIAL SUPPORT PROGRAM The focus of the PSP program is on people’s positive efforts to deal with and come to terms with their COVID-19-related experiences.

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13.3.7.1 PSYCHOLOGICAL FIRST AID (PFA) – A FIRST-ORDER INTERVENTION

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During an adverse event and up to the reconstruction phase, one of the most common and effective informal health community interventions is called psychological first aid or PFA. PFA is a first-order intervention after a crisis, an emergency or a disaster, designed to reduce the distress caused by exposure to a traumatic event, and to enhance the knowledge of the protec­ tive factors that helped the person to survive the event (Sphere Association, 2018). During COVID-19, PFA helps the survivor to identify and enhance resilience and prepares the survivor for long-term recovery. PFA is natural and familiar to everyone. When someone is hurt as a child, the understanding attitude of his or her parents did as much to alleviate discomfort as the application of a bandage or a disinfectant to ease the pain. Taking a walk and talking things out with a friend are familiar ways of dealing with an emotional crisis. The same natural feelings that make people want to help a friend motivates them to give a helping hand and support to a person who is injured or is a survivor of a disaster. The approach consists of five steps of PFA, taught by all persons that participate in the psychosocial program: 1. Intervene immediately close to where the event took place with experiential and simple activities. Take care of the basic needs expressed by the beneficiary. 2. Listen, Listen, Listen. Provide some sense of hope and expectation that the person will ultimately overcome the crisis. However, let the survivor know that things may never be the same as they were before the crisis. 3. Validate the person’s feelings. Do not give false assurances. Always remain truthful and realistic. Emphasize how the survivor has coped with the situation so far and how the survivor has already begun to use the strategies for moving forward. Encourage the survivor to implement solutions or strategies that have a high probability of success. 4. Plan the next steps. Every PFA intervention should have an ultimate outcome or some action that the individual is actually able to take. Restoring the person to the position of active participant rather than victim is critical to success. Provide constructive activities that the survivor can do to assist with the situation, such as helping to put up

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tents or distributing food and water in the camp. Reinforce whatever problem-solving skills the individual has demonstrated to this point. 5. Refer to existing networks in the community. Find a group of peers, family members, community members, or church members who can provide both support and temporary assistance during the crisis. Implement a buddy system so that the survivor is not left alone.

13.3.7.2 ASSESSMENT Assessment is a process to determine the impact of a disaster and the commu­ nity’s needs and strengths and the available services. This section explains the use of both quantitative and qualitative tools in moving from a definition of language of distress in a community to defining and developing a road map to psychosocial competence. Quantitative methods provide objective and measurable data, whereas qualitative methods give information about the subjective perceptions of individuals in a population, giving range, depth, and meaning to people’s experiences. Both methods complement one another. There are three specific sets of needs that survivors generally experience: • • •

Medical needs immediately after the disaster; Practical needs (such as housing, water, livelihood, schools for chil­ dren, contacting family and friends) that continue well into the early reconstruction process; and Psychosocial needs that change over time.

The common strategies for measurement are rapid assessment, quantita­ tive assessment to determine the survivor’s level of distress, and qualitative assessments to determine feelings, actions, stressors, and strategies to move forward and achieve psychosocial competence. 13.3.7.2.1 Rapid Needs Assessment The rapid needs assessment seeks to obtain demographic data from the survi­ vors, identify factors that may be causing stress, determine the agencies that are currently providing services, identify any gaps in services, and determine what is it that community members want and what they are willing to do to achieve community psychosocial competence.

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13.3.7.2.2 Paper and Pencil Tools

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Another tool that the ARC PSP program has used with some degree of success is the Psychosocial Competence Scale. This paper and pencil test consists of 30 items that measure how the individual sees themselves in light of COVID-19, the internal forces that protect him/her, and the willingness to move ahead. In order to determine the effectiveness of the program, we have developed a “Score Card” (see Appendix B) to measure school and community interventions. 13.3.7.2.3 Non-Verbal Tools The third set of tools used is qualitative in nature and aims to collect data pertaining to the language of distress, how the community defines distress, and the steps taken by the community to achieve psychosocial competence. This instrument is a set of 30 cards divided into three scales: somatic, psychological, and sociological. The set of 30 stimuli cards (non-verbal tools) specify overt behavior in the form of a caricature, based entirely on the information obtained from the target communities. These cards have been categorized into social behaviors (fighting with neighbors, playing a group game, talking with a group of peers), psychological behaviors (intrusive thoughts, hopelessness), and somatic behaviors (sleeping with lights on, urinating in bed, thumb sucking). Up to six community members are invited to meet and the cards are set on the floor in front of them. The process consists of six steps to elicit firsthand information from the community members to determine their language of distress. Each member picks a card and explains what the individual sees happening before, during, and after the disaster. Once all members have completed the round, the facilitator attempts to find out: • • • • • •

If there is a local name for this distressful event; How it manifests itself? The severity of suffering and dysfunction; What causes it and who gets it? How is it treated and how effective is the treatment? and How the problem could be avoided?

This process is repeated with the representatives of all community segments. We have found the non-verbal tools to be a very effective instru­ ment as a means for the community members to verbalize their language of

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distress. In Indonesia, feedback from teachers, students, and volunteers have indicated the need to develop a tool specifically for schools that incorporated signs of distress exhibited by children in the classroom (such as restlessness, fear of rain, becoming clingy). They felt that the non-verbal tool could be used to identify causes of stress for teachers and to develop helpful self-care activities for teachers and students. 13.3.7.2.4 Ethnographic Field Studies An approach frequently used in the field is a qualitative approach called ‘ethnography,’ which is a scientific method of recording people’s beliefs, behavior, and culture directly from life (Morgan-Trimmer & Wood, 2016). Cultural anthropologists and cross-cultural psychologists have used ethno­ graphic study for at least the last 50 years. Most recently ethnographic studies are reported in the psychosocial support and mental health programs for the developing countries (Kienzler, 2019). The method consists of participant observation, key informant interviews, and life history collections. Ethnography is an informal and fast way to assess concerns, survey results, and to become familiar with the local ways of thinking, opinions, perceptions, and suggested interventions. It allows for the mapping of current resources, services, and practices. The mapping process helps to identify local resources, people, and community members, including vulnerable groups, and to develop mechanisms for social empowerment and strengthen community networks. It enables ethnographers to explore a diversity of opinions as well as to reach consensus. The key informants give insight into how psychosocial distress manifests itself and what the social networks in the community can do. Life histories provide a collection of valuable accounts as they reveal events that the informant thinks are crucial to his or her personal development and provide a context that helps in the interpretation of beliefs, attitudes, and current behavior. 13.3.7.2.5 Focus Group Discussions A meeting is held with many members of the community, and the results are prioritized through the method of free listing. This process provides the program staff with an indication of the things that block elements of psycho­ social competence and allow planning for preventive and self-care activities.

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The focus group discussions allow a participatory solution-searching process with the community that can assist in identifying the strategies that enable the community to achieve psychosocial competence after the disaster. Focus groups provide a conduit to the target community to express emotional distress; to identify coping mechanisms and sources of psychoso­ cial relief; to project the expected outcome of the interventions; to identify self-help techniques and activities accepted by the community; and to talk with the survivors on ways to move on to reconstruction. The free listing of issues and ranking the responses through the use of stimuli cards, focus group discussions, and the key informant interviews give an insight into the existence and extent of stress in the community. Focus groups are very useful when there are a range of experiences and opinions among the community members in divulging information to the outsiders. Planning built on the community inputs provides the survivors with an opportunity to present their perspectives on the psychosocial distress and allows them to define ways to achieve psychosocial competence. 13.3.7.2.6 Outcome of the Assessment Process The last five years have been very rich in the development of a participa­ tory assessment mechanism that allows for community participation in ascertaining physical and emotional threats. The qualitative and quantitative assessment process generates information, which is vital for understanding the psychosocial problems, resources, and the methods by which the community will cope with stress and survive. Multidisciplinary, rapid, participatory, and coordinated assessments are conducted to utilize the generated information. The overall focus of any community-based psychosocial support program must be to assist the community in transforming its distress into a sense of competence, where the survivors are able to define their needs and list the tools necessary to address those needs. 13.3.7.3 CAPACITY-BUILDING ACTIVITIES One of the objectives of the resource rich National Societies (NSs) strategy in providing technical and financial support to the Red Cross Red Crescent (RCRC) is to conduct staff development activities in all society sectors: national headquarters, state branches, and local branches. In the selected local branches, villages, and schools have been targeted for direct services.

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Teachers and community facilitators are trained through thematic units focusing on group development, community-based disaster mental health preparation, mental health and psychosocial support programs publicity, and skills development. Another aspect of capacity building is providing technical assistance in developing PSP curricula that can be used by the national society for its national level non-tsunami programs. The Red Cross Module for Community Facilitators and Teachers has been adapted by partner-National Red Cross Societies into its national curriculum for PSP volunteers. In some cases, NSs working on PSP have also adopted existing curriculum (IFRC PS Center – see References) to implement PSP programs in other areas. A continuum of capacity building has been formulated to guarantee participants a progression from participating in operational training sessions to becoming a crisis intervention professional. The operational trainings are provided to volunteers immediately upon responding to the disaster. They learn about common responses to disaster-related stress, how to conduct a rapid assessment, give PFA, conduct self-care activities and, if teachers, a core of stress-releasing activities to conduct with children. All the described activities of assessment, material development center, and capacity-building activities are a step towards transforming the community in distress to the one that has achieved psychosocial well-being. 13.3.7.4 ENHANCING PSYCHOSOCIAL COMPETENCE THROUGH SCHOOLS A willingness to prepare for a disaster and practice emergency procedures is a measure of personality that predicts survival in a practical and psycho­ logical sense. The Red Cross experience in disaster-affected areas showed the potential of the schools to be a hub for the rehabilitation and support activities in the communities. This formed the basis of Red Cross schoolbased psychosocial support program. This program is informed by the disaster preparedness literature from the Red Cross and the “Child-Friendly Schools.” A Child-Friendly School (Fitriani, 2020) covers a very wide range of activities. It is about: (i) effective and sensitive communication; (ii) teachers who provide appropriate, constructive feedback about the child’s work and giving encouragement; (iii) pupils who give positive feedback to other pupils and to the teachers themselves; and (iv) a greater attachment and sense of belonging where the school becomes a place where boys and girls want to be.

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13.3.7.4.1 Developing a Healthy Psychosocial Environment in the Schools

The core of school interventions – whether disaster preparedness or friendly schools – is to develop a healthy environment where girls and boys can expe­ rience a safe environment where they can express themselves freely. There are at least four steps in developing a healthy psychosocial environment: 1. Participation: It is important to organize broad participation in the design and implementation of plans to create healthy school environ­ ments. Participants could include school administrators; managers of facilities, transportation, and grounds, parents; and students. It is essential to work closely with the teachers and volunteers so that they fully understand: • • •

The role of the teachers and the school in promoting the physical and emotional development of children; Classroom management that promote positive behavior changes and a safe and secure environment is vital; The learning environment is a safe place for children to express themselves and learn ways to communicate in positive ways. The Red Cross PSP program uses participatory methods with all school groups (children, teachers, volunteers, and other adults in school) to identify psychosocial needs, provide staff development for teachers and other adults, and assist the school community in establishing a psychosocial crisis response plan. Teachers and other school staff and volunteers receive relevant and structured capacity-building activities, teaching aids, and tools to develop their skills. Using these activities and tools enables them to give psychosocial support to students and their families when needed and to promote students’ develop­ ment of psychosocial competence according to the needs and circumstances during emergencies. Teachers are encouraged to share their adaptations and experiences with other adults in the school that can be included in the teacher training curriculum. Teachers and other school personnel are provided with regular supervision and capacity building activities on topics related to psychosocial competence and support for their own psychosocial needs.

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2. Threat Identification: It is helpful to conduct a campus mapping activity to identify the magnitude and relative importance of signifi­ cant threats to psychosocial well-being within the school environ­ ment. Threats may be associated with the following: water quality, sanitation, food safety and nutrition, waste management, transporta­ tion, adjacent land uses, structural integrity, renovation, purchasing, and grounds management. Once the definition of crisis is made operational and the teachers understand the concept of vulnerability and protective factors, they then learn to conduct a situational analysis of their school. The situ­ ation analysis is recorded by doing a three-dimensional map of the school grounds. The two questions that are answered in this exercise are: (i) Where is the particular exposure to the threats identified, and who is at risk as a result? and (ii) How and why are we vulnerable? Usually, the teachers spend a lot of time discussing external sources of the prob­ lems. Once they get back to their map, the discussion turns inward to the reality of their school situation and challenges in the grounds around it. The teachers identify the vulnerable population sectors that may be at risk (kindergarten classes, children with exceptional needs, those that are physically handicapped, etc.). School mapping helps to understand the risks to achieving psychosocial competence of teachers and students. Teachers and students are exposed to capacity building activities that prepare them to handle a crisis or an emergency. Exercises and simulations are conducted every two months to make sure that all members of the school community are able to perform their assigned tasks. Since schools do not have the resources for the equipment needed for this activity, the program provides a resilient school grant to purchase the equipment (more under the section on resiliency projects). The teachers also identify the available school resources that can support the activities to reduce the crisis-related distress. 3. Design of Intervention Plans: Specific intervention plans should be designed to improve psychosocial well-being practices in the following areas: building the capacity of children and teachers in first aid and PFA, identify evacuation routes, and engage parents and other adults in developing search-and-rescue mechanisms. Teachers and other adults start the process of developing a plan by identifying what constitutes a crisis in their respective schools.

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The final part of the capacity building activities for the Safe School Program is the appointment of the coordinating committee and five operational committees. The coordinating committee basically manages the training, simulations, and response. The five operational committees are: • • • • •

Evacuation; Fire prevention; Rescue and first aid; Psychological first aid; and Other support committees.

These five committees are composed of teachers, students, and other adults in the school. Ultimately, the purpose of appointing these committees is to be able to return the children safely to the local authorities and the parents. 4. Implementation of Plans and Evaluation of Progress: The next steps are to: • • •

Implement the intervention plans; Define timetables to meet objectives; Assign clear responsibility and accountability.

Twice a year progress should be evaluated in goal attainment and the effectiveness of interventions in order to adjust policies, intervention plans, and methods of implementation in response to evaluations, changing conditions, and availability of resources. The program’s impact will be measured by the permanence of these committees, once Red Cross funding is no longer available. 13.3.7.4.2 Facilitating an Inclusive School Environment That Leads to Feeling of Positive Psychosocial Competence Once the school has developed the Safe School Program and the children and teachers are capable of conducting the activities in the plan, the projects turn its focus on preparing teachers to facilitate education for the children in an environment that nurtures learning and provides understanding to all the students. Usually, this activity begins in the early reconstruction phase of the disaster (INEE, 2010) (the guidance for this activity is taken from the INEE Standards). The “Friendly School” provides an opportunity for children to express themselves in a safe environment.

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Most classrooms have received school chests (the school chest project was borrowed from the American Red Cross or other non-government organizations (NGOs). The chest contains drawing books, pencils, crayons, colored clay, skip­ ping ropes, etc., that are useful in engaging children and provides a window for sharing feelings and experiences. (However, the experience has been that the chests in the past have been given to the teachers with no clear instructions on how to use the contents. Thus, the chests, instead of being a helpful tool, have become a hindrance for schools that often do not have a secure storage space). 1. Organizing Expressive and Creative Activities in Schools (Reimers et al., 2020): To alleviate the disaster-related stress, the counselors and other school personnel could use one of the three cultural appropriate approaches: i. Talking: The talking approach allows the children to talk about their feelings and experiences related to the disaster. The sequence to follow while using this approach is to speak about disaster in general, discuss this specific disaster; and talk about each person’s experience during the disaster. ii. Drawing: In the drawing approach the child expresses his/her feelings by using a non-verbal medium. The stimulus could be asking: “Where were you when the disaster happened?” Collages have proven to be one of the most powerful ways for children to express themselves. iii. Writing: The writing approach can be used with older children and adolescents. Utilizing drawing, pictures, or paper clippings as a stimulus allows the students to write about their disasterrelated experiences. Under the program, expressive and creative activities (drama, drawing, writing, singing, dancing, group discussions, arts and crafts, collages, storytelling, plays, and community theater) were organized in the schools. These activities enabled the children in the target schools and communities to communicate their feelings. a. Children Develop Skits, Poems, and Songs to Present to Their Peers and Parents: Community-based skits and story­ telling also prove to be a powerful and effective way of venting feelings. These types of activities are used in both the school and community to facilitate the expression of feelings, to reduce

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distress, and to enhance a sense of belonging to the whole community, including the elderly, physically handicapped, widows, and children, and hastens their recovery process. b. Children Develop and Paint School Murals and Collages: Once the students have attended to the task of making their school and campus safe and secure, they can assume responsibility of educating the community. One such activity could be to paint murals on the exterior walls of the community with messages encouraging actions that foster psychosocial competence. The messages are part of an attempt to reduce disaster-related emotional distress and to facilitate community healing.

2. Resilience Projects in School: Resilience projects for increasing the psychosocial competency of the school community are paid for from the small grants from students, teachers, and parents. For example, if there are animals entering the ground of the school, a resilience project may be to put up a fence. If there is a need to pay overtime to a teacher who is conducting some adult education activities, this is again a resilience-enhancing project. The important factor in devel­ oping the proposal is ensuring that the school committee is able to clearly articulate the manner in which the project will enhance the psychosocial well-being of the school community (Kapoor & Kaufman, 2020). 3. Preparing Pre-Service Teachers (Hodges et al., 2020): Preservice teachers are an untapped resource for carrying the message of psychosocial competence into disaster-affected areas as well as unaffected areas. The strategy is to include the topics related to psychosocial competence, resiliency, and the development of a learning environment that fosters positive growth in children, selfcare activities, and PFA into the national teacher training curriculum. Under the program, the pre-service teachers receive approximately 36 hours of training immediately preceding their student teaching semester. The pre-service teachers are supported with school chests and psychosocial activities-related material. Project staff provides supervision, once every month. The Red Cross experience has been that pre-service teachers were enthused about organizing school psychosocial crisis response plan-related activities. The program’s objective is to assist pre-service teachers in developing mental immunity. By mental immunity we mean that the

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individual can: (i) recognize the threat and its characteristics; (ii) use psychological capacities to cope with threatening situations; and (iii) take preventive and objective measures in case the threat of disaster becomes a reality (Singh et al., 2020). 4. Preparing and Supporting the In-Service Teachers (UNICEF MENA Office, 2020): Teachers and school personnel can provide children with an environment that is conducive to participatory learning, long after the disaster. Under the program, the teachers and school personnel are supported for up to three years with timely supervision. Six major areas are addressed in follow-up activities: • Sense of psychosocial well-being in school; • Signs of distress in children and how to address them; • Self-care activities; • Psychological first aid; • Use of school chests; and • Creating an inclusive environment.

13.3.7.4.3 Re-Establishing the Community’s Psychosocial Competence The objective of engaging the community members in a systematic process of looking at themselves and determining their strengths and human capital, is called “Re-establishing the Sense of Place (Marques, Freeman, Carter, & Zari, 2020).” Community interventions that are planned and developed for augmenting resilience and assisting the community to use their own resources for re-establishing their sense of place are found to be proactive, preventive, and positive in minimizing psychological dysfunction. The program’s objectives are to: • • •

Conduct participatory assessment and context analysis of local community’s resources, services, and practices, including identi­ fying local resource people and community members; Provide capacity building and supervise community-based psycho­ social workers on how to administer emergency support to alleviate disaster-related distress; and Address pre-emergency psychological or social symptoms and assist the community members in identifying potential resilience activities that will contribute to the community psychosocial competence.

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The program identifies community volunteers and provides capacity building to them so that they can become community facilitators (non-paid volunteers). The community facilitators assist in the development of commu­ nity-owned and managed psychosocial support activities by promoting posi­ tive coping, individual, and group behaviors and strengthening networks that lead to psychosocial competence. In every community, the effort is to identify one out of 50 people to become a community facilitator. There are three distinct sets of activities that have to be developed by the community facilitator: (i) informal schooling; (ii) informal health; and (iii) community organization. Thus, the challenge in developing community programs is to recognize that by enhancing resilience and assisting the community in attaining its “sense of place” will lead to psychosocial competence – the focus of community-based psychosocial support programs. 1. Informal Schooling: The informal school program works with chil­ dren below five and out-of-school youth and marginalized groups of handicapped individuals, elderly, and widows. Each informal school is provided with recreation kits and other psychosocial support materials. Education within these schools is facilitated by the community facilitators and led by the schoolteachers. In the morning sessions, the focus is on education for children under five. The community facilitator, informal schoolteacher, and adults and adolescents from various marginalized group’s assist in educating this group. In the afternoon session, the activities focus on education for out-of-school youth and tutoring for children who need extra attention. These informal schools also serve as a venue where community elders come together to educate children about their history and culture and enhance their vocational skills. Informal schooling includes creative and expressive activities to facilitate the involvement of the whole community, including the elderly, physically handicapped, widows, and children in its recovery process. Not everyone feels comfortable expressing them­ selves verbally. Creative and expressive activities, such as drawing, storytelling, art, and crafts, can provide creative ways for these indi­ viduals to communicate their feelings. Community-based skits and storytelling have also proven to be a powerful and effective way of venting feelings; it is a simple healing process promoting a feeling of enjoyment and togetherness.

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2. Informal Health Activities: Community health is divided into two sectors: (i) trained medical personnel in the community health clinic or the local hospital who conduct the formal health activities; and (ii) community members who carry out the informal health activi­ ties. These interventions usually rely on the traditional community resources, belief systems, and the definition of psychological wellbeing before the disaster. This level is broad and covers the: i. Strengthening of the support provided by pre-existing commu­ nity resources; ii. Community participatory activities that include getting members of the community together to identify and plan community activities to reduce the mental and social distress and to promote self-care; iii. Activities that address important social factors to reduce social suffering; iv. Structured social services outside the health sector; and v. Strengthening of community networks through community activities that ensure that isolated persons come in contact with one other and generate mutual support. 3. Community Cohesion and Resilience Projects: The commu­ nity facilitator is in charge of mobilizing the community and has responsibilities that are similar to someone working in disaster preparedness or response. But the exception is that the community facilitator is tasked with bringing the representatives of all segments of the community together for generating an understanding of the community and in planning a project jointly. Within the Red Cross, psychosocial program resilience projects are defined as microplanning activities initiated in communities to assist in the develop­ ment of a long-term plan for the reconstruction of the community’s psychological and social networks.

13.3.7.4.4 PSP Long-Term Development and Resilience Projects The long-term development psychosocial support program is predicated on participatory planning by community members. The process proposes a set of community activities that will lead to community ownership, the develop­ ment of human resources, and the sustainability of a representative commu­ nity planning mechanism. The psychosocial project’s role is to enhance the community’s capacity for micro-planning. Micro planning is the process that

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builds the capacity of the community to analyze its current situation and to develop strategies to work toward a better future. The common objective is to gain an understanding of the meaning of development to the community and to determine the currently available human and material resources and the common priorities to all community sectors. Planning of resilience projects is an activity that is proactive rather than reactive and is sequential and collaborative. In emergency settings, the surrounding chaos, suffering, and time pressures push humanitarian agencies to act too quickly without learning about local beliefs and practices. Impor­ tant opportunities thus are lost, and it becomes more likely that culturally inappropriate programming will be imposed. The meaningful participation of project beneficiaries in the assessment, planning, and implementation stages is essential in generating appropriate activities, a sense of ownership, and increased likelihood of sustainability. To ensure that programming is inclusive, contextual, culturally sensitive, and appropriate, it is valuable to consider the four key questions that deter­ mine an effective disaster response and assist in developing a comprehensive, community-based psychosocial support program: •

• • •

All community members get together and identify their psychoso­ cial support needs. They rank the needs on the list and prioritize with the help of the community facilitator. This is the basis of the community-based psychosocial support intervention. Knowledge about the community’s capacity, resources, strengths, and liabilities by analyzing the outcome of the assessment process gives the community an insight into its actual rather than felt needs. The community identifies the resources it has in terms of manpower, tools, land, etc., and in a participatory process, assesses its utiliza­ tion to achieve desired results. The outcomes of the community effort are compared with the program objectives, whether achieved or not.

Before implementing a community-based psychosocial support program, the planners, implementers, and beneficiaries should set up clear goals. The support organizations (Red Cross) function as facilitators, providing struc­ ture and stimulation. Community members are usually willing to engage in the process and learn the skills in the process. The assessment’s outcome acts as a baseline for problem identification and for measuring progress and is, therefore, an important element of community-based monitoring and evaluation.

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13.4 SUMMARY

This chapter presented the psychosocial program that is being implemented by the Red Cross as part of the international response in disasters and long-term recovery. The program focuses on capacity building of local professionals and planning programs with beneficiaries using participatory techniques to identify the language of distress and to determine the commu­ nity’s psychosocial needs and wants. The two major programming areas are the community and schools. To date, the impact evaluation performed in existing programs suggest that non-professional personnel who learn firstorder interventions, such as PFA, and trained community volunteers can conduct timely interventions that will alleviate disaster-related stress. KEYWORDS • • • • • •

circumstances disaster-related stress mental health and psychosocial support micro-planning psychosocial support program Red Cross Red Crescent

REFERENCES Boss, P., (1999). Family Stress Management: A Contextual Approach. Newbury Park, CA: Sage Publications. Dubey, S., Biswas, P., Ghosh, R., Chatterjee, S., Dubey, M. J., Chatterjee, S., Lahiri, D., & Lavie, C. J., (2020). Psychosocial impact of COVID-19. Diabetes & Metabolic Syndrome, 14(5), 779–788. https://doi.org/10.1016/j.dsx.2020.05.035. Egeland, B., & Erickson, M. F., (1990). Rising above the past: Strategies for helping new mothers break through the cycle of abuse and neglect. Zero to Three, 11(2), 29-35. Fiese, B. H., Sameroff, A. J., Grotevan, H. D., Wamboldt, F. S., Dickstein, A., & Fravel, D. L., (1999). The stories that families tell: Narrative coherence, narrative interaction, and relationships beliefs. Monographs of the Society for Research in Child Development, 64(2), Serial No. 257.

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Fitriani, S., (2020). Promoting child-friendly school model through school committee as parents’ participation. International Journal of Evaluation and Research in Education (IJERE), 9(4), 1025–1034. ISSN: 2252-8822, doi: 10.11591/ijere.v9i4.20615. Gopalkrishnan, N., (2018). Cultural diversity and mental health: Considerations for policy and practice. Frontiers in Public Health, 6, 179. https://doi.org/10.3389/fpubh.2018.00179. Health Education Authority, (1997). Mental Health Promotion: A Quality Framework. London. Hodges, T. S., Kerch, C., & Fowler, M., (Lisa) (2020). Teacher education in the time of COVID-19: Creating digital networks as university-school-family partnerships. Middle Grades Review, 6(2), Article 4. Available at: https://scholarworks.uvm.edu/mgreview/vol6/ iss2/4 (accessed on 27 October 2022). IFRC PS Center in Copenhagen has been Providing Tools to Movement Partners for Many Years. For assistance please contact: https://pscenter.org/trainings/online-training/ (accessed on 27 October 2022). IFRC, (2020). MHPSS Resolution and Road Map. Geneva. IFRC. IFRC, (2021). A Roadmap for Implementation of MHPSS: 2020–2023. Geneva. IFRC. https:// pscenter.org/wp-content/uploads/2021/02/MHPSS-roadmap-2020-2023-1.pdf (accessed on 27 October 2022). INEE, (2010). Minimum Standards for Education: Preparedness, Response, Recovery. UNICEF Plaza, New York. https://inee.org/resources/inee-minimum-standards (accessed on 27 October 2022). Inter-Agency Standing Committee (IASC), (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: IASC. Kapoor, H., & Kaufman, J. C., (2020). Meaning-making through creativity during COVID19. Frontiers in Psychology, 11, 595990. https://doi.org/10.3389/fpsyg.2020.595990. Kienzler, H., (2019). Mental Health system reform in contexts of Humanitarian emergencies: Toward a theory of “practiced-based evidence.” Cultural Med Psychiatry, 43, 636–662. https://doi.org/10.1007/s11013-019-09641-w. Lazarus, A., (2004). Relationships Among Indicators of Child and Family Resilience and Adjustment Following the September 11, 2001 Tragedy. Washington DC: The Emory Center for Myth and Ritual in American Life. Mariam, R. A., (2018). Culture, religion, and freedom of religion or belief. The Review of Faith & International Affairs, 16(4), 102–115. doi: 10.1080/15570274.2018.1535033. Marques, B., Freeman, C., Carter, L., & Zari, M. P., (2020). Sense of place and belonging in developing culturally appropriate therapeutic environments: A review. Societies, 10(4), 83. https://doi.org/10.3390/soc10040083. Martela, F., & Riekki, T. J. J., (2018). Autonomy, competence, relatedness, and beneficence: A multicultural comparison of the four pathways to meaningful work. Front. Psychol., 9, 1157. doi: 10.3389/fpsyg.2018.01157. Morgan-Trimmer, S., & Wood, F., (2016). Ethnographic methods for process evaluations of complex health behavior interventions. Trials, 17(1), 232. https://doi.org/10.1186/ s13063-016-1340-2. Reimers, F., Schleicher, A., Saavedra, J., & Tuominen, S., (2020). An Annotated Selection of Online Resources Supporting Education Continuity During COVID-19 Pandemic. OECDGlobal Education Innovation Initiative. https://www.oecd.org/education/Supporting-thecontinuation-of-teaching-and-learning-during-the-COVID-19-pandemic.pdf (accessed on 27 October 2022).

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SAMSHA, (2021). Tips for Healthcare Professionals: Coping with Stress and Compassion Fatigue. Washington, D.C. Department of Health and Human Services. Singh, S., Roy, D., Sinha, K., Parveen, S., Sharma, G., & Joshi, G., (2020). Impact of COVID-19 and lockdown on mental health of children and adolescents: A narrative review with recommendations. Psychiatry Research, 293, 113429. https://doi.org/10.1016/j. psychres.2020.113429. Sphere Association, (2018). The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response (4th edn.). Geneva. Swim, J., (2011). Psychology and Global Climate Change: Addressing a Multi-faceted Phenomenon and Set of Challenges. Washington, D.C. American Psychological Association. https://www.apa.org/science/about/publications/climate-change (accessed on 27 October 2022). UNICEF MENA Office, (2020). Ready to Come Back TEACHER Training Package. Amman, Jordan. https://www.unicef.org/mena/media/9601/file/UNICEF_MENA_TTP_total_0. pdf%20.pdf (accessed on 27 October 2022). Venuleo, C., Marinaci, T., Gennaro, A., & Palmieri, A., (2020). The meaning of living in the time of COVID-19. A large sample narrative inquiry. Front. Psychol., 11, 577077. doi: 10.3389/fpsyg.2020.577077. Walsh, F., (1996). The concept of family resilience: Crisis and challenge. Family Process, 35, 261–281.

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APPENDIX B

Psychosocial Support Program Tsunami Task Force

South-East and South Asia Regions

School and Community Resilience Score Cards

Prepared by: Dr. Joseph O. Prewitt Diaz 27 May 2005

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TABLE B.1

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Community Resilience Score Card

Characteristic Indicator of Success of Resilience Safe community

Mapping of individuals, families, and groups that are at greater risk and identifies local and community strengths. Risks are identified and contingencies are planned to reduce those risks. Information is timely, accurate and easily understood by all members of the community.

Decision making

There is a cadre of outreach services, community volunteers, and gatekeepers. Leadership is representative of the community. Situational leadership is identified. Degree to which people individuals participate in community groups.

Identity

Community is consulted in the development and implementation of an assistance and recovery program. Shared community values, aspirations, and goals. People feel a sense of attachment. Community widely represented in formulating a community vision. Sense of value. Have trust in people and social institutions. Enjoy living among people of different lifestyles.

Community development

Communities value youth as a resource. People feel optimistic and plan for the future. Strong believes in formal and informal education for all groups. Plans for self-help and income generating activities. Positive social and economic trends post disaster. Sustainability of social life.

Social capital

Faith or belief system is present and engaged in community development

activities. Spirit of mutual assistance and collaboration. Group in the community have developed partnerships. The community looks within to seek and secure expertise to address areas

of need. People have and benefit from close ties with family and friends. People involved in the broader community and with social groups (communities of interest). Mapping of resources and skills available.

Country-Level Mental Health and Psychosocial Support Programs TABLE B.2

School Resilience Score Card

265

Characteristic Indicator of Success of Resilience Safe schools Rapid response to danger in school. School identifies risks in its premises and has a risk reduction plan. Establishes meaning and understand the personal significance of a risk. Crisis Response Plan with specific instructions and role definition for all students is available and made public. Supportive family members1,2,3

Roles and responsibilities are assigned to specific individuals. Conviction of parents’ love. Warmth, structure, and high expectations. Warm relations and guidance from extended family members. Sustains relationship with family members who may be helpful in resolving

the crisis and its aftermath. Problem solving and coping skills. Overall outlook of life.

Positive teacher relationships

# of family narratives4 indicating one or more resilience factors. # of scholastic achievements. # of times that student and teacher work together on a committee or a project. # of times in one month that the student expresses constructive plans for the future. All students are mentored and valued by teachers and other adults in school.

Positive peer relationships5 Positive student behavior

School organizations are available for all students. # of group memberships. # of formation and utilization of relationships. Strong social networks. Ability to function autonomously. Coordinates and organizes resources. Emotional self-regulation and responds to the requirements of external situations. Manages upsetting feelings aroused by the crisis. Maintains a sense of competence.

1. Waslsh, (1996). Family Resilience is a Process Developing Over Time. The methods families imple­ ment to overcome stress and promote resiliency may be different. 2. Fiese, et al., (1999). Family Narratives Move Beyond the Individual and Deal with How the Family Makes Sense of its World, Expresses Rules of Interaction, and Create Beliefs About Relationships. 3. Boss, (2001). Family Resilience is Defined as Characteristics of Families that Help Foster Adjustment and Adaptation to Change in Crisis Situations. 4. Taylor, et al., (1993). Resilient Attitudes, Thoughts and Beliefs Can be Instilled in Children Through the Contents of a Story. The benefit of stories is that they entertain and educate. 5. Taylor, et al., (1993). Coping and Healing Processes are Enhanced When Children and

Adolescents Hear Stories About People Who Faced Similar Issues.

CHAPTER 14

Mental Health and Psychosocial Support During and After the Pandemic: A Practical Response JOSEPH O. PREWITT DIAZ

The Pennsylvania State University (Retd.), Pennsylvania, USA

ABSTRACT This chapter sets the stage for the concluding remarks for this book. It briefly mentions the challenges that the World Communities have faced after COVID-19 for a period of 18 months. It then delves into the importance of psychosocial support as a tool during recovery. It illustrates the cycle of recovery, within the context of loss of place, and the ensuing activities to recover place. It concludes with a brief description of the components of a recovered community. 14.1 INTRODUCTION Communities around the world have been faced with a public health chal­ lenge for the last 18 months: COVID-19. Media reports about the pandemic and related deaths had been increasing, as well as the availability of vaccines in developed nations. Yet, the most vulnerable and under-represented were residents of low-income countries in Asia, Africa, and Bhutan, along with Rohingya refugees and global migrant groups. The main stressors of the quar­ antine included duration, fear of infection and dying, frustration, boredom, inadequate supplies, and its stigma. Country restrictions to avoid viral spread were introduced; they included social distancing and self-isolation, increasing Mental Health and Psychosocial Support during the COVID-19 Response: An Overview. Joseph O. Prewitt Diaz (Ed.) © 2023 Apple Academic Press, Inc. Co-published with CRC Press (Taylor & Francis)

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the psychosocial needs of affected and infected communities (Brooks et al., 2020). The fear, stress, and depression were acknowledged, but we have not been able to develop psychosocial strategies to identify protective factors and increase resiliency. Three psychosocial interventions tend to reduce fear and promote wellbeing: (i) it is important to adopt a systemic perspective to appreciate the psychosocial impact of any emerging infectious disease and determine its psychological effects on those who are unseen as family members, nonmedical staff, or medical colleagues. This will enable comprehensive planning to alleviate psychosocial burdens or mitigate their onset in the future (Pedrosa et al., 2020); (ii) the psychological impact may persist over time so that prospective research is warranted; (iii) outcomes of psychoso­ cial interventions should be evaluated, e.g., assessments of individual and group-based interventions, and educational sessions for staff and the public, and communication highlighting updated information. As the humanitarian sector confronted the situation, they were moving towards resilience. This chapter introduces a review of the actions of 37 countries in three regions of the world; they address the psychosocial impact of the quarantine and how to be proactive in various neighborhoods and communities. 14.2 PSYCHOSOCIAL SUPPORT DURING COVID-19 In the context of epidemics, given the need for public health, strong community-based psychosocial support is vital to manage the distress of affected populations, humanitarian workers, and volunteers (Pedrosa et al., 2020). The most frequent reaction to stress includes anxiety, sadness, anger, guilt, difficulty concentrating, and relating to others. Stigma contributes to the distress of this situation, faced by those who became ill, as well as their relatives, health care workers, frontline staff, and survivors. Individuals must overcome the grief of lost loved ones and financial stress. In these circum­ stances, psychosocial support is necessary for recovery. Everyone has a ‘place’ in the world, which becomes a way of identifying and helping the most vulnerable. We must facilitate families, groups, and communities to care for each other for recovery and resilience. We can take actions on our own street to strengthen systems essential to daily life and well-being. An elderly person needs groceries, while others may feel lonely and need someone with whom to talk. We must work towards everyone’s well-being during the COVID-19 pandemic (Figure 14.1).

Mental Health and Psychosocial Support During and After the Pandemic

FIGURE 14.1

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Spiral of emotional recovery after COVID-19.

Source: Reprinted from Diaz, 2020. Copyright © SCHOLINK INC. https://creativecommons. org/licenses/by/4.0/

14.2.1 PRACTICAL RESPONSE TO COVID-19: THE SPIRAL OF RECOVERY COVID-19 has powerfully impacted the world, and we try to develop strat­ egies to move forward. This section introduces—through a Spiral Model, the mental health and psychosocial support (MHPSS) approach and a fieldbased response through the International Federation of the Red Cross (IFRC) and the Red Crescent (PS Center, 2020). In December 2019, the Red Cross approved Resolution 33, mandating MHPSS as part of the protocol. The Spiral of Recovery was developed for this chapter, as well as for the population of volunteers and paid staff, to understand how the MHPSS sees the problem. The first part of the spiral (loss of place) suggests COVID-19’s impact; the second part (community mobilization) suggests the transition from immediate response to early recovery. The third part (mid-recovery) addresses community actions to recover from being victims to becoming volunteers. Other feelings are expressed by community members. The spiral ends with having survived COVID-19 and its MHPSS sequelae. The Spiral of Recovery after COVID-19 depicts 13 emotional conse­ quences to recovery, such that affected community members express feel­ ings of having survived and can also celebrate that. The MHPSS encourages activities that instill hope, as this narrative explains this in detail.

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14.2.1.1 FIRST SPIRAL: LOSS OF PLACE

This spiral represents a cycle of response, addressing losses from the onset of COVID-19. The pandemic has led to a series of losses, without a sense of safety and security, to our social connections and quarantine measures, to financial security with employment loss, especially among those in the lower stratum of the economic ladder, many of whom are women. During this pandemic, many families have experienced a pervasive sense of loss: tragic deaths and loss of physical contact with family and social networks; the loss of jobs, financial security, and livelihoods undermine people’s lives. Social life in families, neighborhoods, and communities had to be redefined by government regulations. The total lack of normalcy due to illness, death, and dislocation. The initial response began in April through June 2020. This included quarantine at home, wearing masks, communication through telephones, TV, radio, or other media, and keeping a safe distance has been distressing for a large portion of the population in the Caribbean, and Central and South America. The MHPSS responders and volunteers found that staying at home, often in small spaces, with little access to national resources (parks, mountains, animals, and open spaces) with family is best described as “loss of place.” The extent of mental health and unaddressed psychosocial support will not be known for some time. Humanitarian actors, United Nation agencies such as the World Health Organization (WHO), and the Red Cross and Red Crescent (RCRC) Move­ ment recommended psychological first aid (PFA) as a first-order interven­ tion, as well as training frontline workers to aid distressed individuals; managing their own self-care has increased, but evidence of PFA training is uncertain. Recent studies suggest that appropriate psychosocial responses and PFA skills support those in acute distress, enhancing self-efficacy and resilience. However, there is a need to understand how culture and context impact training and selection of sensitive outcome measures to strengthen PFA practice, to enhance preparedness for future emergencies. COVID-19 represents a destructive force in these regions (Central and South America, and the Caribbean) for the mental health of the affected populations. We have described the immediate impact of COVID-19: movement restrictions, curfews, isolation, no public gatherings, and closed borders. This is not a regular disaster response: it is a health response (physical/mental health). The community of the region forfeited their sense of place. Physical structures were still intact, but not our emotional selves. People lost daily visuals, such as trees, hills, and rivers, as they were put into

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quarantine: the new ecology was defined by confined spaces. As time passed, and uncertainty became more pervasive, there were limited opportunities to interface with the neighborhood, community, and town. Along with the quarantine, there was a ‘learned’ helplessness: “I don’t have anything here, everything I need is out there.” As time went by—a week, a month—the cultural and psychosocial milieu began to wither. Our window on the world is usually through TV, radio, and conversations by phone. The news was horrible: the topic was death and the inability to control the pandemic or the deaths. Safety and security were curtailed, with feelings of alienation, fear, loss, and uncertainty about the future. COVID-19 led to the loss of employment as well as economic insecurity. In many countries, the economy was based on day-to-day jobs. People could not leave home, with a fear of being infected, along with increased quarantine time. Survivors developed somatic complaints, anger, and severe stress, often experiencing abusive behavior between those in confined spaces. This required volunteers to commit to long hours and operating many phone lines. As a result of closed borders, or being part of a migrant group, many were absent from their families. Yet, in thoughts and dreams, the person is still part of the family and community. People tend to swing between hope and despair, so volunteers are trained to provide psychosocial support, e.g., listening, referring to appropriate resources, follow-up, and acknowledging loss. 14.2.1.2 SPIRAL TWO: EARLY RECOVERY The focus is on the transition to greater community mobilization. As restric­ tions lift around the world, one becomes acquainted with a new environment after COVID-19. The community has changed, communication is different, and those with whom we socialize are different. The readjustment process takes time, as we had to use face masks for 18 months. The spiral includes four spaces: (i) community; (ii) volunteers; (iii) more confidence in the neighborhood; and (iv) celebrating a more open environment as we exit quarantine for new rituals but continuing on the road to recovery. 14.2.1.2.1 Community Activities For example, the difference between pre-COVID-19 communication and early recovery has been threefold: (i) recognizing the upper face through eyebrows, eyes, and upper cheeks as we communicate; (ii) talking louder in quiet settings; and (iii) using telecommunication for interpersonal interac­ tions. Community activities have been affected in both adults and children.

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14.2.1.2.2 Encouraging Community Volunteers

The team was composed of five volunteers, responsible for that number of clusters in Central and South America, and the English-speaking Caribbean National Societies (NSs), as well as Cuba and the Dominican Republic. The team was online in March 2020, with challenges of how to communicate when trained to offer PFA or psychosocial support. Another challenge was lost volunteers. 14.2.1.2.3 Transitioning to the Neighborhood and Community The team realized that timely, appropriate action was needed. The objec­ tive was to share information when traditional media could not. As such, communication occurred with information and technology (IT). Messages went sent by radio, TV, the Internet, and scripts that “sing” to people. Radio support was also used: what are normal reactions during quarantine, what are healthy ways to handle stress, and how to access help. The team developed webinars on MHPSS in English and Spanish, conducting phone banks and telemedicine to meet the emotional needs of the population. The team still works with a large segment of the populations in the Americas, who speak native languages: Aymara, Quechua, Guarani, or Maya. 14.2.1.2.4 Celebration After the Initial Stages of COVID-19 Rituals may provide a steady source of connection; they represent symbols with multiple meanings, symbolic actions, special times and places, with newly invented rituals through stories about couples, families, and communi­ ties. As volunteers and country leaders begin to use the web to communicate more, there will be an increase in rituals in different countries, even with diverse languages. 14.2.1.3 SPIRAL THREE – COMMUNITY: PHYSICAL, PSYCHOLOGICAL, AND SOCIAL REBUILDING Emergence of community. Social capital follows crises and recovery. There had been trust, norms, and networks for easier access to resources, such as information, aid, and financial resources, involving emotional and psycho­ logical support. Social capital might mitigate the spread of COVID-19 in the form of shared norms as well as networks.

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As COVID-19 reduces its impact in communities, the tasks outlined in this spiral will expand. This third part focuses on mid-to-late recovery in a journey of self-exploration: physically, psychologically, and socially. The main characteristic of this phase is the emergence of community networks and determining psychosocial needs and reinvention of an emotional sense of culture, activities, and a return to the physical and natural environment. As exercise projects by community groups are initiated, they may include: (i) safe spaces for children, the elderly, and groups at risk; (ii) informal schooling for young women; and (iii) self-care for other members of the community. A sense of belonging has increased, and community leaders monitor activities for the donors. Psychological crises during the pandemic included emotional, behavioral, and physical symptoms of stress. 14.3 SUMMARY MHPSS is a new pillar in the repertoire of services in disaster response and recovery within the health sector, complementing other areas of community health. The COVID-19 pandemic is the first major disaster since international guidance has recognized the importance of mental health and psychosocial support for the recovery of the affected population. The America’s MHPSS team, as part of a regional health, and community health team supported by the World Health Organization and others, has attempted to identify the most effective ways of responding to the health response, by develop[ing] tools, and strategies that alleviating fear, and prepare a cadre of volunteers that are prepared to provide psychosocial support. This chapter suggests a path to provide such assistance. KEYWORDS • • • • • •

COVID-19 information and technology mental health and psychosocial support psychological first aid psychosocial strategies World Health Organization

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REFERENCES

Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., et al., (2020). The psychological impact of the quarantine and how to reduce it: Rapid review of the evidence. Lancet, 395, 912–920. https://doi.pog/10.1016/S0140-6736(20)30460-8. Cork, C., Kaiser, B. N., & White, R. G., (2019). The integration of idioms of distress into mental health assessments and interventions: A systematic review. Global Mental Health, 6(e7), 1–32. https://doi.org/10.1017/gmh.2019.5. Imber-Black, E., (2020). Rituals in the time of COVID-19: Imagination, responsiveness, and the human spirit. Family Process, 59(3), 912–921. https://doi.org/10.1111/famp.12581. Makridis, C. A., & Wu, C., (2021). How social capital helps communities weather the COVID-19 pandemic. PLoS One, 16(1), e0245135. https://doi. org/10.1371/journal. pone.024513. Mheidly, N., Fares, M. Y., Zalzale, H., & Fares, J., (2020). Effect of face masks on interpersonal communication during the COVID-19 pandemic. Front. Public Health, 8, 582191. doi: 10.3389/fpubh.2020.582191. Orgilés, M., Morales, A., Delvecchio, E., Mazzeschi, C., & Espada, J. P., (2020). Immediate psychological effects of the COVID-19 quarantine in youth from Italy and Spain. Front. Psychol., 11, 579038. doi: 10.3389/fpsyg.2020.5790385. Pedrosa, A. L., Bitencourt, L., Fróes, A. C. F., Cazumbá, M. L. B., Campos, R. G. B., De Brito, S. B. C. S., & Simões, E. S. A. C., (2020). Emotional, behavioral, and psychological impact of the COVID-19 pandemic. Front. Psychol., 11, 566212. doi: 10.3389/fpsyg.2020.566212. PS Center, (2020). Mental Health and Psychosocial Support for Staff, Volunteers and Communities in an Outbreak of Novel Coronavirus. Copenhagen. The IFRC Psychosocial Support Center. https://pscenter.org/wp-content/uploads/2020/02/MHPSS-in-nCoV-2020_ ENG-1.pdf (accessed on 27 October 2022). Ramkissoon, H., (2021). Place affect interventions during and after the COVID-19 pandemic. Front. Psychol., 12, 726685. doi: 10.3389/fpsyg.2021.72668. United Nations, (2019). Indigenous Languages in the Americas. New York: The year of Indigenous Languages. Vaughan, E., & Tinker, T., (2009). Effective health risk communication about pandemic influenza for vulnerable population. Am. J. Public Health, 99(82), 5324–5332. https://doi. org/10.2105/AJPH.2009.162537.

CHAPTER 15

Monitoring and Evaluation of Mental Health and Psychosocial Support* JOSEPH O. PREWITT DIAZ

The Pennsylvania State University (Retd.), Pennsylvania, USA

ABSTRACT This chapter introduces ways to improve the management of a project, cost effectiveness, and time on task, and meeting targets. The second point of discussion is how we can determine the effectiveness of our activities in terms of behavior change. This discussion is framed within the area of mental health and psychosocial support. 15.1 INTRODUCTION This chapter addresses the existing guidance in monitoring how disasteraffected persons use resources. Monitoring is the standardized, ongoing oversight of the implementation of project interventions (Reynolds & Sutherland, 2013; Augustinavicius et al., 2018). Monitoring establishes the extent to which project inputs (e.g., amount of money or external technical support), work timetables, and targeted outputs (e.g., the amount of learning people are doing) are proceeding according to plan. It is divided into the internal, community-level processes, and external process of accountability. Parts of this chapter have been previously introduced by the author as part IV of a book enti­ tled: (i) Advances in Disaster Mental Health and Psychosocial Support (Prewitt Diaz, Murthy, and Lakshminarayana, 2008); (ii) Integrating Psychosocial Programming in Multi-Sector Response to International Disasters (Prewitt Diaz, J. O. American Psychologist. Nov. 2008); and (iii) Recovery: Reestablishing Place and Community Resilience (Global Journal of Community Psychology Practice (Prewitt Diaz, October 2013). These segments are published with permission of the author and the editors. *Note:

Mental Health and Psychosocial Support during the COVID-19 Response: An Overview. Joseph O. Prewitt Diaz (Ed.) © 2023 Apple Academic Press, Inc. Co-published with CRC Press (Taylor & Francis)

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The second part of the chapter addresses issues related to program evaluation, or how the donor knows that the recipients of resources achieved what they proposed to do (Inter-Agency Standing Committee (IASC)). Evaluation is a process that attempts to determine as systematically and objectively as possible the outcome and impact of project interventions rela­ tive to specific target objectives (https://interagencystandingcommittee.org/ iasc-reference-group-mental-health-and-psychosocial-support-emergencysettings/iasc-common-monitoring-and-evaluation-framework-mental-healthand-psychosocial-support-programmes). Evaluation allows for an in-depth analysis of a project’s progress and impact. Usually, these tasks occur as a continuum of development. At other times, the affected people complete certain activities, some by the technical external staff, and an external individual or group of experts completes the final part of the process. Both components monitoring and evaluation form a combined management system. Both components, monitoring and evaluation, improve management of programs, projects and supporting activities to ensure programs are meeting targets, and are making optimum use of funds and other resources (https:// interagencystandingcommittee.org/iasc-reference-group-mental-healthand-psychosocial-support-emergency-settings/iasc-common-monitoringand-evaluation-framework-mental-health-and-psychosocial-support-emer­ gency). The MHPSS (2007) suggest that monitoring and evaluation assist program personnel, disaster affected people, stakeholders, and funding agen­ cies to learn from and share experiences to improve the relevance, methods, and outcomes of programs. In addition, meet donor requirements to see whether resources are being used effectively, efficiently, and for agreed-on objectives (Alegría et al., 2018). The results of this process provide informa­ tion to enhance advocacy for policies, programs, and resources. The chapter is divided into an introduction, summary, and three sections: (i) introducing psychosocial support and gathering initial information; (ii) logic model for the development of a psychosocial support program; and (iii) components of a monitoring and evaluation model. 15.2 INTRODUCING PSYCHOSOCIAL SUPPORT AND GATHERING INITIAL INFORMATION Psychosocial support programs comprise a set of community-based activi­ ties that enhance resilience and improve community wide well-being. This intervention is a relatively new component of the humanitarian assistance to disaster or conflict affected people. Local staff usually provides services,

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with technical assistance for external experts. Program development follows a continuum that will be described below. While, at least conceptually, a program of this nature would only be provided only as part of a humanitarian response, the social and psycho­ logical needs of the affected people fluctuate, and so the first step is to determine the needs and protective factors of the community (PS Center, 2009). Three major areas: (i) needs and assets of an affected community; (ii) symptoms versus disaster/conflict generated problems; and (iii) the extent of stakeholder engagement. In psychosocial support, the primary intervention is to get the affected people to talk (individually, in small groups, focus or interest groups, or larger community representative groups). Information is collected system­ atically that yields an overview of the community history, livelihood, mores and cultural nuances (IOM, 2019). Key informants and indigenous leaders (i.e., the person that sells candies in front of the school building, the person that brings information from the outside, teachers, or traditional healers) emerge and are engaged in conversations with formal leaders (i.e., elected members of the local government, health post personnel, and school teachers) (2019). The primary tools used to elicit information from the community are: (i) participant observation; (ii) community-based participatory research; (iii) comparative ecosystem-based research; (iv) participatory action research; and (v) resilience approach to psychosocial assessment (IASC Reference Group for MHPSS in Emergency Settings, 2010). 15.2.1 PARTICIPANT OBSERVATION

Participant observation is a method of collecting information about the operation of, and attitudes existing in, a disaster affected community through the participation of volunteer and paid staff living in the area for an extended period (Makwana, 2019). The participant observer becomes known within the community and gets to know the disaster/conflict affected community in a more intimate and detailed way than someone who simply comes to do a survey and then departs (Darwin, 2017). The participant observer conse­ quently is given much more detailed information and may identify specific issues and assist groups to address these by developing mutually agreed principles and practices. Project staff are placed in a disaster/conflict affected community with the aim of collecting more detailed information about a community’s

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habits, opinions, psychosocial needs and protective factors with a view to developing psychosocial support activities that foster participation, enhance resilience and promote well-being by incorporating the commu­ nity’s needs and wishes in the program design. Incorporating community needs and opinions will be more acceptable and more useful to the community. In the aftermath of the 2004 Tsunami in Sri Lanka, an international relief organization recruited local volunteers and paid staff that in conjunction with the expatriate personnel identified target communities and engaged system­ atic participant observation process. These personnel gained the trust of the disaster/conflict-affected people, prepared community maps, identified the post-disaster needs and protective factors. As a result of the participant observation activities, the external personnel developed a greater understanding of sensitive community situations. They provided consultation to the donor as to the nature of the community. Volunteer and paid staff was able to scope information and determine key players when the issue was contentious or controversial (role of women in the community political process, or the role of children and adolescent in the rehabilitation and reconstruction process (Dickson & Bangpan, 2018). At the end of the process, the psychosocial projects that were developed meet the immediate and long-term needs of the affected communities (Gil & Kilmer, 2016). 15.2.2 COMMUNITY-BASED PARTICIPATORY RESEARCH (CBPR) Community-based participatory research (CBPR) is a collaborative research approach that is designed to ensure and establish structures for participation by communities affected by disaster or conflicts, external stakeholders, and donors in all aspects of the assessment process to improve psychosocial support, enhance resilience and achieve well­ being through taking action, including social change (Unertl et al., 2016). (i) Co-learning about the affected people pre-disaster needs, current needs and assets and reciprocal transfer of expertise, by all partners, with particular emphasis on the issues that can be studied with CBPR methods; (ii) shared decision making power amongst all segments of the affected communities and other stakeholders; and (iii) mutual ownership of the processes and products of the research enterprise (Prewitt, 2013) (Table 15.1).

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TABLE 15.1 2021)

279

Framework for Community-based Participatory Research Model (Spies et al.,

Steps Full participation of community in identifying psychoso­ cial issues of greatest importance. Community represen­ tatives involved with program design and proposal submission.

Resulting in Increased motivation to participate in the process.

Actions Issues identified based on actual epidemiologic data and funding priorities. Increased accept­ Program ability of psychoso­ designed and cial approach, include funding sought. funds for community.

Benefits Psychosocial concern(s) identified.

Community repre­ Enhanced recruitment sentatives provide and retention. guidance regarding recruitment and retention strategies of local volunteer and paid staff.

Participants, volunteers, and paid staff recruited, and retention systems were implemented.

Assessment instru­ ments developed or adapted with community input and tested in similar population. Community members take on a major role in PS intervention development.

Assessment instruments designed and data collected.

Design based entirely on expressed community needs and feasibility; funding requested primarily for project activities. Approaches to recruit­ ment and retention based on scientific issues and “best guesses” regarding reaching community members and keeping them involved in the psychosocial support project. Assessment instruments developed, adopted/ adapted from other psychosocial programs.

Intervention designed and implemented.

Program staff design intervention based on literature and theory.

Data analyzed and interpreted, and findings disseminated and translated.

Program personnel report findings to community members, the donor, and other stakeholders.

Potentially sensitive issues handled better and increased reliability and validity of measures.

Assures greater cultural and social relevance to the population served, increasing the likeli­ hood of producing positive change. Community members Assures greater assist program sensitivity to cultural personnel with the and social norms and collection, interpreta­ climate and potential tion, dissemination, group harm and and translation of enhances potential for findings. translation of findings into best practices.

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15.2.3 COMPARATIVE ECOSYSTEM-BASED RESEARCH

The purpose of comparative ecosystem research is to promote flexible, resil­ ient, and sustainable levels of skill amongst the disaster affected people that focus on the practical and methodological barriers to developing community assessment protocols that are participatory (Russell et al., 2013). The assess­ ments include the physical (built and natural), cultural, psychosocial, and spiritual ways of a community (Makwana, 2019). Community is defined in three ways: (i) those who live in a similar geographical area; (ii) those who have similar social, psychological, and spiritual characteristics and relate to each other as a community; and (iii) those who come together in response to a disaster or a pandemic (Reichel, 2018). After a disaster, such as the 2009 earthquake in Haiti, the ecosystem is a damaged, as the human beings who avail themselves of its resources. The reconstruction of the ecosystem goes in par with the reconstruction of the build community (physical, social, psychological, and spiritual). The disaster affected people’s physical (natural and build) and psychosocial “history” links into more emotional and general meanings that locate people to places. Many of the disaster affected people told bitter tales of “losing their history” when community representatives from their community reached an agree­ ment with outsiders related to relocation from their communities (OECD, 2020). In a few cases, these forced moves, have decimated the local access to livelihood. In South America, after COVID-19 impacted, unilateral deci­ sions by the government and other interested parties have cumulated with resulting economic, psychosocial, and cultural impacts for entire communi­ ties (Nguyen et al., 2020). Rhetoric of invasion has begun to develop where communities experience such stress. There is considerable scope for improvements in the nature of ‘participa­ tory’ research initiatives in disaster/conflict affected communities, to more closely approach the full potential of the participatory research method (National Academies of Sciences, Engineering, and Medicine, 2017). Three common ‘levels of engagement’ can be identified: (i) including disaster affected people as “subjects” of research planned and undertaken by program developers; (ii) training community affected people to become “research assistants” and to collect data, while program staff plan what data to collect, as well as undertaking the analysis and dissemination of results; and (iii) having disaster affected people identify research questions, then having the collection of data and subsequent analysis carried out by others, such as volunteer and paid program staff (De Ville De Goyet, Marti, & Osorio, 2006). The challenge has been to explore how to fully engage the disaster-affected people in the

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assessment process in order to produce results that are viewed as practical, applicable, and valid by all community members, stakeholders, and donors. The participatory methodology addresses three different levels, or orders, of meaning. The first level involves practical livelihood concerns including what, when, and where to look for work, and with what intensity of effort. Local and external agencies initially engage most adults in cleanup activities and construction of temporary facilities. Psychosocial support activities focus on refining or re-defining the capacities of the community to care for itself (Bavel et al., 2020). The psychosocial support personnel assist the disasteraffected people to identify and protect the resources that already exist in the community. Some of these activities are cleaning the fields, parks, holy places, and schools (Pedrosa et al., 2020). The second level of analysis of interest to disaster affected people social, economic, and political issues—including the kinds of institutional structures that work best in alleviating suffering and promoting well-being (fields, community centers, prayer groups and religious places), the politics of access (in India the caste system is always present where access to all services is concerned) and allocation of goods from external sources (who is best organized to present their case logically and gain external advocates) (Patel et al., 2017). The third level that proved of interest to disaster affected community members involves the values that implicitly or explicitly guide policy devel­ opment and implementation (Prewitt, 2010). For example, how can widows in a Muslim community have access to the properties of their dead spouse? How can collective rights in a resource be balanced in general with individual rights? Sometimes the research designed around these questions brought the issue of values down to the local level. Is some form of local management workable in our community? Are the values underlying policy development sufficiently adapted to the conditions of the disaster-affected people? 15.2.4 PARTICIPATORY ACTION RESEARCH (SPARRE, 2020) This section was originally presented in a paper by the author in 2010. It is reproduced with updates herein with the author’s permission. Participatory action research is “learning by doing” – a group of people identify a problem, do something to resolve it, see how successful their efforts were, and if not satisfied, try again (Tol et al., 2020). Action research contributes to the practical concerns of people in an immediate problematic situation (Depart­ ment of Health and Human Services, 2011). Thus, there is a commitment in

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action research to collaborate with COVID-19 affected people in changing it in what is together regarded as a desirable direction. Accomplishing this objective requires the active collaboration of program planners and client, and thus it stresses the importance of co-learning as a primary aspect of the research process (Baum, MacDougall, & Smith, 2006). What separates this type of research from general professional practices, consulting, or daily problem solving is the emphasis on scientific study, which is to say the program staff studies, the problem systematically and ensures the intervention is informed by theoretical considerations (Donnelly, Toof, & Silka, 2021). Much of the evaluators’ time is spent on refining the methodological tools to suit the exigencies of the situation, and on collecting, analyzing, and presenting data on an ongoing, cyclical basis. Donnelly, Toof, & Sika (2021) suggest that there are several attributes separate action research from other types of research (Donnelly, Toof, & Silka, 2021). The primary focus of action research consists in turning the people involved into researchers, too – “people learn best, and more willingly apply what they have learned when they do it themselves” (Kaluzeviciute et al., 2021). It also has a social dimension – the research takes place in real-world situations and aims to solve real problems. Finally, the initiating evaluator, unlike in other disciplines, makes no attempt to remain objective, but openly acknowledges their bias to the other participants (Prewitt, 2013). 15.2.5 RESILIENCE APPROACH TO PSYCHOSOCIAL ASSESSMENT (PATEL ET AL., 2017) This section was originally written by the author (Prewitt, 2013) and is reproduced herein with revisions. Psychosocial assessment is a process of collecting, organizing, and analyzing information about a community. A resilience approach to psychosocial assessment can be used to understand a community’s vulnerabilities, resources, and adaptive capacities that drive its response to change (Hynes, Trump, Love, & Linkov, 2020). A resilience approach accepts that change is inevitable and unpredictable. The resilience approach identifies the resources and adaptive capacities that a community can utilize to overcome any problems that may result from change. A crucial difference is that rather than relying on external interven­ tions to overcome vulnerabilities, a resilience approach builds upon the capacities (resources, flexibility) already established within a community (Patel et al., 2017).

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This focus on resources and capacities does not ignore the components of a community that may be vulnerable to a particular change. The resilience approach is balanced in that it includes both the vulnerabilities within a commu­ nity (rather than labeling an entire community as ‘vulnerable’) as well as the resources and adaptive capacities that enable the community to overcome these vulnerabilities and manage change in a positive way (Mayer, 2019). A resilience perspective enables an adaptive form of governance, which encourages the use of environmental and social resources in a sustainable way (Luthar, Cicchetti, & Becker, 2000). By the same token, a resilience based psychosocial assessment (RBPSA) recognizes the inherent complexi­ ties and interactions between a community’s resilience, vulnerability, and adaptive capacity, and therefore should not be used as a one-off assessment (Ungar, 2018). An assessment of resilience is never complete. Ungar (2018) suggested that a psychosocial resilience approach gener­ ates a richer and more useful social assessment in three ways: (i) a resilience perspective is able to capture and contend with the complexity inherent in human-environment systems and social changes in those systems instead of attempting to control change; (ii) the resilience perspective recognizes that change and uncertainty are inevitable, and that communities are dynamic; and (iii) the resilience perspective provides a way of assessing the resources and adaptive capacities of a community rather than just its vulnerabilities (Prewitt & Dayal De, 2018). In this way, it provides a core set of capabilities upon which to build adaptation strategies. Role of the Resilience Approach to Psychosocial Assessment in Community-Based Psychosocial Support Strategy (Prewitt, 2018) • Understand the community’s psychosocial characteristics. • Identify the different groups within a community, including those who are most likely to be affected by a change, and understand the relationships between those groups. • Identify the vulnerabilities within a community which may reduce its resilience to adapt to change. • Identify a community’s resources and adaptive capacities which increase its resilience to change. • Develop scenarios to understand how a change might impact on the community, and how that community might utilize its resources and adaptive capacities to respond in an adaptive way to a disaster or a conflict. • Identify practical strategies to strengthen the community’s resources and capacities. • Monitor and evaluate changes as they occur to identify expected and unexpected psychosocial impacts.

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This section introduces a tool for a community to understand its own vulnerabilities, resources, and adaptive capacities that will shape its response to a particular change (such as psychosocial support). This process also enables a donor agency to understand how it can help the community build on its own resources and capacities to respond adaptively. An assessment conducted in this way provides a basis upon which the resilience of that community can be enhanced and developed to ensure that the implemented change has beneficial outcomes for both the community and government. Below is a suggested six-step process for RBPSA. This process is not comprehensive but provides examples of what might be explored in an assessment process (Table 15.2). TABLE 15.2 A Six-Step Process for a Resilience-based Psychosocial Assessment (RBPSA) (Prewitt, 2002) Step

Objective

Elements to Consider

Defining the issue

Understand the RBPSA the impact of a disaster/ conflict on the whole system to which the psychosocial assessment is based.

• Composition of the “community.”

The Internal community structure

Community History

Understand a community’s capacity to respond to change program personnel need to know. Understand how the community has responded to change in the past.

• The process of change that is likely to take place. • Issues arising from this change process in the community. • Values and attitudes of the community towards this change and the change process. • Key social groups that will be impacted. • Relationship between and within the groups. • Values, attitudes, and beliefs held by different commu­ nity groups toward psychosocial support. • Major events that have shaped the community (e.g., disas­ ters, migration, construction, displacement). • Natural and human-made events that continue to impact how the community functions and responds to events (e.g., relationships between different groups within the community).

Develop a work plan with stakeholders to ensure that the • History of conflict and relationships between social community is able to groups within the community. respond adaptively to the • Community’s history of needs of psychosocial support current change. activities, resilience enhancement activities, or self-help.

Monitoring and Evaluation of Mental Health and Psychosocial Support TABLE 15.2

(Continued)

Step

Objective

285

Elements to Consider

Community Communities and • Levels of unemployment in the community. vulnerabilities stakeholders can identify • Degree of reliance on one industry (e.g., fishing). vulnerable components • Financial investment in a particular industry. within a community. • Personal investment in the community’s history. Vulnerabilities are • Location of the community (e.g., isolation). framed in conjunction • Assess of the community to services (e.g., medical, with the resources and counseling services). adaptive capacities that enable the community • People in the community have poor mental health to overcome these resources. vulnerabilities. • Levels of connectedness between community members. Community Resources are the aspects • The community has groups or community leaders who resources of a community that are play an important leadership role in change. explored in partnership • The source of power in the community. Power can be in between the community the form of monetary resources for funding, land owned and stakeholders to by the community, or voting. identify the community’s • The community has a strong social capital (i.e., strong resources and strengths, networks, trust, and relationships between people and and their influence community groups. on adaptive capacity Many people belong to and tap into community • and resilience of the networks and support groups (e.g., the number of people community. who participate through volunteer work). • The community has high social vitality and social inclusion (e.g., how many women are in full-time work, are part of the decision-making process, have access to education. • Skills and educational level of the community.

Adaptive capacities

• Community members report that they have a good quality of life (e.g., feel secure, eat well, recreate, and interact with community members, and volunteer) • Diversity of the local economy.

In assessing a commu­ nity’s adaptive capacity, • The community’s ability to effectively organize itself. the community examines • Leaders (individuals or groups) in the community its ability to take action, can mobilize awareness and resources to manage the that is, to mobilize its process. resources for adaptation. • Community members learn from change. Flexibility and redun­ dancy in the system that • The community seeks creative solutions to change. enables the community • Length of time for the community to respond to changes. to respond adaptively to • Availability of communication channels within the a change. community.

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In the aftermath of the El Salvador earthquake of 2001, the country was destroyed, and the multiple replicas of the earthquakes had impacted the psychosocial well-being of the disaster affected people. A group of Red Cross volunteers was sent out to the affected communities to conduct assessments. Their methods involved meeting with the members of the affected communities and develop maps of the damaged structures, natural places, schools, churches, and community hangouts. The impressive piece was that they were able to identify those that were affected emotionally in each household and suggests community-based activities that would help them (carousel de la Alegria for the children, community TV’s so that people could watch the movies, and handicraft activities for the elderly. At the end of a week, these small groups of volunteers had organized more than 120 communities, sought the information needed, and had a basic work plan that was developed by the affected members of the communities. The action steps taken by the community members provided inputs into the funding mechanism of the donor, and the community achieved its desired objectives. 15.3 LOGIC MODEL FOR A PSYCHOSOCIAL SUPPORT PROGRAM Figure 15.1 is a depiction of a psychosocial support program’s develop­ mental flowchart. The flow of tasks is divided into five distinct moments: (i) entry to the community; (ii) community assessment; (iii) mobiliza­ tion; (iv) psychosocial support; and (v) monitoring and evaluation. The previous section discusses the process of community entry and the socialization of psychosocial support activities as a part of the disaster response repertoire. During the community assessment phase, conversations between the program staff and the disaster-affected community begin to identify predisaster needs, and post-disaster needs, new needs that emerge as a result of the disaster/conflict. In addition, as conversations amongst community members and other stakeholders continue, key informants and elected officials identify the community assets. Assets are the resources that the community has that can contribute to the resolution of the existing needs.

Monitoring and Evaluation of Mental Health and Psychosocial Support

FIGURE 15.1 al., 2020).

287

Flowchart for the development of a psychosocial support program (Tol et

Another task during the community assessment period is to more closely identify what are overt negative behaviors (i.e., increased use of alcohol, self-medicating, inability to sleep), and what are problems (i.e., experienced loss, lack of resources to reconstruct, not having enough information about the future, or a physical condition that arose from the disaster or the conflict). They identify the frequency of occurrence, as well as mapping the location of affected people.

288

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Data is how the stakeholders describe their involvement with the target communities is important. This involvement or commitment is usually in the form of technical assistance, materials, training and grants in aid. The stakeholders will usually establish a timeline and some benchmarks that they deem appropriate (i.e., the project will last three years, and an expected achievement after each year of the project). Once the situation analysis has concluded and there is a fairly clear picture that has been generated by the technical staff, the affected communi­ ties, internal and external stakeholders, and the potential donors, priorities, and intended outcomes are crystallized in a document. This is the beginning of a Psychosocial Support proposal. Usually, a psychosocial support proposal will have three major compo­ nents: (i) inputs; (ii) outputs; and (iii) outcomes. Assumptions are formulated based on environmental considerations as well as existing political, cultural, and spiritual climate in the affected communities. External factors that may impact the outcomes of the program are factored in the planning process (Cruz et al., 2020). Inputs are what the stakeholders invest in the psychosocial support project. These inputs include, but are not limited to, technical assistance, financial support, materials, and equipment, training for local volunteers and paid staff. Initial assessment, baseline data collection and other research initiated by external stakeholders, or the donors are also included as inputs. The outputs are divided into two sections. In the first section, the psycho­ social support project attempts to propose what to do during the project period, that is, what are the activities for the project. The project may begin with conducting training, workshop, and other meetings. It may begin to provide direct services to the affected communities based on the identified psychosocial needs of the population, or develop materials, curriculum or other visual resources. A final output may be a sequence of staff development where volunteers and paid staff receive training on how to use the materials developed and psychological first aid (PFA). The outputs sections also define who will be the participants, and the level of participation these participants will have in the project. The section also defines the progression in roles for different jobs, and the amount of time to be spent in each task. The outcomes section in a psychosocial support program is divided into short, medium, and long-term outcomes. In the short term, it is expected that volunteer and paid staff as well as disaster affected people become aware of their needs and protective factors through assessment, consultation, and

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289

community wide meetings. There is a great emphasis in learning, skill devel­ opment, improving their attitudes, and motivation to reconstruct their lives. The mid-term outcomes focus on action. The great amount off the psychosocial support work is performed during this period. Social action is begun, the communities utilize their resources to reconstruct, they develop proposal, and conduct projects at all age levels. During this period behavior changes, people modify their behavior from feeling like victims to a feeling victorious. The affected community becomes more resilient and begins to identify practices that will help them achieve well-being. The long-term outcome is to have disaster affected people and commu­ nities function at least to pre-disaster levels. The community has become civically occupied. There is an organization in which all the neighbors are active participants. Livelihood activities are established in the community and are supported by community members. There is an effort to restore the environment and guidelines have been established to take responsible actions pertaining to the environment. Disaster affected people and other stakeholders are engaged in planning and preparing to mitigate the effects of a future disaster. The community achieves psychosocial well-being as evidenced by neighbor reports: they feel a part of the community, they volunteer to assist others, and there are mechanism for all to feel secure, calm, and with a desire to remain in the community. An important part of the psychosocial support project development is the evaluation. The purpose of the evaluation is to collect data from an outside source that will tell the community, other stakeholders and the donor if the project has accomplished what it had set out to do. Data is collected during several times in the project cycle; it is analyzed and interpreted. A final report is usually developed and shared with the donors. 15.3.1 COMPONENTS OF A MONITORING AND EVALUATION PLAN (PREWITT, N.D.) With an increased effort to be accountable and transparent about interven­ tions after a disaster or conflict, the psychosocial support programs utilize a monitoring and evaluation plan that will be detailed below. The monitoring process is internal to the organization that is supporting the community in the development of the psychosocial support program. The objective of monitoring is to make sure that the activities are taking place within the plans that were put in place for the project, whether resources (financial,

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materials, and personnel) are used appropriately, whether information is flowing appropriately, and whether the disaster-affected people are satisfied with the activities that are taking place. That is monitoring is concerned with the day-to-day activities during the project cycle. Evaluation, on the other hand, is an external activity that looks at the project from a holistic perspec­ tive. It is concerned with learning lessons and with suggesting next steps once the project has been completed. Figure 15.2 describes the continuum of monitoring and evaluation.

FIGURE 15.2 The components of a monitoring and evaluation plan include (USAID, 2010).

Figure 15.2 describes the continuum for a psychosocial support program monitoring and evaluation continuum. The continuum begins with hiring personnel and defining the resiliency markers with the target community. Resiliency markers are proactive and protective behaviors that are developed as the project evolves and result in psychosocial well-being. The project objectives are defined, and the baseline assessment takes place. Baseline and end line assessments are described below. Approximately every quarter, project staff, community members and other recipients get together to make adjustment to the program implementation plan (DIP). The implementation of the psychosocial support program continues, while monitoring for impact is taking place. These are concurrent activities, and information is sought and

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291

analyzed on a weekly, monthly, and on trimester basis. Below the reader will find a discussion of the major component of a monitoring and evaluation plan: 1. Baseline and Endline Surveys: Assessment of a selected set of indicators before the initiation of project interventions and just prior to the end of those interventions. A baseline describes the situation in a target population before the start-up of a project in that target population. Baseline data are used to set appropriate and achievable objectives and targets for a project, and data collected in monitoring and evaluation systems are compared with these baseline data to determine if a program is meeting its specified targets. The baseline also serves as part of the foundation of the detailed implementation plan. End line gives you the situation in a target population at the end of the project cycle, establish final levels of achievement for many indicators, and provide a quantitative basis for comparison of results from beginning to end of the project. 2. Detailed Implementation Plans (DIP): A proposal summarizes the overall design of a Project. By contrast, a Detailed Implementation Plan (DIP) provides the overall approach and specific plan of action for actually implementing that project. Further, the reality is that between project design, proposal writing, and funding – six months to a year may have elapsed. New project managers may have just been hired to implement the project, and some local counterparts who may have been involved in the original design process may have changed. The Psychosocial Support project team will therefore want to once again check and validate its hypothesis and proposed interventions based on more recently available data. For this reason, the DIP is developed based on primary, quantitative data collected from the project target area (assessments) – usually data obtained from the baseline. As with the overall design of the project, the local partners, community members and other stakeholders develop the DIP in collaboration, often in a workshop setting. The DIP workshop is an opportunity to review the findings of the baseline survey results together with partners, and to develop key sections of the DIP. A good practice is to translate and distribute copies of the DIP (or key parts of the DIP) to all partners, community members and staff members involved in project implementation. The DIP serves as a common road map to guide the program towards achieving its primary goal and objectives.

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3. Periodic Review: Internal assessment of progress and performance of the project over successive quarterly/biannual/annual periods. This generally provides information for project management in resource allocation, and often examines lower levels in the project design, such as inputs, activities, and outputs. These reviews may occur annually. 4. Mid-Term Evaluation or Review: Assessment of project perfor­ mance in the interest of making mid-course corrections. This allows you to measure progress towards achieving impact (usually not the impact itself), as well as review project management and administra­ tion and management. 5. Final Evaluation: Assessment of outcomes and impacts generated by the project as well as its cost-effectiveness and management.

15.4 SUMMARY This chapter presents a brief discussion of monitoring and evaluation as an important component in the development of a psychosocial support program for disaster affected people and communities. Two figures are presented. The first figure details the elements necessary for the development of a psychoso­ cial support project proposal, including all the elements of the project cycle. The second figure presents the continuum of the monitoring and evaluation process. KEYWORDS • • • • • •

community-based participatory research COVID-19 detailed implementation plans introducing psychosocial support methodology resilience based psychosocial assessment

Monitoring and Evaluation of Mental Health and Psychosocial Support

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Index

A Accountability, 115, 233, 253, 275

Accredited Social Health Activist (ASHA), 66 Active

collaboration (program planners), 282

planning, 20, 242

Adaptive capacity, 60, 61, 192, 283, 285

Adolescents, 59, 66, 81, 83, 91, 99, 109,

111, 129, 167, 194, 207, 215, 225, 254,

257

Adverse events (individual-community

psychosocial competence)

effect of, 241 active involvement, 244

activities (psychosocial support

program), 244

assessment, 246

community approach, 243

community participation, 244

components (psychosocial support

program), 243

empowerment, 244

enhancing psychosocial competence

(schools), 250

psychosocial competence, 242

Advocate external partners, 233

Afro-descendant, 86, 212, 221 Alienation, 193, 271

Allopathic medicine, 78, 170

Amazonia, 76, 211 Anganwadi workers, 63, 66

Anti-stigma campaigns, 166

Anxiety disorders, 151

Assessment

methods, 8

process outcome, 249

project performance, 292 Audiovisual

materials, 86

production, 85

Auxiliary Nurse Midwife (ANM), 66

Awareness-raising materials, 210

Aymara, 82, 83, 272

B Bangladesh, 163, 171–175, 178 Bar-dancers, 53

Baseline

data collection, 288

endline surveys, 291

survey, 291

Basic psychosocial support, 214

Bereavement support groups, 234

Bewitchment, 152

Bhopal gas leakage disaster, 48

Bhutan, 169, 171

public radio, 171

Biological weapons, 48

Bio-medical condition, 51

Bio-psycho-social

existence, 51

model, 51

Biosecurity measures, 84

Bleak socio-economic prospects, 30

Blocking-hiding feelings, 219 Bolivarian Republic (Venezuela), 97 Bolivia, 82

government, 84

Bonding capital, 33

Boredom, 267

Breadwinners, 122

Bridging capital, 34

Broad cross-section of members, 126 Buddhism, 164, 171, 176

Buddy system, 246

Build-back-better, 56

C Calisthenics, 189

Cameroon, 139, 141–145 healthcare system, 144

Ministry of Public Health, 144 role (cameroon red cross), 145

298

Cameroonians, 143 Capacity building, 196 activities, 249–251 continuum, 196 civilization, 48 Caravanas migrantes, 98 Cardiovascular disease, 52 Careful listening, 198 Caregiver deaths, 60 vulnerable populations, 141 Caretakers, 120–122, 150, 153 Caribbean Association of Psychologists (CANPA), 218 immigrants, 98 Cat pooling, 25 Catastrophic impact, 9 Central government structures, 87 Chemical biological radiological nuclear (CBRN), 48, 69 Chernobyl nuclear power plant disaster, 48 Child-friendly schools, 250 Children develop paint school murals collages, 255 skits poems songs, 254 school activities, 218 Chile, 110 Chronic diseased condition, 53 illness, 51, 53 psychiatric, 59 Chronological synapse, 209 Churches, 39, 166, 286 Civil society, 8, 56, 60, 98, 219 actors, 56 organization, 60, 67 Civilization, 47 Classroom management, 251 Clinical interventions, 198, 214, 235 mental health staff, 170 program, 133 protocol, 85 services, 222 supervision, 166, 198, 235 Co-develop programs, 20

Index

Colombia, 85 Commemorations, 188 Communication, 6, 7, 19, 25, 57, 58, 65, 76, 83, 89, 110, 111, 130, 143, 145, 154, 189, 196, 210, 211, 218, 221, 250, 268, 270–272, 285 adequacy, 85 Communities, 3–13, 15–21, 23–26, 29–44, 51, 53, 57, 60–69, 76–80, 83–87, 89, 90, 100, 103–106, 110, 113, 115, 116, 119, 120, 122–134, 140–155, 163, 165, 166, 168–172, 175, 185–200, 206–209, 212, 214–218, 222–226, 228, 232–235, 239, 241–252, 254–260, 264, 267–273, 275–287, 289–292 activities, 5, 10, 17, 30, 36, 90, 115, 188, 194, 200, 214, 242, 258, 271, 276, 286 approaches, 5, 31, 89, 154, 243 assessment, 29, 33, 34, 196, 214, 280, 286, 287 objectives, 34 assistance, 9, 126 based participatory research (CBPR), 277, 278, 292 psychosocial support (CBPSS), 57, 60–63, 155, 170, 175 capacities, 240 care drivers, 31 centers, 39, 40, 281 clinics, 37, 78, 128, 170 cohesion resilience projects, 258 committee, 90, 194 compliance, 149 consultations, 77 cooking, 187 disaster mental health preparation, 250 distress, 189 driven agenda, 194 development, 67 support, 67 education, 168 empowerment, 212 engagement (CE), 3, 5, 6, 15, 16, 19–21, 23–26, 29–32, 44, 60, 61, 76, 79, 89, 91, 132, 140, 154, 168, 171, 172, 174, 175, 193, 218, 225, 244 accountability, 225 activities, 239

Index

entry, 193, 286

experiences, 32

facilitator, 36, 194, 195, 250, 257–259 fracturing, 122 generated knowledge creation, 41 healing dialog (CHDs), 128, 129, 131, 134 health, 131, 258

assistants, 127

officers (CHOs), 131, 134 services, 19

volunteers, 66, 147

workers (CHWs), 11, 13, 78, 131, 133, 134, 142, 149, 150, 153, 169, 170 interactions, 122 interventions, 44, 61, 65, 89, 212, 223, 245, 247, 256 intimacy, 186 leadership, 241 led planning, 25 level health workers, 163 labor projects, 87 mapping, 23, 24, 35, 37–39, 41, 90, 194, 195

meetings, 24, 171

members, 8, 17, 19, 23–25, 32, 35, 36, 38, 40, 42, 43, 113, 122, 128, 131, 147, 153, 187, 194, 196, 197, 214, 241, 243, 244, 246–249, 256, 258, 259, 269, 279, 281, 285, 286, 289–291 mental health, 6, 11, 12, 131, 142, 150, 151, 165, 216 care package, 165 centers, 84 clinics, 6 services, 7, 149 system, 127 mobilization, 9, 67, 90, 163, 269, 271 mobilizers, 31, 214 monitoring-evaluation, 259 networks, 19, 79, 168, 242, 243, 248, 258, 273, 285 organizations, 24, 32, 257 participation, 37, 40, 85, 111, 115, 171, 214, 218, 234, 239, 243, 244, 249 accountability (CPA), 115, 214, 218, 225, 226 mapping, 37 perceptions, 192

299

planning mechanism, 258 process, 43 political process, 278 psychiatric inpatient units, 151 psychosocial competence, 239, 242, 246, 256 strategies, 6 support, 29, 42, 43, 69, 128, 155, 170, 172, 189, 193, 249, 257, 259, 268 workers, 166, 256 quarantine facilities, 67 radio, 25, 63, 89, 145 rehabilitation efforts, 129 re-invention, 185

resilience parameters, 15

resilience, 15, 16, 18–20, 29, 32, 35, 87, 185, 191, 194

resources destruction, 30

responses, 89, 140, 189

skits, 254, 257

social protection mechanisms, 80

strategies, 62

supervision, 87

support, 21, 79, 128, 175

tensions, 186

treatment centers (CTC), 176, 177 volunteer networks, 147

wide

activity, 129

friendships, 198 social boundaries, 41 witch doctors, 152 working together, 239 Comorbid chronic medical condition, 52 Comparative ecosystem research, 277, 280 Complementary institutional offers, 116 Complex humanitarian events, 4 Conceptualization, 124 Conducting community assessment, 33 orderly interventions, 187 Confidentiality, 145 Confinement, 83, 133, 208 quarantines, 219 Conflict related displacement, 152 resolution, 129 Construction sector, 80

300

Consultation, 79 Consumerism, 48 Consumption, 47, 57, 65 addiction (psychoactive substance), 57 Contact tracing, 12, 168, 171, 193 Containment adoption, 87 strategies, 9, 189 Continuous supportive communication, 66 Convention on Rights of, Child, 54

Persons with Disabilities, 54

Cooperative organization, 19 Coronavirus disease 2019 (COVID 19), 3–6, 8–13, 15–21, 23–26, 29–37, 43–45, 47, 49–53, 55, 56, 58–60, 62–64, 66–68, 75–90, 92, 95, 96, 99, 104, 107–112, 115, 117, 119–124, 128, 129, 132–134, 139–151, 153–155, 163, 164, 166–178, 185–191, 193–196, 198–200, 205–212, 214–221, 225, 228–236, 239–241, 243, 245, 247, 267–273, 275, 280, 282, 292 associated deaths, 60 infection, 51, 59, 86 mapping, 88

pandemic, 3, 5, 8, 11, 12, 30, 31, 43, 53,

55, 58–60, 63, 75, 76, 79, 83, 88, 95, 96, 99, 107, 109, 112, 117, 120, 123, 128, 129, 133, 142, 143, 145–147, 149, 150, 154, 166–170, 175, 177, 185, 186, 190, 194, 200, 205, 206, 212, 219, 221,228–230, 232, 268, 273 patients, 176, 177

related

experiences, 244

lockdown, 173

misinformation spreading, 174 survivors, 193 Costa Rica, 85 Counseling, 4, 5, 127, 148, 171, 177, 240, 285 medication, 127 service, 127, 169 Counselors, 214 Crisis intervention professional, 250 technicians, 196 Cross-cultural psychologists, 248

Cultural adherence, 128 anthropologists, 248 appropriate communication strategies, 76 medical services, 76, 77 capital, 24 diversity, 169 gender appropriateness, 87 identity, 34, 105, 191 interaction, 127, 190, 191 milieu, 190 nuances, 85, 277 specific indicators, 191 stigma, 117

strengths, 78

Curfews, 17, 141, 166, 270

Index

D Daily family routine, 65 rations, 67 survival requirements, 64 Data collection methods, 37 integrity, 68 mapping, 44 Deforestation, 76 Dehumanization, 53 Demographic data, 246 variables, 57 Department Health Human Services, 281 Health Service, 83 Depression, 4, 7, 10, 18, 30, 50, 52, 58, 59, 66, 83, 121–123, 141, 144–146, 153, 170, 173, 174, 178, 186, 189, 198, 215, 218, 232, 233, 235, 268 disorders, 151 Deprivation, 49 Design intervention, 193 plans, 252 place outcomes, 16 Detailed implementation plan (DIP), 290–292 Detention facilities, 150

Index

Developing

community-owned, 257

human resources, 258

industries, 48

international red cross, 8

opportunities, 61

team, 210

Diabetes, 34, 52

Diagnostic accuracy, 148

Digital

literacy, 59

platforms, 114 recordings, 42

Dignified burials, 154 Direct cast benefit, 68 Disappearance, 96, 102

tourism, 80

Disaster, 47, 55, 57, 275

affected areas, 250, 255

people, 36, 44, 275, 280, 281, 290

conflict affected communities, 277, 280 related

experiences, 254

stress, 250, 254, 260

response model, 216

survivors, 243

Discrimination, 12, 54, 56, 76, 77, 80, 102,

103, 107, 109, 110, 115, 122, 123, 130,

133, 141, 149, 167, 195

medical testing, 77

Disease surveillance, 125

Dispensaries, 170

Disruption

health facilities, 12 social

celebrations, 124

networks, 30

Dissemination

COVID-19-related basic knowledge, 174 information, 90, 148, 169, 176 campaigns, 148

protective equipment, 149

transparent, 33, 34

Distancing, 3, 16–19, 23–25, 30, 31, 33, 34,

36, 69, 75, 76, 78, 113, 120, 123, 124,

133, 154, 166, 171, 174, 177, 200, 206,

219, 232, 267

301

District Mental Health Program (DMHP), 65, 69

Diverse community groups, 34, 194

Documentation, 163

Domestic

disputes, 58

violence, 16, 52, 56, 110, 133, 218, 222

Dominican republic, 97, 98, 216, 272

Droughts, 241

Drug trafficking, 96, 102

E Early recovery, 216, 271

challenges, 219

adaptation (training resources), 223

breaking MHPSS paradigms, 222 change labels, 220

establishing permanent community

MHPSS programs, 223 keep space in response, 220

no one left behind, 221 provide NSS of americas (access to

material), 221

psychosocial support systems (PSS),

219

reinventing oneself (meet population

MHPSS), 219 supporting identified NSS, 217 Earthquakes, 241, 286

Ebola, 119–129, 140, 142, 188 epidemic, 119, 123, 124, 127, 128

virus outbreak, 126

Economic

activities, 12, 58

development projects, 90

exploitation, 81

impediments, 190

insecurity, 271

investment, 19

resources, 76

social life, 168 Ecuador, 86, 110

Educational

dramas, 150

materials, 170

performance, 81 support, 128

302

Effective communications, 171

data management, 68

integrated interventions, 60

psychosocial support, 68

public mental health measures, 189

El salvador, 111

Electronic communications, 50

Emergencies, 4, 5, 7, 55, 231, 241, 251, 270

care systems erosion, 12

committees, 85

management committees, 168

operation center (EOC), 168, 178

powers, 56

Emigration, 97, 98

Emotional

crisis, 123, 245

deterioration, 120

discomfort, 108 distress, 66, 130, 249, 255

exhaustion, 146

impact-stress, 235

intelligence, 216

management, 114

recovery, 214, 235, 269

sense (culture), 273

stability, 177

suffering, 205, 206 support, 114, 116, 117, 147, 177, 224

turmoil, 4

ventilation, 100, 114, 115, 117

well-being, 17, 37, 48, 84, 110, 114, 190

Empathic

bond, 106

skills communication, 117

Empowering, 52, 61, 218, 223, 234, 244, 248

families, 65 Encouraging community volunteers, 272

Enhanced community awareness activities,

172

Environmental

quality, 32

sustainability, 56

Epidemiological

data, 217

vigilance, 84

Epilepsy, 7, 127, 129

Equity-informed responses, 140

Index

Essential government assistance, 174

Ethnicity, 53, 80, 125

Ethnographic, 248

field studies, 248 study, 248

Evacuation, 253

routes, 252

Evaluation continuum, 290

Evidence resources, 168

Exacerbated mental health, 4

Extended lockdowns, 141

Extensive

public health awareness campaign, 174

structural deficiencies, 231 External

advocacy, 212

interventions, 192, 282

spiritual-emotional forces, 152 stakeholders, 37, 39, 187, 278, 288

Extreme poverty, 47, 50, 76, 172

F Facebook live, 25

Face-to-face health care, 83

interventions, 219

Facilitating

community activities, 196

psychosocial attributes, 242

skills, 196

Facilitators, 4, 6, 9, 12, 42, 187, 194, 196,

257, 259

Faith

community organizations, 133 healing activities, 132

institutions, 130

leaders, 31, 172, 196

organizations, 39, 79, 128 Family

cohesion, 128

community life, 51 connectedness, 200

disharmony, 152

rituals, 65

support structures, 11

violence, 58

Fear

infection-dying, 267

Index

provoking consequences, 17

Financial

instability, 143, 155

losses, 17, 195

resources, 78, 207, 272

Fire prevention, 253

First-order intervention, 9, 245, 260, 270

Focus group discussions, 248

Food

insecurity, 78, 80, 174

rations, 82

Formal-informal employment, 31 Freedom of expression, 56 Frontline professionals, 195 responders, 177

service providers, 167

staff, 268 workers, 127, 153

Frustration, 122, 123, 233, 267

Functional definition community engagement (CE), 24

challenges during COVID-19, 24 community engagement (CE), 25

Funding agencies, 276

G Gaps in mental health (mhGAP), 83, 165,

216, 234

Gathering materials, 212

Gender

based violence (GBV), 30, 78, 81, 91,

112, 117

discrimination, 56

violence victims, 222

Genetic predisposition, 51

Geographic, 25, 188

delimitations, 35

locations, 31

scattered population, 170

specificities, 80 Geriatric population, 52

Global

economy, 17, 21

infectious disease outbreaks, 188 mental health principles, 127

migrant groups, 267

organizations, 84

Government

agencies, 85, 86

bodies, 39

funds, 175 home care model, 147

regulations, 270

restrictions, 87

systems, 242

Grief management, 105 Gross national happiness, 169

Guarantee

basic needs, 198, 214

compliance, 87

Guatemala, 86

303

H Habitation patterns, 79 Handicraft activities, 286 Harmonized legal administrative frame­ works, 82

Health activities, 130, 164, 258

advisories, 171

agencies, 34

authorities, 33, 34, 151, 153, 154, 207,

208, 219

care

facilities, 52 practices, 154

professionals, 51, 167, 173 providers, 120, 144, 166

services, 80

supplies, 185

system, 68, 144

workers, 7, 63, 91, 121, 122, 131, 133,

141, 144, 147, 148, 151, 153, 168,

195, 230, 268

community promoter, 78

cordons, 87

emergency systems, 241

facility managers, 153 open communication, 65

policies, 119, 164

post personnel, 277

professionals, 8, 111, 125, 185 promoters, 9

protective behaviors, 189, 196

psychosocial environment, 251

304

related issues, 53, 154, 170 risk behavior, 57, 188 school environments, 251 sustaining resources, 190, 192 systems community-wide interventions, 10 High-stress levels, 209 Hinduism, 164, 171 Historical-ecological data, 193 HIV positive status, 53 Holistic care provisions, 64 Hope, 101 Hospitalization, 63 Household characteristics, 195

level violence, 167

responsibilities, 65

Human aggression, 54

environment systems, 283

made disasters, 55

rights, 11, 49, 53–57, 60, 76, 78, 100, 132, 172, 194

violations, 49

social capitals, 194

trafficking, 96 Humanitarian agencies, 4, 16, 21, 39, 89, 90, 170, 187, 259 assistance, 37, 99, 108, 276 community, 11 effort, 36 emergencies, 4

intervention, 83, 99

needs, 98, 108

migrants, 98

observatory, 108

organizations, 20, 89, 91, 128, 206, 241 personnel, 114 response, 6, 7, 30, 36, 209, 210, 234, 277 settings, 5, 6, 195 tasks, 99 workers, 9, 17, 268 Humanity, 47 Human oriented approach, 62

rights violations, 96

Hurricanes, 241

Hygiene measures, 171 Hypertension, 52, 53

Index

I Identity, 101, 264 Illuminating inequalities, 49 Implementation, 4, 6, 8, 10, 12, 49, 60, 87, 105, 109, 119, 126, 140, 142, 144, 146, 164–166, 168, 174, 212, 213, 232, 234, 241, 242, 244, 251, 253, 259, 264, 275, 281, 290–292 Inaccurate crisis communication, 186, 200 Inadequate mental health workforce, 144 Inclusion activities, 91 Income-generating activities, 120, 124 Indigenous clinical staff, 78 communities, 80, 81, 84, 86–88, 90, 91,

220, 222, 233

cultural radio network, 86

group, 78

members, 83

land, 82

languages, 85, 86

leaders, 37, 277

lifestyles, 78 medicine, 78, 170 organizations, 88 people, 75–87, 89, 91, 217, 221, 222 ethnoterritories, 82 population, 76, 77, 81–85, 87, 89, 91, 123 traditional knowledge, 68 women, 77, 79, 80, 87 Individual indicators, 242 interventions, 100 psychosocial competence, 242 Industry-approved guiding principles, 243 Inefficient administrative strategies, 49 Infected agent, 189

community members, 154

outbreaks, 189

prevention, 151, 196

Infodemic, 171, 208 Informal economic sectors, 167

gossip networks, 40

Index

health, 245, 257, 258

activities, 258

care, 130

schooling, 257, 273

settlements, 147, 168

Informant interviews, 25, 193, 248, 249 Information education communication (IEC), 168, 178

technology (IT), 148, 198, 199, 272, 273 Infrastructure, 25, 32, 51, 142, 148, 166,

186

Inhabitants, 38, 82, 151, 163, 171, 176

Inherent complexities, 192, 283

Inpatient psychiatric beds, 148, 154

Insofar, 197 Insomnia, 173, 174, 188

symptoms, 173

Instagram, 25, 199

Instant messaging services, 224

Instill optimism, 197

Institute of Traditional Medicine Services

(ITMS), 170, 178 Institutionalization, 127 Integrated

child development scheme, 66

public health care, 63

socially oriented counseling method, 4

Inter-Agency Standing Committee (IASC),

8, 10, 34–36, 61, 89, 90, 106, 150, 189,

197, 240, 241, 243, 276, 277

Inter-culturality, 100, 112

Inter-institutional work, 106

Intermittent medicine availability, 166

Internal

agricultural products, 87

assessment (progress), 292

coping mechanisms, 244

International

agencies, 82

bodies, 47

Committee of Red Cross (ICRC), 7, 8, 169, 225

cooperation, 56

Covenant on Civil Political Rights, 54

Crisis Group (ICG), 176

development co-operation, 54

Federation, 7, 8, 61, 90, 95, 96, 99, 205,

210, 215, 226, 228, 269

305

Federation of Red Cross (IFRC), 7, 8, 10, 12, 24, 90, 95, 96, 98–100, 106, 111, 119, 145–147, 150, 151, 171, 188, 205–210, 212, 213, 215–217, 222, 224–226, 228–230, 233–235, 241, 244, 250, 269 Psychosocial Support policies, 215

guidance, 223, 273

health, 33

migrants, 97

migration figures, 97 Organization for Migration (IOM), 10,

30, 96–98, 145, 167, 277 organizations, 4 peace security, 54

relief organization, 278 Internet connection, 59, 208

Interpersonal

conflicts, 152 interactions, 271

relationships, 19

social skill training, 240

style, 187

therapy, 7

Intervention plans, 253

Intra-regional

immigrants, 97

migration, 96

routes, 97

Intrinsic causes (mental illness), 152

Intrusive technique, 214, 235

Invasion rhetoric, 280

Isolation-poverty, 87

J Job opportunities, 58, 63, 67

K Kenya Mental Health Policy, 146, 147 Red Cross, 146, 147

L Labor

exploitation, 109

instability, 108

Lack

access (health services), 104

information guidance, 104

306

Land use settlement patterns, 195 Language barriers, 107 proficiency, 128 Leisure socializing activities, 240 Leprosy, 53 Liberia, 123, 126 Life style diversification, 15 threatening situations, 104 Limited safety equipment, 121 Linguistic groups, 30 rights, 87 Linking capital, 34 Live-online engagement, 59 Local authorities, 90, 253 maintained parks-green spaces, 39

communities, 154

external agencies, 281

health

care systems, 175 workers, 37

languages, 11, 85, 91, 150

participation, 24, 41, 85

Red Cross-National Society, 239

Lockdown-related issues, 174 Logic model (psychosocial support program), 286 components (monitoring evaluation plan), 289 Long-term interventions, 216

M Malnutrition, 49, 76, 102, 175 Management anguish, 110 programs, 276 Manmade disaster, 47 Manual scavengers, 53 Map, 40–42, 44, 195, 244, 248, 252, 287 activity, 41, 42, 252

interpretation, 40

making

process, 41

sessions, 42

people perceptions experiences, 40

Index

Mapuche communities, 88 spiritual practices, 88 Marginalization, 52, 58, 80, 126 communities, 19, 53 groups (handicapped individuals), 257 populations, 140, 146, 199 vulnerable population, 55 Marketing, 65 Material development, 169, 250 Maternal mental health, 7, 198 Measurable data, 246 Medical approaches, 78

attention, 53, 57

care, 87, 102, 129, 167

treatment counseling, 129

colleagues, 268

emergency, 48

facilities, 51, 151 guidance, 109

interventions, 152

needs, 75, 246

personnel supplies, 12

staff, 121 Mental disorders, 129, 133, 170, 174 distress, 167 fatigue, 208 health, 3–5, 7–13, 15, 17, 19, 20, 23, 29–31, 33, 44, 47, 48, 50, 53, 54, 57–60, 63–65, 69, 75, 77–79, 83–85, 89–91, 95, 96, 99, 100, 105, 106, 108, 110, 111, 115–117, 119, 120, 122–134, 139–155, 161, 163–173, 175, 177, 178, 185, 189, 190, 193, 195–197, 200, 205, 206, 210, 212, 215, 216, 218, 219, 222–226, 228–230, 232–234, 236, 239–241, 248, 260, 261, 267, 269, 270, 273, 275, 285

activities coordination, 132

after migration-settlement or return, 103 atlas, 148 before migration, 102 campaigns, 170 capabilities, 140 care, 7, 63, 65, 89, 99, 116, 124, 140, 149, 151, 153, 154, 167, 170, 173, 197, 224, 230 coalition, 132

Index

communication network, 210 community programs, 224 conditions, 12, 91, 133, 146, 166 counseling, 129, 165 deterioration, 111 disorders, 152, 173, 196 disturbances, 59 during migration, 102 facilities, 124, 147, 150, 215 hospital, 128, 164 illness, 50 impact on stages (migration process), 101 incidence, 78 interventions, 5, 6, 8, 96, 119, 129, 212, 218–220, 222, 225, 233–235 issues, 4, 50, 53, 59, 133

legislation, 164

medications, 144

MHPSS structuring, 100 migration (americas region), 99 needs, 17, 143, 146, 168, 175, 215, 219, 232 nurses, 130–132 pandemic, 48 pathologies, 232 policy, 131, 165 prevention, 175 problems, 50, 59, 84, 91, 122, 123, 130, 131, 144, 215, 222, 232 program, 65, 79, 83, 129, 170 programming, 152, 173 providers, 151 psychosocial, 3–5, 7, 8, 10, 13, 17, 19, 20, 44, 79, 83–85, 89–91, 96, 99, 105, 116, 117, 119, 120, 122, 123, 125, 127–131, 133, 134, 139–155, 163–165, 167, 170, 172, 175, 177, 178, 200, 205, 206, 210, 212, 218, 226, 229, 230, 233, 240, 250, 260, 269, 273, 275 psychosocial guidance (Ministry of Health), 152 psychosocial interventions, 104 psychosocial problems, 127 psychosocial support (MHPSS), 1, 3–8, 10–13, 15, 23, 29, 31, 35, 36, 44, 47, 75, 79, 83–85, 89–91, 95, 96, 99–105, 111, 116, 117, 119, 122,

307

123, 125–129, 131–133, 139–143, 145–155, 161, 163–165, 169, 172, 175, 177, 178, 185, 188, 195–197, 199, 200, 205, 206, 210–212, 215–230, 233–236, 238–241, 243, 250, 260, 261, 267, 269, 270, 272, 273, 275–277 psychosocial support program, 84, 134, 250 regional team, 215, 221 related complications, 148, 154 related expenses, 124 related programs, 6 section, 164 sequelae, 269 services, 7, 11, 12, 63, 89, 129, 130, 153, 164, 166, 169, 170, 173, 177, 229 Steering Committee, 132 system, 129, 146, 151, 164 systems reforms, 146 technology innovation, 69 treatment, 4 volunteers intervene, 110 World Atlas, 150 illness, 32, 50, 125, 127, 129, 130, 139, 140, 148, 152, 153, 170, 175 extrinsic causes, 152 immunity, 255 outlook, 19 pathologies, 221, 222 psychosocial support teams, 149 Methodological, 35, 147, 292 barriers, 280 tools, 282 Mexico, 86 Micro-planning, 258, 260 activities, 258 Mid-course corrections, 292 Mid-term evaluation, 292 Mid-to-late recovery, 273 Midwives, 9, 37, 78, 90, 142, 149, 155, 170 Migrant population, 67, 95, 96, 99, 100, 104, 105, 107–110, 112, 114–116 Migration, 81, 95–105, 107–109, 111, 116, 117, 150, 210, 284

cycle, 98

flow, 98 movement, 97

308

Ministries of Health, 66, 83, 85, 86, 126,

131, 132, 139, 145–147, 149, 153, 154,

164, 165, 168, 170, 173, 178

Family Welfare, 66, 173 Population (MoHP), 164, 178 Welfare, 143 Mobile

apps, 111

checkpoints, 113

mental health interventions, 148

phone technology, 169

Mobility, 25, 80, 107, 110, 207, 208, 224, 232

Monasteries, 166

Mortality rates, 32, 122

Mosques, 39, 166

Multi-generational, 172

Multi-purpose-single-use sites, 40

Multi-stake holders engagement (care

recovery), 67

Muslim community, 281

Myanmar, 176

mental health

after 2021 political instability, 178 psychosocial support (MHPSS), 177 ministry of health (myanmar), 176 Rohingya population (myanmar), 176

Mystical traditions, 140

N

Index

Natural

community markers, 40

disasters, 4, 12, 119, 129, 150

Negative

connotation, 208

emotions, 133

mental health, 58, 129

consequences, 58

psychological outcomes, 153

Neighborhood, 12, 16, 19, 32, 83, 128, 130,

188, 199, 232, 268, 270

faith relationships, 198 leaders, 9

Nepal Red Cross Society, 178

Networking, 60

Neurological, 7, 127, 151

condition, 7

services, 198

Nicaraguans, 97

Non-clinical intervention, 9

Non-communicable disease, 164

Non-government organizations (NGOs), 67,

125, 165, 170, 172, 178, 254

sponsored health care providers, 173

Non-indigenous ancestry, 176

Non-medical staff, 268 Non-pathological distress, 30

Non-professional personnel, 260 Non-psychiatric patients, 170

Non-specialized health workers, 91 Non-verbal

behavior, 187

information, 36 tool, 247, 248

Normalcy, 9, 60, 153, 270

semblance, 4, 143

Normality, 113, 197

Normalization, 234 Nostalgia, 103

disorientation, 193

Nuclear disasters, 48

National

government, 34, 154

headquarters, 249

Health Social Welfare Policy, 127 Institute of Indigenous People (INPI), 86, 92

Mental Health Treatment, 173 level examinations, 166

mental health

conferences, 132 plan, 155

policy, 164, 165

response team, 171

O preparedness, 171

societies (NSs), 7, 8, 30, 107, 109, 145, 198, Obsessive

199, 205, 209–212, 214–219, 221–226, behaviors, 18

229–235, 243, 244, 249, 250, 272 compulsive disorder, 232

clinics, 198

Occupational activities, 240

territories, 82

Official health system, 86

Index

309

lockdown measures, 81

mitigation efforts, 77 social restrictions, 18

Panic attacks, 153

Paper pencil tools, 247

Paranoia, 18

Parental

counselling, 66

ill-health, 66

stress impacts, 66

support structures, 125

Participant observation, 277

activities, 278

Participation, 56, 188, 244, 251

action research, 277, 281

assessment, 249, 256

mechanism, 249

CE interventions, 168

community mapping, 29, 40

mapping, 38, 39, 41–44 methodologies, 195, 281

planning, 195

research initiatives, 280

solution-searching process, 249

volunteer, 277

P Partner-National Red Cross Societies, 250

Pan American Health Organization (PAHO), Patient resources, 16

81, 83, 85, 86, 88, 92, 198, 215, 216, 218, Peace

221, 230

building, 129

Panamanians, 97

making, 129

Pandemic, 3, 4, 9–12, 16–19, 21, 24–26,

Peer-to-peer

30, 32–34, 37, 48–53, 55–60, 62, 64, 65,

counseling, 154

67, 68, 75–84, 88, 89, 108–110, 113, 114,

support, 132, 169

120, 123, 124, 139–141, 143, 145–149,

work, 212

151, 153, 154, 164, 167, 168, 171, 173,

People-centered services, 29

174, 176, 178, 185, 186, 188, 189, 200,

Personal relationships, 186

205–209, 211, 212, 216–225, 228–230,

Personality traits, 51

232, 241, 242, 267, 270, 271, 273, 280

Person

communities-value (training volunteers)

centered, 89

culture shift, 11 recovery, 31

developing MHPSS (communities

seeking behaviors, 130

post-COVID-19), 11 to-person approach, 196, 198

impact of COVID-19 (psychosocial

Peru, 87, 109

wellbeing), 9

Pharmaceutical research unit, 170

impact, 9

Pharmacologic solutions, 152

reimagining MHPSS, 10 Phobia, 174

response (MHPSS needs), 10 Physical

fatigue, 208, 217 aggression, 57

impaired sleep quality, 174

Omissions, 38

One-off assessment, 283 Online

engagement, 59

services, 109

survey-type instrument, 211

Operational

committees, 253

resilience, 190

trainings, 250

Organic solutions, 25

Organization community resources, 84

development, 215, 235

Organize community, 25, 26

expressive creative activities (schools),

254

Orientation meetings, 25

Orphanhood, 60

Overt negative behaviors, 287

Overwhelming

patient numbers, 121

personal responsibility, 132

310

distancing measures, 168

health threats, 11

illnesses, 59

symptoms (stress), 273

Plan

programs, 260

reconstruction, 44

related activities, 255

resilience projects, 259

Place-community perceptions, 40

Political

administrative boundaries, 81

commitments, 49

socioeconomic context, 164

strength, 61

Population

density, 32

movement, 107

psychosocial mental well-being, 233

wide distress, 9

Post

conflict community reconciliation activi­ ties, 128

COVID 19 recovery process, 77

community, 37

disaster

needs, 278, 286

settings, 4

graduate training programs, 165

traumatic stress, 58, 121

disorder, 58, 121, 123, 174, 178, 189

Potential

human capital, 24

intervention, 90, 199

approaches, 152

Poverty, 49, 50, 140

alleviation programs, 50

Practical

needs, 246

recruitment, 42

Pre-disaster needs, 278, 286

Pre-existing

community mobilization tools, 9 health conditions, 32, 78

social problems, 30

Preparedness, 19, 67, 166, 188, 250, 251,

258, 270

Index

pre-service teachers, 255

supporting in-service teachers, 256

Pre-service teachers, 255

Preventive isolation, 85

Primary health care center, 66

Proactive community-wide services, 11

Problem

focused interaction, 187 management plus, 10

Process-oriented

engagement, 61

strategy, 193, 195

Professional burn-out, 114

treatment, 243

Program

community health, 223

development, 6, 43

Pro-health social norm, 34

Project management, 292

Protection

gender, 91

inclusion (PGI), 99, 112, 115, 117, 218,

222, 225

measures, 109, 145

Protocols establishment, 87

Provincial government hospitals, 164

Psychiatric

care, 83, 151

disorders, 4, 174

hospitals, 148

institution, 170

nurse, 198

outpatient facilities, 173 patients, 69, 170

training, 165

units transformation, 151 Psychoeducation, 5, 6, 10, 11, 36, 83, 105,

106, 110, 111, 114, 129, 132, 145, 169,

177, 212, 234, 235

activities, 240

Psychological, 3–7, 10, 13, 16, 17, 19, 30,

31, 33, 34, 36, 42, 44, 51–53, 57–60, 65,

77, 79, 81, 83, 100, 102, 104, 109–111,

113, 117, 119–121, 123–126, 128, 133,

141, 142, 144–147, 149, 150, 152, 153,

155, 167, 169, 176, 177, 187, 189–191,

193, 195–200, 209, 212, 214, 215, 222,

Index

225, 226, 230–233, 235, 240–243, 245, 247, 250, 256, 258, 268, 270, 272, 273, 277, 280, 288 abuse, 52 behaviors, 247 competence, 36, 242 connection, 187, 200 consultation, 100 crises, 273 cultural factors, 146 wellbeing, 126 deterioration, 150 disruption, 241 distress, 5, 53, 58, 128, 147, 177, 232 effects, 109, 120, 121, 268 factors, 51, 79 fallouts, 123 first aid (PFA), 5–13, 30, 35, 100, 104, 105, 111, 115, 117, 124, 125, 128–130, 141, 142, 145, 147, 149, 151, 153–155, 169, 171, 177, 187, 196–200, 212, 214, 215, 226, 233, 235, 245, 250, 252, 253, 255, 256, 260, 270, 272, 273, 288 training, 130, 270 impacts, 17, 31, 193 individuals, 144 interactions, 33 interventions, 7, 31, 33, 104, 197, 198, 233, 235 issues, 51, 58, 59, 111 problems, 167, 177, 222, 225 rebuilding (communities), 273 resilience, 17 responses, 144, 189 stress, 17, 193 support, 214, 235 program, 42, 44, 243 well-being, 169 concerns, 167 Psychosocial, 3–6, 8, 9, 11, 12, 15, 16, 18–20, 23, 29–31, 33–44, 47–49, 51, 54, 57, 58, 60–63, 66–69, 75, 77–79, 82, 84, 89–91, 95, 96, 99–117, 119–122, 124–134, 139–147, 149–153, 155, 161, 163, 165–167, 169–173, 175, 177, 178, 185–187, 189, 190, 192–200, 205, 206, 209, 210, 212–216, 218, 219, 221–223,

311

225, 226, 228–235, 239–253, 255–261, 263, 267, 268, 270–273, 275–284, 286–292 activities, 4, 8, 37, 38, 114, 120, 212, 215, 234, 235 related material, 255 approach model, 116 aspects, 84, 100, 177 assessment, 192, 277, 282, 284 assistance, 104, 116, 244 attributes, 242 boundaries, 82 burdens, 268 care, 106, 109, 117, 165 community, 38, 194 competence, 239, 242, 246, 247, 249, 251, 252, 255, 257 elements, 248 scale, 247 concerns, 78 condition, 177 consequences, 18, 121, 122, 141, 142 counseling, 129 counselors, 133, 166 crisis, 77, 251, 255 distress, 122, 131, 167, 240, 248, 249 health (individuals communities), 120, 124, 134 impact, 31, 102, 120, 200, 268 interactions, 17 interventions, 6, 16, 33, 60, 82, 170, 214, 235, 268 issues, 4, 106, 128, 130, 141, 145, 147, 167, 232, 279 needs, 5, 7, 20, 35, 89, 90, 96, 103, 105–107, 115, 116, 130, 143, 150, 169, 178, 209, 221, 251, 260, 268, 273, 278, 288 outcomes, 120, 123, 128, 129 pressures, 18 problems, 131, 133, 219, 249 program, 195, 245, 258, 260 programming, 152 projects, 20, 278 public awareness campaigns, 127 recovery, 20, 48 relief, 249 resources, 125, 129

312

response, 17, 95, 145

stability, 209

strategies, 268, 273

support (PSS) , 4, 5, 8, 9, 11, 12, 29–31, 36–38, 41, 42, 44, 49, 58, 60–63, 65–69, 78, 84, 89, 91, 99, 100, 104, 106, 108–113, 115–117, 119, 125, 127, 129, 131–133, 139, 142–144, 146, 147, 149–153, 170–173, 177, 186, 187, 193–200, 209, 210, 212–219, 223–226, 229–231, 233–235, 238–241, 243, 248, 250, 251, 257–260, 267, 268, 270–273, 276–279, 281, 284, 286–290, 292 activities, 132, 152, 153, 200, 241, 257, 278, 286

care, 116

center, 215, 216

community level, 66

for migrants, 100 gathering initial information, 36, 276 guidelines, 143 interventions, 83, 149, 172, 222 mental health services, 54 pillar, 128 program (PSP), 36, 42, 78, 84, 119, 151, 193, 230, 240, 241, 243, 244, 247, 249–251, 258–260, 276, 286–290, 292 proponents, 186

services, 108

systems, 229

to ease stress (parenting), 66

symptoms, 177

tolerance, 34

tool, 16, 110

kits, 106 volunteers, 9, 11 well-being, 5, 9, 19, 48, 61, 62, 79, 100, 104, 116, 117, 128–130, 140, 144, 147, 152, 196, 229, 230, 232, 233, 241, 242, 250, 252, 255, 256, 286, 289, 290 worker, 151, 153, 240 training programs, 129 Psychosomatic issues, 58 Psychotherapy, 177 Public anxiety, 166

distribution system, 68

education, 148, 189

entertainment, 120

health

burden, 151

challenge, 267

education, 75

emergencies, 10

information, 33, 34 measures, 144

messages, 168

policy compliance, 33, 34

services, 130

system, 173

information campaigns, 12

inaccessibility, 52

mask-wearing, 34

Pyramid interventions, 188 psychosocial intervention, 213

Index

Q Qualitative assessments, 246 Quantitative assessment, 246, 249

data, 291

methods, 246

Quarantine, 10, 16, 18, 23–25, 30, 31, 33, 63, 64, 67, 75, 83, 110, 133, 141, 142, 144, 148, 150, 151, 153, 166, 174, 177, 185, 189, 193, 206, 207, 229, 232, 267, 268, 270–272 Quechua, 83, 272

R Radioactive substances, 48 Radiological, 48, 69 Ragpickers, 53 Real-time integration, 145 Recording analysis, 42 Recovery-oriented, 89 Recreation, 57, 186, 257 activities, 4, 113, 125 Recruitment psychologists, 166 staff, 154

Index

Red crescent, 4, 7, 8, 12, 90, 95, 228, 229, 249, 260, 269 community, 4 Cross, 3, 4, 7–9, 11, 12, 23, 24, 30, 53, 61, 95, 96, 98–100, 106, 108, 110, 111, 113–115, 120, 139, 142, 145–147, 154, 155, 169, 178, 185, 196, 199, 209, 210, 222, 225, 228, 229, 238, 240, 249–251, 253–255, 258–260, 269, 270, 286 Red Crescent (RCRC), 7, 12, 24, 26, 30, 44, 96, 98, 106, 210, 211, 225, 228, 229, 249, 270 crossers, 79 Redundancy, 18, 285 Regional clusters, 212, 215 documents, 100 Rehabilitation, 8, 49, 129, 170, 215, 250, 278 activities, 240 services detention centers, 8 Relevant evidence interventions, 212 Religious activities, 120, 166 beliefs, 17, 140, 243 ceremonies, 187 cultural differences, 107 Renovation, 252 Reproductive health, 56, 77, 79 rights, 56 Rescue first aid, 253 Research assistants, 280 Resilience, 17, 32, 62, 189, 191, 192, 282, 290 across cultures, 191 approach, 192, 277, 282, 283 psychosocial assessment, 192, 282 based psychosocial assessment (RBPSA), 192, 283, 284, 292 components (development), 191 ecological perspective, 189 enhancing project, 255 markers, 290 production, 190 projects (school), 255 research, 191 Resource-limited communities, 6

313

Respiratory etiquette, 168 symptoms, 207 Risk communication, 86, 154, 189, 193, 196 factors for migrants, 103 Rituals, 272 Road connectivity, 50 Robust reference system, 222 Rohingya refugees localization, 172 Rumination, 69

S Safe school program, 253 Sanitation, 78, 172, 186, 213, 252 Santa Cruz intervention strategy, 83 Satanic powers, 152 Scapegoats, 189 School administrators, 251 closures, 229, 232 communities, 196 environment, 57, 252 teachers, 277 Search-rescue mechanisms, 252 Security measures, 64, 68, 113 Self awareness of behavior, 187 confidence, 50, 101 consciousness, 105 isolation, 142, 166, 174, 232, 267 medication, 78, 232, 287 motivating actions, 240 Sense belonging, 105, 116, 188, 191, 195, 250, 255, 273 place, 37, 241, 242, 256, 257, 270 Sexual aggression, 98 behavior, 57 harassment, 58 identity, 52 violence, 198, 214 workers, 53 Sheltered employment activities, 240 in-place orders, 33 Situation analysis, 232

314

Skills development, 250, 289 Sleep disturbances, 153 Smartphone penetration, 149 Social anxiety, 4 behavioral, 247 change communication, 193 capital, 15, 19, 20, 24, 32–34, 43, 187, 194, 264, 272, 285

cartography, 105

cohesion, 15, 19, 21, 61, 146

engagement, 15

community, 187

connection, 17, 32, 270

cohesion, 214

determinants, 125

dimension (health), 60

discrimination, 167

disequilibrium, 53

disrupters, 167

distancing, 26, 30, 33, 34, 124

dynamics, 116, 206, 208

environment, 57, 140, 155

exclusion, 79, 80, 123

factors, 51, 58, 79, 258 gatherings, 133 inequalities, 11, 53, 222 integration, 104, 116 interactions, 17, 113, 188 inter-relations, 31 interventions, 60 isolation, 10, 108, 167, 185, 200, 209, 232 mass media, 63 mechanisms, 241 media news, 59 networks, 20, 33, 114, 122, 127, 131, 141, 145, 167, 224, 242, 248, 258, 265, 270 norms, 57, 279 pressures, 128 protection, 76, 79, 80 security, 53, 62, 64, 68 services, 30, 168, 174, 230 structure, 15, 21 support mechanism, 53 networks, 128 system, 153

Index

symbolic, 98

transmission pathways, 140

trauma, 5

Socialization, 111, 286 Societal inequalities, 49 turmoil, 10 Socio-cultural characteristics, 10, 116 differences, 86 factor, 188 vulnerabilities, 85 Socio-drama, 105 Socio-economic, 30, 34, 48, 50, 51, 61, 76, 92, 103 activities, 171 condition, 51, 76 level, 83 status, 34, 50 Sociological, 247 Solution-focused activities, 25 approach, 187 Somatic, 189, 247, 271 behaviors, 247 Spatial mapping, 37 Special mental health, 198 care, 198, 215 protective measures, 52, 53 Specific intervention plans, 252 Spiraling, 48 Spiritual, 79 development, 81 protection, 88 Staff development activities, 249 emotional exhaustion, 154 Stakeholder, 23, 39, 60, 67, 187, 276, 278, 279, 281, 284–286, 288, 289, 291 engagement, 37, 277 Stigma, 167, 194, 195, 268 reduction, 218 society, 233 Stigmatization, 121, 145, 167, 233 professions, 53 Strategic locations, 168

Index

psycho-educational key messages, 115

Strength

assessment, 11

based perspective (SBP), 61, 69

Stress

management, 145, 189, 224

guidelines, 145

techniques, 189

tragedy, 189

Structural

integrity, 252

referral systems, 143 social services, 258

Sub-clinical areas, 193

Subjective perceptions (individuals), 246

Subjugation, 53

Suicidal, 167

behavior, 232

ideations, 174

Supplementary nutrition, 66

Supporting

community cohesion, 60

health workers, 168

Surveillance, 56, 87, 146, 148, 168, 189,

193, 231

Susceptibility, 49

Sustainable

development goals (SDGs), 50, 53, 69

goals, 49

Symbolic actions, 272

Systematic

documentation, 68

participant observation process, 278

violation, 172

Systemic

oppression, 53

resilience, 20, 185

T Tanzania, 149, 150 Red Cross, 150

Target intervention, 61

population, 6, 208, 291

Tarpaulin shelters, 172 Teacher training curriculum, 251, 255 Technical assessment process, 218

315

assistance, 215, 235, 250, 277, 288

resources deployment, 169

staff, 221, 223, 288 support, 210, 211, 275

workshop, 211

Tele-assistance, 16, 109, 110, 176 services, 234

Tele-communication, 199, 271 Tele-consultation, 199 Tele-counselling, 64, 65 Telemedicine, 143, 146, 148, 272 Telephone, 65, 109, 111, 148, 178, 211, 222,

224

consultation, 64

Tele-psychological, 111 helpline, 65

Teletherapy, 111 Teleworking, 218, 233 Temporary-permanent layoffs, 120, 124 Territorial control, 88 Terrorism, 48 Therapeutic elements, 86

resources, 88

Threat, 58, 104, 167, 256 identification, 252 Three-dimensional map, 195, 252 Tobacco, 188 Traditional community resources, 258

disaster cycle phases, 216

food systems, 76 healers, 11, 31, 37, 78, 79, 90, 130, 131,

155, 170, 194, 277

healing, 130, 132

health centers, 37

indigenous economies, 81

medicinal

plants, 78

practitioners, 132

promotion, 87

natural resources, 82

religious burial rituals, 122

sciences, 68

Traffickers networks, 98 Trained, 9–11, 165 community volunteers, 260

medical personnel, 258

316

mental health workers, 64

personnel, 169, 243

psychosocial personnel, 223

Transcultural Psychosocial Organization Nepal (TPO Nepal), 165 Traumatic spaces, 198 stress, 5, 121, 123, 127, 173, 198, 215, 235 Treatment centers, 75, 76, 141, 153, 177

mental

disorders, 152

illness, 148, 152

psychiatric disease, 152

Trust, 20, 101 Tuberculosis, 53 Two-way communication technology, 25

U Uganda, 139, 142, 151–155 Red Cross Society (URCS), 154, 155 Underrepresented populations, 3 Unemployment, 10, 50, 59, 77, 102, 232, 285 Unhygienic living conditions, 50 United Nations (UN), 7, 12, 50, 52, 54–56, 76, 88, 89, 208, 219

agencies, 270

Charter, 54

Office for Disaster Risk Reduction (UNISDR), 55

Population Fund (UNFPA), 88, 92

Universal Declaration of Human Rights (UDHR), 54, 55 Unprecedented implementation (measures), 232 Urban slum, 50, 51

V Vaccination, 16, 78, 144, 171, 209 Vaccines, 12, 175, 209, 267 Venezuelan, 96, 97, 113 migrants, 108, 113 Verbal interactions, 36 Verbatim copy, 36 Victimizations, 48

Index

Video conferencing, 25, 149 messaging, 16 Violence, 10, 53, 54, 56, 85, 96, 97, 102, 103, 107, 109, 116, 128, 133, 143, 198, 222, 233, 235 Viral pneumonia, 206 Virtual assistance, 110, 112

psychosocial support, 115

Virus behavior, 232 Visual representations, 41 Vocational skills, 257

training, 240

Volunteers, 7–9, 11, 12, 30, 34–36, 63–65, 67, 99, 108–111, 114, 115, 117, 119, 142, 145, 147, 149, 151, 154, 155, 169, 187, 194–196, 198, 199, 209, 212–214, 216, 224, 225, 231, 233–235, 243, 248, 250, 251, 257, 264, 268–273, 278, 279, 286, 288 Vulnerabilities, 10, 30, 49–53, 57, 61, 63, 77, 78, 80–82, 98, 99, 102, 103, 107, 108, 111, 116, 140, 144, 167, 192, 282, 207, 221, 252, 283–285 communities, 53 groups, 34, 55, 56, 58, 67, 69, 98, 103, 108, 167, 168, 225, 230, 248 indigenous people, 79 indigenous children adolescents youth, 81 indigenous girls-women, 80 indigenous people (border areas), 81 villages-forest areas, 79 marginalized families, 67 misinformation, 30 population (COVID-19), 49, 57, 63, 67, 68, 78, 252 chronic poverty-poor families, 49 community situational factors, 53 living (terrain remote areas), 50 personal factors, 51 survivors, 55

W Water sanitation, 50, 76, 99, 210, 235 Wearing masks, 3, 16, 34, 185, 270

Index

Weather-related humanitarian crises, 3 Welfare-oriented nation, 67 Western medical services, 80 societies, 221 WhatsApp, 25, 109–111, 148, 199, 210 Work from home, 69 life balance, 32

imbalance, 188

Network Coordination Organizations, 116 shops, 41, 42, 100, 216 World Bank Blog, 67

317

Health Organization (WHO), 10–12, 31, 52, 57, 60, 89, 92, 119, 124, 125, 127–129, 131, 141, 143, 145, 148, 151, 165, 166, 169, 170, 172, 173, 178, 196, 198, 206–208, 230–232, 234, 243, 270, 273 Wuhan Municipal Health Commission, 206

X Xenophobia, 30, 56, 102, 103, 109, 115

Z Zoned travel restrictions, 171