COVID-19’s impact on mental health in humanitarian contexts

Since July 2019, Naya Jeevan has been a part of our GSMA Mobile for Humanitarian (M4H) Innovation Fund portfolio. Round two of the Fund focused on supporting organisations to enable solutions to empower, assist or protect individuals and communities affected by complex emergencies and forced displacement.

Naya Jeevan’s M4H Innovation Fund project Muhinjo Sohno Thar (‘My Beautiful Thar’, MST) focuses on using mobile technology to increase the resilience, socioeconomic integration and gender empowerment of the Thari indigenous people by mitigating the many effects of climate change on the community. The first area of focus has been on offering livestock insurance to smallholder farmers and veterinary care to 2,000 animals located in 8 villages in the Tharparkar district. The second component has focused on offering remote healthcare by training groups of women as community health promoters, training them on a telemedicine platform and providing them with tablets and 4G connectivity, enabling them to connect local health seekers to remotely located doctors and veterinarians. Telenor is one of the mobile network operator (MNO) partners in this project, and their primary role is to provide 4G internet devices and train all field staff on the EasyPaisa mobile app.

To find out more about how the project has adapted and responded to the COVID-19 pandemic, I recently spoke to Heman Kumar, project manager for the MST project and Dr Komal Fatima Rizvi, who has been leading on content, training and facilitation of Naya Jeevan’s COVID adaptation project.

Can you briefly describe the importance of mobile technology within these activities?

The Thari population, especially women, have poor access to affordable, quality health care.  Catering to this problem, the breakthrough role of mobile technology in the MST project via telemedicine and tele-veterinary care in remote communities and humanitarian contexts – that would otherwise not have access to qualified healthcare providers (HCPs) – is potentially transformational. It allows the health seekers to receive the adequate healthcare that they deserve without additional incurred costs and from the comfort of their homes via trusted intermediaries from their local community, who connect them to medical specialists by leveraging technology with the use of telemedicine.

The frontline health workers (FHW) are trained to use the digital platform for teleconsultations via door-to-door visits. Our model supports the socioeconomic inclusion of women, both in terms of income generation as well as in the effective use of digital technology in promoting gender-inclusive employment.

How has COVID-19 impacted the delivery of the project? How was your target population impacted by the pandemic?

In response to the outbreak of the COVID-19 pandemic in Pakistan, all field-based operational activities of the MST project were suspended from March 2020 through the end of May 2020 after a strict lockdown was imposed by the government.

Thar is one of Pakistan’s poorest regions, where 95 percent of the population lives in remote villages with only a single source of income, livestock, which accounts for 80 percent of the local economy. The prolonged lockdown by the government and crippling restrictions to stop the spread of coronavirus stopped the traditional annual migration of the desert-dwellers, or Tharis, to adjoining districts in search of water and fodder for the livestock and temporary jobs for themselves as harvesters on farmlands. Livestock trade markets also closed in March 2020 and as a result these farmers were unable to generate any income. Despite this, they continued to incur costs of keeping their livestock nourished. This imposed a burden on their finances and as a result many families started rationing their food with potentially devastating effects on children and especially pregnant women.

Another problem that Thar faces is the impact of COVID-19 on mental health and the alarming increase in the suicide rate in this region. Over 125 women have killed themselves by suicide in the last 13 months. While the causes are being investigated, providing the community with resources to cope with the crisis has become necessary.

In light of COVID-19, how have you adapted your project to focus on mental health?

One of the most significant challenges related to COVID-19 that we were confronted by, has been the effect of COVID-19 on the mental health and wellbeing of our target population. While the resumption of FHW-assisted telemedicine in July 2020 has been favourably received by the community, our FHWs have expressed concern around a high incidence of untreated mood disorders (anxiety and depression) that are potentially linked to the adverse impact of COVID-19 on the incomes and livelihoods of smallholder farmers and the increased risk of gender-based violence (GBV), due to the enforced lockdown and social distancing protocols.

Additional support via the M4H COVID-19 Adaptation Fund has been used to screen this target community for the incidence/prevalence of mental health problems including mood disorders, and to provide psychosocial support to community members in need of mental health services by connecting them (via mobile-enabled telemedicine as these communities do not have physical access to mental health services) to trained therapists or clinical psychologists and psychiatrists, where appropriate.

What interventions have been planned as part of this adaptation?

Education and awareness trainings on mental health, well-being and gender-based violence for the community health works (CHWs) and doctors. One of the most important components of any mental health project is to train and prepare the team before they are sent out in the field. It has been observed that healthcare professionals and their attitudes towards mental health can add to the stigma and false beliefs associated with it, causing further damage and a disservice to the cause. Therefore, topics such as empathy, dignity for all, practicing non-judgment and confidentiality, trauma informed psychological first aid, suicide awareness and GBV and how to support survivors and other necessary topics have been covered to equip the field teams with the relevant knowledge. Due to the strict COVID protocols in place, all trainings were held remotely via technology using Zoom and Google meets.

Educating the community on mental health and wellbeing via in-person group sessions and door to door visits. The stigma in the community attached to mental health has prevented many from seeking support and help. Eliminating false beliefs and normalizing the conversation around mental health is the only way to stop the marginalization and social isolation of people living with these conditions. Educating about mental health will also help remove the shame associated with it, making it easier for people to seek help. Humanitarian emergencies may exacerbate existing violence against women, therefore the COVID-19 adaptation project is also about creating awareness around this topic in the community and providing psychological and emotional support to women in Thar who were identified as survivors.

Screening and management of depression, anxiety and stress using technology. One of the goals of this project was to screen women in 250 households for depression, anxiety and stress. DASS-21 was used as a screening tool that was translated into the regional language, Sindhi, and integrated into our EMR platform ‘Click Medix’. CHWs were trained to screen women in their door-to-door visits. Those scoring mild to severe on the screening scale were referred to a therapist by our general practitioner. At the end of 6 to 8 sessions of therapy, these women are going to be interviewed to assess for improvement.  Talk therapy via technology is being provided by our network of clinical psychologists/ therapists who evaluate the client for mood disorders, mental health conditions and gender-based violence. The therapist/psychologist provides psychological and emotional support and refers the client to the nearest psychiatric facility or tertiary care if needed.

Mental health can often be a difficult topic to discuss. How were you able to navigate these challenges?

Some of the biggest challenges that we had to deal with were a lack of mental health professionals in that region and a lack of a lexicon in the local language, Sindhi, to address this issue without re-stigmatizing. Many words associated with mental health in the Sindhi language carry a negative connotation due to the years of socio-cultural stigma this topic has carried, words that can perpetuate shame. Therefore, it was of utmost importance that all translations and training of the field teams was done by experts who were trauma informed and spoke and understood the local language well.

Technology played a vital role in mitigating these challenges by bridging the gap in the system. We were able to connect our remote teams to mental health professionals all across the country and ensure that the care and the content provided to the community was of the highest quality. From conducting training virtually for frontline health workers to connecting the community to remote psychologists and therapists, technology proved to be the most important and efficient resource for the project, especially during a time when all other methods of connection were lost.

How have you ensured that privacy and data security issues have been appropriately addressed through the service?

The use of Click Medix platform as the telemedicine platform added to our efforts of maintaining privacy, Click Medix commits to the protection of privacy and maintains ISO 27001 accreditation.

Partnering with Sukaar Foundation as the implementation partner in Tharparkar helped in mitigating potential issues of health data privacy concerns. It is essential to have a local partner to develop trust with the community and with our organization itself.

What are the next stages for the project and what is the long-term future of this project?

The project is still in its implementation phase and so far, the results have been phenomenal. Sadly, more than 50 per cent of the target population has been screened positive for depression, anxiety or stress. However, the community’s response to speaking to a therapist online has been a pleasant surprise. Women have been very open and upfront in the therapy sessions, quite contrary to what we had assumed because of the conservative and patriarchal norms in that community.

Technology has been proven to be a great asset in providing mental health care in a community that has suffered immensely due to the lack of quality services. The project’s sustainability depends on the establishment of public private partnerships. We are already in the process of having conversations with the authorities and MNOs to incorporate telehealth services into the public health system as MST has provided with sufficient evidence that technology can be an efficient way to unbridged the gap our healthcare system currently faces.

The M4H-Naya Jeevan project is in its final stages, and we look forward to sharing more lessons from the project in the near future. To learn more about the M4H Innovation Fund and the organisations we are working alongside, you can visit our interactive map detailing all of our grantees.  To read more about how the M4H-Naya Jeevan project and other grantees adapted their programmed in the COVID-19 pandemic, check out our report.

This initiative is currently funded by the UK Foreign, Commonwealth & Development Office (FCDO), and supported by the GSMA and its members.
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