Mental health and psychosocial support in the context of peacebuilding: lessons learned from Somalia

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Mental health and psychosocial support in the context of peacebuilding: lessons learned from Somalia

https://doi.org/10.21203/rs.3.rs-4685327/v1

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Conflict tends to break down health systems by damaging health care infrastructure, forcing health care workers to flee from dangerous work environments, and causing an upsurge in displacement, starvation and recurrent epidemics. In Somalia, three decades of conflict and ongoing humanitarian crises have profoundly impacted the physical and psychological well-being of the people.

As part of the World Health Organization’s Health and Peace Initiative, the Government of Somalia, WHO and partners have implemented a project to integrate mental health and psychosocial support in the context of peacebuilding, the first of its kind in Somalia. The project encompassed training of health workers on mental health, provision of services, awareness and addressing the stigma and discrimination.

Drawing on the project evaluation as well as primary research conducted as part of the project to understand the epidemiology of mental health and substance use issues in the project sites, valuable lessons have been learned from this multi-agency project implemented in a challenging context during the COVID-19 pandemic and an ongoing complex conflict and humanitarian crisis in South Central Somalia.

This case study provides an overview of the project, delving into its conceptual framework, activities and outcomes. It highlights the challenges, lessons learned and recommendations. The lessons discussed below are derived from the implementation process, project outcomes, research findings, training and evaluation reports. The case study considered every aspect of the project to enable us to capture the process as well as outcomes.

The global impact of mental, neurological and substance use disorders (MNS) stand at 10% of the general population, but that percentage jumps to more than double at 22% in countries affected by humanitarian crises [1-2]. The majority (75%) of those affected by MNS are in low- and middle-income countries, especially in conflict and post-conflict settings, and lack access to effective MHPSS services [2-3]. With the high rates of mental health conditions in humanitarian settings, the current climatic crisis compounded by the COVID-19 pandemic has only made the mental health situation worse [4].

In Somalia, the protracted conflict, social unrest and ensued political instability since the fall of the central government in 1991 has left the country fractured in a complex humanitarian situation. The continuous conflict and violence, exacerbated by recurring climatic shocks, have deeply fragmented the social fabric of the society and eroded people’s coping mechanisms and community resilience. The profound impact of political instability, conflict, insecurity, coupled with the resulting economic stagnation and poverty, has been a driving force behind the increased rates of mental illness and psychosocial distress across all segments of society, with a particularly pronounced effect on vulnerable groups such as women and youth.

A systematic review focusing on mental health in Somalia [5] estimated that a third or more of the population is experiencing mental illness. The review also identified that many of the psychosocial problems faced by the people stem from the effects of both acute and protracted conflict, trauma and violence that have led to long-term displacements, economic turmoil and social deprivation. As a result of systemic neglect and low prioritization, mental health remains one of the most underfunded health problems in the country. The country’s mental health services are close to non-existent with a strikingly low ratio of just 0.5 psychiatric beds per 100 000 population. In stark contrast, the WHO Eastern Mediterranean Region maintains a ratio of 6.4 beds/100 000, and globally, the figure stands at 24 beds/100 000 [6]. Apart from a handful of inadequately staffed and under-resourced psychiatric hospitals, the country has no community based mental health services [5]. This dire situation leaves the population without adequate support and exacerbates the challenges faced by those suffering from mental health issues.

WHO’s Global Health and Peace Initiative

WHO’s Global Health and Peace Initiative acknowledges the power of health as a bridge for peace and to the attainment of both the Sustainable Development Goals (SDGs) for good health and well-being (SDG 3) and for peace, justice, and strong institutions (SDG 16), signifying the interlinkages between health, development, peacebuilding and humanitarian support [7-8]. It is within this context that WHO Somalia partnered with the Federal Ministry of Health (MoH), Somali National University (SNU), International Organization for Migration (IOM), and United Nations Children’s Fund (UNICEF) to implement an MHPSS project in the context of peacebuilding in South Central Somalia, areas most affected by armed conflict, drought and displacement. As is increasingly recognized, the integration of peacebuilding and MHPSS services are vital to support communities to rebuild their social systems after fractures due to conflict [9].

Improving psychosocial support and mental health care for conflict-affected youth in Somalia

This project was developed in close consultation and alignment with the Somalia National Development Plan (NDP)^[1] and the Somali Mental Health Strategy^[2] and contributes to the social and human development chapter of the NDP which prioritizes MHPSS. Additionally, the project aligns with and contributes to a number of other governmental youth polices, strategies and plans, including the Federal Government of Somalia’s Social Development Roadmap Goal 4, which prioritizes the provision of affordable and accessible basic social services, such as health and education; the National Reconciliation Framework, which identifies trauma healing as an important piece of reconciliation; the National Youth Policy and National Mental Health Strategy, which support the provision of mental health in conflict settings; the National Health Sector Strategic Plan, which identifies MHPSS as a critical gap and proposes that it be part of key priorities; the National Strategy and Action Plan for Preventing and Countering Violent Extremism, by addressing barriers of youth to participate in peace building and conflict resolution initiatives; and finally the Somali Youth 4 Peace Pact and Convention on the Rights of Persons with Disabilities which was signed by the Government in October 2018.

To this end, the main objectives of this project were:

To develop an institutional response to the mental health needs of conflict-affected populations with a focus on youth through the integration of mental health services into primary health care
the development of a youth-centred and gender-aware MHPSS training module for health workers and professional;
to strengthen community-based support for addressing mental health and psychosocial needs through the establishment of community based psychosocial support structures using the local health facilities as entry points;
to improve awareness and reduce stigma around mental illness and substance abuse through youth-led education and communication campaigns;

to advance understanding of interlinkages between mental health and peacebuilding in the Somali context through research to inform future interventions and help contextualize results.

This project targeted urban centres of Baidoa in South West state and Kismayo and Dollow in Jubaland state along with their surrounding settlements for internally displaced people (IDPs). These target locations were selected based on a combination of factors including the number and density of IDP settlements and communities, conflict dynamics and severity. These regions have also been severely affected by the ongoing drought and famine in Somalia, triggering large influxes of more IDPs into the urban centres, which have in turn exacerbated the already-challenging conflict dynamics.

The project directly benefited about 26 500 people across the three sites, across a range of groups including:

internally displaced youth and their families reached through community based psychosocial support services (PSS) or who received care and treatment for mental illnesses at integrated primary health care facilities;
survivors of gender-based violence (GBV) who received care, support, and appropriate referral linkages at community and primary health care centres;
young people reached in awareness raising activities about substance use, harmful practices and opportunities for positive empowerment;
health workers trained in provision of MHPSS services within primary health care; and
community members trained in psychosocial first aid (PFA) and GBV response.

The project's positive impact extended beyond the direct beneficiaries, as it also reached various indirect beneficiaries, including the broader communities residing in IDP settlements and the neighbouring non-displaced populations.

Undertook training of trainers (ToT) for capacity-building training in Mogadishu in December 2020 for 24 mental health workers selected from Jubaland, South West and Galmudug states as well as Banadir administrative region. The training used the evidence-based Mental Health Action Gap (mhGAP) module developed by WHO for scaling up mental health services particularly in the areas with limited resources. Fig. 1 represents the difference between the pre- and post-test scores.

Fig. 1. Average pre- and post-test scores for TOT participants (n=24 participants, full score =16)

Organized cascade mhGAP training in Baidoa, Kismayo and Dollow. A total of 60 frontline health workers selected from the three sites (20 per site), including physicians, nurses, midwives and public health practitioners were trained on the provision of mental health services using the mhGAP manual. This training was facilitated and delivered by the ToT participants. After the cascade training, mental health services were integrated into 15 existing health facilities and the trained health workers deployed in these facilities.
Trained 60 community health workers and community stakeholders in the targeted locations on MHPSS skills including PFA, clinical management of rape (CMR), GBV management, stigma reduction and PSS.
Trained 45 community-based counsellors, including 30 youth counsellors.
Formed 24 support groups^[3] with 192 participants consisting of 102 females and 90 males.
Identified and furnished 3 MHPSS resource centres in the selected sites.^[4]
Trained 30 youth-aged animators to actively mobilize community activities towards improved social cohesion and peacebuilding.
Developed contextualized messaging with support from scholars from the National Islamic Advisory Group and disseminated through FM radio stations and interpersonal communication channels. Overall, messages were broadcast at three radio spots, five times per day for 30 days across ten 10 radio stations.
Contributed to sustainability beyond the life of the project with a number of modalities that were integrated within the design, including:

integration of MHPSS into existing primary health care services by training existing health staff and community workers in the selected sites;
creation of opportunities and structures (i.e., MHPSS Resource Centres) for community engagement and mobilization;
collaboration with the MoH to ensure retention of trained staff and on-the-job training of other staff in the target sites;
integration of the MHPSS training modules developed under project with the relevant curricula at SNU so that future cadres of clinicians can be trained; and
storage of data from health facilities providing MHPSS services into a data repository at SNU that can serve as a source for analysis.

Lessons learned from the project

Valuable lessons have been learned from this multi-agency implemented project in a challenging context during the COVID-19 global pandemic and an ongoing complex conflict and humanitarian crisis in South Central Somalia.

Impact of conflict on livelihoods and dignity

Protracted conflict, displacement and continued insecurity has left residents in the target sites with significant distress due to the enduring challenges of precarious living, difficulties in affording necessities and continuous exposure to violence. Participants reported an overall sense of uncertainty for their future, and a profound sense of loss, including of opportunities, self-esteem and status.

“Our people were seriously affected by the civil war and suffered from post-traumatic stress disorder. Also, during the biting drought situation, many people who had a large number of livestock suddenly lost all of them. So, people got stressed. In some cases, we heard some committed suicide. Basically, those are some of the issues that we keep hearing”.

--- A community elder, Kismayo

A report from the United Nations Population Fund (UNFPA)^[5] shows that a lack of access to livelihood opportunities and education are the most pressing concerns of young people in Somalia with one in every two young people in the country been unemployed or economically inactive. This state of high unemployment (87%) was also confirmed in our cross-sectional study across the three sites (Table 1) including the IDP settings where unemployment and lack of economic opportunities are also seen as contributory factors to psychological distress.

“Stress can result not only from being insane but also being unemployed”.

--- Youth, Kismayo

Education and skills training are essential ingredients for development for economic and individual advancement in any country. Somalia has a significant youth population, the majority of whom lack such opportunities, including education. This was evidenced in our study participants, of whom, 38% could not read or write, only 17.5% had any high school education and just 2.5% had a college or university degree (see Table 1).

Table 1. Sociodemographic characteristics of respondents stratified by study site (n=713)

Conflict, poverty and its impact on mental health

Findings from our research and evaluation show the dire need for mental health services. Mental health and substance use problems are considered widespread [see Fig. 1], and there was a lack of health or community support systems across the sites.

There is also consensus among the communities that there is a need to address the root causes of mental health issues including conflict, poverty and unemployment. The interconnections between adversity, poverty and mental illness were clearly articulated by some respondents.

“Due to unemployment, youth become mentally ill. It is easy to become mentally ill as there are droughts and wars going on. They are using drugs and the project did not change this much. If more jobs were created, then youth would have been too busy to use drugs. The drugs that they were using have become more popular in the city, so I do not think there is a change”.

-- A health worker, Dollow

Conflict, vulnerability and substance use

Individuals exposed to multiple stressors such as violence (physical, sexual or emotional), loss of livelihood can be pre-disposed to use substances and alcohol especially in the context of conflict and post-conflict settings, including as a coping mechanism [10]. In addition, the economic hardships, as well as limited opportunities available in a conflict setting, may also increase vulnerability [10].

Substance use and mental health problems are often intertwined, and in humanitarian crises, affected individuals are at greater risk of developing mental health conditions such as post-traumatic stress disorder, depression and anxiety, which in turn increase the likelihood of substance abuse [11-13]. The availability of drugs tends to increase as regulatory systems break down. Conflict, especially large-scale civil war, can lead to collapse of government institutions and weaken the regulatory bodies and rule of law which can further proliferate illegal drug trade, and substance use and abuse [14].

This is supported by the outcome of the study that shows significant substance use among the population (see Fig. 2).

Figure 2. Substance use among participants (n=713)

While it is imperative to address the issue of substance use through mass awareness and clinical management of those with substance use disorders, there is a need to tackle the root cause of the problem.

“Supporting Somali youths, whether they are street children or those who are addicted to drugs, is surely welcome. I think the long-lasting solution to this problem is to solve the root causes including unemployment, recurrent droughts and lack of functional mental health centres”.

--- A youth leader, Baidoa

Youth engagement in peacebuilding

The research (both qualitative quantitative) and end of project evaluation findings indicate that youth engagement with peacebuilding activities is generally limited. This could be due to societal values around the bigger role typically played by elders and faith leaders in politics, justice and conflict resolution within the Somali community. Young people reported a lack of engaged in the peacebuilding:

“We don’t participate in such programmes [peacebuilding] because in the first place, we don’t get opportunities that would allow us. And as youth you find at most times that no one is ready to listen to our opinions or even have them implemented”.

--- A young person, Kismayo

As such, perceptions of the peacebuilding process were rated poorly in more than 50% of cases across most of the different aspects of perception.

Nevertheless, some community elders seemed to acknowledge the link between addressing mental illness and community cohesion in the context of the overall objective of the project.

“This awareness programme was much needed. Some patients were unchained when awareness reached their families, and they gained knowledge about how to care for mentally ill people. The project also increased the bond between community”.

--- A community leader, Dollow

Protracted conflict not only destroy lives themselves, but also ways of life, social and cultural assets and public institutions. They typically fester in contexts rife with social problems – such as poverty, unemployment, lack of education, gender violence – which are in turn made worse by conflict. These problems not only exacerbate psychosocial impacts of armed conflict, but also have psychological ramifications of their own. This project shows that even though health-based supports are helpful in promoting well-being to some extent, they cannot on their own reduce drivers of conflict and lead to sustainable peace. The outcome of the project underscores the need for holistic approaches that not only improve health-based supports available to young people, but also address other needs that drive substance use and mental health problems in youth e.g., a lack of employment opportunity.

The evidence built throughout the project generates a call for action to further address the mental health and psychosocial needs of conflict-affected young people in Somalia, through the following four areas.

Addressing conflict and restoring peace. The country’s three-decade-long conflict is a major root cause of the challenges faced by Somali youth, creating economic, educational and employment hardships, as well as putting their physical and mental well-being at risk. Partners across the humanitarian-development-peace nexus, including the government, civil society, the United Nations and development partners must work together to restore peace and stability to the country.
Investing in basic, vocational and tertiary education. Somalia has a high school graduation rate of less than 30%, and lack of education is a key challenge faced by youth in Somalia. The government and its partners should prioritize building educational infrastructure and providing educational resources, including adult education programmes for youth who are out of basic education age, to empower them and enable them to achieve better personal development.
Integrating addiction treatment in a strengthened health care system. It is important to recognize that the substance use and addiction is a public health matter and that the long-term negative effect of protracted conflict in Somalia contributed to the issue. To this end, the health care system should include and provide compassionate care through trauma-informed practices for the young generation who are dealing with significant mental health conditions, including substance use as evidenced in this study, while the stigmatization of mental illness and addiction should be addressed.
Providing integrated solutions for generational trauma and the mental health crisis. A generation of Somalis has grown up traumatized by the ongoing conflict, and many struggle with basic and essential services and opportunities such as education, health care and employment. Somalia’s crisis is far from over and the youth in this country need significant attention and an integrated approach to address their trauma and resulting psychological distress within a culturally appropriate framework that involves the contributions of multi-stakeholders in the health, social, educational, political and economic sectors.

Human ethics and consent to participate declarations

This study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and ethics approval was granted by the Somali National University Ethics Review Board Ref: 03/08/SPHR2021.Research and ethical process of voluntary and informed participation and confidentiality was adhered to.

Funding declaration

Funding for this project was provided by the United Nations Peacebuilding Fund

Authors' contributions

MI coordinated the manuscript development, literature review and analysis, MM provided overall lead of the project and edited the manuscripts, ZN oversaw data collection and contributed to literature review, JM contributed to data analysis and AS contributed to data collection, analysis and interpretation.

Acknowledgement

This project was multi-sectoral and we acknowledge and thank all the stakeholders (Ministry of Health Somalia, Somalia National University, UNICEF, International Organization of Migration, MHPPS Collaborative and Africa Mental Health Foundation) for their contributions in implementation, data collection and evaluation.

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¹ Somali National Development Plan (https://mop.gov.so/wp-content/uploads/2022/07/Somali-National-Development-Plan-9-2020-2024.pdf, accessed 6 August 2023).

² Somalia Mental Health Strategy (https://moh.gov.so/en/wp-content/uploads/2020/07/Somali-Mental-Health-Strategy-2019-2022.pdf, accessed 6 August 2023).

³ Divided into male and female groups and across two age groups – 18 to 25 years old and 26 to 35 years old.

⁴ These centres were identified jointly with camp coordination and camp management and community leaders in the respective locations.

⁵ Somali adolescents and youth. Boom or gloom? (https://somalia.unfpa.org/en/publications/somali-adolescents-and-youth-boom-or-gloom, accessed August 2023).

Table 1. Sociodemographic characteristics of respondents stratified by study site (n=713)

Variables	Frequency	Percentage
Sex of the respondent
Male	417	58.5
Female	296	41.5
Age of the respondent
15–24	170	23.8
25–34	279	39.1
≥35	264	37.0
Education level
Cannot read or write	276	38.7
Quranic school	294	41.2
Secondary grade or less	125	17.5
College or university graduate	18	2.5
Occupational status
Unemployed	618	86.7
Employed	94	13.2
Area of residence
Community	576	80.8
IDP settlement	137	19.2

No competing interests reported.

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Mental health and psychosocial support in the context of peacebuilding: lessons learned from Somalia

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Abstract

Figures

Introduction

WHO’s Global Health and Peace Initiative

Case Presentation

Key project activities and results

Lessons learned from the project

Impact of conflict on livelihoods and dignity

Conflict, poverty and its impact on mental health

Conflict, vulnerability and substance use

Youth engagement in peacebuilding

Conclusions and recommendations

Declarations

References

Footnotes

Table

Additional Declarations

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