From the editors: introducing Intervention’s special issue on the mental health and psychosocial wellbeing of Rohingya refugees Wendy Ager, Rebecca Horn, Muhammad Kamruzzaman Mozumder, Andrew Riley, Peter Ventevogel Intervention 2019 17(2):117-121

How to conduct a mental health and psychosocial support situational analysis in a refugee-based emergency context: a case study example from Cox’s Bazar, Bangladesh Sarah Harrison, Alex Ssimbwa, Mohamed Elshazly, Mahmuda Mahmuda, Olga Alexandra Rebolledo Intervention 2019 17(2):122-129 Early in 2019, a situational analysis of mental health and psychosocial support services for Rohingya refugees in Cox’s Bazar was carried out jointly by International Federation of Red Cross Red Crescent Societies Reference Centre, International Organisation for Migration and United Nations High Commissioner for Refugees. The main objective of this situational analysis was to identify the approaches that were working well within the current response, the gaps within existing mental health and psychosocial support (MHPSS) services for Rohingya refugees in Cox’s Bazar and to provide practical options and recommendations for MHPSS service providers working through different sectors. The methodology included: 1) a review of existing knowledge about MHPSS services for Rohingya refugees in Cox’s Bazar through desk review methodology; 2) analysis of updated 4Ws (who is where, when and doing what) MHPSS service mapping; 3) strategic priorities mapping which was conducted with members of the MHPSS Working Group in Cox’s Bazar; 4) focus group discussions with camp populations; and 5) meetings with service providers. The results from the strategic priorities mapping are shared in another article in the Special Issue of Intervention (Harrison et al., 2019, pp. 206–211). This article draws upon the Cox’s Bazar case study to outline the methodological approaches and process used to conduct a situational analysis, with a view to guiding agencies interested in undertaking future situational analyses in other, ongoing, refugee and humanitarian contexts. Key implications for practice An MHPSS situational analysis conducted in an ongoing emergency or refugee setting is a useful programming and advocacy tool for country-level MHPSS working groups and the agencies that co-lead these working groups. The process of conducting an inter-agency MHPSS situational analysis supports the functioning, purpose and coordination activities of a country-level MHPSS working group. Future MHPSS situational analyses should be conducted with the full involvement of persons with severe mental health conditions, to ensure that the perspectives of service users are included, in addition to persons suffering from psychological distress and persons with transient MHPSS problems.

Integrating mental health into primary health care in Rohingya refugee settings in Bangladesh: experiences of UNHCR Sadya Tarannum, Mohamed Elshazly, Sandra Harlass, Peter Ventevogel Intervention 2019 17(2):130-139 Hundreds of thousands of Rohingya refugees fled from Myanmar to Bangladesh. The greatly increased mental health needs are paired with limited resources for mental health care, particularly human resources. Therefore, UNHCR, the refugee agency of the United Nations, designed a programme to integrate mental health within refugee primary health care, using the Mental Health Gap Action Programme Humanitarian Intervention Guide (mhGAP-HIG) as the central tool. The aim was to scale up mental health services through capacity building of medical staff in refugee health facilities to enable them to identify and manage people with mental, neurological and substance use conditions. This paper is a process description of the programme, using direct experience of the authors, analysis of training evaluations and data from the refugee health information system and clinical supervision reports. Sixty-two primary health care workers were trained. Participants of the mhGAP training showed clear improvements in the post-training knowledge test. These trained staff started providing mental health and psychosocial services after the training in primary health care centres in the refugee camps. Fifteen of them participated in a bi-weekly supervision/on-the-job training visit. Within this period of time, almost 1,200 mental health consultations were realised in the primary health care facilities. Supervision reports of mhGAP-trained participants showed that in order to become effective mental health providers, the participants need to strengthen various skills including performing mental state examinations, providing psychoeducation and using psychosocial support techniques. In conclusion, the integration of mental health within the Rohingya refugee settings faced many challenges but proved to be feasible. Key implications for practice Health system preparation and readiness is an important pre-requirement for integration of mental health into primary health care services. This is particularly significant in humanitarian settings in which the health system is fragile and struggling to keep services at a minimally acceptable level. Capacity-building efforts alone cannot guarantee the success of the integration process, that is, adequate attention should be paid to communication with health policy and decision makers especially on facility and local level to foster the process of integration and support scaling up. On-the-job supervision is a critical factor in mental health capacity building of non-specialist health providers. Without supportive clinical supervision, any plan for integration of mental health into primary care should be considered deficient and ineffective.

Physical activity as a psychosocial intervention among Rohingya refugees in Bangladesh: a rapid ecological community assessment Ruth Wells, Shaun Némorin, Zachary Steel, Meghna Guhathakurta, Simon Rosenbaum Intervention 2019 17(2):140-148 Over 907,000 Rohingya refugees are currently living in mostly makeshift camps in Bangladesh with limited resources to address their psychosocial needs. Physical activity is a scalable, low-cost intervention effective for prevention and treatment of non-communicable diseases and mental health problems. Understanding community attitudes to physical activity and mental health is key to designing community endorsed and accessible interventions. We employed the ‘community readiness model’, a tool to assess community climate, needs and resources regarding physical activity as a community-driven psychosocial intervention. Fifteen Rohingya key informants were interviewed across multiple refugee camps in Cox’s Bazaar district in January 2019. Community readiness scores were calculated. Thematic analysis explored community-identified priorities. Community members strongly endorsed physical activity as an effective biopsychosocial strategy for relieving tension (a local idiom of distress). Despite leadership endorsement, space and resources to support community initiatives are extremely limited. For women, restrictions of movement were identified as barriers to participation. Physical activity is a feasible and acceptable community-identified strategy to promote psychosocial wellbeing among Rohingya refugees. Resources for physical activity programmes are extremely limited despite the identified social, mental and physical health benefits. Key implications for practice Physical activity was identified as a psychosocial strategy by Rohingya refugees living in Cox’s Bazar, Bangladesh, which can help to relieve tension, which is a local idiom of distress. Resources (such as space and equipment) to support community-led physical activity initiatives are limited, despite support from community leadership. Access to physical activity is limited for women, due to security fears and cultural attitudes, as well as for people with disabilities and older people, due to overcrowding and lack of accessibility planning.

Contextual adaptation and piloting of Group Integrative Adapt Therapy (IAT-G) amongst Rohingya refugees living in Bangladesh Mahmuda Mahmuda, Mohammad Abdul Awal Miah, Mohamed Elshazly, Sanjida Khan, Alvin Kuowei Tay, Peter Ventevogel Intervention 2019 17(2):149-159 A main gap in the delivery of mental health and psychosocial (MHPSS) services to Rohingya refugees in Cox’s Bazar district in Bangladesh is the limited coverage of psychotherapeutic interventions. There is a shortage of mental health professionals who can provide culturally adapted and linguistically appropriate psychotherapeutic interventions that are congruent with the refugee experience. This article describes preliminary work on training Bangladeshi psychologists and para-professionals in applying a novel group-based psychological intervention for refugees, Group Integrative Adapt Therapy (IAT-G). This is a pragmatic, eclectic and transdiagnostic approach, based on the Adaptation and Development After Persecution and Trauma (ADAPT) model. It aims to help refugees to develop resilience and capacities for managing maladaptive reactions to trauma and post-migration living difficulties. This paper describes the key strategies and challenges during the first phase of the project. Activities included an extensive desk review, a one-week training workshop with competency assessments, cultural adaptation of the treatment manual and assessment measures, training on digital literacy and electronic data collection and a blended supervisory model (involving onsite and online sessions). It proved to be generally feasible but not easy to introduce IAT-G in this population. Key implications for practice The introduction of a brief scalable psychological intervention within an acute and ongoing emergency was feasible, but faced considerable challenges including high staff turnover. Implementation involves multiple components including stakeholder engagement, contextual adaptation of tools and materials, training and supervision and setting up a monitoring system. Setting up a supervision is of critical importance but can be complicated in the context of an unfolding emergency.

Supporting maternal mental health of Rohingya refugee women during the perinatal period to promote child health and wellbeing: a field study in Cox’s Bazar Francesca Corna, Fahmida Tofail, Mita Rani Roy Chowdhury, Cécile Bizouerne Intervention 2019 17(2):160-168 In humanitarian crises, such as the Rohingya situation in Bangladesh, maternal and child health may be strongly affected. Maternal mental health is a well-recognised key factor for child survival, development and health. Promoting maternal mental health during the perinatal period, especially in emergencies, contributes to the prevention of child mortality, morbidity and psychological distress. Despite this, few humanitarian psychosocial interventions have been evaluated to measure their effect on maternal mental health and child care. In 2012, Action Against Hunger in collaboration with the International Centre for Diarrhoeal Disease Research, Bangladesh, evaluated the effect of a psychosocial support groups intervention on 260 pregnant Rohingya women, living in the registered camps of Cox’s Bazar. A set of questionnaires (including MMSE, CES-D scale and Rosenberg’s Self-Esteem scale) was administered to participants to measure the improvement on mental health and childcare knowledge after a three-month psychosocial intervention. Maternal wellbeing and childcare knowledge improved significantly over the three months of intervention. Findings suggest psychosocial intervention can be effective despite the chronic stressful conditions of the refugees in the camps. This study reinforces the importance of community-based interventions promoting mental health in contexts of chronic crisis and contributes to the research discussion on the impact of maternal mental health and childcare promotion programming. Key implications for practice Supporting maternal mental health during the perinatal period has a positive impact on women's wellbeing and is also a key factor for good childcare, children's wellbeing and early childhood development. In an emergency situation such as the Rohingya crisis in Bangladesh, promoting maternal mental health is an effective way of preventing difficulties during the perinatal period that may aggravate family, maternal and children's wellbeing. Psychosocial support groups appear to provide an effective methodology to work with refugees on mental health and childcare promotion, since refugees are often isolated, with disrupted social support and with limited access to external resources. Reinforcing women's internal and external resources through group support helps to improve their self-esteem, which is a key factor for general wellbeing.

Exploring host community attitudes towards Rohingya refugees in Bangladesh Mst. Ismat Jerin, Muhammad Kamruzzaman Mozumder Intervention 2019 17(2):169-173 Acceptance and assistance from the host community is crucial to ensure support for refugee populations. This article explores attitudes of the host community about Rohingya refugees in Bangladesh. In total, 202 respondents from Ukhiya in Cox’s Bazar participated in a questionnaire survey about their attitudes towards Rohingya refugees. Respondents from the host community demonstrated mixed attitudes. This article discusses these attitudes and their likely future impacts on the two populations. Findings may contribute to planning strategies towards preventing conflict escalation and increasing integration in the provision of assistance to the Rohingya in Bangladesh. Key implications for practice The findings provide a baseline on host community attitudes and beliefs regarding the refugees, which may prove useful in tracking and understanding changes over time. It orients the readers to the need to consider a host community perspective in providing refugee care. This article calls for action to improve host–refugee relationships to avert possible conflict.

Emotional distress among Rohingya refugees in Malaysia Stacey A Shaw, Hamid Karim, Noelle Bellows, Veena Pillai Intervention 2019 17(2):174-180 Malaysia hosts over 175,000 refugees or asylum seekers who are registered with the United Nations High Commissioner for Refugees, over half of whom are ethnically Rohingya. Economic, social and health challenges are common among refugees residing in countries of asylum such as Malaysia with limited legal rights and uncertainty regarding the future. This study examined emotional distress among a sample of 115 Rohingya refugees living in urban areas within Malaysia. We utilised both quantitative and qualitative methods to assess psychosocial wellbeing. After measuring emotional distress with the Refugee Health Screener-15, we examined socio-demographic and environmental characteristics associated with distress scores. We then examined open-ended responses to qualitative questions regarding perceptions of difficulties refugees experience in Malaysia as well as perspectives on needed assistance. Findings indicated that emotional distress was widespread among this sample. Age was associated with higher rates of distress, while gender, time in Malaysia, employment and other measured factors were not associated with distress. Qualitative themes emphasised challenges with income, documentation and concerns regarding global conflict. Findings point to the need for services that address economic needs as well as reducing distress, in addition to policy challenges that will enable stability and security for Rohingya refugees.

Mental health of Rohingya refugees and asylum seekers: case studies from Malaysia Xavier Pereira, Sharuna Verghis, Cheng Kah Hoe, Asma Binti Zahir Ahmed, Shasvini Naidu Nagiah, Leo Fernandez Intervention 2019 17(2):181-186 Rohingya refugees are one of the oldest and largest asylum-seeking populations in Malaysia. Yet, there is a dearth of literature in relation to this population and their mental health. Through case studies, this paper seeks to add to the emerging body of knowledge on the Rohingya. These case studies highlight the unique factors which contribute to mental ill-health among them. It also seeks to identify mental health and psychosocial support strategies that are currently being implemented to address the mental health needs of the Rohingya in Malaysia, the challenges encountered and possible ways forward. Key implications for practice The importance of psychological and psychosocial interventions beyond pharmacotherapy. The need for an multi-disciplinary approach. The importance of cultural sensitivity and cross cultural communication. The role of advocacy in complementing clinical interventions in developing sustainable solutions to addressing the mental health needs of the Rohingya.

Intimate partner abuse among Rohingya in Malaysia: assessing stressors, mental health, social norms and help-seeking to inform interventions Courtney Welton-Mitchell, Noor Arifah Bujang, Hasnah Hussin, Sharifah Husein, Fajar Santoadi, Leah Emily James Intervention 2019 17(2):187-196 Intimate partner abuse (IPA) is one of the most common forms of gender-based violence worldwide. Risk for IPA can increase during periods of displacement, especially for refugees and other forced migrants. The current study explores patterns of IPA, its correlates and help-seeking behaviours among Rohingya refugees in Malaysia − a group that is particularly marginalised and vulnerable, being stateless and often unable to legally work or access various services. As part of a larger study, a multinational team collected information about IPA among displaced Rohingya in Malaysia through structured household interviews and focus groups, including women, men, community leaders and service providers (n = 75). Results indicated high rates of IPA. Respondents also reported numerous chronic stressors and suggested links between stressors, mental health and IPA. Social norms emphasising the acceptability of IPA and discouraging help-seeking were also common. These data have broad implications, including for development of a ‘healthy relationships’ intervention integrating social norms and mental health approaches to address IPA in Rohingya communities, with potential for scale-up within Malaysia and elsewhere. Key implications for practice Practitioners will better understand intimate partner abuse among Rohingya communities, including links with historical and chronic stressors, social norms and mental health. Practitioners will better understand preferred sources of help-seeking and barriers to help-seeking for intimate partner abuse among Rohingya communities. Practitioners will better understand how to develop interventions for intimate partner abuse, including healthy relationship workshops and public health messaging campaigns based on social norms.