The violent upheavals over the last decades have led to large numbers of refugees living in camps in the African Great Lake area. The UNHCR and the staff of the implementing NGOs are confronted with refugees suffering from mental health problems and/or severe psychosocial stress. The UNHCR seeks ways to strengthen the competencies of the staff of implementing organizations in the fields of mental health and psychosocial assistance. This project with as main goal to develop, implement and evaluate a model of comprehensive services for mental health and psychosocial support within existing UNHCR-supported care structures for refugees, is started in 2009 and will be continued till the end of 2011.
Psychological stress and social determinants
To address the needs of the refugees and the care providers, it is critical to look at psychological stress not only from the ‘medical’ perspective, but to take a broader perspective with attention for contextual aspects. A multidisciplinary approach is required to address the observed problems. The refugees in the camps are vulnerable: on a political, social and cultural level. This vulnerability is caused by their status as a refugee, by the situation in the refugee camps, and it is also related to humanitarian aid. However, not all problems are caused by the refugee situation. Psychosocial and mental problems can be pre-existing for refugees related to disaster, violence, loss of relatives, status, or belongings.
Social factors are known to be major determinants of mental disorders. Three key social determinants are risk factors for mental disorders: poverty, social exclusion and gender violence. Dependency is a central element in the worldview of the refugees, which results in the feeling that their future is blocked. They seem to develop apathy, but beneath this passivity there is a wish to be active agents in shaping their own future. Refugees want to work toward self-sufficiency, but care providers often believe that refugees are no longer able to organize their lives.
Changing gender roles, due to refugee status and of the structure of the camp (the lack of income-generating activities for men) cause significant stress in marriages. Respondents in all camps mentioned high levels of gender-based violence. Violence is not limited to refugee settings, but the specific dynamics of the refugee setting together with dysfunctional or broken extended family support systems increase the incidence of violence.
There is established evidence that domestic violence has a significantly negative impact on women’s mental health. Addressing gender violence requires that agencies work closely with refugee communities, rather than setting up parallel systems for them. Community-based psychosocial work can have a unifying effect by crossing the boundaries between various services.
Regarding mental health, the stigma of epilepsy and mental disorders is high among refugees and health care providers. However, in general, only very severe mental disorders such as psychosis and depression were recognized in the camps. Worldwide the burden of depression and other common mental disorders is significant among refugees, but in our assessment health workers found it difficult to recognise people with depression.
Activities and results
The project implements activities for two main groups:
(1) People in the refugee camps:
(2) For returning refugees:
Covering the Southern provinces of Burundi (Makamba, Rutana, Bururi) where there is a high repatriation movement from Tanzania. During the first six months of 2010, repatriation was too slow, due to the period of elections that were organized in Burundi and refugees feared to return to by that time. But towards the end of the year 2010, returnees from Tanzania were registered in the Burundi transit camps. The actual (total) figure in the southern provinces in Burundi is 209.451 returnees. Also in 2010, around 45O refugees from the camps of Burundi repatriated to DRC.
Activities in the refugee camps
In 2010 a workshop was organized. The objective of the workshop was to share information on the situation and needs assessment on mental health and psychosocial support in refugee camps in Tanzania, Rwanda and Burundi with members of local UNHCR offices and their implementing partners, in order to design a capacity building framework to which all partners are committed.
We developed training modules on mental health and psychosocial support for general health workers, dedicated mental health workers, general (psycho) social workers, staff in community services and dedicated psychosocial workers. De trainings ware mainly done by local (HNTPO) trainers and experienced psychiatrists. The training focused on 3 levels:
Both classroom learning and field practices were organized to ensure skills were mastered and to see how capable the trainees were to apply the knowledge and skills acquired. As a result, refugees get improved quality care and seek help with more confidence to people who have knowledge and skills. It was noticed that the trainees both in mental health and psychosocial support are using properly the skills they acquired during the training. The trainings were also followed by field supervision in the different camp sites.
These supervisions are being continued in 2011. Through these supervisory visits, it was found that the refugees in the different camps are informed about the existence of the mental health and psychosocial services. This is made possible through sessions of awareness raising on mental health, epilepsy and psychosocial problems and psycho education that are organised in the community. As a result, the community members seek help, offer minimum support to their members in need of support or refer individuals/groups to the trained mental health nurses or community service providers.
Activities done regarding the returnees in Burundi
Psychosocial care of the returnees (by the psychosocial workers and the local structures) is an ongoing process. Problems that can arise are for example: family separation, land problems, cohabitation problems, stress, socioeconomic complaints, domestic violence, alcoholism, sexual violence, health complaints, HIV/Aids, mental health problems, epilepsy, stigma, educational problems and rejection.
To support the refugees, interventions such as conflict management, psycho-education, recreational activities to the youth and children, referral and advocacy, support groups are being used to manage problems presented by the returnees. As a result, local structure members feel comfortable to use the learned skills while attending to psychosocial problems of the individuals. The community members in their respective localities trust them and collaborate with them in conflict management or problem solving.
Through the information on psychosocial and mental health care that is being shared in the community by psychosocial workers and the local helping structures attitude change is observed. Situations like: hatred, exclusion, conflicts, tension between residents and returnees decrease or are eradicated. The returnees integrate easily in the community because of the helping groups that act as liaison between the community and the helping services.
Aim: Improving and increasing capacity of mental health care and psychosocial support for refugees the refugee camps (and returning refugees from Tanzania in Burundi).
In 2011 the following activities are planned:
1. Capacity building: increased capacity of UNHCR staff, the implementing partners and the staff of the transit camps, through training and technical support to deliver integrated Mental Health and Psychosocial Support.
2. Evaluation: The effectiveness of this intervention package in the settings of Burundi, Rwanda and Tanzania is evaluated. Lessons learned and recommendations for scaling up services will be formulated. There will also be a general project evaluation report by an external consultant who will document lessons learned and recommendations.
3. Integration: There should be a continued access to mental health and psychosocial support services for returning Burundian refugees into the existing health systems developed by HealthNet TPO in Burundi.
4. Research: Community-based programmes will be developed in the field of (sexual) gender based violence, trough action research in one of the camps, and documented. Read more on this research project.