DRAFT VERSION Jan 28 2010 (NOT FOR WIDE DISSEMINATION)
Mental Health and Psychosocial Situation and Needs Assessments in Major Humanitarian Crises:
WHO Toolkitfor Humanitarian Health Actors
(Draft Version[1])
Quick guide to identifying tools in this document
Actions by Humanitarian Health Actors / Appendices in this document / Page number- Coordination
1B (IASC RG MHPSS 4Ws) / 14
16
- Meeting the basic needs of people with mental disorders in institutions
- Providing access to basic mental health care for urgent mental health complaints in PHC
3B (mental health section in UNHCR HIS)
X (free listing on local indicators of distress, daily functioning and coping methods) / 25
28
51
- Providing access to psychological first aid to people in acute distress after exposure to extreme stressors.
- Ensuring that community health workers strengthen community self-help and social support
- Initiate plans for development of a sustainable community mental health system in the region and for a more comprehensive response
6A (summary of mental health system formal resources)
6B (interview guide on alcohol and other substance use)
X (free listing on local indicators of distress, daily functioning and coping methods) / 25
30
33
51
- Advocacy on the burden of the problem
7B (12 item WHO-DAS 2.0) / 35
40
- Informing any of the above 7 actions by knowledge on the context
8B (example questions for interviews on context))
8C (participative ranking of problems and resources)
8d (example questions for interviews with healers) / 43
44
47
49
Table of Contents
1. Introduction
2. Overview of the assessment process
3. Assessment methodology
4. Translating assessment into practice
Appendices
1AAvailable health services:Health Resource Availability Mapping System (HeRAMS)14
1BWho is doing What Where When (4Ws) in Mental Health and Psychosocial Support: Mapping 16
2A.People in institutions in acute emergencies: Checklist for site visit 24
3A MHPSS in PHC services provision: Checklist25
3BCase identification in PHC services: Health Information System (HIS) data 28
6AResources of the formal mental health system across the affected area (district/province/country): Summary 30
6BAlcohol and other substance use: sample interview guide33
7AEpidemiology of serious symptoms of distress: very brief survey35
7BFunctioning: WHO DAS-2.0 interviewer-administered 12-item version40
8A Existing contextual information from Clusters/sectors: Checklist43
8BUnderstanding the context: example questions for key informant / group interviews44
8CParticipative ranking of problems and resources47
8DLocal perceptions of mental health: Interview with traditional/ religious healers49
XLocal indicators of distress, daily functioning, and coping methods: Free listing51
YLocal indicators of distress, daily functioning, and coping methods: Key informant interview 53
Annex: Bibliography for further reading55
1. Introduction
Background and rationale
This guide is intended to assist those designing and conducting mental health and psychosocial needs assessments in humanitarian settings. Consensus exists among international stakeholders concerning the need to perform assessments, as well as which types of information need to be covered by assessments (IASC, 2007). Needs assessments are aimed at (a) providing a broad understanding of the humanitarian situation, (b) analysing people’s problems and capacities, and (c) analysing resources to determine, in consultation with stakeholders, whether a response is required, and if so, the nature of the response.
Table 1 displays recommended informationforassessment according to the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Although the IASC MHPSS guidelines outline on what topics data should be collected, (a) the IASC Guidelines do not provide detailed guidance on how to collect the data and (b) the IASC Guidelines do not specify what information is typically needed for what actions in the health sector. This document – written for humanitarian health actors - is intended to help fill thesetwo gaps.
Table 1.1. (IASC, 2007; p. 40-41)[2]
Relevant demographic andcontextual information / • Population size and size (and, where relevant, location) of relevant sub-groups of the population who may be at particularrisk• Mortality and threats to mortality
• Access to basic physical needs (e.g. food, shelter, water and sanitation, health care) and education
• Human rights violations and protective frameworks
• Social, political, religious and economic structures anddynamics (e.g. security and conflict issues, including ethnic,religious, class and gender divisions within communities)
• Changes in livelihood activities and daily community life
• Basic ethnographic information on cultural resources, norms,roles and attitudes (e.g. mourning practices, attitudes towardsmental disorder and gender-based violence, help-seekingbehaviour)
Experience of the emergency / • People’s experiences of the emergency (perceptions of events and their importance, perceived causes, expected consequences)
Mental health andpsychosocial problems / • Signs of psychological and social distress, including behavioural and emotional problems (e.g. aggression, social withdrawal, sleep problems) and local indicators of distress
• Signs of impaired daily functioning
• Disruption of social solidarity and support mechanisms (e.g. disruption of social support patterns, familial conflicts, violence, undermining of shared values)
• Information on people with severe mental disorders (e.g. through health services information systems)
Existing sources ofpsychosocial well-beingand mental health / • Ways people help themselves and others i.e. ways of coping/ healing (e.g. religious or political beliefs, seeking support from family/friends)
• Ways in which the population may previously have dealt with adversity
• Types of social support (identifying skilled and trusted helpers in a community) and sources of community solidarity (e.g. continuation of normal community activities, inclusive decision-making, inter-generational dialogue/respect, support for marginalized or at-risk groups)
Organisational capacitiesand activities / • Structure, locations, staffing and resources of psychosocial support programs in education and social services and the impact of the emergency on services
• Structure, locations, staffing and resources for mental health care in the health sector (including policies, availability of medications, role of primary health care and mental hospitals etc. ) and the impact of the emergency on services
• Mapping psychosocial skills of community actors (e.g. community workers, religious leaders or counsellors)
• Mapping of potential partners and the extent and quality/ content of previous MHPSS training
• Mapping of emergency MHPSS programs
Programming needsand opportunities / • Recommendations by different stakeholders
• Extent to which different key actions outlined in the IASC MHPSS guidelines are implemented
• Functionality of referral systems between and within health, social, education, community and religious sectors
Informed by IASC MHPSS Guidelines action sheet 2.1 (‘Conduct assessments of mental health and psychosocial issues’), recommendations are provided in this guide on how to conduct needs assessments for a variety of humanitarian actions and, importantly, examples of questions and tools to consider are provided. Reference is made to existing guidelines and resources, which are likely helpful when implementing needs assessments.
This document should be usedflexibly as toolboxand not as a cookbook. Different parts of it should be used for specific situations.
Phases and Timing
Within the UN–INGO humanitarian system, agencies increasingly discuss assessment in terms of 4 phases with respect to major humanitarian crises (See Table 1.2).
It is noted that that
- The times-frames in the Table below vary with the scale and severity of the major humanitarian crises.
- In general the vast majority of humanitarian aid (including all aid in complex emergencies) occurs in Phase 4
- Most mental health assessmentstend to take place in Phase 4.
- Where possible, vertical (stand alone) mental health assessments should be avoided in phases 2-3 when integration in broader assessments is recommended.
- All assessments in phases 1-3 need to be extremely rapid (data collection, analysis, and reporting) in order to be meaningful because the situation on the ground changes rapidly with time.
Most of the tools and questions covered in this document are for Phase 4. Some tools can be applied in earlier phases as part of integrated assessments (eg questions on institutions can be added to the multi-sectoral Initial Rapid Assessment (IRA)[3] in Phase 2; survey questions on serious symptoms of distress can be added to general health surveys in Phase 3, mental health categories can be added to the H.I.S. in Phase 3, etc).
Target audience
The booklet is written primarily for MHPSS staff working for health agencies in humanitarian settings. Health agencies may work at any of the following four level of the health system: (a) community health care, (b) primary health care clinics (i.e., first-level health facilities), (c) secondary care (e.g., general hospitals), and (d) tertiary care (e.g., mental hospitals). As the social determinants of mental health and psychosocial problems are multi-sectoral, the booklet also covers - although not in depth –some MHPSS assessment issues related to sectors other than the health sector.
This booklet assumes knowledge of mental health and psychosocial concepts as outlined in the IASC MHPSS Guidelines (2007). The booklet also assumes a basic knowledge of assessment techniques (e.g. how to conduct key informant interviews, group interviews, and surveys, etc), although some explanations on specific assessment techniques are given throughout the text.
Table 1.2 Phases, time frames and amount of attention to mental health in assessments of major sudden onset crises
Phases with examples of time frame after begin of major sudden onset crisis (as suggested by OCHA)[4] / Suggested amount of mental health items in assessments conducted by health agencies after major sudden onset crisis[5]Phase 0 (before the sudden onset crisis) / An in-depth assessment focused on mental health and psychosocial wellbeing, including an overview of available services and mapping of actors.
Phase 1 (e.g. first days of sudden onset crisis) / Projections on mental disorders may be made based on knowledge of previous crises.
Assessment of basic survival needs of people with mental disorders in institutions.
Phase 2 (e.g. first 2 weeks of sudden onset crisis) / A very limited amount of questions on mental health and psychosocial support as part of a multi-sectoral Initial Rapid Assessment (IRA) covering the most urgent humanitarian concerns
Collection and review of secondary data to understand context
Phase 3(e.g. second 2 weeks of sudden onset crisis) / A substantial subsection on mental and social aspects of health in a general health assessment.
Preparation for a more in-depth mental health and psychosocial wellbeing assessment in Phase 4
Phase 4(e.g., remaining) / An in-depth assessment focused on mental and social aspects of health.
2. Overview of the assessment process
Assessing needs is a continuous process. Figure 2.1. depicts this continuous process and outlines the different steps involved in assessing needs.
Before starting any assessments, coordination with the relevant stakeholders, including - as appropriate - government, representatives of the target group, local leadership, and humanitarian actors, is crucial. Coordinating assessments (e.g. dividing topics or areas of investigation between humanitarian actors) is advisable (a) to make efficient use of resources, (b) to gain a likely more complete picture of needs, and, importantly, (c) to avoid asking the same questions to the same participants.
Assessments generally involve 4 types of data collection:
a)Review of published and grey literature
b)Collecting existing information from relevant stakeholders
c)Gathering new information through integrating questions related to psychosocial and mental health concerns in assessments from diversesectors/ clusters (protection, health, education, food security & nutrition, shelter and site planning, and water & sanitation)[6]
d)Filling in any gaps in knowledge, by collecting new information on mental health and psychosocial issues through separate, focused interviews (e.g., surveys, group interviews).
In terms of data collection the IASC MHPSS guidelines describe 8 good-practice principles(see Table 2.1.).
Table 2.1. Assessment good practice principles
- Participation of relevant stakeholders (including governments, NGO’s, community and religious organizations, and affected populations) in design, interpretation of results, and translation of results into recommendations
- Inclusiveness of different sections of the affected population, including attention for children, youth, women, men, elderly people and different cultural, religious, and socio-economic groups.
- Analysis with a focus on action, rather than purely collecting information.
- Attention to conflict, e.g. maintaining impartiality, independence, considerate of possible tensions and putting people at risk by asking questions.
- Cultural appropriateness of assessment methodology and of behaviour pf assessment team members.
- Ethical principles, including respecting privacy, confidentiality, voluntary participation, and the best interest of the interviewee, and also taking care to avoid raising expectations and making sure that assessments are linked to action where possible.
- Assessment teams trained in ethical principles, possessing basic interviewing skills, knowledgeable about the local context, and balanced in terms of gender.
- Data collection methods; literature review, group interviews, key informant interviews, observation, and site visits. Psychiatric epidemiological surveys - assessing the prevalence, distribution and correlates of mental disorders are considered of academic, and advocacy value, but are outside the scope of the IASC MHPSS Guidelines and the current document.
- Dynamism and timeliness. The guidelines describe assessment as a dynamic phased process. Assessments can take place in phases, with more detailed assessment taking place in later phases (See Chapter 1)
Figure 2.1 Flow Chart Needs Assessment
3. Assessment Methodology
3.1 Surveys on the distribution and course of mental disorders
This document does not cover surveys on the distribution and course of mental disorders (psychiatric epidemiology). Such surveys are more complex than estimating rates of individual symptoms, as surveys of mental disorders in humanitarian situations need to be accompanied with studies that involve criterion validation of the diagnostic instrument (see also IASC, 2007, p.43).[7]
If a quick estimate has to be made on prevalence of mental disorders, existing WHO projections may be used for a general indication of mental disorders in crisis-affected populations (see below in Table 3.1), with the acknowledgement that this is a rough estimated median expected rate that observed rates vary widely with context and study methodology (better studies report lower rates), extent of exposure to adversity (more adversity is associated with higher rates), and the nature recovery environment (insecure, unsupportive recovery environment is also associated with higher rates)
Of note, although the document does not cover surveys of mental disorders, it does cover surveys of serious symptoms (see appendix 7A)
Table 3.1. WHO projections of psychological distress and mental disorders in adult emergency-affected populations
BEFORE THE EMERGENCY:12-month prevalence
(median across countries and across level of exposure to adversity) b / AFTER EXPOSURE TO THE EMERGENCY:
12-month prevalence
(median across countries and across level of exposure to adversity)
Severe disorder
(e.g., psychosis, severe depression, severely disabling form of anxiety disorder) / 2-3% / 3-4% c
Mild or moderate mental disorder
(e.g., mild and moderate forms of depression and anxiety disorders, including mild and moderate PTSD) / 10% / 15-20% d
"normal" distress /
other psychological reactions
(no disorder) / No estimate / Large percentage
Notes: PTSD indicates posttraumatic stress disorder.
a Observed rates vary with setting (e.g. time since the emergency, socio-cultural factors in coping and community social support, previous and current disaster exposure) and assessment method but give a very rough indication what WHO expects the extent of morbidity and distress to be.
b The assumed baseline rates are the median rates across countries as observed in the World Mental Health Survey 2000.
c This is a best guess based on the assumption that trauma and loss (a) may exacerbate previous mental illness (e.g., it may turn moderate depression into severe depression), and (b) may cause a severe form of trauma-induced common mental disorder.
d It is established that trauma and loss increase the risk of common mental disorders (depression and anxiety disorders, including posttraumatic stress disorder).
3.2How to select assessment topics and tools
Organizations should only rarely cover all topics and methods in one assessment for the following reasons:
- To avoid burdening people, study of any available information is crucial to select topics for assessment during a specific humanitarian situation. There is no point in collecting the same information twice, unless there is doubt whether existing information is up-to-date or of sufficient quality.
- Not all agencies need in-depth information on all topics. This may depend on their capacity to do the assessment and the mandate and capacity to act on the assessment.
- When inter-agency assessments are done, the large burden of doing assessments can be shared. Indeed inter-agency assessments are recommended as they tend to be credible and open the door to collaborative planning. Agencies may divide topics and select a number of more specific topics according to the agencies’ strengths.
- Choices for methodology should be based on available resources (skills, time, money), and the decision to check the reliability offindings by collecting data on the same concept in different ways (triangulation).This document at timesprovides more than one method to assess an issue, and assessors will want to select the methods most appropriate and feasible for them.
Thus, assessments usually need to focus on a selected amount of topics. Figure 3.1 depicts the process of choosing assessment topics and subsequent methodology graphically, including an example in italics. Subsequent to the selection of topics and methodology, an estimation of needed time and human resources may be made.
Figure 3.1: Selecting assessment methodology
3.3Assessment topics and their methodology
Assessment should be linked to action. Table 3.2below gives a range of actions that are relevant to humanitarian health actors in emergencies. For each action a number of tools are described in the appendices. As mentioned above, agencies should only assess topics if they have the capacityto do the assessment and the mandate and capacity to act on the assessment.