GLASGOW, Scotland — Mental health is increasingly seen as a vital part of global health, and program development needs to be sensitive to local cultures and faith to be most effective, experts say.
“How mental health conditions manifest and how people express themselves can vary considerably based on context, cultural and religious background,” Mesfin Teklu Tessema, head of the health unit at the International Rescue Committee, told Devex in an email. Programs that are not designed and implemented to meet the specific needs of a community and its individuals will not only be ineffective but could actually do more harm than good, Tessema cautioned.
Mental health cannot be an afterthought in the coronavirus response, experts say.
Jihad Bnimoussa, a psychologist and CEO of InspireCorp, a Morocco-based start-up that supports the mental well-being of young people, said there can be tensions between local sources of support, which are faith- and community-based, and science-based interventions.
With all programming, there has to be a broad sensitivity to what makes sense to various populations, communities, and individuals around the world, said Annie Bonz, director of resilience programs at HIAS, an organization that works with refugees in more than 20 countries. This means recognizing the nuances that are specific to different groups, such as how community members practice a religion or recognize their own culture in a way that an outsider might not.
“You also need to ensure that you have the relevant voices that aren’t otherwise being heard.”— Annie Bonz, director of resilience programs, HIAS
In Chad and Kenya, HIAS is already implementing the World Health Organization's Problem Management Plus — a scalable psychological intervention package that can be utilized by nonspecialists and has been successful in low-resource settings, Bonz said. But everything has to be localized, she added, and implementers must look for creative ways to adjust this model to what makes sense for local communities.
So what does it take to design a mental health program that is sensitive to culture and faith? Devex asked the experts.
Listen locally and include diverse voices
The initial part of the design process is critical, Bnimoussa said. There needs to be a deep analysis of the local culture, including determining which existing strengths can be leveraged for mental health and developmental purposes and which risks exist that need to be mitigated, she said. From there, international best practices in mental health can be used as guidance, but local contexts should not be forced to fit within these.
Start by asking a lot of open questions, even those that might seem obvious, such as how an individual defines “family,” “support,” or “success,” Bnimoussa said. Sometimes, the best insights come when you ask questions that check your assumptions, she noted.
Listening locally is key, Bonz said. It is important to figure out which leadership and faith structures exist, what the roles and expectations of individuals in that society are, and what the community's normal response would be to mental health issues. Community elders and faith leaders are often good places to start, since without their blessing, it could be difficult to get other members of the community to engage. Providing real-life examples of how supportive environments have helped other communities can assist in getting key decision-makers on board, Bonz suggested.
But she added that “you also need to ensure that you have the relevant voices that aren’t otherwise being heard.” In many societies, these include women, children, adolescents, and marginalized groups such as the LGBTQ community. Ask questions that are relevant to their experiences and how they cope, she said, but without specifically labeling their problems as mental health-related.
Consider how you are asking questions
Creating a space where people feel they can safely open up is crucial but difficult, Bonz admitted. Focus groups are often used, but even in women-only group discussions, there can be existing power structures or participants may feel they cannot speak openly for some other reason. It is therefore important to “be very critical in how we ask questions and the delivery method of that,” she said.
WhatsApp and phone calls can be used to reach out to locals individually. But it is often more effective to put information out in the community via a few key people from those marginalized groups, Bonz suggested. Local staff members play a vital role in this, as they may already be aware of existing hierarchies and know how to reach marginalized groups. “They can help figure out who to talk to and how to best capture that information,” she added.
Bnimoussa works with local associations to ensure that focus groups represent a range of young people. “The details of how you run those conversations makes a big difference,” she said. To ensure open conversations with girls, the interviewer and note taker should be women, and the tone and language used are also important. For example, using classical Arabic words, which most children are familiar with from school, can create a more formal style of interview and a sense that the participants need to perform and provide the answers expected of them, she said.
“There is no one size fits all approach to mental health.”— Mesfin Teklu Tessema, head of health, International Rescue Committee
What works and what doesn’t
Mental health and psychosocial support doesn’t always work best as a stand-alone intervention, due to the stigma around it. Design and frame programs in a way that normalizes mental health issues and involves people in various ways, Bonz suggested.
“Think ... about intersectoral collaboration,” she said, “so, looking at different ways to attract people to groups and activities that may be more based around a common issue or concern but not necessarily targeting mental health.”
Child- and women-friendly spaces can present opportunities for counselors and social workers to interact more frequently with groups to address their problems, and these activities also offer peer support, Bonz said. Group-based interventions generally work well in contexts where there is a strong focus on community. “It’s not normal in many places for people to seek out individual attention for something; it’s more a communal experience [in] seeking help,” Bonz said. This is also a more sustainable way to deliver interventions in low-resources settings.
Bnimoussa is passionate about the use of “gamification” in tackling mental health and well-being issues. In Turkey, she found that soccer-based activities were a great way to help refugee boys develop skills around expressing emotions and dealing with their negative feelings. Use activities as a medium to pass on these skills in an indirect way and in a context that the individuals can understand, she said.
Meanwhile, group yoga sessions are one component of IRC’s mental health and psychosocial support in Thailand. Yoga is a relaxation technique that is already part of the local culture there, Tessema said, but this approach might not be effective and could even increase stigma in other places, such as Yemen, where it is not a common local practice. Some culturally specific activities may be effective in one context but not in another. “There is no one size fits all approach to mental health,” he said.