1

DRAFT VERSION OF WHO TOOLKIT March 2010

Mental Health and Psychosocial

Situation and NeedsAssessments

in Major Humanitarian Crises:

WHO Toolkitfor Humanitarian Health Actors

(Draft Version)

Quick guide to identifying tools in this document

Potential actions by humanitarian health actors / Relevant appendices to be considered for use in assessment / Page number
  1. Coordination
/ 1Health Cluster HeRAMS
2 Who is doing What Where When (4Ws) in mental health and psychosocial support: Excel based tool / 14
16
  1. Meeting the basic needs of people with mental disorders in institutions
/ 3 Checklist for site visits at institutions / 25
  1. Providing access to basic mental health care for urgent mental health complaints in PHC
/ 4 Checklist for integration of mental health in PHC
5 Key Health Information System (HIS) mental health data / 26
29
  1. Providing access to psychological first aid to people in acute distress after exposure to extreme stressors.
/ Coping section of appendix 12covering free listing on local coping methods / 48
  1. Initiate plans for development of a sustainable community mental health system in the region
/ 6 Summary of mental health system formal resources / 31
  1. Addressing alcohol and other substance use
/ 7 Interview guide on alcohol and other substance use / 34
  1. Advocacy on the prevalence of problems
/ 8Integrated assessment of serious symptoms of distress in humanitarian settings / 36
  1. - Ensuring that community health workers strengthen community self-help and social support
- Informing any of the above actions by knowledge on the context / 9Example questions for key informant or group interviews on context
10Participative ranking of problems and resources
11Interview with traditional/ religious healers on local perceptions of mental health
12 Free listing on local indicators of distress, daily functioning and coping methods
13 Key informant interview on local indicators of distress, daily functioning and coping methods
14 Checklist on obtaining existing information from Clusters / 41
44
46
48
50
52

Table of Contents

1. Introduction

2. Overview of the assessment process

3. Assessment methodology

4. Translating assessment into practice

Appendices

  1. Health Cluster HeRAMS14
  2. Who is doing What Where When (4Ws) in mental health and psychosocial support: Excel based tool 16
  3. Checklist for site visits at institutions25

4.Checklist for integrating mental health in PHC26

  1. Health Information System (HIS) data 29
  2. Summary of mental health system formal resources31
  3. Interview guide on alcohol and other substance use34
  4. Integrated assessment of serious symptoms of distress in humanitarian settings36
  5. Example questions for key informant or group interviews on context41
  6. Participative ranking of problems and resources44
  7. Interview with traditional/ religious healers on local perceptions of mental health46
  8. Free listing on local indicators of distress, daily functioning, and coping methods: Free listing48
  9. Key informant interview on local indicators of distress, daily functioning, and coping methods50
  10. Checklist on obtaining existing information from Clusters52

Annex: Bibliography for further reading53

1. Introduction

1.1 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 health sector actions. This document – written for humanitarian health actors - is intended to help fill thesetwo gaps.

Table 1.1. (IASC, 2007; p. 40-41)[1]

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.

This document should be usedflexibly as toolboxand not as a cookbook. Different parts of it should be used for specific situations.

1.2 Phases and timing

Within the international 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

  1. A common language on the order of phases and tasks is useful for collaborative planning.
  2. The times-frames in the Table below vary with the scale and severity of the major humanitarian crises.
  3. 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.
  4. In general the vast majority of humanitarian aid (including all aid in complex emergencies) occurs in Phase 4.
  5. Most mental health assessmentstend to take place in Phase 4.
  6. Where possible, vertical (stand alone) mental health assessments should be avoided in phases 1-3, when integration in broader assessments is recommended.

Most of the tools and questions covered in this document are for Phase 4.Yet some tools can be applied in earlier phases as part of integrated assessments. For example

  • questions on institutions can be added to the multi-sectoral Initial Rapid Assessment (IRA)[2](phase 2);
  • survey questions on serious symptoms of distress can be added to general health surveys. (phase 3),
  • mental health categories can be added to the health information system (H.I.S) (phase 3).

1.3 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 levels 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 that are relevant to other sectorsin addition to 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 lesser-known assessment techniques are given in 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)[3] / Suggested amount of mental health items in assessments conducted by health agencies after major sudden onset crisis[4]
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[5]

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

  1. 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
  2. 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.
  3. Analysis with a focus on action, rather than purely collecting information.
  4. Attention to conflict, e.g. maintaining impartiality, independence, considerate of possible tensions and putting people at risk by asking questions.
  5. Cultural appropriateness of assessment methodology and of behaviour pf assessment team members.
  6. 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.
  7. Assessment teams trained in ethical principles, possessing basic interviewing skills, knowledgeable about the local context, and balanced in terms of gender.
  8. 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.
  9. 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

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 (i.e., psychiatric epidemiology). Such surveys are very challenging to conduct in a meaningful manner, becausesurveys of mental disorders in humanitarian situations need to be accompanied with studies that involve criterion validation of the diagnostic instrument to avoid confounding the concept of disorder with that of non-disordered distress (see also IASC, 2007, p.45).[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 anestimate onlyand that observed rates vary widely with context and study methodology:

  • more adversity (loss and trauma) is associated with higher rates,
  • an insecure, unsupportive recovery environment is associated with higher rates,
  • higher quality studies (involving diagnostic tools, random samples, and large sample sizes) are associated with lower rates

Of note, although the document does not cover surveys of mental disorders, it does cover surveys of serious symptoms (see appendix 8).

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:

  1. To avoid burdening people, study ofalready available information is crucial to minimize the topics for further assessment. 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.
  2. Most agencies do not need in-depth information on all topics. The information needed depends on their mandate and capacity to act on the assessment.
  3. When inter-agency assessments are done, the large burden of doing assessments can be shared across agencies. Inter-agency assessments are recommended, because they tend to be more credible, and they tend to facilitate collaborative planning. Agencies may divide topics and select a number of more specific topics according to the agencies’ strengths.
  4. 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. 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. The table on the front page of this document gives a range of actions - consistent with the proposed Sphere 2010 Mental Health standard - 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.