Document Analysis of International Mental Health Guidelines for Humanitarian Aid Workers
This academic essay was written for a school paper assignment in grad school.
Background
The prevalence of mental health
problems is rampant among individuals exposed to disasters. Humanitarian
workers are among the most vulnerable groups to experience the mental health
impact of these stressful situations
The World Health Organization (WHO), as the leading
institution for health, recognizes this gap of service. In its effort to
promote holistic health, WHO is focused on the improvement of mental
well-being, prevention of mental disorders, and the care for people affected by
mental health disorders. WHO acknowledges that better access to mental health
support for humanitarian workers is imperative. The organization is aware of
existing international toolkits and manuals that guide the delivery of mental
health services. However, there is scant review and analysis of these
documents, especially in terms of access. It is in this light that WHO is
commissioning independent research to investigate and analyze these
international guiding documents. WHO believes that the analysis and
understanding of these documents is a worthy undertaking as it influences how
humanitarian organizations craft their manuals and implement their practices
for aid workers’ mental health. The outcome of this study will contribute
greatly to the future mental health programming of WHO and other humanitarian
organizations.
Purpose
This research mainly aims to contribute
to the ongoing discourse of safeguarding humanitarian aid workers’ mental
health. It will review and analyze selected international mental health
guidelines for aid workers. Specifically, it will examine how access is
mandated in those documents and what mechanisms are available for better
service access. It is expected that the result of this research will contribute
to improved delivery of mental health services among humanitarian
organizations.
To achieve this end goal, the research
asks:
1. Are
there specifications on mental health access in international mental health
guidelines for humanitarian aid workers?
2. If
existent, what are the mechanisms for mental health access?
3. If
existent, when and how long does the service extends (before, during, after)?
4. If
existent, is the service face-to-face or virtual?
5. If existent, are these standing or ad hoc posts?
Scope
The main focus of this research is to
understand access to international mental health guidelines for humanitarian
workers. The research will not include the exploration of the efficiency and
effectiveness of these guidelines. Relatedly, this research will not delve deep
into investigating the impact of these guidelines in any specific organization.
This paper will exclude the extent of inclusion in accessing mental health
services. Lastly, the data sources will be limited to the commonly referenced
and widely used international guidelines on humanitarian workers’ mental
health. The manual and handbook of specific organizations will not be covered.
The researcher discerns this project as a largely qualitative study based on a review and analysis of existing documents, as specified in the Terms of Reference (see Appendix A). The researcher will cross-reference to the current literature on aid worker’s mental health to make the project more comprehensive, timely, and relevant. Given the time constraint of this project, the research will focus mostly on sections on mental health and not the entirety of international mental health guidelines as several of them are generic manuals in nature.
To implement this project, the researcher will focus solely on a desk review. A systematic document review and analysis will be employed. Using the pre-selected available documents, the researcher will conduct an in-depth analysis vis-à-vis the selected theme, which is mental health access. Particularly, the “when who and how” of access will be analyzed.
Data
Selection
The
researcher will use the documents listed below as data sources. These documents
are chosen due to their prominence and wide utilization in the humanitarian
field.
·
Data Source 1: Approaches to
Staff Care in International NGOs
This report was published by InterHealth/People in Aid
that aims to guide organizations in creating and sustaining a culture of
well-being
·
Data Source 2: The Sphere
Handbook
The Sphere Handbook is used for planning, managing, or
implementing a humanitarian response. This includes staff and volunteers of
local, national, and international humanitarian organizations
·
Data Source 3: Antares
Managing Stress in Humanitarian Workers: Guidelines for Good Practice
This guideline aims to help organizations define their own
needs in relation to stress management and develop their own staff care system
·
Data Source 4: Inter-agency
Standing Committee Guidelines on Mental Health and Psychosocial Support in
Emergency Settings
This guideline intends to enable humanitarian actors to
plan, establish, and coordinate a set of minimum multi-sectoral responses to
protect and improve people’s mental health and psychosocial well-being in the
midst of an emergency
Limitations
Although
document analysis is advantageous in terms of efficiency and
cost-effectiveness, there are inherent limitations with the nature of this
approach. First, the data are secondary, hence, they were produced for some
purpose independent of this research. Second, this research is purely document
analysis so information to enrich the result is limited by what’s inside the
documents. Interviews, focus group discussion or survey questionnaires will not
be administered. Lastly, the selection of material sources might raise concerns
about bias.
Results and Analysis
The overview of the result is shown below
in Table 1. In general, the results show that international mental health
guidelines have specific provisions on mental health access. All data sources
consider mental health services during pre-deployment, actual deployment, and
post-deployment of aid workers. Most of these services are face-to-face or
in-person. Finally, most of the guidelines mention having a standing committee
to address any mental health concerns of staff members.
Not surprisingly, the results show the availability of mental health service mechanisms in all phases of employment. It is noteworthy how comprehensive are these mechanisms in Data Source 1 (Approaches to Staff Care) and Data Source 3 (Antares Managing Stress in Humanitarian Workers). Data Source 1 contains a report with key findings that illustrate the current state of staff care in humanitarian work. Based on these findings, it suggests specific key actions needed for holistic psychological health. For instance, based on its finding that post-assignment staff care is the most neglected phase, it suggests debriefing and re-entry programs for aid staff who just finished deployment. On one hand, Data Source 3 adheres to principles that inspire its suggested actions. Among the rest, only this source has clear active indicators that list recommendations for better access and quality of service. For example, the section on preparation and training is grounded on the principle that “the agency ensures that all staff have appropriate pre-assignment preparation and training in managing stress”. This is followed by indicators that list needed actions: training on stress symptom recognition, and arrangement of support for individual staff, among others. In addition, Data Source 3 has extended comments on each indicator that give descriptive and critical notes in achieving the indicators to ensure effective service. Data Source 4 (IASC) has relatively comprehensive key actions that match those of Data Source 1 and 3 but lacks a clear flow of mechanisms of access. Among the data sources, Data Source 2 has the least comprehensive content on delivering mental health access. Not to undermine its value, this source has acknowledged the importance of mental health service for staff but it does not present specific recommendations that can translate into real actions. Due to the dearth of comprehensive information in Data Source 2, most of the detailed results presented below are common themes extracted largely from Data Sources 1, 3, and 4. A closer aggregate review and analysis reveal the particular mechanisms of access in all phases of employment:
Before
Deployment
Pre-assignment screening and orientation are common among
the guidelines. An important emphasis is put on screening and assessment as these
mechanisms provide information about the aid worker that helps prevent extreme
reactions to traumatic events. Screening guides organizations to recognize
coping strategies and learn workers’ resilience ability. Assessment includes
but not limited to physical and psychological health (history of mental illness
and ongoing treatment for mental disorder); support and continuity of mental
health care; assignment probable risks and the extent of available service the
agency can provide; personal dispositions (resiliency and coping mechanisms)
and self-report surveys. Both of these allow organizations to acquire data
about the strengths of an aid worker. Accordingly, screening and assessment
facilitate an effective response based on an individuals’ personal disposition.
Having these mechanisms at the outset can help aid workers understand the
minimum health and resiliency demands of the work. The data sources caution
humanitarian organizations to ensure the proper communication of assessment
results as not mainly for screening out potential staff with a history of
psychological problems and with special mental health needs but an instrumental
process for better delivery of future mental health services. In addition, the
data sources prompt organizations on the value of maintaining ethical codes,
particularly confidentiality.
Additional results demonstrate that the key to a well-prepared aid worker lies in the pre-deployment training. These include sessions on recognizing signs and effects of different types of stresses and how to manage them (e.g. relaxation techniques, anger management, self-care, among others). Relatedly, ensuring responsive services involves a monitoring mechanism that is regular and on a routine basis. Most of the guidelines underscore the role of humanitarian team managers in this aspect, in terms of monitoring the condition and welfare of the aid workers.
During
Deployment
Data sources generally stressed the importance of ongoing support during deployment as a necessary indicator of mental health service. This includes the promotion of collegial support with respect to safety and security and general health. The role of an existing community or social support is also necessary. Facilitating the maintenance of staff communication with their families and pre-existing social capital are identified as key actions. Provided that previous training has been conducted, refresher training for staff guarantees that aid workers communicate their needs and continue learning from the experience. During the deployment, the guidelines accentuate that it is essential that staff are provided with a healthy working environment. In other words, basic food and hygiene and good accommodation are available. Policies on rest and recuperation are existent. Moreover, results indicate that it is vital to obtain greater access to Psychological First Aid (PFA) for aid workers who experienced an extremely traumatic event. Hence, mechanisms to train staff on PFA to help in urgent cases of crisis support and management are a good key action during the deployment period.
After
Deployment
Among the phases of employment, post-deployment health
service, a minimum standard of good staff care practice, is the most
ineffective, if not absent. Despite this result, it is interesting that the
guidelines illustrate heavily on ideal key actions and indicators for improved
post-assignment psychosocial care. During the end of the contract of the staff
aid, mental health services after assignment include personal debriefing that
aims to process the experiences and feelings of aid staff. This processing also
facilitates the meaningful integration of workers to their families and home
communities. Relatedly, data sources illustrate mechanisms of supporting staff
with stress-related disabilities such as severe stress, depression, burnout,
and compassion fatigue. On top of these psychological and emotional tasks,
organizations are responsible for formulating mechanisms that attend to the
practical and transitional needs of aid workers after the termination of the contract.
At this juncture of the employment, organizations provide overall health
check-up, including stress review and assessment. In a rare and ideal case, humanitarian
workers seek informational materials about stress.
The guidelines suggest an ideal standard of service in terms of timeline, sensitivity to context and diversity, and presence of referrals. Particularly, post-contact mental health services are not later than three months after exposure to adversely stressing event exposure. This includes both national and international staff. Noteworthy, most of the handbooks highlighted the value of response that is culturally and linguistically appropriate. Results present that post-deployment referrals to trusted professionals for follow-up are common among the sources. Moreover, other than having an updated referral list of psychosocial experts, opportunities for peer support groups are also mentioned in the guidelines as considerations for good staff care.
Face-to-Face
Versus Virtual
Most of the data sources mention mental health services that are conducted with physical contact with the service provider/expert. In the results presented above, all of those mechanisms in the phases of employment transpire on a face-to-face basis. Only Data Source 1 has a remarkable mention of the virtual delivery of mental health services. In particular, the virtual service assistance program that involves email support ran by an external professional is exemplified. Another platform for non-physical delivery is through a telephone support system that operates 24/7 to cater to any sudden psychological needs of the aid worker. However, this telephone service is rarely available to staff working in remote places. In other words, it only accommodates those humanitarian workers within the country where the office is stationed. Lastly, solely Data Source 1 explains online communities for peer support. It lists sample websites (e.g. aidworkers.net, epn.peopleinaid.org) where aid workers can join support networks.
Standing
Versus Ad-hoc
Almost all of the data sources describe standing posts to
respond to the mental health needs of aid workers. An in-house capacity to
respond to sudden emergencies is the standard but not always given prime
attention, as reflected in the source guidelines. Frequently, in-house services
are operational only in headquarters or regional offices. Some humanitarian
organization outsources professional services. A standing specialist is a
helpful back-up for serious psychiatric concerns such as suicidal feelings, and
psychoses. Likewise, standing contracts with local, regional, or international
mental health professionals ensure timely response during the occurrence of
events. For serious and urgent cases, ad-hoc services are authorized. Particularly,
psychological first aid (PFA) operated in an ad-hoc mechanism, especially when
trained senior staff members are insufficient.
Table 1.
Overview of Review and Analysis Matrix
|
Materials |
Mechanism of Access |
||||||
|
When |
How |
Who |
|||||
|
Before |
During |
After |
Face-to-Face |
Virtual |
Standing |
Ad Hoc |
|
|
Data Source 1 |
✔ |
✔ |
✔ |
✔ |
✔ |
-- |
✔ |
|
Data Source 2 |
✔ |
✔ |
✔ |
✔ |
-- |
-- |
-- |
|
Data Source 3 |
✔ |
✔ |
✔ |
✔ |
-- |
✔ |
-- |
|
Data Source 4 |
✔ |
✔ |
✔ |
✔ |
-- |
✔ |
-- |
The primary objective of the research is
to investigate mental health access mechanisms in international mental health
guidelines through a document review and analysis. The results showed that
access mechanisms are present among the data sources. In a more fine-grained
analysis, this study yielded three salient findings worth further discourse:
(1) mental health access is mentioned in all phases of employment; (2) the
delivery of the mental health services are mostly conducted in person, and (3)
half of the data sources indicate a standing post in responding to
psychological needs of aid workers.
First,
the availability of mental health access in all phases has been collectively
agreed to be important for humanitarian workers. In a study by Quevillon et al
(2016), they highlighted that access to mental health programs at the preparation
stage, during deployment, and after an emergency operation is critical to the
mental well-being of aid workers and the overall quality of humanitarian
operations. Relief workers who perceive inadequate mental health support may
feel disappointed, and angry toward the organization
Core
to the findings of this study is centered on the importance of organizational
and social support. This finding is supported by a wealth of literature
demonstrating how mental health programs focused on building social network and
support by the employer organization can lead to the improved well-being of aid
workers
The
second major findings show that most of the content of the guidelines are
focused on face-to-face delivery of mental health service. While face-to-face
interventions have been praised for its proven effectiveness, the reality of
humanitarian operations does not always allow in-person sessions, especially
for extreme and severe psychological concerns. Conversely, recent studies have
shown the effectiveness of internet-supported and mobile-based interventions
Finally,
the third salient findings indicate that most of the guidelines are geared
towards standing posts instead of ad-hoc. This is contradictory to reality
where most of the interventions are on an ad-hoc basis. If not ad-hoc, most
humanitarian organizations have in-house capacity but are accessible only at
the headquarters or regional offices. Henceforth, it is recommended for
humanitarian agencies to have a mechanism that is more responsive to the
unexpected mental health needs of aid workers. This entails having a steady
standing post that can respond to any sudden call for mental health services.
Notwithstanding
the contributions of this study, a number of limitations need to be noted. As
mentioned above, the methodology of the research has inherent restrictions in
terms of triangulating data sources; only the international mental health
guidelines were considered. On top of the concerns on reliability and validity,
document analysis relies heavily on secondary data which means the data sources
were made for something entirely independent of this research
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