| Context |
Conflict-affected females who are internally displaced in low-resource settings. Have experience of historic and collective trauma, social and gendered inequality, live in poor displacement conditions with poor access to services |
Conflict-affected females who are internally displaced in low-resource settings. Have experience of historic and collective trauma, social and gendered inequality, live in poor displacement conditions with poor access to services, during a global pandemic
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| Intervention |
Group and individual psychotherapy (narrative exposure therapy, cognitive behavioural therapy, interpersonal therapy and thought field therapy), livelihood programmes, EMDR, art therapy, relaxation techniques, counselling |
| Mechanism |
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Therapeutic relationship: movement restrictions have resulted in road closures for many months [Interview 6] and an inability of service providers to deliver in-person care: ‘Regarding going to the field or inside the community centres, no one was allowed to do that’ [Interview 7]. Organisations have tried to keep camp members connected to services using portable devices, however ‘some NGOs stopped totally without conducting any online services’ [Interview 7]. Unstable internet connections and frequent electrical shortages mean that many have limited access to regular support [Interview 3]. Restrictions also meant it was ‘difficult communicating with the work team because all of our meetings and communication went online’ [Interview 6]. Safe spaces: If able to engage in online support, many feared speaking about their experiences at home [Interview 6]. Increased time at home due to lockdowns also increased rates of IPV: ‘Patients are more isolated which increases stress and rates of violence in the family. We have seen increases in domestic violence and violence against children…the issue with mobile delivery is that people have no privacy – if you are working with a Yazidi woman in a tent, she has suffered ISIS abuse but it is also likely that she has suffered abuse in her household. Some people we've been working with have protested and said they can't work over the phone anymore’ [Interview 5]. To deal with the closure of safe spaces, one stakeholder noted that they had ‘converted some centres used for art activities into consultation rooms where clients can come in and speak to staff remotely’ [Interview 3]. Another has been working on ‘strategic planning which involves moving video conferencing to centres rather than leaving them in camps’ [Interview 5]. Social connection: despite evidence of an increased prevalence in common mood disorders since the outbreak of the pandemic, group-based interventions have been reduced from 20 participants to 4 or 6 [Interview 2]. ‘This is necessary to prevent spread of the virus because in the camp, the tents are close to each other’ [Interview 1]. Sewing and drawing classes were reduced to 5–6 participants [Interview 1] Mental health literacy: interventions have mostly focused on mental health disorders surrounding COVID-19 and neglected the stigma associated with other forms of trauma, such as CRSV: ‘The only activity that we were having was COVID-19 psychoeducation’ [Interview 7]. Gender-matching: redirected human resources to COVID-19 mean gender-matching has not been prioritised. Stakeholders did not provide specifics but spoke generally about reallocation of resources due to the pandemic. Empowerment: loss of livelihoods and economic strain meant ‘higher levels of deprivation and stress –almost no one has access to work’ (Interview 5); ‘[they fear] they might not be able to work and get money for the family if they get COVID-19’ [Interview 7]. ‘The curfew also meant they might not be able to go to Dohuk for work’ (Interview 8). Being unable to protect loved ones from the virus has also reactivated feelings of helplessness experienced during genocidal attacks [Interview 7]. Cultural competency: urgent public health messaging failed to integrate cultural factors such as high illiteracy rates: ‘Some were saying it [COVID-19] is a political and economic issue that has been created to get money and such things. But then, day-by-day, the cases were increasing. So then they realised that it's true. But there are also factors which impact on that, for example, an educated person will not be like an illiterate one. IDPs they are not educated. Yeah, they are illiterate’ [Interview 7].
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| Outcome |
Reduced PTSD, depression, anxiety, suicidal ideation and suicide attempts. Improved functioning scores, conduct behaviours, well-being |
Regressed treatment progress: ‘It has affected treatment and therapy sessions. Many who were getting better, COVID-19 came and damaged all the progress.. Some are afraid of COVID-19 but most would rather receive mental health treatment – they want someone to help’ [Interview 8]. Symptom relapse: ‘Cases who suffered from PTSD and flashbacks, the interventions made them stable but COVID-19 means they had to stay in tents for 3 months and this caused their mental health to decline. Their homes aren't like houses but are poor living conditions. When they don't go out for a few weeks, their flashbacks returned’ [Interview 8]. Fear of attack: ‘There have been 20 attacks by Turkey in towns and near camps. Many ISIS fighters were Turkish in origin, so when we heard that Turkey was coming, we know ISIS will come with them’ [Interview 7]; ‘Some of the women were afraid because of the memories of genocide’ [Interview 8]. Increased symptoms including flashbacks, boredom, frustration, shortness of breath, loss of energy, nightmares, fear, suicidal thoughts, PTSD, depression, anxiety [Interviews 1, 3, 7 and 8]; ‘COVID-19 has affected cases very badly’ [Interview 8]; The women understand what is happening and they are really scared” [Interview 5]; ‘Since the start of the Coronavirus, suicide for young men and girls have been detected’ [Interview 8]. Increased desire to emigrate abroad [Interview 1] or anxiety about whether to return to Sinjar: ‘Some others were saying that if they didn't come back to our home town [Sinjar], they will not be able to go back again. So, they were having a big anxiety about that’ [Interview 8]. Lack of trust in authorities: ‘Some people don't believe that COVID-19 is real, it is political’ [Interview 8]; ‘There are allegations and rumours that more and more cases are in camps and authorities are not reporting them’ [Interview 3].
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