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FIELD REPORT
Year : 2023 | Volume
: 21
| Issue : 1 | Page : 14-19
Psychosocial Programming in Uganda: Adaptations during COVID-19
Gary Samuel Agaba1, Ben Otto1, Rehema Kajungu1, Grace Obalim1, Katie Hindes2, Flora Cohen3
1 Transcultural Psychosocial Organisation, Uganda
2 Inner City Fund, Kansas City, MO, USA
3 George Warren Brown School, Washington University in St. Louis, St. Louis, MO, USA
Correspondence Address:
Flora Cohen
GeorgeWarren Brown School, Washington University in St. Louis, Campus Box 1196, One Brookings Drive, St. Louis, MO, 63130
USA
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/intv.intv_16_22
The COVID-19 pandemic brought concerns about mental health to the fore. While more and more people struggle with the mental health effects of experiencing a global pandemic, people in humanitarian settings may be even more at risk. In humanitarian settings, it may be more challenging to ensure accessible to mental health services and support staff who are implementing essential programmes amidst concerns for their own health. We present a report of programme adaptations during COVID-19, including measures to support staff wellbeing, communicate with donors to support protective measures, and adapt programmes to be safer and more accessible for beneficiaries. Lessons learned from adaptations during COVID-19 can inform additional programming in humanitarian settings, especially in sub-Saharan Africa.
Keywords: COVID-19, psychosocial, Uganda
The COVID-19 pandemic brought about significant changes worldwide and forced nations to make large-scale adaptations to their institutions. Ugandan officials received word of the country’s first positive case on 21 March, 2020, and control of transmission was accomplished mainly by the population’s adherence to strict lockdowns, large-scale testing efforts, the closure of country borders and informational public health campaigns (Olum & Bongomin, 2020, p. 19). Many other nations enacted similar measures to disrupt the local transmission of the virus.
The COVID-19 pandemic severely impacted the mental health of individuals and communities. Globally, individuals reported increased anxiety regarding disease transmission, isolation and detrimental financial implications (Kola et al., 2021, p. 19). For populations affected by armed conflict and humanitarian crises, the compounded predisposition to extreme mental health challenges and ongoing pandemic anxieties were particularly worrisome (Charlson et al., 2019). The United Nations High Commissioner for Refugees (UNHCR) reported an increase in the number of phone calls related to self-harm and suicide from refugees in Lebanon, who expressed an inability to see a way out of their current circumstances. In a north-western Syrian city, mental health consultations for new patients doubled in the year 2020 (OCHA, 2021). This phenomenon was also seen within refugee settlements in Uganda, where suicide attempts increased by over 60% from 2019 to 2020 (Nuri, 2020). Children in refugee settings were significantly affected by the mental effects of COVID-19, as 70% of them express a need for psychosocial support as a direct result of the pandemic and subsequent lockdowns (Haddad et al., 2020).
Despite the significant increase in the need for mental health services, the delivery of services that supported the mental wellbeing of individuals affected by armed conflict and humanitarian disaster was challenged by the implications of the Ugandan national lock-down and staff burnout. As of October 2020, roughly three-quarters of school and workplace mental health services were disrupted, even though requests for mental health and psychosocial support increased globally (WHO, 2020). Schools in Uganda were fully closed for roughly 18 months before unsuccessfully attempting to reopen public schools in 2022, depriving children and caregivers of access to essential services (Barigaba, 2021). Many professional mental health facilities were closed entirely to be used as care facilities for those with COVID-19, leaving those in need of mental health services with limited support. People also sought psychiatric services less frequently, particularly in hospital settings, for fear of contracting COVID-19. These reduced and limited services put more pressure on humanitarian workers in countries affected by conflict and disaster. The International Committee for the Red Cross reported a dramatic increase in requests for mental health services from staff members since the pandemic began. These employees faced extended hours exposed to stressful events as they responded to not only people in conflict-affected settings, but also to a large number of deaths and illnesses (ICRC, 2020).
Programmes providing psychosocial support have been forced to adapt quickly to an increased demand and a diminished capacity, due to the closure of other programmes, as well as COVID-19 social distancing and isolation guidelines. The Inter-Agency Standing Committee released guidelines for programmes to follow during the pandemic to ensure programme delivery and safety of clients and staff. These guidelines include: discussing when and how to reduce face-to-face activities, prioritising urgent versus non-urgent service users based on individual risks and needs, and implementing distancing measures when providing face-to-face programmes (IASC, 2020). Based on community and organisational discussions regarding these considerations, as well as the consideration of the digital divide in Uganda, our only option to continue programming was to meet in-person as was originally planned. We were aware that safety precautions would need to be implemented, and public health guidelines heeded, but our face-to-face meetings would be the only way to deliver services based on our population. To prepare for the implementation of services during the pandemic, we looked to other organisations that continued in-person services for guidance. The International Rescue Committee continued in-person programmes in Burkina Faso, but they removed from the programme people who were at a higher risk of contracting COVID-19. These included people with underlying health conditions and those over the age of 50. Nearly all of the International Rescue Committee’s staff remained in Burkina Faso with strict distancing measures, except for two staff members deemed nonessential, who were sent home (Mednick, 2020). The remaining staff members were informed that if they were to attend non-office-related gatherings, they must self-isolate for 2 weeks before returning to work. Some organisations also took it upon themselves to inform their employees of the public health environment at work, like the Burkina Faso and Niger branches of the Norwegian Refugee Council, who played COVID-19 informational briefings at 8 am to combat misinformation about the virus in the office.
Globally, organisations were able to adapt their delivery of psychosocial support services within humanitarian settings in innovative ways. Many organisations, even those supporting refugee mental health, transitioned to virtual services during the pandemic, which was vital to programmatic success and increased programme equity (Charlet et al., 2023). Health Equity Initiatives (HEI), a group that provides psychotherapy to refugees in Malaysia, was able to continue programming through online counselling and support groups (Verghis et al., 2021). Clinical psychologist Andrea Alvarado had success with the unconventional approach of helping service users access an intervention delivered via Facebook and WhatsApp in Ecuador (Gray & Abdi, 2020). Other organisations, specifically psychiatry providers who service individuals, were successful in implementing home visits to their populations. For example, an organisation in Brazil implemented an effective hybrid model of in-person and at home services to treat individuals with psychotic disorders. A similar model was attempted in Uganda (Kola et al., 2021).
Based on the information available, phone-based and video services have delivered the best results in continued service during the COVID-19 pandemic. While many organisations were able to adapt these technologies to their programmatic areas, these strategies are not plausible in many regions of the world, particularly in the parts of Uganda that experience the extreme “Digital Divide”. Access to digital technologies in Uganda is limited for many people in the country, who believe the technology to be unaffordable. This is particularly true of the poor, rural populations, women and persons with disabilities. Uganda has the third largest urban-rural internet access gap in the world, with only 9% of rural Ugandans able to access the internet and roughly 30% of those in urban areas able to do so (Gillwald et al., 2019). This is in part due to the underdeveloped infrastructure of the country, which provides only 18% of Ugandans with electricity. In a study conducted of 22 countries in the Global South, Uganda had the second lowest smartphone device ownership, with only 16% of mobile phone users owning a smartphone (Gillwald et al., 2019). This technological environment, besides depriving Ugandans of opportunities and information, also prevents the implementation of digital psychosocial interventions, particularly in humanitarian settings in the country. Transcultural Psychosocial Organisation (TPO) Uganda, is a national Non-Governmental Organisation (NGO) that has been operating in Uganda for over 28 years, since 1994. It is registered as a non-profit organisation by the Ministry of Internal Affairs of Uganda. TPO Uganda’s field of operations lies within the thematic area of mental health and psychosocial support. These areas are supported by programmes in child protection, disaster risk reduction, food security and livelihoods support, prevention and response to gender based violence, prevention of HIV/Aids, emergency response and peace building & conflict resolution. It enjoys a strong partnership with the Ministry of Gender, the Ministry of Labour and the Ministry of Social Development with whom it has a valid memorandum of understanding for years. TPO Uganda also works closely with the Ministry of Health, the National Psychiatric Hospital in Butabika and is a World Health Organisation (WHO) implementing partner for mental health services. Furthermore TPO Uganda has partnerships and works with the Office of the Prime minister and UNHCR as agency largely mandated with humanitarian responses. TPO Uganda specialises in providing people suffering from mental health conditions with psychosocial support, trauma management and clinical referrals for specialised care.
Organisational Adaptations during COVID-19In Uganda and the region, TPO Uganda is a major provider of community- and family-based mental health services. TPO Uganda has, over the past 25 years, worked with the government to build capacity and train health care workers to integrate the identification, screening and management of mental illness into primary health care programmes. We have worked closely with the ministry of health to develop community education and awareness raising guides on MHPSS including treatment of epilepsy at household level. TPO Uganda has worked with the ministry of health to respond to national crisis, in particular setting up a psychosocial response for the Ebola affected communities and at risk health workers and responding with psychological first aid to victims of the mudslides in eastern Uganda in 2012.
TPO Uganda has an active presence in over 32 districts and employs up to 41 clinical psychologists who can be quickly called upon to provide technical support and backstopping to the proposed scale up project. The organisation is also known for its training programmes, training social workers, health workers and district technocrats in the identification, screening, management and referral of persons with mental illness approaching them for treatment. TPO Uganda primarily serves internally displaced persons (IDPs) in Uganda and refugees from neighbouring countries such as South Sudan, the Democratic Republic of Congo, Rwanda, and Burundi. The service TPO Uganda generally provides is mental health and psychosocial support to these conflict-affected communities.
Staff Support
TPO Uganda developed a COVID-19 working strategy focused on ensuring the safety of all programme staff and beneficiaries. As the COVID-19 pandemic progressed, assessments were made about the impacts of social distancing measures and safety protocols on programme delivery. Organisational strategies were refined to down to the “core of the core” activities that were vital to communities and could feasibly be implemented. Responsibilities were clarified with everyone in the organisation. Key staff, who included the finance team, transport team, project coordinators, social workers, and clinical team kept working. TPO Uganda headquarters developed a rotating shift with only four staff at the office at any time. Senior management met thrice a week during the pandemic to make sure operations were adequately supported. At the beginning of the pandemic TPO Uganda was quick to respond with an evacuation plan, all non-essential staff were immediately evacuated from the field locations. A fleet of vehicles was assembled by TPO Uganda to evacuate and deliver every staff member to their homes safely.
During programme implementation activities, office staff were minimised. Staff were encouraged to work from home, with 10% reporting to their offices. The rest of the staff were advised to stay at home, however TPO Uganda being an essential service, meant that field activities continued to be implemented. Activities were implemented following government guidance as applicable and strictly complying with standard operating procedures (SOPs). Information was provided to TPO Uganda staff through trainings about COVID-19, methods to prevent it, handwashing advice, how to report, and what to do if someone suspects they have COVID-19. Furthermore, staff and visitors were provided with hand sanitizers, tissues, masks and cleaning products. Additional information was displayed in the office, including handwashing techniques and other hygiene related relevant information in the form of images and posters at relevant spots in the office space. Office staff jointly ensured that the cleaning regimes were in place, including sanitizing surfaces frequently. There were reductions in staff travel for work. Previously, staff from headquarters travelled to the office approximately five times a week, this was reduced to twice a week. Staff also worked in shifts with not more than six people at the office per day. Public means of travel were no longer available for TPO staff, vehicles were identified to pick staff a limited number of times per month. Furthermore, a restriction was implemented, wherein only three people were allowed to travel per vehicle. Online platforms also reduced the need for in-person meetings and paperwork. DocuSign was introduced organisationally, where all documents or paper work could be signed online.
TPO also collaborated on the work at home policy. Staff were provided with planning, guidance, hardware, and software. Core staff had laptops and internet provided to them to work at home and support the field staff who were amongst frontline workers. Working at home included sharing expectations and targets with supervisors for monitoring. Team supervisors held regular online meetings to share accomplishments, challenges and ways forward. TPO also adapted using video calling or video conferencing apps and platforms, including Microsoft teams and zoom. Staff were also provided with emergency contact details in order to ensure they felt supported.
During COVID-19 TPO was able to adapt to staff and community needs. TPO was able to retain and provide salary for staff. While other organisations were downsizing, TPO continued to engage with donors and funding was accelerated to maintain staff. Responding to staff needs and continuing programming despite the challenges of the global pandemic kept staff motivated. TPO was also able to provide counselling services for staff affected by COVID-19, this was done through the clinical teams in the field, and teleconferencing was also available to assist various staff. Counselling provided support structures and encouragement to staff during these challenging times and prevented exacerbating mental health concern among staff. Staff were also able to receive COVID-19 treatment through the organisation’s health insurance.
Information Transparency
In order to ensure the smooth implementation of programmes in a humanitarian context, information transparency was key and support mechanisms were implemented to keep staff safe and healthy. Timelines for deliverables also had to be adjusted to allow for any lock downs or other barriers to implementation. Disseminating information to staff about vaccinations provided by the United Nations for humanitarian workers was vital, and a Mental Health and Psychosocial Support (MHPSS) helpline for mental health related services was provided for all staff. The TPO clinical team also provided psychosocial support to the staff on the radio, where they discussed how to cope with stress during COVID-19, Psychological First Aid, and how to deal with the stigma around COVID-19. TPO also encouraged staff vaccinations. This communication had a positive impact as several staff were able to get vaccinated. However, challenges were met in the need for more vaccines in country and vaccine hesitancy among staff.
TPO provided regular updates about safety guidelines from the Ministry of Health (MoH) and international bodies like the WHO, and related programmatic changes. This information ensures that all organisation staff have appropriate information while implementing activities during COVID-19. Information transparency allowed for people to make informed decisions about their health and follow SOPs accordingly. Furthermore, programme staff were catered for in the realigned budgets, with a focus on making sure staff were empowered with knowledge about COVID-19, able to access treatment, and a COVID-19 fund was set up to assist staff in case they fell sick.
Trainings were also provided for psychosocial support staff by health implementing partners like International Rescue Committee (IRC) who are the lead health partners in the humanitarian setting. Trainings involved creating awareness on COVID-19, including how to cope with related mental health impacts and access to health services. In Kiryandongo, an intensive care unit was set up for treatment of COVID-19 patients by IRC. Effective training for staff around Uganda was a bit challenging, TPO offices are quite spread out and some are in hard to reach areas, so some trainings were delivered virtually.
District task force meetings supported information sharing and pandemic surveillance. Task force meetings are held weekly, discussions include updates about COVID-19 infections, treatment and vaccinations. The district task force includes the District Health Officer, Resident District Commissioner (RDC), and psychosocial support (PSS) officer from TPO. The local government also used the task force to update stakeholders on operating procedures around COVID-19. Furthermore, updates on vaccination rates were shared, including the number of people being vaccinated, and barriers to increased vaccinations. The District Health officer focused on information from government on availability of vaccines and schedules for priority populations, availing of information on vaccines and proper usage. The RDC focused on security and implementing the government policies on COVID-19 like the curfew, wearing masks and avoiding group gatherings. The PSS officer focused on MHPSS services for COVID-19 patients, especially under home-based care issues like dealing with stigma in community.
Information transparency was necessary on multiple levels, between implementation staff and beneficiaries, between implementing organisations, and between the implementing organisation and funders. TPO was also in discussions with donors about the challenges related to COVID-19 during the implementation of programmes. Fortunately, many donors offered support and flexibility during this challenging time. The pandemic also created a need for the realignment of some budget items to cover materials like personal protective equipment (PPE), including masks, face shields, and hand sanitizers for staff in the field.
Programmatic Adaptations
Programme beneficiaries and community members were at risk of being impacted by COVID-19. The groups of people who were most vulnerable are those with pre-existing health conditions, people of elderly ages, and those who were part of socially marginalised vulnerable populations. TPO played a major role in spreading awareness and information, educating people about preventive measures, and last but not the least, showing care and empathy. This awareness-raising was provided through radio shows and television programmes. Radio shows were delivered in the local languages of the displaced community being served by TPO Uganda.
Programme activities were managed according to local conditions. It is important to remember that the impacts of the COVID-19 pandemic include mental health in addition to physical health concerns. Therefore, TPO introduced tele-counselling services to provide counselling services through toll-free lines. The lines were for the community to call to receive MHPSS support. The toll-free lines were handled by a social worker and clinical psychologist. The telephones also acted as a referral tool for community challenges. The helplines were established to support those in self-isolation or those who are facing mental health issues due to the pandemic. In-person programmes were also adapted through innovative ways. Group sessions like Journey of Life and Cognitive Behavioral Therapy for Trauma (CBTT) were reduced from a group size of 20 to 10 participants, in an open space, with a 4-m seating distance, using sanitizers, and wearing masks throughout (Stark et al., 2023). TPO Uganda was also able to support People Leaving with AIDS (PLWA) in medication distribution programmes. TPO was able to pick up and distribute medications to PLWA, these efforts saved many lives during the pandemic (TPO, 2022).
The impact of COVID-19 on programme beneficiaries was a major concern, which led to the diversion of resources to support public health infrastructure such as hand washing facilities, and mask distribution. Beneficiaries were given this PPE to help them prevent contracting COVID. Donors were engaged in budget realignments to have components of COVID-19 support, for example, funding originally allocated to transport staff for field visits was diverted to buying PPE for beneficiaries.
During the lockdown in Uganda, there were concerns about the ability to continue implementing programmes. The lockdown prohibited inter-district travel and many activities within the settlement were curtailed, leaving additional time and resources for mental health programme implementation. The lockdown actually increased attendance in many locations, which was beneficial for TPO programming (Stark et al., 2023).
DiscussionThe COVID-19 pandemic has brought significant challenges around the world in terms of service delivery. The mental health of individuals and communities has been highlighted as a key concern during the pandemic. In order to meet the complex mental health needs of communities, organisations operating in humanitarian settings had to adapt. TPO Uganda quickly made services available through innovative means, supported staff wellbeing amidst uncertainty, and transparently communicated with key stakeholders to ensure uninterrupted programme delivery.
There were some challenges to programme delivery during COVID-19. While training staff in the SOPs and procedures for coping with COVID-19 was vital, it took a lot of work to reach all staff, especially those located in remote areas. Additionally, while some budgets had to be realigned in order to account for additional PPE, it was not always possible to coordinate this realignment with donors. Lastly, staff and beneficiaries who contracted COVID-19 experienced a stigma that left them feeling uncomfortable with seeking support. However, trainings helped to ease COVID-19 stigma.
Lessons learned from implementing psychosocial programmes during COVID-19 can be utilized to expand future programming. Throughout services it was important for TPO to maintain high standards for research and programme implementation. Supervision was key to supporting and motivating staff. Additionally, continuous training and capacity building opportunities for the team was vital to high quality programming.
ConclusionIn order to meet the growing mental health needs of the COVID-19 pandemic, organisations providing support in humanitarian settings had to adapt. TPO Uganda was able to tailor supports for staff, communication with donors, and service delivery for beneficiaries in order to ensure safe, timely and supportive care delivery. TPO’s commitment and drive for continued service delivery during COVID-19 led to effective adaptations in COVID-19 pandemic. Lessons learned from TPO’s adaptations can be used to continue to improve services within humanitarian settings.
Financial support and sponsorship
The research team was supported by the United States Agency for International Development (USAID) under the Health Evaluation and Applied Research Development (HEARD), Cooperative Agreement No. AID‐OAA‐A‐17‐00002. This study is made possible by the support of the American People through USAID. The findings of this study are the sole responsibility of TPO Uganda and Washington University and do not necessarily reflect the views of USAID or the United States Government.
Conflicts of interest
There are no conflicts of interest.
References
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