International Journal of Disaster Risk Reduction 54 (2021) 102051

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International Journal of Disaster Risk Reduction

journal homepage: http://www.elsevier.com/locate/ijdrr

A proactive approach: Examples for integrating disaster risk reduction and

mental health and psychosocial support programming
Brandon Gray a, *, Julian Eaton b, Jayakumar Christy d, Joshua Duncan c, Fahmy Hanna a,
Sekar Kasi d
a
Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
b
CBM Global, and Assistant Professor, London School of Hygiene & Tropical Medicine, London, United Kingdom
c
Mental Health Coalition of Sierra Leone, Freetown, Sierra Leone
d
National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India

A R T I C L E I N F O A B S T R A C T

Keywords: Natural disasters and humanitarian emergencies exert devastating impacts globally. Among these effects are
Mental health and psychosocial support disruptions in mental health and psychosocial well-being. Traditionally, mental health and psychosocial support
Disaster risk reduction (MHPSS) interventions have been implemented in response and recovery phases. Yet, the field of disaster
Disaster risk management
management has demonstrated a shift towards disaster risk reduction (DRR). The degree to which the MHPSS
Lessons learned
field has followed this trend has been limited by several factors, including a lack of consensus-based guidance for
MHPSS and DRR integration. However, examples from the field exist and demonstrate the feasibility of taking
proactive approaches to supporting mental health and well-being and building better before emergencies occur.
The following article outlines two case examples, one project in Sierra Leone and another in India, integrating
MHPSS and DRR approaches and principles. Lessons learned from these cases and specific challenges in each
context are highlighted and discussed.

1. Introduction & background experience exacerbation of pre-existing conditions. In conflict settings,

approximately one in five persons experiences a mental health condition
Natural hazards and emergencies have a substantial impact on in­ [6]. When left unaddressed, these conditions can significantly impact
dividuals and communities globally. Natural hazards alone led to 1.35 individual, communal, and societal functioning [7]. However, the ma­
million deaths and approximately US$ 2.6 billion in total losses between jority of individuals affected by emergencies tend to demonstrate
1994 and 2013 ([1]. These impacts will only increase as the global remarkable resilience in the face of these events, particularly when they
climate emergency worsens: by 2050, an estimated 143 million people are able to meet basic needs, access social supports and re-establish
will be displaced due to climate related risks in just three regions (Latin community networks in a timely manner [8].
America, South Asia, & Sub-Saharan Africa; [2]. Additionally, violence Traditionally, mental health and psychosocial support (MHPSS) ac­
and conflict continue to rise, resulting in a ten-fold increase in tions have been focused on the response and recovery phases of emer­
battle-related deaths between 2005 and 2016 [3] and a global economic gencies with the aims of reducing suffering and re-establishing
impact of US$ 14.1 trillion measured by purchasing power parity [4]. functioning of those impacted. Until recently, this approach had been
Meanwhile, 6% of global income, nearly US$ 500 billion, is lost annually aligned with disaster management models. However, recently this
due to epidemic risks [5], a figure certain to skyrocket in the aftermath disaster management field has begun to expand beyond reactive ap­
of the global COVID-19 pandemic. Stated simply, the incredible devas­ proaches to encompassing more proactive disaster risk management
tation and loss inflicted by emergencies cannot be overstated. (DRM), with the goal of disaster risk reduction (DRR). DRR has been
In reaction to these significant threats to safety, deprivation of live­ described as the policy objective of DRM and refers to “activities aimed
lihood, and material, economic, and social losses, evidence suggests that at preventing new and reducing existing disaster risk and managing
individuals will develop significant mental health problems or residual risk, all of which contribute to strengthening resilience and

* Corresponding author.
E-mail address: grayb@who.int (B. Gray).

https://doi.org/10.1016/j.ijdrr.2021.102051
Received 15 July 2020; Received in revised form 27 November 2020; Accepted 12 January 2021
Available online 21 January 2021
2212-4209/© 2021 World Health Organization; licensee Elsevier.
B. Gray et al. International Journal of Disaster Risk Reduction 54 (2021) 102051

therefore to the achievement of sustainable development” [9]. This shift been ill-defined to date, actors may not have explicitly defined their
towards DRM has been marked both by formal agreements, such as the projects as “DRM” or referred to their projects as MHPSS-DRM inte­
Sendai Framework for Disaster Risk Reduction 2015–2030 [10], and gration. Thus, cases were selected if they 1) represented hazard prone
widespread adoption in countries globally (e.g., Ref. [11]. regions or countries; 2) had begun in the last 10 years; and 3) involved
Nonetheless, while psychosocial support is explicitly mentioned in activities that aimed to promote mental health and psychosocial well-
the Sendai Framework for Disaster Risk Reduction and identified among being and resilience for the future while reducing risks that contribute
functions in the WHO Health Emergencies and Disaster Risk Manage­ to the development of mental health problems. These projects selected
ment Framework [12], implementation of proactive MHPSS activities were also not being implemented in active response to a humanitarian
have been limited globally. Yet, examples exist in the field that emergency or crisis but rather were being implemented as initiatives to
demonstrate the feasibility and value of integrating MHPSS activities better prepare and develop systems that would be more functional in
with DRM perspectives and approaches. In the realm of health, emer­ responding to emergencies. This might be through: prevention efforts
gency and disaster risk management takes a holistic approach to prior to, and preparedness for, emergencies; reduction of further expo­
reducing hazard risks to health by linking activities focused on pre­ sure and suffering during emergencies; and building the mental health
venting health problems and preparing for events that are hazardous to system back better following emergencies and in preparation for future
health to activities implemented in response to and in recovery from events. In both cases, the current case studies selected were also faced
emergencies, thereby reducing their risk [12]. This same approach can with the challenge of an emergency response after the project was
also apply for MHPSS. Therefore, MHPSS actions that are implemented implemented, which allowed further evaluation of their relative success
from a DRM perspective may be in some cases unique to preparedness (e. and areas for improvement.
g., simulation exercises that integrate MHPSS considerations and testing Because the purpose of this article was to demonstrate a proof of
of MHPSS response activities) or those that are similar to and link concept, highly detailed reports regarding the nuances of each case were
strongly with those implemented in the acute response phase or in re­ beyond the scope. However, in an effort to follow standardized approach
covery from emergencies and other crises (e.g., raising awareness and for collecting case studies, the Centre for Global Mental Health at Lon­
advocating for MHPSS). However, when these activities are imple­ don School of Hygiene and Tropical Medicine (LSHTM) and CBM’s Case
mented from a DRM perspective, they are done so from the viewpoint of Studies Project methodology [13,14] was followed with adaptations to
preparing for multiple potential hazards (i.e., prior to emergencies), and incorporate and emphasize domains of interest and relevance to DRR
with the intention to build the resilience of communities, countries and (see Table 1). This methodology organizes and integrates information
systems before, during and after emergencies, thereby strengthening the from a variety of sources across 14 domains of interest and has been
humanitarian and development nexus. Existing examples of such efforts employed in multiple prior case studies (e.g., Refs. [14–16]). In line with
can greatly encourage continued shift towards risk reduction among this approach, where possible, data collection ought to include partici­
MHPSS actors and lay the foundation for the development of pant observation carried out over a series of field visits with the explicit
consensus-based approaches for integrating MHPSS practices with DRM. intention of answering the overarching research questions of “is this
Yet, in order to further advance the field’s understanding of, and con­ programme working? Why or why not?” This approach then allows in­
fidence in, integrating MHPSS and DRM practices, more information and vestigators to develop a narrative description and SWOT (strengths,
evaluation are necessary. Therefore, this article demonstrates the weaknesses, opportunities and threats) analysis. While field visits with
feasibility of the integration of these two fields while extending and these specific questions in mind were not taken for this project,
reinforcing current knowledge in the area. The current article intends to co-authors J.D. and J.E were present during the work in Sierra Leone,
contribute new learning to the field through case studies that demon­ and co-authors K.S. and J.K. led the work in India. Authors coordinated
strate MHPSS preparedness and risk reduction activities. Our intentions to provide narrative descriptions of each case and conducted analyses
is that these case studies may de-mystify the notion of integrating based on the co-authors’ knowledge of quantitative and qualitative in­
MHPSS with DRM by demonstrating that there are many actions, some formation relevant to the 14 domains of the LSHTM-CBM Case Study
also commonly implemented during an MHPSS response, that can methodology adapted to emphasize DRR (Table 1). Additional infor­
greatly reduce the risks posed to mental health and psychosocial mation was also gathered via literature searches and document review
well-being by hazardous events. We also hope that these cases demon­ as well as discussions with relevant programme staff.
strate the value of applying these actions proactively, across the phases
of prevention, preparedness, response and recovery, The article dis­ 3. Case study descriptions
cusses key case studies from Sierra Leone and India demonstrating a
proof of concept. These case studies were chosen because they demon­ 3.1. India
strate effective measures taken in diverse settings. Major achievements
and challenges for each case are discussed and key lessons learned The Republic of India is large and diverse country in South Asia with
emerging from these experiences are summarized. In considering these a population of nearly 1.4 billion, equivalent to approximately 18% of
case studies, it is hoped that both humanitarian and development actors the world’s total populace. India is frequently affected by multiple
may further understand the feasibility of integrating MHPSS and DRM hazards and demonstrates a diverse profile of disaster risks across its
approaches while recognizing their own capacity and the capacity of regions. Common hazards include heavy rainfalls and flooding, cy­
others to do so. clones, mudslides, avalanches and earthquakes. Research across Indian
communities has demonstrated that prevalence of common mental
2. Case study methodology health problems and psychiatric morbidity are both significantly higher
among persons affected by disaster, relative to the general population (e.
Case examples of initiatives integrating MHPSS actions and DRR g., Ref. [17]; [29]). However, mental health care gaps have existed with
principles are outlined in the following section. Potential case studies major deficits in training, limited availability of mental health pro­
were identified through a larger mapping exercise initiated by the Inter- fessionals [18], and partial implementation of mental health reforms
Agency Standing Committee Reference Group on Mental Health and and policies [19].
Psychosocial Support (IASC MHPSS RG), facilitated by the World Health In order to increase the national capacity for psychosocial support
Organization and lead by the first author in January 2019. As part of this during and after emergencies, the “Developing Resilient Cities through
initiative, all respondents were asked to provide project descriptions and Risk Reduction to Disaster and Climate Change” project was initiated in
operational summaries of any completed, in-progress, or planned ini­ 2017. This DRR-Focused project began as a collaborative effort imple­
tiatives. Given that what may constitute DRM and MHPSS practices has mented by the United Nations Development Programme (UNDP) and the

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B. Gray et al. International Journal of Disaster Risk Reduction 54 (2021) 102051

National Institute of Mental Health & Neurosciences (NIMHANS) in

Were there efforts to promote access such as stigma reduction, mental health promotion, etc.?
India. NIMHANS aspect of the project focuses on mental health psy­
chosocial support (MHPSS) preparedness in India’s ongoing DRM efforts
across six municipalities (see Fig. 1) and was led by co-authors JK and

What lessons were learned? Did these impact local policies and practices thereafter?

Were there indicators related to mental health risk reduction or resilience building?
KS. The effort represents the first large-scale MHPSS preparedness

Were there challenges in collecting funding, building support etc., for the project?
initiative in India.
The process of developing the Indian model of Community Resilience
What motivated the project organizers to implement this DRR approach?
• What were the disaster risks in this context and in relation to MHPSS?

began with a review of the literature and multi-hazard risk and

Who was involved and how was this similar/different from a response?
Did stakeholders involved consider this project to be “DRR?” How so?
Were there any known efforts at risk reduction prior to this project?

vulnerability analyses in each of the six cities. Thereafter, a needs

Was the project tested by an emergency after it was implemented?

• How was mental health viewed in the area prior to this project?

assessment tool was developed and implemented across each site to

How were at-risk groups involved in developing this project?

assess psychosocial needs in each area in-line with local cultural, lin­
How were international norms adapted to the local context?

How was preparedness or prevention a part of this project?

guistic, and social differences. Needs assessment information was
collected through key informant interviews (KII) with key stakeholders
If so, did your project coordinate or link with these?

and field workers, focus group discussions and transect walks in com­
munities to identify risks and also engage stakeholders. Assessments
revealed that psychosocial support was not a part of existing disaster
How was capacity-built for interventions?

management plans. Moreover, results indicated that health pro­

How were these challenges overcome?

fessionals were largely not prepared to meet MHPSS needs, education

How was the program evaluated?

professionals were ill-equipped to handle high-risk behaviors and

mental health concerns among adolescents and children, women were in
How was info distributed?

need of greater focus and inclusion in DRM efforts as they were often not
included as part of the decision making process, and governmental and
DRR Considerations

NGO stakeholders were in need of greater sensitization to and capacity

for building MHPSS preparedness among communities.
Informed by this psychosocial mapping and needs assessment,
NIMHANS engaged in considerable advocacy and awareness raising
across the departments of government involved in emergency response
and management and with at-risk communities to increase support for
MHPSS capacity building and risk reduction. NIMHANS actors began
this process through a top-down approach, wherein sector heads from
various departments of local government were first gathered to discuss
Psychosocial interventions (including self-help groups and livelihood programmes)

the value of MHPSS preparedness and risk reduction. Thereafter, mid-

level officers working in the communities were gathered with heads of
their departments to further develop collaboration and buy-in while
reducing stigma. Finally, community workers, community leaders, and
community members, and members of particularly vulnerable groups
were gathered to discuss the value of MHPSS preparedness and risk
reduction and tailor planning to specific needs in each city. Through
these efforts, NIMHANS was able to raise awareness, reduce stigma, and
develop partnerships that would later aid in integrating mental health
Health system in which the programme functions
Environment in which the programme functions

and psychosocial components into existing DRR initiatives at multiple

levels of society. Thereafter, NIMHANS and partners developed a suite of
tools for scaling up MHPSS preparedness and DRR activities, including a
manual on DRR ([30]), which informed the actions taken by NIMHANS
Programme conceptual framework
Engagement with broader systems

and partners during “Developing Resilient Cities through Risk Reduction

to Disaster and Climate Change” project described here. The manual
Programme management

included discussion and review of ‘psychosocial risk reduction’,

Accessibility of services
History of Programme

Programme resources

Clinical interventions
Client characteristics

Information systems

including common reactions in emergencies; coping, adaptation and

Overview of LSHTM-CBM case study methodology domains.

Pathways to care

resilience; vulnerable groups in the Indian context; cultural factors in

Relevant Areas

MHPSS and DRR; and support and risk reduction for caregivers and first
Medications

responders. The manual also outlined stepwise processes for integrating

psychosocial considerations within Participatory Preparedness Ap­
praisals and Hazard, Risk and Vulnerability Analyses, for engaging and
Note. Table adapted from Ryan et al., [16].

empowering vulnerable groups, and for implementing programmes to

prepare an MHPSS response should an emergency occur. To accompany
this primary manual, training materials were also developed, including a
facilitator’s manual on MHPSS considerations in DRR and a participant’s
workbook intended for general public participants in the project.
Additional pamphlets discussing concepts such as understanding
Programme Organization

disaster and disaster impacts, do’s & don’ts in disaster, emotional re­
actions in disaster, principles of emotional support, children in disaster,
Programme Model

Client populations

women in disaster, special considerations for persons with disability &

Interventions

elderly persons, how to make a referral, tips for stress management and
Information

considering marginalized groups in disaster settings were also produced

Domains

Context

History
Table 1

to expand awareness and increase access to appropriate information

among communities.

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B. Gray et al. International Journal of Disaster Risk Reduction 54 (2021) 102051

Fig. 1. Multi-hazard profile of six cities.

Following awareness raising and tool development, capacity build­ and promote preparedness throughout the densely populated country.
ing became a major focus of the project. In order to build capacity,
project actors also developed a three-day training on basic psychosocial
support and psychological first aid (PFA; [20]. that was integrated with 3.2. Sierra Leone
pre-existing DRM-related trainings being implemented through UNDP.
A training-of-trainers (ToT) was held involving 20 trainers from each of Sierra Leone is a coastal country of approximately 7.7 million people
the six municipalities. Following the ToT, master trainers returned to in sub-Saharan West Africa. The past three decades have seen a series of
their cities and began to localize and implement preparedness and ca­ major emergencies which have resulted in substantial challenges to
pacity building efforts with the support from NIMHANS actors. These long-term development. Sierra Leone was overrun first by a brutal civil
trainings targeted multiple layers of municipal administration and war between 1991 and 2002 and subsequently by the Ebola Virus Dis­
community, similar to the initial approach to developing support for ease epidemic of 2014–2015, both of which have frustrated efforts at
MHPSS. In total, approximately 244 stakeholders had been trained by economic recovery despite substantial natural resources and some pos­
the end of 2019. Monitoring and evaluation results indicated that par­ itive economic reforms. In addition, in 2017, mudslides killed over
ticipants developed increased knowledge of and preparedness for 1,100 people and displaced many more living in poorly built housing on
providing MHPSS in each of the six cities. While challenges faced the hills around Freetown. This disaster demonstrated the housing
included scarcity of resources, competing priorities, and the need for insecurity and poor infrastructure that also exists in many other areas of
frequent disaster responses that interrupted preparedness, these train­ the country. It also showed how such poor infrastructure can result in
ings continue to be accepted and implemented across the country due in unnecessarily high rates of death and injury when hazardous events
part to the political capital and name-recognition of the NIMHANS occur.
institute. Life expectancy remains at 53 years in Sierra Leone, and the Human
The value of this program has since been demonstrated in response to Development Index (a useful composite of health, education and eco­
the COVID-19 pandemic. Many stakeholders involved in conceptual­ nomic measures) is 0.438. Human Development Indices range from 0 to
izing the programme continue to provide input in shaping the direction. 1, with scores below 0.550 representing very low human development,
Those who have been previously trained have responded to increased while scores above 0.800 represent very high development [31].
mental health needs across the six municipalities and beyond. As part of Although the current score actually represents progress since the civil
the greater COVID-19 response in India, relief camps were established war, it remains near the bottom of global rankings at 181/189. This is
by the Ministry of Home Affairs to provide food and shelter to many largely driven by the ongoing post-conflict legacy of high youth unem­
citizens and migrant workers severely impacted by the pandemic and ployment, weak governance, poor health and education infrastructure
resulting protective measures. Within these camps, previously trained and widespread poverty.
community health workers have been engaged in raising awareness of These issues are also reflected in the mental health system. In 2010,
effective coping strategies, providing basic psychosocial support, and mental health services in Sierra Leone consisted of a single psychiatric
conducting outreach and referral for individuals in need of greater care. hospital in Freetown [21,22], located near the coast and hundreds of
These efforts have been conducted and integrated with regular health kilometers away from many communities. Previous efforts to increase
promotion and education on the importance of social distancing and are the availability of MHPSS had been undertaken in the country during
supported by governmental departments administering the camps. and shortly after the civil war, but, this work had largely stopped and
However, capacity for providing MHPSS in the context of COVID-19 focused mainly on combatants and child soldiers. However, lessons
remains an issue in many areas across India, particularly those that learned from gaps identified during the response to MHPSS needs during
were not able to be targeted in this project. Greater attention to and the civil war informed the need for system strengthening and greater
focus on DRR and MHPSS efforts is needed in order to reduce suffering awareness of mental health and psychosocial issues. Still, the value of
mental health was largely underrecognized prior to the Ebola outbreak.

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B. Gray et al. International Journal of Disaster Risk Reduction 54 (2021) 102051

Very little investment occurred, mental health services were largely stereotypes, and reducing stigma within communities. Additionally, the
non-existent in many districts, and mental health system development process was centrally important to deriving a locally contextualized
efforts were mainly resourced through funding from international ac­ model for providing mental health care (for further discussion of the
tors. Thus, building political support remained an essential need. approach, please see Ref. [25].
In 2010, prior to the Ebola virus outbreak, WHO identified Sierra The value of these mental health services built through the Enabling
Leone as a primary country for piloting the Mental Health Gap Action Access to Mental Health programme was clearly demonstrated during
Programme (mhGAP) aimed at strengthening the mental health system the Ebola crisis in Sierra Leone. Initially, there was a risk that the MHPSS
through integrating mental health at the primary and general health response would be poorly coordinated, as it fell ‘between clusters.’
care level. To implement this programme, CBM international, the Sierra However, a cross-sectoral MHPSS Working Group was established based
Leone Ministry of Health and Sanitation, and other partners and stake­ in-part on pre-existing coalition partnerships and proved an important
holders established a strong intersectoral coalition (Mental Health means of coordination. Additionally, the fact that several clinicians
Coalition – Sierra Leone) to address these issues through the “Enabling trained by the project were already in place when the Ebola outbreak
Access to Mental Health in Sierra Leone” initiative [23]. Still in opera­ occurred meant that they could be utilized to support wider efforts to
tion today, the initiative began with the goals of 1) building capacity for meet the MHPSS needs across the country. These providers proved to be
mental health service delivery at the district and primary level, 2) an essential complement to the field-based psychosocial support activ­
developing a national mental health advocacy and peer support ities delivered widely by the many actors who arrived to respond to the
network, and 3) developing a national mental health awareness and Ebola crisis. Front-line health, social, education and other staff trained
community engagement programme. Coalition partners ultimately in psychological first aid provided basic support to many affected
worked to strengthen governance and enhance prioritization of mental communities and also identified individuals with needs for higher levels
health in the country by developing a mental health policy, liaising with of supporte. The people identified were therefore able to benefit from
a Steering Committee at the Ministry of Health and Sanitation (MOHS), local access to the next level of health care established through the prior
increasing financing and human resources, advocating for decentralized capacity building efforts. Without this, the full range of recommended
service provision, developing information systems and building this interventions in a balanced approach to MHPSS, as recommended in the
network of experienced and effective advocates and service providers. Inter-Agency Standing Committee (IASC) Guidelines on MHPSS in
This coalition was crucial to successfully promoting investment in a Emergency Settings [8], would not have been available. The psychiatric
sustainable mental health system. nurses and other clinicians trained played an essential role, not only
Between 2010 and 2014, a cohort of 21 psychiatric nurses were seeing the many patients referred by front line workers, but also in
trained as part of the Enabling Access programme through a course supporting Ebola Treatment Centers and survivors’ clinics, providing
developed at the College of Medicine and Allied Health Sciences. services for children orphaned by the epidemic, and supporting health
Ongoing supervision was thereafter provided by senior nurses and and other staff who themselves experienced high levels of distress. These
visiting professionals (through the King’s Sierra Leone Partnership) to services were an essential element of the provision of care, which was
further support quality care provision by those trained. In addition, only possible because they were set up in advance.
general primary care nurses received basic mental health training at the In addition, coalition partners worked with local organizations of
University of Makeni and thereafter worked in providing integrated care people with disabilities during the crisis to ensure that key public health
in primary health care settings across the country. Additionally, through messages, such as actions to prevent the spread of the outbreak or to
the Mental Health Leadership and Advocacy (mhLAP) programme, ensure healthy coping while taking these actions, were made available
mental health leaders traveled annually to a short course in mental in accessible formats, that barriers to accessing response services were
health leadership and advocacy in Ibadan Nigeria (2009–2019) to addressed, and that people with disabilities participated in planning and
further enhance capacity. More recently, training of trainers in the coordination, so that their needs and priorities were heard and risks
mhGAP-Intervention Guide (mhGAP-IG) [24] and in the QualityRights greatly reduced. Though not immediately evident before the crisis, the
tool kit [22] were also carried out and resulted in over 60 doctors and impact of these risk reduction and preparedness efforts on individual
500 Community Health Officers receiving training in a contextualized and community resilience was clearly demonstrated during and after the
version of the mhGAP – IG manual and thus enhancing access to needed Ebola outbreak. Furthermore, the value of investing in and strength­
care for persons with mental health conditions. ening mental health systems was recognized and became greatly prior­
In order to ensure approaches to supporting mental health itized. For instance, nurses who were quickly deployed received proper
throughout the initiative were inclusive and accepted among the local payment, an issue that had been ignored for years prior.
communities, local traditional healers and religious leaders were Unfortunately, following the shift from the crisis response phase in
engaged to support the initiation of mental health services in districts mid-2016 to more recovery focused activities, the resources, prioriti­
where they had been largely non-existent. To this end, mental health zation of MHPSS, and ongoing support for people trained quickly
nurses led Community Mental Health Forums (CMHF), involving formal receded. Maintaining the proper support for mental health services and
and informal care providers, religious leaders and traditional healers in support systems outside of emergencies, and finding means of sustaining
order to enable stakeholders to discuss and identify locally and con­ investment, remain an essential need for both routine care and support
textually relevant approaches to promoting mental health while during future crises in Sierra Leone. Nonetheless, recent disaster re­
reducing or preventing local practices that may be harmful, abuse rights sponses have relied heavily on the mental health infrastructure put in
or lead to other negative outcomes. The intention was to develop a place by the programme. For instance, these previous efforts have led to
shared understanding of mental health and how to build a more func­ better preparedness for and response to the COVID-19 virus outbreak,
tional mental health system. The content of these CMHF was determined which has utilized many of the same coordination mechanisms put in
through multiple participatory workshops where stakeholders discussed place by this project. Mental health nurses previously trained by the
local myths regarding mental health, local idioms of distress and un­ project are now being deployed to quarantine places (hotels and
derstanding regarding mental health care, and barriers in the health approved residences) and are working side by side with other re­
system that would pose challenges. In doing so, nurse facilitators were sponders, such as contact tracers and health promotion teams. In part­
able to also form collaborative relationships by connecting with tradi­ nership with the coalition, training for social workers and community
tional healers and community leaders, thus establishing a more func­ actors have also been planned in order to increase capacity for the
tional system. Ultimately, these inclusive approaches served as an provision of an evidence-informed model of PFA [20] and reinforce
important tool for addressing many of the challenges identified, previously established referral pathways in the context of COVID-19.
providing accurate mental health information, dispelling myths and

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B. Gray et al. International Journal of Disaster Risk Reduction 54 (2021) 102051

4. Lessons learned 4.4. MHPSS-related DRM policies and plans should be clear, brief, and
realistic and should be integrated with pre-existing structures and
These lessons are derived from the case studies above. An additional initiatives
source of information was a review of the MHPSS response that was
carried out by WHO after the Sierra Leone Ebola crisis subsided, drawing Case study actors identified the importance of creating plans and
on the experience of local and international actors in the crisis ([28]). procedures that were clear, brief, and realistic in order to ensure
available resources for implementation. This was clear in the case of
4.1. Community acceptance and ownership are essential for successful Sierra Leone, where resources were extremely limited and where plan­
and sustainable programming ning to implement programmes required practical and realistic plans
that did not require the presence of many specialist care providers,
As is the case with any approach to emergency and disaster prepa­ hence the usefulness of cost-effective initiatives such as mhGAP. In the
ration, response and recovery, case study actors asserted that commu­ case of India, actors also demonstrated the value of integrating such
nities must not be identified simply as the target of activities. Instead, plans with pre-existing DRM or governmental efforts to ensure MHPSS-
trusted local persons must be engaged as leaders to build trust, motivate DRM efforts also do not become stand-alone or siloed. This is an essential
behaviour change and ensure community ownership of and acceptance effort during response and recovery efforts that must also be maintained
for strategies. Such was clearly the case demonstrated through CMHF during prevention and preparedness.
processes implemented in Sierra Leone and in initial planning proced­
ures across the six cities in India. Community engagement is essential in 4.5. Advocacy for funding and support should take place at multiple levels
integrating MHPSS with risk management approaches and will lead not prior to emergencies
only to more thorough implementation but also to increased sustain­
ability. As identified in Sierra Leone through the process of under­ Prior history of hazardous events may inspire DRM projects. How­
standing local myths and perceptions of mental health that may ever, obtaining funding and support for MHPSS preparedness efforts
contribute to increase mental health risk (e.g., stigma, lack of under­ prior to future emergencies may be difficult. Yet, these actors demon­
standing of mental health), it is clear that communities must play a key strated that such support was feasible, representing a shift in thinking
role in identifying risks and developing reduction strategies. It is only in that must take place in order to strengthen MHPSS and reduce risks prior
this way that acceptance and uptake of MHPSS messages and services to emergencies. Such prior investment makes an enormous difference in
will occur and inaccurate and harmful perceptions can be combated. ability to respond effectively and represents a very good return on in­
vestment. While detailed return on investment analyses have not been
4.2. DRR strategies and plans must include vulnerable and at-risk voices completed to this point for either project, responding to the COVID-19
pandemic has demonstrated some level of sustainability in both cases
Inclusion was a focus generally within both case studies. that can speak to cost-effectiveness. In both cases, fewer resources may
Community-based partners, such as organizations for persons with dis­ be required to mount the MHPSS response to the pandemic because
abilities and other advocacy groups, can provide valuable insight into previous efforts have been made to build the capacity. Moreover, in
the specific risks faced by the most vulnerable groups and strategies for effort to reduce risks, stigma and other factors that have may impact
reducing these risks and preventing harm. In the case of Sierra Leone, mental health outcomes during the pandemic emergency in both
these partners were crucial to ensuring risk communications about countries have been at least addressed in-part thanks to these initiatives.
reducing the spread of the outbreak were made accessibly and could Such would not be possible without significant advocacy for a change in
reach vulnerable groups. Meanwhile, in India, women were specifically thinking from seeing MHPSS as solely a response and recovery activity
identified as largely excluded in many local previous risk reduction to seeing it as an all-phase component of DRM.
approaches, and their subsequent inclusion as decision makers was key
to ensuring that strategies that were implemented to address MHPSS 4.6. Name recognition and prior working relationships can be crucial to
risks were comprehensive. Such an approach of meaningful participa­ creating buy-in
tion will ensure that trust is built, that interventions developed are
appropriate and impactful, and that communication is relevant and The recognition of reputable national institutions as key partners can
accessible. be crucial for developing local motivation and collaborations to ensure
uptake. Prior working relationships and respect for these institutions
4.3. Multi-sectoral and varied stakeholder collaboration, such as between and their missions may be key to realizing implementation and
MHPSS actors, DRM actors, governmental, and local at at-risk individuals obtaining support. In the case of India, NIMHANS can be identified as a
and communities is necessary leader in MHPSS responses nationally. This name recognition was easily
leveraged to develop partnerships to support the integration of MHPSS
Effective MHPSS responses cannot be implemented by any one or­ in DRM projects in the country. In Sierra Leone, the convening power of
ganization or within any one sector and must be coordinated across CBM, WHO, and the Sierra Leone Ministry of Health and Sanitation was
relevant stakeholders [8]. Cases also demonstrated that these lessons are key to ensuring widespread collaboration and developing working re­
applicable to MHPSS-DRM projects, which must include lationships prior to the emergency.
community-based stakeholders, governmental actors, and preferably
professionals with experience or expertise in the MHPSS and DRM fields. 4.7. Investing in health and information systems, capacity, and
Some aspects of projects were led by experts designated as DRM focal preparedness prior to emergencies is essential for reducing risks and
points within their respective organizations and coordinated with rele­ strengthening response and recovery efforts
vant government officials and community leaders, such as in the case of
India, where projects were co-led by mental health professionals and Both cases demonstrated clearly and simply the value of prepared­
colleagues working in previously initiated DRM projects. Others were ness and early investment before emergencies happen. Capacity building
implemented by individuals with interests or backgrounds in pre­ and system-strengthening was key to ensuring services were in place
paredness but little to know prior expertise in DRM, such as the case of when emergencies occurred and have been crucial to combating the
Sierra Leone project, where DRM was less of explicit focus but where unforeseen but devastating impacts of the COVID-19 pandemic. These
DRR was an identifiable outcome nonetheless. In any case, both projects efforts dramatically improved response and could be linked to greater
required strong collaboration to be effectively implemented. resilience in recovery phases. Investing in health system strengthening

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B. Gray et al. International Journal of Disaster Risk Reduction 54 (2021) 102051

in advance of an emergency is much more efficient and effective if populations affected by an unprecedented emergency [26]. In the face of
carried out prior to an emergency, where there are many restrictions and this challenge, it is crucial that we as a global society recognize the value
time constraints to building capacity or promoting systems reform. of mental health and psychosocial well-being and enhance its priority in
the global health, humanitarian and development agendas. By expand­
4.8. Easily accessible and dispersible materials can be effective for raising ing the emphasis of preparing MHPSS services and reducing global risks,
awareness and increasing preparedness both those who are affected by emergencies and those who respond are
more likely to demonstrate resilience, engage actively in preparedness,
Communication of necessary information may be difficult in low- response, and recovery, and work to re-establish societal functioning.
income countries and areas where infrastructure may be limited.
Easily accessible and dispersible materials can be utilized in these situ­ 5.1. Limitations
ations as mechanisms for distributing information about preparedness,
healthy coping, early warnings, and evacuation procedures. These av­ Despite the powerful messages in these cases, limitations in the
enues proved essential for creating effective and efficient communica­ collection and analysis of the information reviewed above must be
tion. In creating such materials, it is essential that care is taken to have a noted. First, many agencies participated in the mapping exercise refer­
good cultural and contextual understanding, and that they are accessible enced earlier and provided in-depth information for developing case
for people who are illiterate, have sensory impairments, or are difficult studies of their work to link MHPSS and DRM concepts. Discussion of
to reach (for example in rural areas). People with severe physical, psy­ each of these projects was beyond the scope of this article. Therefore,
chosocial or intellectual disabilities might be particularly unlikely to several other relevant case examples exist which may or may not come
access messages if barriers are not considered. Such was the case to the same conclusions, though a recent review of literature and map­
demonstrated in Sierra Leone, where community-based organizations ping exercise materials indicated the potential commonality of the
were engaged as essential partners to ensuring that public health themes discussed herein [27]. Conversely, many organizations who may
messaging was accessible. be active in linking MHPSS and DRM either did not provide responses
during the mapping exercise discussed previously or relied on reporting
5. Discussion from regional and local focal points who may have been overburdened
or time-limited and thus unable to fully participate. As a result, many
The cases described above demonstrated the utility of implementing other relevant cases and lessons learned may exist and apply here that
risk reduction approaches in order to improve mental health and psy­ were not collected. Second, the purpose of this review was not to provide
chosocial well-being and reduce risks to the same. These studies also complete analysis of each project, and so discussing and reviewing these
demonstrated how MHPSS actions can be viewed as more than solely cases was not completely exhaustive. As a result, the current case de­
recovery activities, as listed in Priority Four of the Sendai Framework for scriptions must be noted as reviews of each project rather than intensive
Disaster Risk Reduction 2015–2030, to activities that can be imple­ analyses. Therefore, the material in this review relevant to those
mented to prevent or reduce mental health risks, while also supporting agencies may not represent the entirety of their work. Additionally, the
preparation for better response and recovery to emergencies. Despite the devastating COVID-19 pandemic presented a unique opportunity to
relative novelty of this approach in the MHPSS field and the challenges evaluate further the impact, sustainability, and cost-effectiveness of
discussed, both cases demonstrate the integration and implementation these projects. However, such an analysis was not feasible in either case
of MHPSS and DRR principles and DRM approaches. Although these due to the complex and ongoing nature of the pandemic at the time of
cases represented contexts with their own unique socio-cultural envi­ this article’s writing. Therefore, future studies would benefit from
ronments and hazard profiles, we found substantial commonalities generating in-depth analysis and discussion of the impact of these ini­
across the sites, and the lessons learned identified collectively remain tiatives during and after the response to and recovery from COVID-19.
relevant for many contexts. Third, the cases studies in this review represented diverse regions
Additionally, these cases demonstrate the feasibility of integrating globally. However, many areas and regions were not discussed through
the MHPSS and DRR fields and mainstreaming this integration. Many of those projects selected. Therefore, the generalizability of these cases
the organizations involved in these cases are active in multiple settings must be considered within the context in which they occurred. Fourth,
and countries globally. Therefore, potential avenues for increased while case studies described herein detail important considerations and
development and innovation in the implementation of MHPSS-DRM actions for integrating MHPSS and DRM, many issues that are commonly
strategies and projects exist and may be facilitated internally among overlooked in MHPSS humanitarian response field were also not
actors and externally through formalized mechanisms for increasing completely addressed in these efforts either. Specifically, efforts to
attention to this integration.1 address social determinants of mental health and reduce the antecedents
The value of such approaches has also been demonstrated in the of mental health problems are of central importance to MHPSS-DRM and
context of the COVID-19 pandemic. Now more than ever the world is must be further defined and prioritized in order for risks to mental
faced with the challenge of meeting the mental health needs of large health and well-being to be adequately reduced.

6. Conclusions
1
MHPSS.net, a global platform for connecting agencies and organizations
and housing resources focused in the area of MHPSS in emergency settings, Despite these limitations, the review outlines a number of key
includes a forum for discussing MHPSS and DRR concepts (“MHPSS.net: practices of DRM and MHPSS integration and identifies realistic exam­
Disaster Risk Reduction”). Moreover, the Inter-Agency Standing Committee ples for future projects and focus in the field. These cases demonstrate
Reference Group on MHPSS in Emergency Settings (IASC MHPSS RG), a unique that, despite the barriers to obtaining support and funding and the
collaboration between non-governmental organizations (NGOs), United Nations relative lack of priority given to mental health needs in many settings, it
and international agencies with the mandate of developing and disseminating
is possible to implement projects focusing on DRM to meet and reduce
guidance on MHPSS and providing country-level support, has developed a
the mental health risks posed by emergencies.
forthcoming guidance document and tool for integrating MHPSS and DRR
programming. The IASC MHPSS RG’sTechnical Note Linking Mental Health and There is increasing recognition and consensus that when persons and
Psychosocial Support and Disaster Risk Reduction: Practical Tools, Approaches and communities affected by emergencies are supported and their mental
Case studies aims provide guidance on and practical tools for incorporating health and well-being is promoted through risk reduction and man­
MHPSS considerations in DRR and vice versa. This tool was developed through agement, they are more likely to demonstrate resilience, engage actively
widespread consultation and collaboration from experts in both fields. in prevention, preparedness, response, and recovery, and work to re-

7
B. Gray et al. International Journal of Disaster Risk Reduction 54 (2021) 102051

establish societal functioning during and after emergencies. The value of [4] Institute of Economics, Peace, Global Peace Index 2019: Measuring Peace in a
Complex World, Author, Sydney, Australia, 2019. http://visionofhumanity.org/r
these proactive approaches has become even clearer in the context of the
eports.
global COVID-19 pandemic and in response to the increasing mental [5] V.Y. Fan, D.T. Jamison, L.H. Summers, Pandemic risk: how large are the expected
health needs that have resulted. However, this unprecedented emer­ losses? Bull. World Health Organ. 96 (2) (2018) 129–134, https://doi.org/
gency has also demonstrated many clear and stark gaps in ability to meet 10.2471/BLT.17.199588.
[6] F. Charlson, M. van Ommeren, A. Flaxman, J. Cornett, H. Whiteford, S. Saxena,
the need for MHPSS services globally. Thus, there is a clear and signif­ New WHO prevalence estimates of mental disorders in conflict settings: a
icant need for further integration of MHPSS and DRM practices in order systematic review and meta-analysis, Lancet (2019) 240–248, https://doi.org/
to reduce risks of problematic mental health and psychosocial outcomes 10.1016/S0140-6736(19)30934-1.
[7] T. Van Bortel, A. Basnayake, F. Wurie, M. Jambai, A.S. Koroma, A.T. Muana, L.
and to increase resilience to hazardous events now and in the future. B. Nellums, Psychosocial effects of an Ebola outbreak at individual, community and
Fortunately, in addition to these case studies, several tools and manuals international levels, Bull. World Health Organ. 94 (3) (2016) 210, https://doi.org/
exist [27] that may support this integration. Moreover, consensus-based 10.2471/BLT.15.158543.
[8] Inter-Agency Standing Committee, IASC Guidelines on Mental Health and
guidance and actions established in the forthcoming Inter-Agency Psychosocial Support in Emergency Settings, IASC, Geneva, Switzerland, 2007.
Standing Committee “Technical Note Linking Mental Health and Psycho­ https://www.who.int/mental_health/emergencies/9781424334445/en/.
social Support and Disaster Risk Reduction: Practical Tools, Approaches and [9] United Nations General Assembly, Report of the Open-Ended Intergovernmental
Expert Working Group on Indicators and Terminology Relating to Disaster Risk
Case studies” will further promote comprehensive and inclusive risk Reduction, Note by the Secretary-General, New York (NY): United Nations, 2016.
reduction. WHO, CBM, NIMHANS and other leading organizations have Retrieved from A/71/644, https://www.preventionweb.net/terminology.
championed the goal of the Building Back Better (BBB) approach in [10] United Nations Office for Disaster Risk Reduction, Sendai Framework for Disaster
Risk Reduction 2015-2030, UNDRR, Geneva, Switzerland, 2015.
order to build mental health systems and promote well-being. These case
[11] A.T. de la Poterie, M.A. Baudoin, From Yokohama to Sendai: approaches to
studies and forthcoming framework expand upon this BBB approach by participation in international disaster risk reduction frameworks, International
emphasizing the value of also Building Better Before emergencies Journal of Disaster Risk Science 6 (2015) 128–139, https://doi.org/10.1007/
happen, through inclusion of MHPSS in prevention and preparedness. s13753-015-0053-6.
[12] Health Emergency and Disaster Risk Management Framework, World Health
Risk reduction is an opportunity to greatly strengthen mental health and Organization, Geneva, 2019. Licence: CC BY-NC-SA 3.0 IGO.
psychosocial resilience. The time to prepare for the events of the future [13] A. Cohen, J. Eaton, B. Radtke, V. De Menil, S. Catterjee, M. De Silva, V. Patel, Case
and comprehensively reduce individual and collective risks is now. Study Methodology to Monitor & Evaluate Community Mental Health Programs in
Low-Income Countries, London School of Hygiene and Tropical Medicine, London,
Author Contributions: F.H. administered the project; B.G. and F.H. UK, 2012.
conceptualized the scope and methodology and selected the cases; B.G. [14] A. Cohen, S. Raja, C. Underhill, B.P. Yaro, A.Y. Dokurugu, M. De Silva, V. Patel,
carried out the methodology of the case studies with oversight from F. Sitting with others: mental health self-help groups in northern Ghana, Int. J. Ment.
Health Syst. 6 (1) (2012) 1, https://doi.org/10.1186/1752-4458-6-1.
H.; B.G. produced the initial draft of the manuscript; J.E., S.K., and J.K. [15] A. Cohen, J. Eaton, B. Radtke, C. George, B.V. Manuel, M. De Silva, V. Patel, Three
expanded case study descriptions and reviewed and revised necessary models of community mental health services in low-income countries, Int. J. Ment.
details; all authors contributed to the review and revision of the entire Health Syst. 5 (1) (2011) 3, https://doi.org/10.1186/1752-4458-5-3.
[16] G.K. Ryan, E. Nwefoh, C. Aguocha, P.O. Ode, S.O. Okpoju, P. Ocheche, J. Eaton,
manuscript. Partnership for the implementation of mental health policy in Nigeria: a case study
of the comprehensive community mental health programme in benue state, Int. J.
Funding Ment. Health Syst. 14 (1) (2020) 1–13, https://doi.org/10.1186/s13033-020-
00344-z.
[17] S.M. Becker, Psychosocial care for adult and child survivors of the 2004 tsunami
This project was funded by the World Health Organization and the disaster in India, Am. J. Publ. Health 96 (8) (2006) 1397–1398, https://doi.org/
United States Agency for Development and Office of U.S. Foreign 10.2105/AJPH.2005.064428.
[18] World Health Organization, Mental Health Atlas 2017, Author, Geneva,
Disaster Assistance. Switzerland, 2018.
[19] Government of India Ministry of Health & Family Welfare, Regional Workshops on
Disclaimer National Mental Health Programme: a Report 2011–2012, Government of India,
Bangalore, India, 2011. Retrieved from: https://mohfw.gov.in/sites/default/files/
ComprehensiveReport%20Part%201-78786581_1_0.pdf.
The authors alone are responsible for the views expressed in this [20] World Health Organization, War Trauma foundation, world vision international,
article and they do not necessarily represent the views, decisions, or in: Psychological First Aid: Guide for Field Workers, Author, Geneva, Switzerland,
2011.
policies of the institutions with which they are affiliated. [21] World Health Organization, Mental Health Atlas 2011, Author, Geneva,
Switzerland, 2012.
[22] World Health Organization, WHO Quality Rights Tool Kit, Author, Geneva,
Declaration of competing interest Switzerland, 2012.
[23] A. Mohammed, T.L. Sheikh, G. Poggensee, P. Nguku, A. Olayinka, C. Ohuabunwo,
J. Eaton, Mental health in emergency response: lessons from Ebola, The Lancet
The authors declare that they have no known competing financial Psychiatry 2 (11) (2015) 955–957, https://doi.org/10.1016/S2215-0366(15)
interests or personal relationships that could have appeared to influence 00451-4.
the work reported in this paper. [24] World Health Organization, mhGAP Intervention Guide for Mental, Neurological
and Substance Use Disorders in Non-specialized Health Settings, mhGAP-IG).
Author, Geneva, Switzerland, 2016.
Acknowledgments [25] B. Adams, F. Vallières, J.A. Duncan, A. Higgins, J. Eaton, Stakeholder perspectives
of community mental health forums: a qualitative study in Sierra Leone, Int. J.
Ment. Health Syst. 14 (1) (2020) 1–13, https://doi.org/10.1186/s13033-020-
We would like to thank the organizations involved for providing 00382-7.
related materials and participating in the mapping exercise and case [26] United Nations General Assembly, Policy Brief: COVID-19 and the Need for Action
on Mental Health, Note by the Secretary-General, New York (NY): United Nations,
study interviews discussed within this document.
2020. Retrieved from, https://unsdg.un.org/resources/policy-brief-covid-19-and-
need-action-mental-health.
References [27] B.L. Gray, F. Hanna, L. Reifels, The integration of mental health and psychosocial
support and disaster risk reduction: a mapping and review, Int. J. Environ. Res.
Publ. Health 17 (6) (2020) 1900–1917, https://doi.org/10.3390/ijerph17061900.
[1] Centre for Research on the Epidemiology of Disasters (CRED), The Human Cost of
[28] J. Eaton, Mental health and psychosocial support in Sierra Leone, in: Report of a
Natural Disasters: A Global Perspective, CRED, Brussels, Belgium, 2015 http://
Consultation Meeting, World Health Organisation, 2014.
cred.be/sites/default/files/The_Human_Cost_of_Natural_Disasters_CRED.pdf).
[29] N. Kar, P.K. Mohapatra, K.C. Nayak, P. Pattanaik, S.P. Swain, H.C. Kar, Post-
[2] K.K. Rigaud, A. de Sherbinin, B. Jones, J. Bergmann, V. Clement, K. Ober,
traumatic stress disorder in children and adolescents one year after a super-cyclone
J. Schewe, S. Adamo, B. McCusker, S. Heuser, A. Midgley, Groundswell: Preparing
for Internal Climate Migration, World Bank, Washington, DC, 2018.
[3] Global Terrorism Database, Global Terrorism Database. College Park: National
Consortium for the Study of Terrorism and Responses to Terrorism, University of
Maryland, 2017. https://www.start.umd.edu/gtd/.

8
B. Gray et al. International Journal of Disaster Risk Reduction 54 (2021) 102051

in Orissa, India: exploring cross-cultural validity and vulnerability factors, BMC [31] United Nations Development Programme, Human Development Report 2019:
Psychiatr. 7 (1) (2007) 8–17, https://doi.org/10.1186/1471-244X-7-8. beyond Income, beyond Averages, beyond Today: Inequalities in Human
[30] K. Sekar, C. Jayakumar, S.K. Manikappa, L. Zacharias, M.G. Khaute, Facilitation Development in the 21st Century, Technical note, 2019. Available, http://hdr.
manual on disaster risk reduction: enhancing institutional and community undp.org/sites/default/files/hdr2019_technical_notes.pdf.
resilience to disasters and climate change, in: USAID, NIMHANS, UNDP: Bangalore,
India, Manual in preparation for public release, 2019.