Nepal is exposed to several types of natural and human induced hazards. A wide variety of physiographical, geological, ecological and hydro-meteorological factors contribute to this while demographic factors like rapid population growth, slow economic development and widespread unawareness on disaster issues make the country extremely prone to disasters (Ministry of Home Affairs, 2011).

 

Globally, Nepal ranks 4, 11 and 13th in terms of vulnerability  to   climate  change,  earthquake  and  flood risks, respectively. Within 45 years (1971-2015), more than 40,000 people were killed by disasters meaning at least two (2) people died a day in Nepal due to disasters (Ministry of home affairs (MoHA), 2018).

 

MAJOR DISASTER EVENTS     

 

In 2009, a diarrhea outbreak in Western Nepal killed approximately  282  people.  Nineteen districts (out of 75)  suffered from this public health crisis. In October 2014, avalanches in Manang and Mustang district killed 43 people. Earthquakes are also liable for thousands of human casualties and property damages. From the first ever-recorded earthquake in 1255 to the 2015 earthquake, Nepal faced 17 big earthquakes over 6.0 magnitudes in which 49,286 people lost their lives.  On 25 April 2015, Nepal faced a devastating earthquake of 7.8 magnitudes that took lives of over 9,000 people. According to the National Planning Commission (2015), housing sector has remained one of the most affected sectors by this disaster. Accidents account for 3.18% of total mortality rate of the country whereas nearly 10,000 people have been killed by landslides and flooding in last 45 years. 134 people lost their lives in 2017 South Asian floods in Nepal, which affected 18 districts severely (National Planning Commission, 2017). A fire destroyed Patala, an ancient place in Western Nepal in December 2018 where eighty seven (87) houses were burnt (The Himalayan times, 2018). All such disaster events leave millions of people affected each year, many of whom are displaced.

Over the years, the Government of Nepal has made significant progress in disaster response and management in the country. Primarily, the “Disaster Relief Act” was promulgated in 1982 and Local Self-Governance Act in 1999. These were the legal provisions of disaster system in Nepal and all the disaster relief activities have been carried out under this act since then. By endorsing the Hyogo Framework for Action (HFA), The National Strategy for Disaster Risk Management was also formulated in 2009 by the Nepal government to develop Nepal as a disaster resilient country. The government also prepared the National Disaster Response Framework (NDRF) in 2013 with the purpose of implementing and coordinating a response plan of national level disaster by ensuring all the elements of disaster management cycle (Ministry of home affairs, 2013). It has allocated appropriate roles for governmental and humanitarian organizations. Recently, Nepal has prepared the “Disaster Risk Mitigation and Management Act” in October 2017, which has been considered as the biggest achievement to manage disaster issues in the country. In addition, the government has prepared the 12 years (2018 - 2030) strategic plan for disaster risk reduction in the country.  

 

Nepal has also established the cluster system to foster effective and collaborative disaster response and management mechanism. The cluster comprised 11 sectors, which become effective during the major disasters. Previously, government had adopted the “reactive” policy to disaster, which means focusing on response and rescue. This has now shifted to the“proactive” policy focusing more on preparedness  and  mitigation. The government is preparing disaster first responders in every local unit of the country to prepare, manage and respond to disasters. Few local government units have already started to recruit such responders and training them. 

According to the Sphere Project (2011) and Inter-Agency Standing Committee (IASC) (2007), Psychological First Aid (PFA) is described as “a humane, supportive response to a fellow human being who is suffering and who may need support”.  PFA involves the following themes:

 

(1) Providing practical care and support, which does not intrude

(2) Assessing needs and concerns

(3) Helping people to address basic needs (for example, food and water, information)

(4) Listening to people, but not pressuring them to talk

(5) Comforting people and helping them to feel calm

(6) Helping people connect to information, services and social supports

(7) Protecting people from further harm

 

Vernberg et al. (2008) define, “PFA as an evidence-informed modular approach for assisting children, adolescents, adults, and families in reducing the initial distress caused by catastrophic events and in fostering short and long-term adaptive functioning. During the major crisis events, the environment seems to be sporadic and scattered. The affected populations would be in confusion, chaos and frailty. There would be mourning, suffering, pain and numbness all over the surroundings. During such stages, PFA is the way of assessing needs and concern of a people and helping people to address basic needs. PFA provider listens to the issues of the affected population without pressuring them to talk and comforts them to feel calm by connecting them to information, services and social support systems. PFA also tries to protect the people from further harm during crisis events”.      

 

World Health Organization (2011) describes PFA as not something like only professionals can do. It is neither a psychological counseling nor clinical or psychiatric intervention. It is also not a psychological debriefing. It requires no license to practice PFA and Para-professionals can provide PFA after some basic training on it.

 

NEED FOR MAINSTREAMING PFA INTERVENTION DURING DISASTER IN NEPAL 

 

Psychosocial responses have received less priority during  disasters in Nepal. Whenever a disaster strikes, a major move relies on ‘search and rescue’ and ‘relief supplies’ initiated by the Nepal Army, Armed Police Force and security personnel.  The practice of PFA has hardly been seen in a country during disaster. However, the community leader, senior family members, relatives and neighbors are upfront to provide support and care to the person nearby them during disasters. They offer such support based on their experience and best of their judgment than an actual PFA trained knowledge, focusing more on logistical management and shelter issues instead of psychological aspects. Despite several limitations, developmental organizations (NGOs/INGOs) provide PFA during major disasters in Nepal. The Nepalese population is comprised several heterogeneous groups with the representation of more than hundreds of ethnic/caste groups sharing unique features with each other along with different spoken languages. Open spaces, which can be converted as evacuation sites for disaster, are also very limited in the country. In the capital city (Kathmandu), there are just 83 identified open spaces for more than 5 million of the population (Ministry of home affairs (MoHA), 2015). Child trafficking, bribery and pedophilia are also likely to be encountered during the large scale disasters. Child and women protection, missing cases and management of evacuation site always becomes challenging during disasters. The vulnerable population is less accompanied for disaster relief services when they are in dire need to be assisted. The rapid level of foreign migration has shifted the family structures in Nepal, leaving single wife and senior citizens at home. During disasters, such families face many challenges in the emergency shelters and are found to be living in chaos, confusion and uncertainty.     

 

As recommended on the NDRF (2013), psychosocial response is to be provided after one to two weeks of the disaster by the Government of Nepal though it is believed that dispatching psychosocial responses during initial hours of disasters is also important. As the government is preparing first responders as part of disaster preparedness in local units and ward offices of the country, the integration of psychological first aid is vital at this stage to reduce the challenges associated in emergency context. The discussion about the integration of PFA still remains despite the fact that the government has endorsed the significance of psychosocial support during disaster events. 

After the earthquake, there was certain rise in psychosocial programs in Nepal (some of them are in continuation as a part of the community mental health interventions). The emergency response program like PFA, setting up child friendly space, and female friendly space also took a sharp rise. However, after the few months, the government  prioritized  housing  issues  and reconstruction as its major agenda. It established the national reconstruction authority on August 2015 to govern all such recovery process. The majority of the organizations shifted their focus afterwards. The disaster program also took a dramatic rise but only few incorporated PFA into their programs. Most of such programs included the training on fire disaster management, flood resilience and Community Based Disaster Risk Reduction (CBDRR) programs. PFA is still a very new concept in Nepal among the majority of policy makers, disaster responders and community populations.    

 

Program description

 

In collaboration with IsraAID Nepal, Japan International Support Program (JISP) implemented an Intensive ToT program on PFA as a part of ‘Building Sustainable Community Resilience’ project in Kathmandu, Nepal from March 2018 to March 2019. Different participants took part in these intensive sessions (that spanned in two different periods) from different PFA specialists - one from a Japanese specialist and another from the members of Good Practice Group, Sri Lanka. Two Nepalese co trainers who received ToT from international PFA trainers[i] in 2015 as a part of “Nepal Disaster Specialist Education Program” (previous project) developed by JISP co-facilitated the session with the expatriates. This PFA training reached over 600 populations including the community trainings conducted by the participants. JISP and IsraAID had signed an agreement with Transcultural Psychosocial Organization (TPO) Nepal as a local implementing partner of the project.

 

Objectives

 

The program was designed to train the multiple stakeholders and disaster first responders in Community Based Disaster Risk Management (CBDRM) and Psychosocial Support during disaster emergencies. The strategy included the intensive ToT on PFA and community management skills during earthquake disaster. The psychosocial component, especially the purpose of ToT on PFA was to integrate the PFA skills while responding to the upcoming disasters in Nepal. The overall aim of the program was to strengthen the community based disaster response mechanism in the core city area of Kathmandu with the comprehensive PFA skills and other relevant expertise necessary to deal with disaster emergencies.

 

Participating stakeholders

 

The participants for this program were recruited from heterogeneous  entity.  This  included  the Government of Nepal units; representatives from the Department of Urban Health and Disaster Management Division of Kathmandu Metropolitan City and the Department of Psychology and Philosophy, Trichandra College, Tribhuvan University, civil societies and non-governmental organizations. Raksha Nepal (a leading organization working to provide support for sexually exploited girls, women and their children) and Bihani Social Venture (Nepal’s first and only social enterprise working in the field of ageing) were also a part of the program. In addition, Psychiatric Nurses Group (an active group for nursing intervention during disaster and epidemics) and Special School for Disabled and Rehabilitation Centre (a leading institution for protection and socialization of children with autism) were the stakeholders/participants of the program.  

The participating organizations selected and sent the relevant person for training as per the invitation letter sent from the organizer with details of the training. The nurses, government health and disaster workers, university postgraduate level students and NGO frontline workers during disasters were participants for the training. During the special trainings like ToT on PFA, the recommended participants were verified by looking at their resume and letter of interest for the training.

 

Program team

 

The program team included the representative director from Japan, chief coordinator, MHPSS Coordinator and Project Coordinator from Nepal. The collaborative organization IsraAID Nepal provided technical and supervisory support for the program while the implementing partner TPO Nepal helped with logistical and coordination essential for field level operations. The JISP headquarter representatives made several visits to Nepal for guidance and supervision. The training specialists comprised nationals from Japan, Sri Lanka and Nepal. A chief coordinator, national staff, was in charge of the program, team management and supervision.

 

Project interventions   

 

Training of trainers (ToT) session on PFA

 

The ToT on PFA comprised a precise module that was conducted from 16 to 19 of August 2018. This training was designed for four continuous days and was facilitated from the trainer from The Good Practice Group, Sri Lanka. The content of the t­raining was followed based on the model prescribed by the World Health Organization that was developed in 2011 and was endorsed by 24 UN/NGO international agencies. The first two days was focused on providing  trainings  from  the  specialists  and the next two were focused on facilitation skills and session designs followed by the presentations done by participants. The specialist shared comments to each participant at the end of the session. The major contents of the sessions included were what is PFA, what is not PFA, why PFA, people’s reaction to crisis events, who can provide PFA, to whom can PFA be provided, how can PFA be provided, PFA action principles, communication skills, ethical guidelines for PFA, etc.  

 

In order to understand the concept better, well-planned simulation exercises were practiced. The exercises were based on the context. The simulation on earthquake disaster was denied to avoid potential re-traumatization to the fellow participants.          

 

Community trainings on PFA

 

After four days of training on PFA, participants were asked to deliver at least one full day training to their fellow participants or community members in order to be eligible for certification and practical implication. They were supposed to complete this within two months. The follow up/roll out sessions conducted by ToT candidates took place in different cities of Nepal which reached over 500 people, comprising mixed groups in different trainings. The organizer and the co-trainer of the training gave the technical support and supervision while observing each session. It was a mandatory provision for the participants to send the slides and session plan to the organizer for review before the confirmation of the training date. The organizer and Nepalese PFA co trainer reviewed and provided feedback to all such documents beforehand. In addition, the program provided logistic support to such sessions. Some of the sessions were conducted separately for the university teachers, nursing staffs/students, women’s group, school guardians and so on. Some of the participants conducted the sessions separately on their own and some made a team of two to three for conducting the program. Altogether, 27 community sessions on PFA were conducted. All forty (40) participants successfully completed each session and certified as ToT.

 

Co joint workshops on PFA

 

Another component of the program was to strengthen the relationship between the participating stakeholders with other local community groups through the extension of PFA knowledge. Altogether eight trainers who were trained under this program were chosen. They were in charge of facilitating the four sessions. They were divided into four groups representing different organizations. 

 

All eight trainers and the organizers spent several hours for the support and preparation of the workshop. The “trial and error”  method  was  used  several times for the simulation of each trainer. After the preparation was completed, the stakeholder organizations coordinated with each other and conducted four different sessions on PFA to their fellow colleagues and beneficiary groups. One session was conducted with the senior citizens (60+ in Nepal) and their caregivers and the next with the guardians of autistic school going children and their teachers. The other session took place with the bachelors/masters level university students. The final session was performed with the beneficiary children and their caregivers (shelter staff).

 

The PFA expert from Sri Lanka was in charge of the supervision and evaluation of the session. The expert spent one full day before the session with all trainers for techniques and preparation and one full day after the session with feedbacks and reflections. The organizer provided logistic support and overall supervision required for the session.

 

Network meeting

 

The network meeting was organized to facilitate the discussion among the head of organizations (stakeholders), participants of the training and the organizer. All the program activities were reported and explained into the forum during such meetings and discussion was carried out for opinion, direction and potential suggestion to strengthen the program in a better way. The challenges and its potential solutions were discussed along with the upcoming responsibilities to the stakeholders and the organizer.      

 

Program evaluation

 

The program was evaluated by using both subjective and objective measures. The “Monitoring and Evaluation” plan gave special attention to the three major indicators for evaluation, which are; i) increment of participants knowledge after the PFA training, ii) participant’s ability to conduct the PFA training sessions and iii) the reflection received from the participants/stakeholders regarding the effectiveness of such trainings.      

 

In order to measure the increment of participants’ knowledge after the training, a set of standardized pre-post test was used for evaluation. This questionnaire provided the comparative evaluation of the participants against their pre training knowledge and post training knowledge. Such questions contained two sections having 24 questions in total. The first section contained information about the confidence level to provide PFA to the distressed population and the second section includes knowledge questions about PFA. On an average, the total participants’ pre training knowledge was 38% and post training knowledge was 91%. After each  training,    the   knowledge  received  an  increment among the participants.   

 

The evaluation of the community trainings and the co-joint workshop confirmed that the participants are able to facilitate PFA trainings to the community. Three sets of evaluation tests were developed to measure this indicator. The first one is a set of standardized pre-post test; the next is an evaluation checklist for PFA community trainings and the last one is a session evaluation developed by the Sri Lankan expert. At the end, all such test showed the effectiveness of the intervention.   

 

The reflection received from the participants and the head of participating organization values the effectives of the PFA trainings and its interventions. After each training, a round session was carried out for the reflection of that day and overall importance of the program. Majority of the participants recognized the importance of PFA training in a country like Nepal where the government’s response comes late. Because of geographical issues, it is very difficult to conduct disaster intervention in some places or it may take several days to reach there. Most of them expressed that since the community members are the first to respond to the disaster, it is inevitable that they need to be trained first on such important issues. According to the stakeholder organizations, PFA is a comparatively new training in Nepal and it carries tremendous importance and can play crucial role to strengthen the disaster response system of our nation. They further mentioned that PFA is essential not only for them but also to all staffs, beneficiary groups and family members. They felt fortunate to be a part of this program to get new things to their staffs and beneficiary groups.

 

For the ToT participants, getting a chance to enroll in this program has come with ample pros. It has enhanced their training skills while getting to know about the basic but very important concept of PFA. After the completion of all community trainings and co-joint workshops, during the reflection sessions they mentioned that they got to know important skills about the PFA as well as the facilitation skills to a variety of population/participants.  

 

Since the program comprised different organizations working in different themes, the relevance, importance and scope of PFA to them were found to be different. For those who are university students, the ToT and community training facilitation stands as a milestone to enhance their confidence and foster their public speaking ability along with a new way of looking psychological response to disaster. For the Urban Health Department of Kathmandu city, PFA needs to be integrated into their health response plan during the disaster. They mentioned that it is essential to facilitate PFA trainings to all the female community health volunteers, which are 558 in number in Kathmandu Metropolitan City. For nursing professionals, PFA trainings have given them a new way to integrate medical first aid response with psychological first aid during  disasters in Nepal. According to them, this is the first time they got to receive knowledge on PFA though they are psychiatric nurses. They mentioned that it is relevant to all the nurses of Nepal who are likely to make initial response to disasters in the country with health interventions.

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Few limitations were noticed in the program. Initially, rigorous follow up and supervision of the community trainings on PFA was not planned as it was supposed to be conducted by the participants after the ToT training. Nominal budget was assumed and allocated for few sessions. It was also not assumed that more than 25 sessions would be conducted which in fact turned out to be 27 in total. As the sessions were conducted in different periods and some in different cities, time management and deployment of staff to monitor the session became a major issue. In addition, there were important Nepalese festivals (Dashain and Tihar) that came around the same time as the session rolls out. The participant group was heterogeneous which most of the times contributed to provide dynamism to the session but sometimes prevented potential interaction to the sessions as different people had different capacities that did not match with the other. Occasional power shortage was another problem in the training venue that lead the session to being stopped for a while or changing of the session plan to some extent in the middle.

During a short span of time, the program attempted to reach over larger implications. It strived to bring psychosocial response to disaster into the mainstream by providing intensive training on PFA to government units, university students and civil society organizations. By reaching over 600 people, it gave an insight about the importance of PFA response during disasters to the diversified populations as it included school guardian, community leaders, university lectures, etc., in the sessions. The program included variety of participants from the designated professionals to the local level community members.  

 

It further helped on skills enhancement of the participants and provided substantive skills on PFA interventions during disasters along with hand-to-hand community training experience. The participants are now prepared for psychosocial intervention in disasters and can facilitate the sharing session to whomsoever necessary. 

 

The leading organizations of Nepal who are supposed to be working jointly during the emergency periods have developed a certain level of understanding through the participation   in   this   program.   By   attending   network meetings and arranging the co-joint workshop together, they have gotten to know each other’s working areas in detail. Moreover, they have also identified potential areas of collaboration to work together in coming days ahead. The government units (Urban Health Division and Disaster Management Division) spoke about the necessary collaboration of these stakeholder organizations for psychosocial intervention during the crisis stage in the country and vowed to lead this consortium afterwards. 

 

Hence, the program initiated the baby steps to assimilate the psychosocial response during disasters in Nepal. It supported and contributed the nation’s vision to be disaster resilient society as committed into the international forums by the government delegates.