final dissertation

An Integrated Approach to Mental and Psychosocial
Health Rehabilitation in the Aftermath of Boko Haram
Insurgency in North-East Nigeria.
BY
MUSA ABUBAKAR
MASTER OF PUBLIC HEALTH
[INTERNATIONAL]
AUGUST, 2016
Nuffield Centre for International
Health and Development
Leeds Institute of Health Sciences

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the award of Masters of Public Health [International]. The examiners cannot,
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the contents”.
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The University of Leeds
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Signed: Date:

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DEDICATION
This is dedicated to my parents whose unflinching support has propelled me to
this level.

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ACKNOWLEDGEMENT
I want to thank Almighty Allah for leaving me alive and healthy to witness the end
of this programme. It was by His blessings that I came here to study.
I wish to acknowledge and thank my parents for the support they have been
providing from the beginning of my life till now. May Allah reward them
abundantly.
My wife Amina, my Son Musa (Kalim) and my Cousin Nura (Kawu Musa II) also
deserve a special appreciation for their support. Their company all through the
year provided me with the necessary comfort of a family. I never came back home
to look for what to eat all through the year. This was a luxury only a few get in the
UK.
To my dear friends Ralph, Kamran, and Ismail, I say a big thank you and I will
surely miss you guys. The understanding and friendship we shared over this 1 year
is second to none.
My supervisor Mayeh Omar and personal tutor Jennifer Parr deserve a big thank
you. Your guidance and support kept me on track. I appreciate you a lot, and I
hope this is the beginning of a lifelong relationship.
To all the teachers at the Nuffield Centre and of course the wonderful people in
Room G03 and G04, your support throughout this year was incredible. Thank you
very much, all of you.
I also appreciate the support I received from friends and family here in the UK and
abroad during the course of this programme.
I will not conclude without acknowledging my classmates for their understanding
and friendship all through the year. I appreciate and thank you all.

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TABLE OF CONTENTS
DEDICATION......................................................Error! Bookmark not defined.
ACKNOWLEDGMENTS ....................................Error! Bookmark not defined.
TABLE OF CONTENTS......................................Error! Bookmark not defined.
ABBREVIATIONS AND ACRONYMS .............................................................vii
ABSTRACT.........................................................................................................viii
CHAPTER 1:INTRODUCTION ...........................................................................1
1.1 Dissertation Overview.............................................................................1
1.2 Concept of Mental Health as a Component of Health ............................1
1.3 Global Burden of Mental Disorders........................................................2
1.4 Mental Health in Populations Affected by Armed Conflict....................2
1.5 Boko Haram Conflict and Mental Health in Nigeria ..............................3
1.6 Problem Statement ..................................................................................3
1.7 Study Rationale .......................................................................................3
1.8 Aim and Objectives.................................................................................4
1.8.1 Aim...................................................................................................4
1.8.2 Objectives.........................................................................................4
1.9 Author –Topic relationship .....................................................................4
1.10 Expected Output and Intended Use.........................................................4
1.11 Main stakeholders ...................................................................................4
1.12 Dissertation structure...............................................................................5
1.13 Summary .................................................................................................5
CHAPTER 2 : METHODOLOGY ........................................................................6
2.1 Chapter Overview ...................................................................................6
2.2 Study Type ..............................................................................................6
2.3 The Conceptual Framework ....................................................................6
2.3.1 Safety/Security.................................................................................6
2.3.2 Bonds/Networks...............................................................................6
2.3.3 Justice...............................................................................................8
2.3.4 Roles and Identities..........................................................................8
2.3.5 Existential Meaning .........................................................................8
2.4 Justification .............................................................................................8
2.5 Analytical Tool........................................................................................8
2.6 Sources of Data .......................................................................................9
2.7 Literature Search Strategy.......................................................................9
2.8 Inclusion and Exclusion Criteria...........................................................10
2.8.1 Inclusion criteria ............................................................................10

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2.8.2 Exclusion criteria ...........................................................................10
2.9 Study Limitations ..................................................................................11
2.10 Summary ...............................................................................................11
CHAPTER 3 : SITUATION ANALYSIS ...........................................................12
3.1 Chapter Overview .................................................................................12
3.2 Background ...........................................................................................12
3.3 Conflict and Mental Health in Nigeria ..................................................13
3.3.1 Security and Safety ........................................................................13
3.3.1.1 Emergency Situations in Nigeria ...............................................13
3.3.1.2 The Boko Haram Insurgency .....................................................13
3.3.1.3 Mental Health Impact of Insecurity ...........................................13
3.3.2 Interpersonal Bonds and networks.................................................13
3.3.3 Systems of Justice ..........................................................................14
3.3.3.1 Marginalisation of the North-East..............................................14
3.3.3.2 Frustration, Anger and Antisocial Behaviours ...........................14
3.3.3.3 Human Rights Violations...........................................................15
3.3.4 Roles and Identities........................................................................15
3.3.4.1 Identities.....................................................................................15
3.3.4.2 Roles...........................................................................................15
3.3.5 Existential Meaning .......................................................................16
3.4 Mental Health Services in Nigeria ........................................................16
3.4.1 Mental Health Policy .....................................................................16
3.4.2 Mental Health Seeking Behavior ...................................................17
3.5 Summary ...............................................................................................17
CHAPTER 4 : ANALYSIS OF INTERVENTION STRATEGIES FOR MHPSS
IN POST-CONFLICT SITUATION ...................................................................18
4.2 Target Population for Intervention........................................................18
4.3 Selection of Proposed Interventions for Analysis .................................18
4.4 Re-Establishing Security and Ensuring Protection ...............................20
4.5 Community-Based Social and Family Support Activities ....................21
4.6 Trauma Counselling ..............................................................................22
4.7 Measures to Promote Justice and Reduce Marginalisation...................23
4.8 Traditional/Religious/Spiritual Healing ..............................................244
4.9 Summary ...............................................................................................25
CHAPTER 5 : CONCLUSION, RECOMMENDATIONS, AND
DISSEMINATION PLAN...................................................................................26

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5.2 Study Conclusion ..................................................................................26
5.3 Recommendations .................................................................................26
5.3.1 Specific Recommendations............................................................26
5.3.1.1 Community-Based Social Support.............................................27
5.3.1.2 Trauma Counselling ...................................................................27
5.3.1.3 Traditional/Spiritual Healing......................................................28
5.3.2 General Recommendations ............................................................28
5.3.2.1 Improve governance and reduce marginalisation.......................28
5.3.2.2 Improve the socio-economic environment.................................28
5.3.2.3 Education and Awareness ..........................................................28
5.4 Dissemination Plan................................................................................29
5.5 Reflection..............................................................................................32
CHAPTER 6 : REFERENCES ............................................................................33
List of Tables
Table 1.1: Stakeholders and their role . .................................................................5
Table 2.1: Results of the database search conducted ..........................................10
Table 4.1: Proposed Interventions Selected for MHPSS ....................................20
Table 5.1: Dissertation dissemination plan .........................................................30
List of Figures
Figure 1.1: Interactions of factors influencing mental health status in an
individual . .............................................................................................................2
Figure 2.1: The ADAPT Model Conceptual Framework . ....................................7
Figure 2.2: Prisma flow diagram showing selection of the study materials. .......11
Figure 3.1: Map of Nigeria showing the geopolitical zoning. .............................12
Figure 4.1: The IASC intervention pyramid for mental and psychosocial
support .................................................................................................................19
WORD COUNT: 9,997

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ACRONYMS
BBC British Broadcasting Corporation
CSOs Community- Based Organisations
IASC Inter-Agency Standing Committee
IDP’s Internally Displaced Persons
IOM International Organisation for Migration
LMIC Low and Middle Income Countries
MHPSS Mental Health and Psychosocial Support
MoE Ministry of Education
MoH Ministry of Health
NEMA National Emergency Management Agency
NGOs Non-Governmental Organisations
NPC National Population Commission
NRC Norwegian Refugee Council
OHCHR Office of the High Commissioner for Human Rights
PHC Primary Health Care
PTSD Post-Traumatic Stress Disorder
RCT Randomised Controlled Trial
UNDP United Nations Development Programme
UNHCR United Nations High Commissioner for Refugees
UNICEF United Nations Children Fund
WHO World Health Organisation
WHO- AIMS WHO-Assessment Instrument for Mental Health Services
WHO-MOH World Health Organisation and Ministry of Health

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ABSTRACT
Introduction: Conflict has become a global public health problem as over 50
countries have been involved in armed violence over the last 30 years. More than
60% of these are in the developing countries. The global rise in conflict is among
the major factors responsible for the increasing prevalence of mental and
behavioural disorders which are estimated to account for 15% of the global burden
of disease by 2020. Initial studies have revealed a rise in the prevalence of these
disorders in North-East Nigeria due to the Boko Haram conflict in the region
which has caused the death of over 200,000 people and uprooted more than 1
million others from their places of natural abode.
Problem: In Nigeria, no desk exists in the ministries of health for mental health
care and no emergency preparedness plan exists for mental health rehabilitation
despite the reported increase in the prevalence of mental and psychosocial
disorders due to the Boko Haram conflict. There is no comprehensive action plan
for mental health and psychosocial support of the people affected by the conflict
to the best knowledge of the author.
Aim: The aim of the study is to develop a suitable approach for mental and
psychosocial health rehabilitation in North-East Nigeria. The specific objectives
are: To discuss the causes and the impact of the Boko Haram conflict on the mental
health of the population, describe the factors responsible for increasing the
prevalence of these disorders in post-conflict settings, identify appropriate
interventions that have been used in similar settings and appraise their
applicability within the context of Nigeria.
Methodology: This dissertation is an in-depth study using secondary data. The
Adaptation and Development after Persecution and Trauma (ADAPT) Model
Conceptual Framework was used to guide the analysis of the causes and impact of
the conflict on the mental and psychosocial health of the population. Identified
interventions were appraised for applicability in the context of Nigeria using the
criteria of technical effectiveness, organisational, gender/cultural and financial
feasibility.
Findings: Social drivers such as poverty, illiteracy, unemployment,
marginalisation, and social inequality are the remote causes of the Boko Haram
conflict in the North-East region. Pervasive state of insecurity, disruption of family
and community social networks, persisting injustices, identity confusion and the
existential challenges survivors of war face are the key factors associated with
increased prevalence of mental and psychosocial disorders in post-conflict settings.
Restoring security and addressing the social drivers of the conflict will result in
the resolution of most symptoms associated with the trauma of violence. However,
certain groups of vulnerable people would still require focused psychosocial
interventions like trauma counselling, community-based social support and
traditional healing to promote their recovery. All these interventions are feasible
for implementation in North-East Nigeria.
Conclusion: Factors associated with the Boko Haram conflict in Nigeria are
multiple and cut across many sectors. Therefore, a multi-sectoral approach to
rehabilitation should be pursued to achieve mental health recovery of the people.

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Recommendations: An integrated, sequenced approach to intervention is
proposed in which social drivers and security are addressed first, and then
specialised interventions should be provided for individuals whose distress does
not abate with the repair of the social environment.
Dissertation Key Words: Mental health, psychosocial, rehabilitation, post-
conflict, Boko Haram, Nigeria.

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CHAPTER 1: INTRODUCTION
1.1 DissertationOverview
Conflict is among the most traumatic events that could affect individuals in their
life. Its impact on the health of the population, and especially their mental and
psychosocial health is one of the most significant (Al-Ghzawi, 2014). There is an
increasing recognition that addressing mental health and psychosocial needs in
post-conflict situations is critical to ensuring effective and sustainable
reconciliation and reducing the likelihood of future conflicts (Bell et.al, 2012).
This dissertation would explore the causes of the Boko Haram conflict in Nigeria
vis-a-vis its key drivers within the social system and examine its consequences on
the mental and psychosocial health of the population. Appropriate interventions
that could be used to promote mental health recovery shall be analysed so as to
make suitable recommendations.
This chapter shall define basic concepts, describe the problem statement and give
the study rationale. The aim and objectives of the study as well as the structure of
the dissertation would also be given.
1.2 Conceptof Mental Health as a Component of Health
Mental health constitutes one of the 3 main concepts in the World Health
Organisation (WHO) definition of health “as the complete state of physical, mental
and social well-being and not merely the absence of disease or infirmity” (WHO,
2012 p3). These 3 components are closely related and inter-dependent. The
Organisation also defined the concept of mental health as:
..a state of well-being in which the individual realises his or her abilities, can
cope with the normal stresses of life, can work productively and fruitfully, and
can make a contribution to his or her community (WHO,2014, p1).
Mental health, therefore, means more than just the absence of mental illness in an
individual. It is influenced by a combination of 3 factors as described below and
represented in figure 1.1 (WHO, 2012):
i. Individual attributes and behaviours: these are the innate (biological)
characteristics and the learned ability to deal with one’s thought,
feelings, and manage him/herself in daily life.
ii. Social and economic circumstances: the social environment influences
the capacity of an individual to develop and achieve their innate
potential, engage positively with family members or friends, and earn a
living.
iii. Environmental factors: mental health status is also influenced by the
socio-cultural and geopolitical environments of an individual. These
include exposure to certain cultural beliefs, attitudes or practices, social
inequality (levels of access to essential services), discrimination, and
conflict, etc.

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Figure 1.1: Interactions of factors influencing mental health status in an individual (Adapted
from WHO, 2012).
1.3 Global Burden of MentalDisorders
About 450 million people globally are said to be suffering from mental illness, and
this prevalence has been predicted to be more in the near future due to ageing of
the population, worsening social conditions and the rise in civil unrest (De Jong,
2002; WHO, 2001). Mental disorders account for 12% of the global burden of
disease and constitute 4 out of the 10 leading causes of disability worldwide (WHO,
2001).
Despite this huge burden, more than 40% of countries have no mental health policy,
over 30% have no mental health programme, and most countries spend less than
1% of their health budget on mental health services (WHO, 2001). This reflects
the neglect of mental health resulting in widening of the treatment gap.
1.4 Mental Health in Populations Affected by Armed Conflict
Prevalence of mental illness increases significantly in situations of armed conflict
(WHO, 2013). The Global Burden of Disease study estimated that the burden of
disease from mental and behavioural disorders would increase from 12 percent in
1990, to close to 15 percent by 2020 because of the global rise in violent conflicts
(De Jong, 2002). Several studies in post-conflict settings have demonstrated this
increase. In Somalia for example, one in five families had at least one family
member with severe mental disorder (World Bank, 2003). These severe disorders
are commonly Post-traumatic stress disorder (PTSD), mood disorders especially
depression, and anxiety disorders (Priebe et.al, 2010). In a systematic review of
181 studies of adults exposed to conflict, the Rebuild Consortium (2015) reported
the prevalence of depression and PTSD to be more than 30% in almost all the
studies.
A lot more individuals in conflict-affected areas may experience symptoms not
severe enough to meet the criteria for classification as the severe disorders above,
but would significantly interfere with their normal functioning (UNHCR, 2013;
World Bank, 2003). These group of symptoms are classified as psychosocial
disorders. They are caused or influenced by life experiences often resulting from
the interaction of the factors that influence mental health discussed above (WHO,

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2012). Individuals with these disorders have difficulties in social functions.
Persistent social dysfunction is linked to decreased productivity, poor mental
health outcomes, and can lead to suicidal ideation or attempt, substance and drug
abuse, and interpersonal violence (Roberts et.al, 2009).
1.5 Boko Haram Conflict and MentalHealth in Nigeria
United Nations Children Fund (UNICEF) reported a 40% increase in the incidence
of complex emergencies over the last decade (UNICEF, 2000). It has become a
global public health problem as armed conflict has afflicted over 50 countries since
1980 with about 60% of this occurring in the developing countries (De Jong, 2002).
Nigeria started experiencing her share of the menace as early as the 6th year of her
independence when the civil war broke out (BBC, 2015). Since then, other internal
conflicts have been occurring, but by far the most severe is the recent Boko Haram
crises that started in 2009 and is threatening the security of the nation and its
neighbouring countries (Dambazau, 2014). The Boko Haram conflict has claimed
the lives of more than 200,000 people and the displacement of over 1 million
others (IOM, 2015). There is wide spread insecurity and fear among the people,
disruption of social and economic ties in the communities, and destruction of
homes and essential infrastructure (Alaba-Ajileye, 2014). This exerts a lot of
psychological stress on the people leading to a breakdown in mental health status.
Initial studies have demonstrated a rise in the number of individuals seeking
mental health care in the affected areas (Ndajiwo, 2014). With the associated
dearth of mental health resources in the country, the problem becomes even more
severe and need immediate action to mitigate its consequences on the population.
1.6 Problem Statement
The recent increase in the number of people seeking mental health care in North-
Eastern region of Nigeria affected by Boko Haram crises is as a result of the direct
exposure to conflict-related violence arising from insecurity, disruption to social
support networks, and limited ability to access essential services including mental
health care. Addressing these factors is, therefore, necessary for a successful
rehabilitation in the region. What are the interventions that can reverse these
factors in the context of Nigeria with shortage of mental health resources?
1.7 Study Rationale
Until recently, most governments and humanitarian agencies believed in the
“rubber- band” model of mental health in a post-conflict setting where it is
assumed that once food, shelter, water and other essential services are provided,
the people affected would snap back and resume their normal activities (Baingana
et.al, 2005). However, it has been shown that populations traumatised by conflict
experience lasting mental health and psychosocial problems and do not easily
revert to normal at the end of the conflict (WHO, 2013; Baingana et.al, 2005). The
mental health effects of conflict often remain hidden and (under-reported) in the
societies even when basic needs have been addressed (WHO, 2000). This
underpins the need for integration of mental health rehabilitation into post-conflict
support programmes. Failure to address the mental health and psychosocial needs
of populations affected by conflict will impede on reconstruction efforts on human
development, poverty reduction and health improvement (WHO, 2013).

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In Nigeria, despite the above understanding, no disaster or emergency
preparedness plans for mental health exist and the emergency management
agencies have no specific mental health work (WHO-AIMS, 2006).
1.8 Aim and Objectives
1.8.1 Aim
The aim of the study is to develop an appropriate approach for the mental and
psychosocial health rehabilitation of the people affected by the Boko Haram
conflict in North-East Nigeria.
1.8.2 Objectives
i. To discuss the causes and impact of the Boko Haram crises on the mental
and psychosocial health of the population in North-East Nigeria.
ii. To describe the main factors responsible for the increased prevalence of
mental and psychosocial disorders in post-conflict settings.
iii. To identify and appraise appropriate interventions that can be used to
achieve mental health recovery in the affected population.
iv. To develop suitable recommendations for the mental and psychosocial
health rehabilitation of the people.
1.9 Author –Topic relationship
The author of this document is a medical practitioner with over 5 years working
experience in mental health care in North-East Nigeria, the epicentre of the Boko
Haram insurgency. He has been directly involved in the provision of mental health
services to victims of the crises and has a first-hand experience of the challenges
of mental health care needs in the region.
1.10 ExpectedOutput and Intended Use
This dissertation aims to recommend evidence-based, acceptable, context-specific
interventions for the mental and psychosocial health rehabilitation of victims of
the crises. It is also intended to draw attention to this important often overlooked
issue that ought to be a priority in the early stages of reconstruction of war-torn
societies.
1.11 Main Stakeholders
The primary stakeholders and their roles are outlined in Table 1.1.

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Table 1.1: Stakeholders and their role (Source: Author).
Stakeholder Role
Ministries of Health, Social
Services, Education, etc.
Include MHPSS in policy formulations and
implement the recommended interventions.
The federal and state
governments
Policy makers and financial support
International NGOs (IOM,
UNDP, USAID, OXFAM
etc.)
Financial and technical assistance
Local NGOs and CSOs
involved in support activities
in the North-East
Implementation of MHPSS interventions
Mental health professionals,
Social workers
Raise awareness and provide appropriate
services
Religious, traditional and
women leaders
Provide community-based support that
increases resilience
Media and advocacy groups Raise awareness
Members of academia and
researchers
Further research
1.12 Dissertationstructure
This dissertation consists of 5 sections;
Section 1: general introduction with the definition of concepts, aim and objectives,
describes the study rationale and expected output.
Section 2: describes the research methodology, conceptual framework and the
limitations of the study.
Section 3: examine the causes of the crises, its impact on the mental and
psychosocial health of the population and briefly describes the state of mental
health services in Nigeria.
Section 4: analyses the interventions for mental health rehabilitation in post-
conflict situations and determine their applicability in the context of North-East
Nigeria.
Section 5: Gives the dissertation conclusion, recommendations, and dissemination
plan.
1.13 Summary
This chapter has given an introductory background to the topic including concepts
definition, the burden of the problem and justified the importance of the study.
The next section would describe the conceptual framework; sources of data,
literature search strategy and outline the limitations of this work.

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CHAPTER 2 : METHODOLOGY
2.1 Chapter Overview
Chapter one introduced the research topic, described the burden of mental and
psychosocial disorders in post-conflict settings and highlighted the importance of
the research in Nigeria. This chapter will describe the study methodology,
including the conceptual framework, sources of data, literature search strategy and
study limitations.
2.2 Study Type
This dissertation is an in-depth study of secondary data on the causes and impact
of the Boko Haram conflict on the mental and psychosocial health of the
population in North-East Nigeria. It also analyses intervention strategies for
providing mental health and psychosocial support (MHPSS) that were employed
in other contexts similar to Nigeria and where evidence is insufficient, from other
low-and-middle-income countries (LMIC) that experienced similar problems.
This is with the view of suggesting feasible recommendations to improve the
mental and psychosocial well-being of the people traumatised by the conflict in
Nigeria.
2.3 The ConceptualFramework
The Adaptation and Development after Persecution and Trauma (ADAPT)
conceptual framework model developed by Silove (2013), illustrated in Figure 2.1,
would be used to guide this dissertation. The framework postulates that five core
psychosocial pillars form the building blocks for stable societies. Conflict
fundamentally disrupts these pillars, and this disruption accounts for the rise in the
prevalence of mental and psychosocial disorders. Repair of these pillars is,
therefore, considered essential to restoring mental and psychosocial well-being.
These core pillars are:
2.3.1 Safety/Security
Pervasive state of insecurity due to prolonged or repeated threat to life exerts a lot
of stress on the population. This stressful conditions have been shown to increase
the rates of Post-Traumatic Stress Disorder (PTSD) and exacerbate existing mental
ill-health in the community (Steel et.al, 2009). Restoring security is, therefore,
fundamental to recovery, which often leads to resolution of acute stress reactions
(IASC, 2007).
2.3.2 Bonds/Networks
Conflict destroys the social fabric that binds societies (Morina et.al, 2010). It
destroys family and community support structures and predisposes individuals and
families to extreme social stress thereby increasing the risk of psychosocial
problems (IASC, 2007). Re-establishing social ties and community support
improves mental health in post-conflict settings (Miller and Rasmussen, 2010).

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Figure 2.1: The ADAPT Model Conceptual Framework (Source: Silove, 2013).

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2.3.3 Justice
Persisting preoccupation with cumulative injustices of the past and those
associated with the conflict such as human rights abuses and sexual violence have
a negative influence on psychological health (OHCHR, 2015). Promoting an ethos
of justice helps in the recovery and prevention of future conflicts (Rees et.al, 2013).
2.3.4 Roles and Identities
Conflict disrupts established roles within the family and the society (Tajudeen,
2013). It also interferes with the people’s sense of identity to ethnic, religious and
cultural practices. Identity confusion contributes to a range of adverse
psychological outcomes (Ojua et.al, 2013). Re-establishing meaningful roles and
a sense of identity tends to promote adaptation and resilience thereby improving
mental well-being (Silove, 2013).
2.3.5 Existential Meaning
Conflict challenges the survivor’s belief and views about the world compelling
them to re-appraise their fundamental belief systems (Silove, 2013). Giving
meaning to the experience of conflict enhances coping process and recovery (De
Jong and Kleber, 2007). Religion plays a significant role in ascribing meaning to
the experience and offers a powerful means of promoting resilience in people
affected by conflict (Baingana et.al, 2005).
2.4 Justification
This framework was chosen because it provides a simple but comprehensive set
of principles supporting a range of psychosocial interventions for MHPSS in post-
conflict situations. It is a unified framework that bridges the split between trauma-
focused and psychosocial approaches to understanding and addressing mental
health needs in populations affected by conflict (Miller and Rasmussen, 2010). It
shows the multi-sectoral approach required to promote the process of recovery and
rehabilitation. It is also in line with the Inter-Agency Standing Committee (IASC)
intervention guidelines for MHPSS in emergency situations.
2.5 Analytical Tool
The criteria identified by Walley and Wright (2010) would be used to appraise the
proposed interventions. This tool was chosen because it offers a systematic and
simplified approach for appraising public health interventions. These criteria are
defined as follows:
i. Effectiveness: the ability of an intervention to be successful in achieving
mental and psychosocial health recovery among victims of the conflict.
ii. Organisational feasibility: the ease in terms of man and materials with
which an intervention can be implemented.
iii. Cultural and gender issues: the cultural acceptability of an intervention
by the people and gender considerations.
iv. Financial feasibility: the cost implication associated with implementing
the intervention.

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2.6 Sources ofData
Electronic and non-electronic sources of data were used as described below:
i. Non-electronic sources: books from the University of Leeds library and
lecture notes relevant to the topic were consulted. Authors personal
experience in the field was also drawn at to support the analysis and
discussion at some points.
ii. Electronic sources: online literature were identified through internet-based
search of databases, websites, online journals and search engines described
below:
a. Databases: The Leeds University Library (c2016) was consulted to gain
access to Global Health (1973-2016), Medline (1996-2016) and PubMed
(1990-2016) which contain articles relevant to the topic (See Table 2.1).
These databases were chosen because they are key databases for
International Health and provide a wide range of peer-reviewed articles.
They are also frequently updated with recently published articles.
b. Websites: The website of the World Health Organisation (WHO) was
consulted because it is the highest recognised international body of health.
c. Online Journals: The Lancet series and African Journal Online because
they contain relevant peer-reviewed articles.
d. Search-Engines: Google Scholar was also consulted because it contains
relevant articles which could not be found or accessed in the databases
above.
2.7 Literature SearchStrategy
Keywords and their synonyms used in the search strategy include: conflict*, war*,
violence*, mental health*, psychosocial health*, trauma*, developing countr*,
sub-Saharan Africa*, Africa*, low-and-middle income countr*, and Nigeria*.
These keywords were chosen because they form the basis of the study topic.
Boolean operators “AND” and “OR” were then used to obtain a final set of results
containing most aspects of the topic. The search results are as shown in Table 2.1.

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Table 2.1: Results of the database search conducted (Source: Author).
S/N Search term
Database
Global
health
PubMed Medline
Number of Hits
1 Conflict* OR post-conflict
OR war* OR violence
81490 329706 335455
2 Mental health* OR
psychosocial health* OR
trauma*
46025 578242 280763
3 Developing countr* OR
Low and middle income
countr* OR Sub-Saharan
Africa* OR Africa* OR
Nigeria*
192317 396435 176640
4 1 AND 2 And 3 935 1950 1024
5 4 And mental health
interventions
5 184 6
6 4 And 5 And Recovery 16 38 1
7 4 And 5 And 6 And
Rehabilitation
17 98 23
N.B.: * denotes truncation which is used to gathermore results- both singular and plural forms of
a word.
Initial article selection was based on article title/abstract. Full-text articles that met
the inclusion criteria were then selected for detailed reading and analysis. An email
alert was set up to receive weekly updates on new publications relating to the topic.
Snowballing was also used to identify further relevant articles by scanning the
references of those identified from the database search. The results of this search
and the other sources stated above, were then systemically reviewed according to
the inclusion and exclusion criteria to arrive at the final list of materials used. This
process is illustrated in figure 2.2.
2.8 Inclusion and Exclusion Criteria
The following criteria were used to narrow down the search further:
2.8.1 Inclusion criteria
i. Only full-text articles written in English were used (author reads only
English).
ii. Only articles relevant to mental and psychosocial health in populations
affected by conflict and not other forms of emergencies because the focus
of the study is on conflict.
iii. Articles based on studies in LMIC from 1990 - 2016 because most conflicts
over the last few decades occurred in those countries.
2.8.2 Exclusion criteria
i. Articles on MHPSS following other emergencies such as earthquake,
tsunami, etc. because the focus of this work is on post-conflict.

11
ii. Articles based on studies in Western context because the study's focus is
on LMIC.
iii. Articles on mental impact of war on veterans because the focus of the study
is on the civilian population.
Identification
Screening
Eligibility
Analysed
Figure 2.2: Prisma flow diagram showing selection of the study materials (Source: Author).
2.9 Study Limitations
i. The paucity of data on the mental health impact of Boko Haram conflict
on the population in North-East Nigeria necessitated the use of data from
other similar contexts in LMIC.
ii. Some other useful articles require a subscription to enable access which is
beyond the capacity of the author.
iii. Exclusion of articles published in other languages may have obscured other
relevant information.
iv. Time and especially words constraint were significant limitations. Hence,
every aspect of MHPSS may not have been analysed.
2.10 Summary
This chapter has described the study methodology and its limitations. The next
chapter will analyse the key issues relating to Boko Haram conflict in the North-
East region of Nigeria and examine the impact of the insurgency on the mental
and psychosocial health of the population.
138 identified
through electronic
database
167 materials
screened
29 identified from
the other sources
108 materials
assessed for
eligibility
76 materials
included in the study
38 materials
excluded based on
criteria & 21
duplicates
discarded
17 had no full-text
& 15 on
veterans/military
also removed

12
CHAPTER 3 : SITUATION ANALYSIS
The previous chapter described the study methodology and the conceptual
framework. This chapter will give a brief description of the study area and use the
conceptual framework to guide analysis of the factors responsible for the Boko
Haram conflict in Nigeria and discuss the mental and psychosocial impact of the
conflict on the population. The factors responsible for the increased prevalence of
these disorders in post-conflict situations shall also be analysed.
3.2 Background
Nigeria is the most populous Country in Africa with a population of about 170
million people (NPC and ICF International, 2013). The country is administratively
divided into six geopolitical zones – North-East, North-West, North-Central,
South-East, South-West and South-South as shown in figure 3.1. There is a wide
disparity in poverty rate, literacy level, health services delivery, resource
allocation and socio-economic status between the geo-political zones, with the
North-East zone having the worst indices in the country (UNDP, 2013). Not
surprising, it is the epicentre of the Boko Haram insurgency.
Figure 3.1: Map of Nigeria showing the geopolitical zoning (Source: NPC and ICF International,
2013).

13
3.3 Conflict and MentalHealth in Nigeria
3.3.1 Security and Safety
3.3.1.1 Emergency Situations
Nigeria has experienced an increase in the number of man-made emergencies over
the last 15 years (NEMA, 2016). Most of these are due to violent conflict that
could not be effectively dealt with due to the inefficiency of the nation’s security
system (Okpaga et.al, 2012). These conflicts have been induced by ethno-religious
differences, land dispute, communal clashes or politically motivated (Allen et.al,
2014). The most severe of the conflicts is the Boko Haram crises in the North-East
region, which has become a threat to regional security in the West of Africa
(Okpaga et.al, 2012).
3.3.1.2 The Boko Haram Insurgency
Boko Haram insurgency is one of the most significant conflicts globally, with the
insurgents ranked the deadliest terrorist group in the world in 2014 (Allen et.al,
2014). Boko Haram started in 2009 as an Islamic religious group officially known
as “Jama’atul Alhul Sunnah Lidda’wati wal Jihad” meaning “people committed
to the propagation of teachings of the prophet and Jihad” (Alaba-Ajileye, 2014
p.1). Boko Haram translates to Western education is forbidden in the local
language (Author). The crisis has led to the death of more than 200,000 people
and the internal displacement of over 2 million others, making Nigeria have the
third largest number of Internally Displaced Person’s (IDP’s) in the world (IOM,
2015; NRC, 2014).
3.3.1.3 Mental Health Impact of Insecurity
Insecurity is at the core of every conflict and exerts significant physical and
psychological stress on the people. Stress resulting from a pervasive state of
insecurity and fear is a known risk factor for poor mental health (Hassan et.al,
2016; Coldiron, et.al, 2013; Baingana et.al, 2005). The significant increase in the
rates of Post-Traumatic Stress Disorder (PTSD) and other stress-related disorders
with persisting conditions of insecurity has led to the suggestion of the use of the
prevalence of PTSD symptoms as a measure of the extent of insecurity in a society
affected by conflict (Steel et.al, 2011). The WHO estimated that 10% of the
people who experience traumatic events associated with armed conflict, will have
severe mental health challenges and another 10% will develop behaviours that will
hinder their ability to function effectively (WHO, 2001).
In North-East Nigeria, a recent psychosocial needs assessment revealed a high
prevalence of trauma-related psychosocial disorder among the population (IOM,
2015). An increase in the number of individuals presenting with PTSD was also
reported by the specialist mental hospital in the region, even though no official
prevalence was quoted (Ndajiwo, 2015). Health care professionals in the region
have also noted a rise in the number of people requesting for psychological
counselling (Personal experience).
3.3.2 Interpersonal Bonds and networks
Conflict fractures social ties, breaks up families and communities, and displaces
populations (World Bank, 2003). It is a social catastrophe associated with the
destruction of community’s economic, social, cultural and religious structures
(Morina et.al, 2010). Conflict erodes normally protective supports and increases
the risk of diverse problems (IASC, 2007). The material and personal losses

14
associated with it exerts significant stress on the population. These social factors
are more important in determining the onset and severity of mental disorders in
war- affected societies than the severity of direct trauma (Al-Ghzawi et.al, 2014;
Miller and Rasmussen, 2010). However, critics have argued that a narrowly
psychosocial approach is likely to underestimate the adverse impact exposure to
the conflict can have on mental health (Shoelte et.al, 2011).
Nigerians share a strong attachment to family and community social systems
(Personal experience). The strong social networks in the family and community
help the people in coping with conditions of hardships and grief, contributing
significantly to their resilience (Ojua et.al, 2013). The Boko Haram crises have
destroyed these family and community networks among the affected population
(Alaba-Ajileye, 2014). Several families have witnessed the death and
disappearance of members, loss of homes and valuables, and several have had to
flee their communities and leave behind all they had lived for (Amnesty
International, 2015). The breakdown in these support structures deprives the
people of the usual means of coping with adversities which further worsens their
psychological well-being. Early studies have shown many families in the
communities to have started showing signs of anxiety and depression as a result
of the physical and psychological trauma faced during the conflict (Daily Trust,
2016; Ndajiwo, 2015).
3.3.3 Systems of Justice
The pre-existing problems of social injustice and inequality in the North-East have
been identified as the key drivers of the Boko Haram conflict in the region as
discussed below. Yet, conflict also amplifies these problems (IASC, 2007).
3.3.3.1 Marginalisation of the North-East
The North-East is the most under-developed region of Nigeria (UNDP, 2013).
Poor governance associated with endemic corruption has led to the marginalisation
of the zone in the allocation and management of resources (Ismail, 2013). Key
factors identified as the primary drivers of the conflict in the region are those
related to marginalisation in terms of development making the zone to have the
highest rates of poverty, unemployment, illiteracy, and worst health indicators in
the country (Ogege, 2013; Ismail, 2013; Rogers, 2012; Adenrele, 2012).
To make it worse, conflict causes further breakdown of social services including
health and education. Early studies have reported limited access to social,
educational and health services in the communities in North-East Nigeria which
have been destroyed (IOM, 2015). Inadequate access to essential health services
leads to exacerbation of chronic mental health problems in post-conflict settings
(Hassan et.al, 2016; Ndajiwo, 2015; Mollica et.al, 2004). A strong link between
literacy level and undesirable social behaviours has also been documented (UNDP,
2013). Displacement resulting from conflict also makes the people unable to
engage in productive activities further plunging them into poverty. Poverty is an
important determinant of health including mental health, and it also affects the
ability of people to recover from an illness or an emergency (WHO, 2012).
3.3.3.2 Frustration, Anger and Antisocial Behaviours
The inability of humans to fulfil their basic needs elicit a violent reaction in them
(Ogege, 2013). Therefore, when an individual or a group is denied their legitimate
need as a result of the way the society is governed, that feeling of frustration is

15
expressed as anger and violence usually directed at those believed to be
responsible (Ismail, 2013). This frustration also leads people especially the idle
youths turning into religious fundamentalism, often as a means of coping with
their lack of basic needs (Rogers, 2012). This factor contributed to the evolution
of the terrorist group in the region (Weeraratne, 2015). Frustration is a major risk
factor for mental illness, often manifesting as antisocial behaviours, substance
abuse, depression and suicidal behaviours (Lahey, 2009).
3.3.3.3 Human Rights Violations
Boko Haram had attacked and in some cases held more than 130 villages and
towns in North-East Nigeria, where it imposed its interpretation of Sharia law
perpetrating all kinds of human rights abuses including sexual violence, forced
marriage, and forceful faith conversion (OHCHR, 2015). Other atrocities
committed include the indiscriminate killing of civilians, abduction of over 500
women and girls, forceful conscription of young men and boys, and destruction of
villages, towns, and schools (Human Rights Watch, 2015). Evidence has shown
that persistent preoccupation with injustice acts as a precursor to psychological
symptoms following exposure to human rights abuses (Rees et.al, 2013).
3.3.4 Roles and Identities
The identity of a people influences their perception, attitudes, and behaviour
towards their health especially mental health, social relationships, and their
response to adversities such as conflict and displacement (Ojua et.al, 2013).
3.3.4.1 Identities
Nigeria is a multi-ethnic country with over 250 ethnic groups each with its
different cultural practice and belief (NPC and ICF International, 2013). These
diverse identities have significantly played a role in shaping the political and social
institutions, deeply dividing the country along ethnic, religious and regional
identities (Tajudeen, 2013). Conflicts including the Boko Haram insurgency
evolved along issues relating to religious-related questions of identity (Ojua et.al,
2013; Tajudeen, 2013). Traumatic experiences associated with conditions of mass
violence and displacement interferes with the person’s sense of identity and the
challenge in resolving these contrasting identities when normalcy returns play a
critical role in psychological adjustment (Tajudeen, 2013).
3.3.4.2 Roles
A common feature that cuts across all ethnic groups in Nigeria is gender role
differentiation (NPC and ICF International, 2013). There is a sharp categorisation
of its citizenry into sex and gender, each with its defined sets of roles in the society
(Ojua et.al, 2013). Women and children are viewed as vulnerable groups and
confined to domestic roles. The Boko Haram crisis has challenged these roles in
the affected areas. The terrorists have recruited young boys and girls in support
roles and combat (IOM, 2015). Boys were abducted for indoctrination into Boko
Haram’s fighting force, while women and girls were abducted for sexual
exploitation, forced marriages and suicide bombing (OHCHR, 2015). Studies in
post-conflict settings have shown such confusions of roles and identity to act as a
catalyst to a range of adverse mental and psychological sequelae (Smith and True,
2014).

16
3.3.5 Existential Meaning
Religion plays a prominent role in the people’s life and in shaping community
values in Nigeria (Ndajiwo, 2015). The significant prominence given to ethnic and
religious differences exacerbated divisions between Muslims and Christians,
Northerners and Southerners, and various tribal groups (Tajudeen, 2013). Such
differences have often been exploited by some groups especially the political class,
resulting in recurrent social violence in the country (Ismail, 2013). The Boko
Haram crisis is no exception. Forceful conversion of people to Islam by the
insurgents and ideological indoctrination of abductees have been reported
(OHCHR, 2015). Maladaptation to this existential challenges creates a sense of
alienation resulting in depression, drug and alcohol abuse, somatoform disorders
and suicidal tendencies (Silove, 2013).
3.4 Mental Health Services in Nigeria
Only about 33% of Nigerians have access to mental health services (Gureje et.al,
2015). This is due to paucity of mental health facilities. Services are available only
at specialist mental hospitals at secondary and tertiary levels. These facilities are
around 30 in total, disproportionately distributed across the regions and all located
in the main urban cities, with the North-East region having only one facility for its
18.9 population (Abdulmalik et.al, 2013). The lack of access to mental services at
community level contributes to the excessive patronage of traditional or religious
options for mental care by most rural Nigerians (Aghukwa, 2012). A recent study
showed only 20% of patients with mental illness received any form of orthodox
treatment (Gureje et.al, 2015). Even though the study is not without criticism as it
was conducted in only 1 of the 36 states and with a small sample size, it is, however,
a pointer to the serious challenges in accessing mental health service in the country.
Mental health services are also poorly resourced in the country, with only about
3 % of the nation’s health budget expended on mental health (WHO-MOH, 2006).
Human resources for mental health are also grossly inadequate with Nigeria
having just about 200 psychiatrists and very few auxiliary mental health
professionals (Gureje et.al, 2015). More so, less than 20% of the mental health
facilities offer specific psychosocial interventions for trauma-related illnesses
(WHO-MOH, 2006).
3.4.1 Mental Health Policy
Nigeria has no comprehensive modern mental health legislation (Esan et.al, 2014).
There is no desk in the ministries at any level for mental health, and no
disaster/emergency preparedness plans exist for mental health in the country
(WHO-MOH, 2006). The emergency or disaster agencies have no specific mental
health responsibilities (NEMA, 2016).
However, despite the considerable neglect of mental health services, a mental
health policy was formulated recently (WHO-MOH, 2006). Its components
include promotion, prevention, treatment, and rehabilitation. The policy allows for
the integration of mental health into Primary Health Care (PHC), in recognition of
the lack of mental health services in rural communities and the strategic role of
PHC in improving access to health services (Gureje et.al, 2015). Unfortunately,
this has not yet been fully implemented (Esan et.al, 2014).

17
3.4.2 Mental Health Seeking Behavior
Mental health help-seeking behaviour in a native African society is often
influenced by the community's concept of mental illness (Esan, 2014). Many
African societies including Nigeria believe in native existential ideologies and
religious doctrines in the causation of mental illness (Aghukwa, 2012). As such,
when an abnormal behaviour is noticed, it is unusual for the people to seek
orthodox medical care. They rather consult the herbalist/spiritualist.
Understanding these existential ideologies and challenges faced during conflict is
essential to the planning of psychosocial rehabilitation (Silove, 2013). Involving
religious and spiritual healers in the rehabilitation process could be effective since
most people consult with them first.
3.5 Summary
This section has described the causes of the Boko Haram conflict in North-East
Nigeria and its impact on the mental and psychosocial health of the population. It
has described the state of mental health services in the country and highlighted
some broad areas of focus for interventions. The next chapter shall identify and
appraise intervention strategies for mental and psychosocial rehabilitation that
have proven effective in post-conflict settings in other LMIC and appraise their
applicability within the context of North- East Nigeria.

18
CHAPTER 4 : ANALYSIS OF INTERVENTION
STRATEGIES FOR MHPSS IN POST-CONFLICT
SITUATION
The preceding chapter discussed the causes and impact of the Boko Haram conflict
on the mental and psychosocial health of the population in North-East Nigeria.
This chapter shall explore intervention strategies that could be used to promote
mental health and psychosocial recovery. The interventions would be analysed
according to the core pillars of the conceptual framework described in chapter 2.
4.2 TargetPopulationfor Intervention
Due to resource limitation and capacity constraints in the developing countries like
Nigeria, the Inter-Agency Standing Committee on mental health and
psychoscocial support in humanitarian settings (IASC, 2007) recommended that
the scope and coverage of interventions should be targeted towards the most
vulnerable groups. More so that, most of the affected people show resilience
(ability to cope relatively well with situations of adversity), but these vulnerable
people are at increased risk of experiencing severe mental/psychosocial disorder.
These vulnerable groups include:
i. Populations who have been uprooted (IDPs and refugees) and within these,
those who have suffered or witnessed violence;
ii. Survivors of gender-based sexual violence, especially women, and
minors;
iii. Survivors of genocide, massacres or violence targeted on civilians and
communities
iv. Child soldiers and women
v. Children and adults with physical disabilities caused by conflicts, such as
amputees and landmine survivors
vi. Orphans and other children made vulnerable by conflicts, such as those in
child-headed households, AIDS orphans, and street children.
4.3 SelectionofProposedInterventions for Analysis
To guide the development of MHPSS interventions that meets the needs of
different groups in complex emergencies, the IASC (2007), also developed a
multi-layered system of approach to serve as a guideline for organising MHPSS
programmes in populations affected by emergencies. This is known as the
intervention pyramid, shown in figure 4.1

19
Figure 4.1: The IASC intervention pyramid for mental and psychosocial support (Source:
IASC, 2007).
The interventions that are in line with the recommendation of the IASC guidelines
above and specifically address the damaged pillars in the conceptual framework
were selected for analysis. These are shown in Table 4.1

20
Table 4.1: Proposed Interventions Selectedfor MHPSS (Source: Author).
IASC support
layer
Pillar in
conceptual
framework
Proposed Intervention
Basic services
and security
Security and safety
Systems of justice
Re-establishing security and ensuring
protection
Promoting human rights approach
Equity in the distribution of essential
services
Community and
family support
Bonds and
networks
Family tracing and re-unification,
structured social and recreational
activities, providing and facilitating
group sociotherapy, counselling,
Focused, non-
specialised
supports
Roles and identities
Existential meaning
Traditional/Religious/spiritual healing,
Trauma counselling
4.4 Re-Establishing Security and Ensuring Protection
According to Belard (2005) cited in Ogege, (2013, p83):
Insecurity entails lack of protection from crime (being unsafe) and lack of
freedom from psychological harm (unprotected from emotional stress resulting
from paucity of assurance that an individual is accepted, has opportunity and
choices to fulfil his or her own potentials including freedom from fear.
As discussed in Chapter 3 and further enshrined in the above definition, security
is as equally important to psychological well-being as it is to physical safety. Re-
establishment of security is key to improving the capacity of people affected by
the stress of war to recover and to achieve psychosocial stabilisation (Silove, 2004).
Evidence has shown that in post-conflict situations the greatest stress arises from
the threats of insecurity, and measures taken to protect the physical safety of the
people has led to the resolution of most psychosocial symptoms (IASC, 2007).
Apart from its direct impact on the mental and physical health of the people, re-
establishing security forms the foundation on which long-term sustainable
development can be built (Valters et.al, 2014). Improving the security situation
allows for rebuilding of vital systems such as education and health care, social
networks and community bonds, protect the people's livelihoods, etc. all of which
promote mental and psychological well-being (Valters et.al, 2014; Ogege, 2013).
Ensuring a safe environment, therefore, is an integral part of psychosocial support
even though the implementation is the responsibility of the state’s armed forces -
the police and military security systems (IASC, 2007). The analysis of the
intervention strategies for restoring security in post-conflict settings is, therefore,

21
beyond the scope of public health and by extension this project despite its strong
impact on psychosocial well-being. Nevertheless, it is the responsibility of mental
health experts to apprise the policy makers of the importance of this intervention
in order to achieve mental health recovery in post-conflict settings (Silove, 2013).
4.5 Community-Based Socialand Family Support Activities
Repairing the social fabric of societies affected by conflict through the facilitation
of community-based social and family support for vulnerable individuals is one of
the most commonly used interventions for MHPSS in LMIC (Tol et.al, 2011). This
intervention which is usually delivered as a package aims to improve the
psychological and social well-being of the individual through the repair of
community and family social structures (Jansen et.al, 2015; Richters et.al, 2008).
It mobilises community-based resiliency and increases adaptation by restoring
normal community life (Mollica et.al, 2004). Activities in the intervention package
include establishing a family tracing and re-unification service, structured
recreational and creative activities, organising safe spaces for social interactions,
re-starting community cultural customs such as dancing or storytelling to improve
community cohesion (Shoelte et.al, 2011).
There is mounting evidence that most persons with acute stress reactions recover
spontaneously if attention is given to repairing the social environment (Al-Ghzawi
et.al, 2014; Miller and Rasmussen, 2010; Ager and Loughry, 2004). A
community-based social intervention implemented by Medecins San Frontieres
(MSF) among war-affected populations in Uganda and Sierra Leone resulted in
improvement of the psychological well-being of 65% of the clients (De Jong and
Kleber, 2007). Although MSF is not a scientific organisation, the evaluation done
by them on a small sample size showed findings concurrent with other studies in
LMIC (Neuner et.al, 2008).
Also, Ager et.al (2011) reported a significant improvement in psychological well-
being among children following the implementation of structured psychosocial
activities in schools in Uganda. However, a randomised controlled trial (RCT) of
creative play alone showed no effect on the psychological health of victims of
violence in another study on adolescents in Uganda (Tol e.al, 2011). Arguably, a
structured recreational and cultural activities programme which consists of at least
2 different activities was found to be effective in improving the emotional and
behavioural well-being of Palestinian populations affected by conflict (Loughry
et.al, 2006). The study, however, did not examine the duration and quality of the
activities needed to achieve the improvement. Fewer sessions with decreasing
quality over time may affect the sensitivity of the study in identifying intervention
impact.
In a more robust quasi-experimental study in Rwanda, Shoelte et.al (2011) also
showed community-based social intervention to be effective in reducing
symptoms of distress and improving the mental well-being of survivors of mass
violence. In Nigeria, a recent psychosocial needs assessment conducted on a
sample of internally displaced population in the North-East showed that 23% of
participants identified partaking in recreational activities as a major factor
promoting resilience (IOM, 2015). The other main ways of coping found in the
study were engaging in group discussions and social activities where new friends

22
are made. Therefore, structured social intervention can be effective if implemented
in the affected region.
Psychosocial interventions are easily arranged and facilitated by community
leaders after some minimal training (Jansen et.al, 2015). This makes it
organizationally feasible requiring less technical expertise in delivering the
intervention. Implementing social interventions at the community level also have
the capacity to reach a large number of people over a short time (van Ommeren
et.al, 2008). This is because the interventions can be provided to groups rather than
individuals to reduce cost and increase coverage. Group interventions have shown
a positive impact on health outcomes in other areas of public health (Scholte et.al,
2011).
The intervention was found to be culturally acceptable to the community in
Rwanda because of it been a community-based intervention owned and facilitated
by its members (Scholte et.al,2011). The Africa’s tradition of organising
communities in groups could increase the acceptability of the intervention. In
Nigeria, studies have shown wide acceptance of most community-based
participatory programmes (Ezeanolue et.al, 2015). This intervention is, therefore,
likely to also be accepted, more so that Nigerians show strong attachment to
community and family structures as discussed in chapter 3.
4.6 Trauma Counselling
Trauma counselling is among the most popular interventions in post-conflict
settings (Tol et.al, 2011). It is offered as a psychotherapy to those with established
symptoms of PTSD, victims of sexual and human rights abuses, and other severe
psychological effects of organised violence (Miller and Rasmussen, 2010).
Counselling consists of listening (not forcing talk), conveying compassion and
empathy delivered by a trained counsellor (Mollica et.al, 2004). It creates a safe
environment for survivors of conflict and it's associated atrocities to talk about
significant life events, feelings, emotions, ways of thinking and behaviour.
Counselling offer systematic support to help resolve the difficulties and suggest
ways of coping through culturally-acceptable techniques (Neuner et.al, 2008).
An RCT showed counselling to be an effective intervention in reducing symptoms
of PTSD among Rwandan and Somalian refugees (Neuner et.al, 2008). Although
the study was conducted in refugee settlements, the findings corroborate with
results of smaller trials in the general population (De Jong and Kleber, 2007).
Also, studies among the IDP population in Nigeria conducted by IOM (2015)
revealed supporting each other through giving advice as a major coping strategy
expressed by most of the participants. This shows the acceptability of such forms
of support by the people. Leveraging on this, the support provided by a trained
counsellor may even be a more effective way of providing relief to the people and
improving their coping abilities. The impact of a stand-alone trauma counselling
intervention on coping has however been debated. Critics have argued and proved
in two RCT in Indonesia and Nepal, that the effectiveness of counselling is highly
enhanced by delivering it along other social support activities using an integrated
approach (Tol et.al, 2011).
In settings like Nigeria, where there is a shortage of mental health workers, trained
volunteers could be used to deliver this intervention. Several studies in LMIC with

23
similar context have demonstrated the feasibility of trained volunteers providing
effective counselling services (Vijayakumar and Kumar, 2008; Neuner et.al,
2008). Trained volunteers have been used in Nigeria to provide essential
community services in their communities (Personal experience). Hence, this
approach could be used for trauma counselling as well. This would reduce cost
and enhance community acceptance and participation.
Counselling can be delivered either in small groups or on an individual basis. For
instance, a rape victim may benefit from one-on-one counselling, but may also
benefit from sharing experiences in a group with other women victims, since this
can minimise the stigma and help the victim realise she is not alone (Baingana
et.al, 2005). Where the affected populations are large like in Nigeria, group
counselling also has the tendency to reach a large number of people over a short
period. However, in certain cultures especially the Northern part of the country,
certain groups of people such as women may not feel comfortable discussing their
problems in a group (Personal experience). In such situations, combining group
support with individual sessions could be utilised if sufficient counsellors have
been trained.
4.7 Measures to Promote Justice and Reduce Marginalisation
Studies have shown that past injustices contribute significantly to the daily
stressful events that exacerbate psychological ill-health in war-torn societies as
discussed earlier. Interventions that reduce these daily stressors are mostly those
programmes that improve living conditions and strengthen the social coherence of
the people (Neuner et.al, 2008). These interventions include: providing education,
programs to reduce poverty in the society, creating employment opportunities,
provision of basic health care, and an improved justice system which enables
citizens to seek redress for crimes against them (Valters et.al, 2014).
Addressing marginalisation, human rights violations and broader issues of equity
and gender considerations as was done in Sierra Leone and Afghanistan has been
proven to improve the psychological well-being of the people affected by conflict
(Baingana et.al, 2005). Improvement in living conditions and provision of
employment opportunities was also associated with significant improvement in
mental health symptoms in an RCT among refugees in Uganda (Neuner et.al,
2008).
Specific programs to address this pillar requires a multi-sectoral approach and
strong commitment from the government and supporting partners. Detailed
analysis of these interventions is beyond the scope of this dissertation. However,
when planning mental health rehabilitation in post-conflict settings, it is important
to ensure these issues are given due consideration as discussed in chapter 3. They
are the key drivers of the Boko Haram conflict in Nigeria and must be addressed
if future war is to be prevented. Studies in Nigeria have shown the resurgence of
conflict in a different form due to failure in dealing with the critical social factors
associated with violence ( Ogege, 2013).

24
4.8 Traditional/Religious/SpiritualHealing
Ascribing meaning to traumatic experience has been found to enhance the coping
process (De Jong and Kleber, 2007). In most African societies, meaning is given
through the spiritual world otherwise known as traditional or religious healing
usually provided by traditional healers (Mollica et.al, 2004). A traditional healer
is often a spiritual leader, herbalist, family, or community elder.
Traditional healing has shown promising roles in MHPSS especially in African
traditional systems, where religious/cultural rituals have been used by
communities emerging from conflict to deal with various forms of psychosocial
stress (Abbo, 2011; Baingana et.al, 2005). It enhances coping tremendously in
most African societies. Several studies in post-conflict Sudan, Angola, Sierra
Leone and Uganda have shown the effectiveness of traditional healing practices in
helping survivors of war deal with their traumatic experience leading to
improvement in their mental well-being (Abbo, 2011; IASC, 2007; De Jong and
Kleber, 2007; De Jong, 2002).
Religious beliefs and meditations enhance coping by calming the distressed mind
(Abbo, 2011). Cultural practices and other acts of worship were found to be a
major means of coping with the stress of war in Cambodia as expressed by the
survivors (Agger, 2015). This result is similar to the finding in Afghanistan where
Reading the Quran was found to be the most commonly used coping strategy
employed by Afghans after the war (Baingana et.al, 2005). In a study in North-
East Nigeria, IOM (2015) found that majority of IDPs surveyed resorted to prayers
as a means of coping with negative feelings. These findings show the importance
people attach to their cultural/religious beliefs. In populations where religion plays
a significant role in their life and well-being, promoting traditional healing offers
a potentially more effective means of reducing psychological symptoms than
western therapeutic models (Agger, 2015; Abbo, 2011).
Although, some authors have argued that traditional healing is unhealthy, harmful,
uncivilised and open to a wide range of magical or mystical explanations that fall
outside the laws of natural science, several RCTs have shown the effectiveness of
traditional therapies in alleviating symptoms of mental distress while
acknowledging some pitfalls in the system (Abbo, 2011; Mollica, 2004). However,
this practice requires stringent regulation and supervision (Mollica, 2004).
It is organizationally feasible to provide traditional healing services as these
providers are usually members of the communities who are already providing
healing services.
Traditional healing is culturally acceptable and widely practised in Nigeria and
Africa in general, often the first point of seeking care for people with mental
distress as discussed in chapter 3. Studies have shown a significant increase in the
uptake of interventions offered through religious infrastructure and traditional
community networks (Ezeanolue et.al, 2015). These institutions have well-
established networks and most communities in Nigeria has at least one worship
centre even in areas where health facilities are not available. They, however,
require some training in the recognition of the symptoms to enhance their
usefulness. This was also recognised more than 40 years ago in Nigeria in studies
done by Lambo in the 60’s as evaluated by Jegede (1981). He introduced the
village community mental health system which mobilises the traditional socio-

25
cultural resources in the treatment of mentally sick people. Even though the
research is old, it showed promising potentials in the use of traditional practices
for the treatment of mental illness.
4.9 Summary
This section has identified and analysed possible intervention strategies that could
be used to promote MHPSS recovery. It has discussed the applicability of such
interventions within the context of the setting of North-East Nigeria. From the
appraisal, all the intervention strategies are highly feasible for implementation in
Nigeria. The next chapter shall conclude the dissertation by recommending all
these 3 interventions to the stakeholders for implementation in an integrated
approach.

26
CHAPTER 5 : CONCLUSION, RECOMMENDATIONS,
AND DISSEMINATION PLAN
The preceding chapter analysed the interventions that have proved useful in
promoting mental and psychosocial health recovery in other LMIC affected by
conflict and appraised their feasibility in North-East Nigeria. This chapter would
give a conclusion of the study, and propose appropriate recommendations based
on the analysis of evidence in the preceding sections. It would also give the
dissemination action plan to the stakeholders. A reflection on the authors learning
experience of writing this dissertation shall then be given.
5.2 Study Conclusion
This study found that social drivers such as poverty, marginalisation, poor
governance associated with endemic corruption, inadequate essential services
such as education and health care and issues of identity are among the major
factors responsible for the Boko Haram conflict in North-East Nigeria. The
conflict has caused significant psychological trauma on the population, resulting
in an increase in the prevalence of mental and psychosocial disorders in the region.
Insecurity and fear associated with violence, damage to social and family ties in
the communities, persisting injustices such as sexual abuse and human rights
violations, and the existential challenges survivors of conflict face are some of the
factors that increase the prevalence of mental and psychosocial disorders in the
post-conflict settings.
The study found that restoring security and addressing the fundamental social
drivers of the conflict is key to any sustainable mental and psychosocial
support/rehabilitation. It would result in significant improvement in the mental
health of the majority of the population. However, certain vulnerable groups who
are at risk of severe mental health problems would require further focused non-
specialized/specialised forms of support to promote their recovery. These supports
include community-based social support, religious or spiritual support, and trauma
counselling. All these interventions were found to be feasible for implementation
in North-East Nigeria and are recommended for implementation in a multi-sectoral
approach.
5.3 Recommendations
5.3.1 Specific Recommendations
These recommendations are to be implemented within the health sector to
facilitate delivery of the interventions for mental health rehabilitation.
i. The Ministries of health in each of the concerned states should conduct
advocacy visits to community leaders, traditional rulers, policy makers
(politicians), national and international development partners to canvass
for integration of mental health and psychosocial support (MHPSS) into
post-conflict development planning in North- East Nigeria.
ii. A Mental health department should be created in all the ministries of health
in the North-Eastern states and at the national level to coordinate mental
health programmes.

27
iii. The policy that allows for the integration of mental health services into
primary health care should be implemented to make the services available
in the communities.
iv. A committee composed of all the relevant stakeholders should be formed
in each of the affected states to oversee the delivery of the proposed
interventions.
5.3.1.1 Community-Based Social Support
Short Term (6 Months – 1 year)
The proposed committee in collaboration with community leaders should:
i. Involve the communities in the design and delivery of the community-
based interventions. The community and women leaders should be
encouraged to form self-help support groups which would create a safe
avenue for social interactions.
ii. Establish a family tracing and reunification service within the communities.
iii. Identify the most vulnerable people in the communities and assign roles to
those who are capable so as to aid their recovery.
Medium Term (1- 3 years)
i. The proposed mental health department should collaborate with the NGOs
in the region to provide necessary inputs for local recreational and
vocational activities in the communities.
ii. The NGOs in collaboration with community leaders should re-establish
community socio-cultural practices that promote cohesion and bonding.
Long Term (3-5 years)
i. The MoH in collaboration with MoE should incorporate psychosocial
structured social activities programme in the curriculum of schools to
support the development of resilience.
ii. The ministry of social services in collaboration with community leaders
should establish community centres that would serve as safe spaces for
social interactions.
5.3.1.2 Trauma Counselling
Short Term – Medium Term
i. The local NGOs should recruit volunteers giving equal opportunities to
men and women and train them to provide counselling services in the
communities.
ii. The MoH should establish emergency counselling centres in the
communities and post the counsellors to their respective communities to
provide psychotherapy support services.
Long Term
i. The MoH should integrate counselling services into mental health care
provision at PHC level in the country.
ii. The MoH should employ permanently and post the trained volunteer
counsellors to provide psychotherapy at the PHCs.

28
5.3.1.3 Traditional/Spiritual Healing
Short Term – Long Term
i. The proposed department of mental health in the states ministries of health
should integrate religious leaders and traditional/spiritual healers into a
Culturally adapted mental health system to provide rehabilitative services
in line with established guidelines.
ii. They should provide emotional, spiritual and social support services in
their communities. However, this should be implemented with caution
considering the ethnic and religious cleavages that are common in the area
and its role in the evolution of the crises.
iii. They should be trained to recognise and refer severe cases.
iv. The MoH in collaboration with community leaders should supervise their
activities.
5.3.2 General Recommendations
These recommendations are for actors outside the health sector to create the
enabling environment for sustainable mental health recovery.
5.3.2.1 Improve governance and reduce marginalisation
Medium Term – Long Term
i. The federal and state governments should pursue a long-term strategy to
strengthen its governance systems, reduce corruption, and ensure equitable
distribution of resources for national development.
ii. The federal government should give special support to the North-East
region to accelerate development and reduce the existing inequalities.
iii. The plan for the creation of the North-East Development Commission by
the federal government is laudable, and if created, should be given
adequate support to ensure it meets its intended purpose.
5.3.2.2 Improve the socio-economic environment
Medium Term - Long Term
The proposed North-East Development Commission should include special
programmes to improve the socio-economic status of the people. This should be
at the core of all rehabilitation efforts in the region. Creating employment
opportunities, poverty reduction programmes, measures to improve the provision
of essential health care services, etc.
5.3.2.3 Education and Awareness
Medium Term – Long Term
i. Improving educational opportunities through both formal and informal
sectors should be pursued by the ministries of education. This would
ensure de-radicalization of the populace and correct the anti-western
education ideology propagated by the Boko Haram.
ii. The government should involve the religious institutions in this effort to
promote religious tolerance and preaching of peaceful co-existence among
the people.
iii. Schools should integrate the teaching of peace, reconciliation, and
religious tolerance into their curricula.

29
5.4 DisseminationPlan
The findings and recommendations of this dissertation shall be disseminated to the
major stakeholders as shown in Table 5.1. The aim of the dissemination is to raise
awareness of the enormity of the challenge while calling for the implementation
of the recommendations.

30
Table 5.1: Dissertation dissemination plan (Source: Author).
Activity Who is
responsible
Timeframe Target group
(Stakeholders)
Purpose Resources
required
Source of
funding
Meeting with
officials of
state
ministries of
health, social
welfare,
education and
women
affairs of the
North-
Eastern
states.
Author in
liaison with
the permanent
secretaries or
their
representatives
January
2017
Honourable
commissioners,
permanent secretaries
and the directors of
planning in the
ministries.
To present the
results of the
research and the
recommendations
made.
Money for
logistics and
refreshments.
Meeting would be
conducted in the
ministries of
health in each of
the six states in
the region so that
only the author
gets to travel to
reduce cost.
The author
will liaise
with Gombe
state
government
to finance the
dissemination
activities.
Seminar Author and the
Directors of
PHC in the
States
January
2017
Primary health care
workers involved in
providing mental
health care and
mental health
professionals
To enlighten
caregivers on the
benefits of the
interventions.
The cost of travel,
renting venue and
materials for
presentation,
refreshments, and
printing of
research findings
and
recommendations.
Meeting with
International
Organisations
and NGOs
(UNDP,
IOM,
USAID,
Author February
2017
The international
organisations and
NGO’s involved in
the provision of
humanitarian support
in the North-East
To present
findings and
highlight the need
for integrating
MHPSS into their
programmes. To
seek for financial
The cost of travel,
venue, and
presentation
materials.
Meeting to be
conducted in
Abuja where the

31
Activity Who is
responsible
Timeframe Target group
(Stakeholders)
Purpose Resources
required
Source of
funding
OXFAM,
etc.)
and technical
assistance in
implementation.
offices of the
organisations are
located.
One-day
Workshop
Author February
2017
Local NGOs, CSOs,
Traditional/Religious,
and community
leaders.
To generate
interest in
MHPSS and
motivate
implementation
of the study
recommendations
The cost of
logistics, venue
and refreshments.
Workshop to be
conducted in the
conference hall of
Gombe State
MoH.
Town hall
meeting
Author March 2017 Media and advocacy
groups, members of
academia and
researchers
To raise
awareness of the
enormity of the
challenge and
canvass for
support in
implementing the
interventions.
The cost of
venue,
presentation
materials, and
refreshment.

32
5.5 Reflection
As a practicing mental health physician in Gombe State, one of the 6 states that
make up the North-East region of Nigeria, I noticed a surge in the number of
people presenting with depression and PTSD since the Boko Haram crises became
heightened in 2012-2014.From previous learning, I knew the iceberg phenomenon
which states that the patients whom we see in the health facilities are only the tip
of the iceberg. The majority of people suffering from an illness especially mental
illness are in the communities and only seek for care when the condition becomes
unbearable or complicated.
When the opportunity came my way to come to the UK to study for a master’s
degree in Public health, I thought of how I can use this opportunity to touch the
lives of those several people wallowing in the villages of North-Eastern Nigeria
with mental and psychosocial problems due to the Boko Haram crises. The one
idea that came to my mind was “how about writing my dissertation on this topic?”
However, I was confused thinking public health is all about communicable
diseases. I approached one of my teachers in Nigeria for advice. His opening
statement was awesome! “Everything about mental health is public health.” He
advised I read around the subject to familiarise myself with the body of literature
on the subject and perhaps find a suitable topic.
I thought having a topic from the onset would make my work easy, but I was
proved wrong. Writing chapter 1 was relatively easy with only a few corrections.
Next, I wrote chapter 3 and finding an appropriate conceptual framework to fit
into my work was tough. At last, I found one and tried to make it fit my work. I
realised I had to do almost a new work if I am to use the framework. It was very
difficult for me to make it work. Chapter 4 was also not very different, and I
contemplated severally on whether I should even change my topic at this point. I
then realised what Tom Dessofy told us about writing a dissertation in the
preparatory lectures was very true. At some points in the process, one gets
confused and frustrated while at some other one thinks he is doing the best that
could be done.
Writing this dissertation has tested all my critical learning domains. From
developing an idea to searching for evidence and narrowing of the topic for a
focused research and critical analysis. It also brought out the resilience in me to
withstand the stress of multiple assignments and deliver all within the scheduled
time. I never knew I could be a good planner, thanks to the effective time
management and planning skills the Nuffield Centre has helped me to discover
lies within me. Writing this dissertation has made me broadened my knowledge
about the topic and realise the potential of our culture and belief system to be used
in promoting mental health recovery following complex emergencies. Now I feel
more confident and better equipped to make a difference when I return home. The
knowledge and skills I have acquired would not only be used in promoting mental
health care in Nigeria but would be transferred to several others I work with back
home.

33
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