This brief explores the humanitarian needs of forced rural area-to-city migrants in the north-west of the Federal Republic of Nigeria, with an emphasis on their vulnerability to mental health challenges. The brief presents key considerations in addressing the humanitarian needs and vulnerabilities of the forced migrants. The focus is on people displaced between 2021 and 2024, a period that has witnessed a surge in this form of migration.
Calling for action to address the needs of these hitherto underserved internally displaced people (IDPs), the brief is targeted at the Government of Nigeria (especially the National Emergency Management Agency), relevant United Nations agencies (UN Office for the Coordination of Humanitarian Affairs, United Nations Human Rights Council, UNICEF and International Organization for Migration) and other relevant international and local actors in the humanitarian space in Nigeria.
Key considerations
- Conduct a rapid assessment of vulnerability in general, and mental illness vulnerability in particular, among forced migrants in north-west Nigeria. The rapid assessment will help identify existing external responses, community responses and resilience, and vulnerabilities within the population.
- Use media publicity to raise awareness of, and sensitise people to, the importance of mental health and well-being. Strengthen messages rather than merely focus on clinical aspects of mental health.1 It is also important to address stigma about mental health to increase the number of IDPs seeking healthcare and provide supportive environments for people with mental health needs.
- Engage the community on mental health to ensure the participation and inclusion of the relevant groups, religious and traditional leaders, networks, and local influencers. Good community engagement would reveal tensions and conflicts that may not be obvious between the host communities and IDPs, and it would allow mental health issues to be addressed quickly.
- Deepen understanding of mental illness among IDPs. Practitioners seeking to address mental illness among IDPs need to take a nuanced approach that begins by seeking to understand the concept through lived experiences of IDPs in north-west Nigeria and considering world views in a respectful way.
- Involve IDPs in the design of mental health services provided in formal camps for IDPs and provided to IDPs living outside formal camp settings. Establish an Accountability to Affected Population mechanism to ensure the participation of IDPs in the initial design of the mental health services and to collect and respond to their complaints and feedback. The mechanism would also provide the opportunity for those responsible for the services to share timely information about the response and resource management.
- Put in place a well-coordinated humanitarian response to the humanitarian situation. While noting the commendable impact of the current response, we call for an outright acknowledgement of the humanitarian crisis by relevant local, national and international actors working in the humanitarian space. We also call for a commitment by these actors to work together in a coordinated manner – and uphold core humanitarian standards – with the affected communities, to integrate all efforts to address the problems and achieve the best outcomes for all concerned.
- Address the mental health challenges of displaced people. While psychological therapies and other interventions can help address the mental health needs of displaced people, capacity building is needed to expand the provision of mental healthcare. Task-shifting – where trained community members are assigned the task of providing mental health therapy – may be needed in areas where there are few healthcare workers. The role of traditional healers is paramount as they are often the first responders available to support people with mental health needs, either as prevention or recovery from mental health treatment.
Socio-political context of insecurity
On 7 March 2024, gunmen attacked a primary school in Kuriga, Kaduna State in north-west Nigeria, kidnapping mostly schoolchildren (Box 1).2–4 This was one of several attacks by armed bandits operating in many parts of north-west and north-central Nigeria, especially in Kaduna, Zamfara, Katsina and Niger states. Such attacks have increased in the last five years, and they are becoming regular day-to-day occurrences in many rural communities in the region. In several other similar instances, the victims have never returned.
Box 1. Report of gunmen attacking a primary school in Kuriga, north-west Nigeria
On 7 March 2024, gunmen attacked a primary school in Kuriga, Kaduna State in north-west Nigeria, kidnapping at least 287 people, mostly schoolchildren.2–4 About a week later, the armed bandits demanded a ransom of naira (NGN) 1 billion for their release, threatening to kill the abductees in 20 days if their demand was not met. The Government of Nigeria ruled out the possibility of making such a payment,5 and in a positive twist of fate, the world received the news of the release of ‘all 137 kidnapped people’ on 24 March.6 It turned out that there was a mix-up in the actual number of kidnapped people.7,8 |
Source: Authors’ own. Sources cited.
Before the recent surge in armed attacks on communities in the north-west, attacks by Boko Haram, Nigeria’s homegrown terrorist group since 2009, had left more than 3.2 million people displaced in the Lake Chad Basin in north-east Nigeria.9 While the situation in north-east Nigeria has been largely contained, there has been a recent surge in insecurity with the kidnapping of about 200 IDPs near a camp for IDPs in Gamboru Ngala, Borno State.10
The focus of Nigeria’s battle against insecurity has shifted to attacks by armed bandits in the north-west and north-central regions.11,12 These armed bandits terrorise citizens by carrying out terrorist acts, such as attacking people on highways and at transit points, kidnapping, committing arson, shooting, rape, pillaging, cattle rustling, killing and looting.13
Rural communities are usually targeted by the armed bandits because they are under-governed, poorly policed and vulnerable to harm in many different ways.12 As a result of these terrorist acts, thousands of people have been forced to migrate from these rural communities to cities in search of security and safety.
Different theories exist on the drivers of armed banditry in north-west Nigeria, but a combination of factors best explains the situation:
- Attacks on locals may have begun first as a conflict between herders and farmers. This conflict, which has been going on for decades but appears to have taken a more violent turn since 2011, is the result of competition for resources between farming communities and nomadic pastoralists and herders. The conflict is mainly about herders claiming the right to graze animals across the country, including through the farms of people living in farming communities. When resisted, the herders attack the locals,14 a situation which may have intensified due to climate change, desertification and the expansion of cultivated land.15 These attacks by herdsmen are believed to have morphed into armed banditry.
- Another theory is that when the Boko Haram insurgents were flushed out of the north-east, some remained dormant for years in the north-west and later regrouped to form bandit groups.16
- A third theory is that before the 2015 nationwide elections, politicians invited Fulani mercenary fighters from across the West African region to Nigeria to unleash mayhem on their opponents on terms that remain in the realm of speculation, but which were not met. The result is the rise in criminal activities by these mercenary fighters.17
- Another factor that may have contributed to the rise in armed banditry is the contest for local resources, especially the struggle for control of the largely unregulated mining activities in the region.16
We posit that a combination of these – political economy and a struggle for resources, global and local terrorism, and local politics – drive armed banditry in the north-west. Banditry thrives on these factors in the face of large, ungoverned spaces that serve as hideouts for criminals and a weak security architecture.
Impact of forced migration
Nigeria and the neighbouring countries in the Chad Basin – Niger, Cameroon and Chad – have had to deal with the complex humanitarian crisis resulting from the Boko Haram insurgency since 2009.18 The humanitarian situation in north-east Nigeria is globally reported and has attracted financial and technical support from national and international organisations. In contrast, the humanitarian needs in north-west Nigeria have only recently been acknowledged in the (inter)national media, and more is required in the areas of coordination and response.
In 2022, the governor of Zamfara State, one of the affected states, estimated that banditry has led to the displacement of 700,000 people in the state.19 Evidence suggests that this number has continued to grow. The most affected states are the north-western states of Kaduna, Katsina, Zamfara, Sokoto and Kebbi, and Niger State in north-central Nigeria.20 While IDPs may shelter in formal or informal camps (Box 2), anecdotal evidence suggests that in some of these states there are no proper camps for IDPs, making it difficult for them to be reached with targeted services. In other places, IDPs are reached with services that are hardly comprehensive, with high-quality mental health services often being a missing component.
Box 2. Formal and informal camps for internally displaced people
Formal camps: Formal camps offer displaced people a safe space, shelter, food, water, sanitation and hygiene facilities, healthcare services, education and the opportunity to coordinate humanitarian aid to displaced people. In some cases in north-west Nigeria, internally displaced people shelter in camps that are provided and managed by the state emergency management agencies.
Informal camps: Internally displaced people may seek shelter in open fields, school buildings and uncompleted buildings, and sometimes they take residence with their relatives or friends in cities. Although government agencies and other humanitarian actors have centres where internally displaced people in informal camps are reached with humanitarian aid, coordination may be complex and many displaced people may be missed by providers of humanitarian healthcare services in general and mental health services in particular.20 |
Source: Authors’ own. Sources cited.
The forced migration is mostly subtle, hence the gravity of the problem it poses is missed by the local authorities in the north-west states. This contrasts with what is observed during conflict or other emergencies when families have had to move en masse. Those who are forced to migrate move in small batches, with people deciding to move as their communities continue to experience attacks.
When the people move to cities, they impact the facilities in these communities because local amenities are often inadequate, and the influx of IDPs exacerbates the strain on these already limited resources. Since the displaced people are mostly poor, they cannot afford healthcare services and resources to meet their basic needs. Learning from the experience of north-east Nigeria, where IDPs have been found to experience acute malnutrition and limited access to healthcare,21 one can expect that malnutrition and poor access to healthcare, especially mental health services, will accompany those displaced in the north-west.
The forced migration poses a threat to national security by undermining the government’s authority and stretching the security agencies to their limits. The forced migration also negatively impacts development by forcing the government to channel resources to security-related issues rather than development efforts. It also undermines food security and economic stability, as research has shown that rural farming communities are severely impacted. Also, rural farming communities have been shown to be vulnerable to mental health and psychological challenges.22
Vulnerabilities among displaced people in north-west Nigeria
Vulnerabilities in this context are related to various dimensions, such as demographics (e.g., sex, education, marital status) and economic (e.g., loss of livelihood or savings), which can increase the risk of physical or mental harm and/or reduce displaced peoples’ access to healthcare in general and mental healthcare in particular; see Box 3. To address the issue of vulnerability among forced migrants, we acknowledge that all those affected are vulnerable because of the general loss of livelihoods. Yet we point out that some individuals, groups or demographics may be at greater risk of physical or mental harm or may not be able to meet their basic needs.
Box 3. Key dimensions of vulnerability among displaced people in north-west Nigeria
• Socio-cultural, including sex, education, marital status and dependents;
• Economic: loss of livelihood or savings, access to capital; • Health/(dis)ability; • Location within the city: internally displaced people living in city slums are more vulnerable than those living in more formal neighbourhoods. |
Source: Authors’ own.
The current humanitarian response has been poorly coordinated in general, resulting in duplicated efforts that fritter away resources rather than provide solutions to the problems. Potential beneficiaries may be unwilling to give truthful information about their needs if and when they are reached, especially considering mental health stigma in Nigeria. This may complicate attempts to gather evidence for the humanitarian response.
Key dimensions
Nigeria’s northern regions have high rates of poverty and low levels of formal education, which may also influence how mental health conditions among IDPs are perceived and treated. There are also contextual issues in north-west cities, including different preexisting dimensions of inequality.
Socio-cultural: The cultural context in northern Nigeria is marked by patriarchal practices that disadvantage women and girls. These practices include denying women and girls access to formal education, promoting girl-child marriage and excluding girls from the public sphere. These contextual factors may contribute to the vulnerability of forced migrants, particularly female forced migrants.
Displaced women and girls, in particular, are vulnerable to sexual abuse and exploitation.23 A lack of shelter exposes females and children to sexual abuse and disease outbreaks due to poor access to water, sanitation and hygiene; limited access to immunisation for the children; and lack of food, resulting in survival sex, malnutrition, stunting and wasting. Survival sex increases unwanted pregnancies and unsafe abortions as well as poor access to postabortion care and other sexual and reproductive health challenges.
Women who lack basic education or skills to give them access to resources are most impacted by the loss of income and displacement from their local communities. They are also more vulnerable as the community they move to does not provide the formal or informal network required to mitigate the impact of displacement. Nationally representative data show that 64% of women and 38% of men in the north-west have no formal education.24 Most of the nation’s poor are in the northern states and the rural parts of those states in particular.25 With this population migrating to cities, the region is witnessing the loss of livelihoods for hundreds of thousands of people whose skills cannot guarantee decent livelihoods in the cities. Forced migrants living in informal settlements may also have reduced access to formal education.
Economic: The forced migration crisis has deepened the problem of poverty through displacement. Displaced people have lost their livelihoods. There has been a disruption to communities that had previously stayed together and could give opportunities to individuals to access social support. Community members are left with depleted social capital and networks for addressing challenges. They often find it difficult to regain their means of livelihoods or possess any property of their own, and they may not have the capacity to express their needs to the relevant authorities. Displaced people are also affected by the loss of formal and informal networks available within the communities to support them.
Farming activities have been significantly affected by the armed attacks: some farmers have been forced to migrate, while others cannot access their farmlands.26,27 Historically, farming and animal husbandry have been the main sources of livelihood for people in the rural parts of the most affected regions. When the people are displaced and move to the cities, they are forced into gathering wood for sale, manual labour for daily wages, petty trading and service provision (e.g., barbering, hair plaiting, tailoring). This is because the disruption caused by their displacement separates them from their source of livelihoods.
In the context of Nigeria, livelihood activities play a crucial role in mental health and well-being, particularly among IDPs. The loss of livelihood due to displacement has been associated with increased anxiety, distress and hopelessness, which exacerbate existing vulnerabilities.28 Restoring livelihood activities is essential to improving psychological well-being and regaining a sense of hope and empowerment. The other important aspect is ensuring equal access for everyone, including vulnerable people (particularly women with a lack of skills and education), to opportunities to acquire skills or attend vocational, livelihood and mental health and psychosocial support training.
Health/(disability) dimension: It is difficult for IDPs to access essential services, including healthcare services generally.29 This is further complicated by disability.30 It is also particularly difficult for IDPs to access mental health services, even with the prevalence of mental health challenges among displaced people in Nigeria.31,32 Forced migrants may also be vulnerable to unmet sexual and reproductive health needs.
Location within the city: Many IDPs in the north-west lack shelter, or they may live in formal camps for IDPs, in informal settlements, in uncompleted or abandoned buildings, in makeshift shelters, or they may live with relatives; see Box 2.
The migration of displaced people to urban areas in the affected north-west states has resulted in the expansion of urban slums, and the issue of lost livelihoods results in a surge in crimes committed for survival. Studies have documented poor integration of migrants in urban slums in northern Nigeria.33 This poor integration suggests a high likelihood of social exclusion from services for the forced migrants. This is partly due to the country’s ‘metropocentric’ nature of service provision, that is, urban-biased provision of services.34 The presence of formal and informal camps for IDPs has also led to increased needs for water, sanitation, hygiene and healthcare in the cities.20
While trying to understand vulnerabilities within the population of IDPs, it is important to acknowledge inherent resilience within the community and consider ways to build this resilience to facilitate social cohesion between IDPs and host communities. We note that the migrants and host communities speak a common language, Hausa, and they have a common culture, which are important factors in increasing their integration into host communities and reducing their vulnerability to poor mental health. Shared culture and language contribute to IDPs’ social capital and aid their adaptation and integration into their new environment.29 We also note that there are social networks that support individuals and households, and relatives who may offer varying forms of support to forced migrants. Unfortunately, not all IDPs benefit from such social support, which is considered necessary for their mental health.
Common mental health problems in displacement
Research has identified migration and postmigration stressors as significant causes of mental health problems among displaced people.35,36 By implication, displaced peoples’ terrifying experiences in conflict situations and their exposure to stressors while migrating and after migrating are responsible for their poor mental health. As a study has shown, displaced people suffer mental illness because of relocation and the difficulty in adjusting to new cultures.37 It is important to note, therefore, that apart from the traumatic experiences that may have motivated the forced migration of IDPs and the stressors encountered while migrating, the context at their destination community determines their mental health. A favourable context that supports smooth integration reduces the likelihood of a mental health problem, while living in precarious conditions in open fields or uncompleted buildings may further heighten their vulnerability to stressors and poor mental health. In many camps for IDPs, there is no structured and specialised mental health support,32 reflecting the neglect of mental health in the larger society.1 Resettling displaced people should be approached with care to avoid discrimination and ensure local acceptance and a sustained integration programme.38
Common mental health problems in displacement have been assessed in a biomedical framework to include post-traumatic stress disorder (PTSD), anxiety disorder and depression.32,39–41 To understand the vulnerability of the people identified in this brief, it is important to consider their unique experiences in the face of banditry. Generally, traumatic experience is considered to be a significant cause of mental health problems among displaced people.39 Some groups of IDPs may be most vulnerable to mental illness (Box 4). It is likely that distress related to extreme events is expressed in diverse ways, and it is important to acknowledge that biomedical categories of distress and mental illness might not represent the range of experiences in difference socio-cultural contexts.
Box 4. Internally displaced people most vulnerable to mental illness
Women and children: Globally, studies have shown that internally displaced women and children are more vulnerable to mental health problems.35,42 Widowed women and girls who have no formal education and have children (dependents) are at greater risk because they may not be able to earn, and they have little social support. Studies in Nigeria are similar – showing, for example, that more women present with early warning signs and symptoms of mental illness than men.43 Another study suggested greater likelihood of females experiencing mental illness in a pandemic.44 Women’s increased vulnerability may be as a result of pregnancy and birth-related stressors46 and marriage at an early age.45
In contrast, one study has shown that being female reduces the likelihood of mental health challenges among internally displaced people.46 Thus, the findings on gender and mental illness in settings for IDPs are mixed. People with disabilities: People with disabilities are additionally vulnerable to mental illness, and women with disabilities may be even more vulnerable due to the intersectionality of gender and disability. People living outside formal settings for internally displaced people: People living in urban slums outside formal settings for internally displaced people are also vulnerable because they may not be able to access provisions and healthcare services provided in formal camps or the benefits that may be available to those living with relatives in cities. |
Source: Author’s own. Sources cited.
PTSD is a ‘mental health condition triggered by a terrifying event – either experiencing it or witnessing it’.47 People who have PTSD may experience flashbacks, nightmares, anxiety and uncontrollable thoughts about those events responsible for their mental health condition. However, the conceptualisation of PTSD as a diagnostic category may not fully capture the diverse experiences of trauma. Instead, cross-cultural instruments should examine locally relevant reactions, such as idioms of distress and explanatory models of illness, and account for ongoing stress and adversity.48
Often, IDPs watch their loved ones (family and neighbours) being killed and their houses burnt, a reason why they suffer PTSD symptoms.32 While IDPs are vulnerable to PTSD, it often goes undiagnosed and may be poorly managed because of the relatively low level of public awareness of the condition. While research has often used PTSD as a way of understanding people’s experiences, it is important to appreciate that experiences of trauma and distress may be more diverse than what is captured by the PTSD diagnosis alone, as shown in the following studies:
- A study of internally displaced young people who had been exposed to Boko Haram terrorism assessed people using a biomedical framework. The study found that almost two-thirds of the people met the diagnostic criteria for PTSD.31
- A study of IDPs in Borno State documented experiences of stress, trauma, shock, sadness and symptoms of anxiety, depression and PTSD.32
- Cases of people experiencing psychosis have also been documented among displaced people.49
- In a study in the north-east of Nigeria, 94% and 92% of IDPs were diagnosed with symptoms of PTSD and depression in Yobe State.46
- Among internally displaced students, a study that established an association between displacement and poor academic performance found depression, anxiety disorder, loneliness, suicide ideation and persistent fear to be common mental health challenges.50
While such research provides valuable insights, the experiences and expressions of distress may vary across different cultural and individual contexts.
Biomedical research suggests that people who lack social support are more likely to develop PTSD than those with social support. By implication, those IDPs who are disconnected from family members or do not benefit from any form of social support, even if not physically disconnected, are at a high risk of PTSD. In support of this position, a study shows that family separation resulting from conflict and displacement is a major cause of anxiety disorder because displaced people are often concerned that their family members are still in harm’s way and may be killed or seriously harmed. Displaced peoples’ feelings of helplessness in such situations contributes to mental health problems.51
Research shows a significantly higher likelihood of suicidal ideation in humanitarian settings (among refugees) than in host communities,52 a sign that displaced people may be more vulnerable to poor mental health than the general population.
Support services for people with mental illness in Nigeria
In general, mental health suffers significant neglect in Nigeria.1 The mental health challenges of displaced people may therefore not get sufficient attention. Learning from evidence from across the world and north-east Nigeria, many of the people displaced as a result of the activities of armed bandits in the north-west and the north-central will be contending with mental health challenges that may be yet to be properly acknowledged or addressed.
Formal healthcare system
In Nigeria, comprehensive assessment, diagnosis, treatment and psychosocial support services for people with mental illness are available mainly at psychiatric hospitals, which fall under the tertiary level of Nigeria’s three-tier healthcare system. At the primary and secondary levels of the healthcare system, biomedical (non-psychiatric) professionals, such as nurses and social workers, manage mental illnesses. At the community level, mental illnesses are managed by non-biomedical professionals, such as spiritualists/clerics and traditional healers.1,53,54
Access to biomedical mental healthcare is limited across Nigeria, often due to the high cost of care and stigma,55–57 low numbers of mental health professionals,57,58 beliefs feeding a preference for non-biomedical or traditional mental health services,56 and its unavailability at the primary healthcare level.56,57,59
Non-biomedical mental healthcare is favoured in many contexts, such as the first step in the pathway to biomedical care,60,61 as a last resort when biomedical care options have been exhausted or simply because it is available.62 Belief in spiritual causation often means that spiritual healing is the preferred option for mental healthcare, with biomedical care being used sometimes as a supplement.63,64
Diverse preferences: Traditional and religious healers
In many parts of Nigeria, mental health conditions are attributed to supernatural or spiritual curses or causation, including sorcery, witchcraft and divine punishment. Also, research in Nigeria has shown that people with mental health challenges are stigmatised because of the perception that they are carriers of a curse and cannot reason normally;65–67 this has implications for their mental healthcare.
For this reason, people often approach traditional healers for mental health conditions rather than seek biomedical care.65–68 Even those presenting with mental health conditions in formal health facilities would usually have first sought care from religious or traditional healers.69 The belief in the spiritual or supernatural causation of mental illness is more prevalent in rural areas in Nigeria.70 While this may be a marker of how IDPs from rural communities may approach mental illness, one study in a rural community in northern Nigeria noted that close to half of the people favoured biomedical care.71 These findings suggest that caregivers of IDPs with mental health challenges may use traditional healers, religious healers and/or biomedical healthcare facilities, depending on what is accessible to them. Approaches to mental healthcare service provision need therefore to consider these diverse preferences.72
Need for a nuanced approach to mental illness in Nigeria’s humanitarian setting
Our brief is guided by the understanding that preferences, cultural suitability and local acceptance are important considerations in the provision of mental health services to displaced people in Nigeria’s north-west.
Social science research has challenged the universalist Western psychiatric framework for understanding and addressing mental illness, especially in non-Western contexts. The debate has gained traction with the recent emphasis on decolonisation and the search for a more inclusive understanding and treatment of mental illness.73 Critics have argued that the biomedical approach neglects social, economic and political contexts, and they advocate for a more nuanced understanding of cultural differences in mental health research and practice. Some approaches in Western psychiatry have been suggested to not be efficacious, and complementary and alternative approaches have effective practices that have been previously dismissed.74 Even where Western psychiatric methods are efficacious, they may not be suitable for some populations.75 The diagnosis of PTSD, for example, has been shown to be limited in cross-cultural contexts, and diagnostic instruments sensitive to contextual diversity have been suggested for improved fit outside Western settings.48 In addition, purely Western psychiatric approaches may miss out people who prefer traditional and complementary care.74,76
For the reasons above, calls have been made for the integration of traditional and Western mental healthcare in different parts of the world76,77 – and in Nigeria.62,72 Evidence suggests that such a collaboration is possible.78 A major challenge remains that the referenced studies adopt the Western psychiatric approach, diagnostics and categories. Yet, there is a broader range of ways in which mental illness is understood in northern Nigeria and people seek multiple approaches to mental health challenges.69,71 This indicates a need for context- and culturally sensitive interventions.
Mental health services and therapies for displaced people
Several healthcare services are targeted at displaced people, including psychosocial support for children and young people. There are challenges to the adequate provision of these services, notably poor access of humanitarian actors to locations where there are IDPs, limited resources or aid, disruptions of communities and separation of family members.51 Other problems include the scarcity of mental health professionals, insecurity – which prevents health facilities from operating – and poor coordination of humanitarian actions.79 Mental health therapy sessions have also been provided through a task-shifting programme, even where there are too few qualified healthcare providers.80
Mental health and psychosocial support services are provided to displaced people through community support services; specialised services for at-risk groups, such as widows, orphans and people with disabilities; recreational activities; informal education; and counselling and support groups.81 Providers often include local and international nongovernmental organisations and UN agencies.80,82
Mental health screening tools need to be culturally appropriate. This means adapting difficult concepts for local understanding, identifying and removing concepts considered unacceptable for discussion or stigmatising,83 and taking world views and lived experiences of IDPs into consideration in the provision of mental health services.
Psychological therapies, such as cognitive behavioural therapies and narrative exposure therapy, have been found to be effective in the treatment of mental health issues among certain populations of refugees.84 A study identified interventions effective for children, such as psychological first aid, psychoeducation, psychological debriefing and eye movement desensitisation and reprocessing.85 Another study found that positive experience offers protection against mental illness.86 Enhancing the positive experiences of children exposed to conflict and stressors associated with displacement can, therefore, improve their mental health. There is evidence that therapies can be used to address the mental health needs of displaced people. However, social science research continues to emphasise the need to consider culturally appropriate interventions that align with local perceptions of distress and healing. It is crucial to identify what displaced individuals themselves find helpful and to address their other priorities, such as food security. Rather than simply implementing Western therapies, responses should be tailored to respect cultural norms and incorporate acceptable ways of addressing mental health concerns within the affected communities.48
Barriers to accessing support
Financial and socio-cultural barriers to accessing mental health and psychosocial support remain,39 and many displaced people with mental health challenges are not able to access mental healthcare.37 Delays in getting official mental health services are linked to worsened results. Capacity building is needed in the provision of mental healthcare as there is currently inadequate provision.54 We therefore propose that barriers to mental healthcare are carefully documented in this context and approaches are put in place to overcome them.
Approaches to address the mental health vulnerability of displaced people in north-west Nigeria
We believe that the mental health of displaced people in north-west Nigeria will be significantly improved with the following approaches.
Rapid assessment of vulnerability and mental health vulnerability
A rapid assessment of vulnerability in general – and mental illness vulnerability in particular – among forced migrants in north-west Nigeria will help to identify existing external responses, community responses and resilience, and vulnerabilities within the population. We recommend the Barefoot analysis tool – a rapid, participatory, and visual assessment methodology used to identify and prioritise community needs, vulnerabilities and local capacities through simple, non-technical drawings and discussions with local stakeholders.87 The tool can be used for assessing the households based on various categories including: (a) households with malnourished children, (b) households with school-age children not attending school, (c) households with reduced utilisation of resources (land, housing, income, etc.), (d) households with children living in substandard accommodation, (e) female-headed households with young children, (f) households in which the main domestic carer is male and (g) households in which the male or female carer is aged less than 18 years.87
Raise awareness on the importance of mental health and well-being
Use media publicity and strengthen messages to raise awareness of, and sensitivity towards, the importance of mental health and well-being beyond clinical aspects of mental health.1 It is also important to address stigma about mental health to increase healthcare-seeking behaviour of the IDPs and to provide supportive environments for people with mental health needs. Drawing the desired national and international media attention will require press releases, interviews, featured stories and short documentaries to project the plight of the IDPs and give particular attention to the issues of mental health. We hope this brief will contribute to this process.
Community engagement
Engage the community about mental health to ensure the participation and inclusion of the relevant groups, religious and traditional leaders, networks and local influencers. Good community engagement would reveal tensions and conflicts that may not be obvious between the host communities and IDPs. Community engagement would also draw attention to issues of mental health in the communities so that they are addressed quickly to prevent the matters worsening. The Indigenous community structures and modes of cooperation and resilience that are formed where they are found to be weak should also be assessed, and mechanisms should be put in place to strengthen them. People might see a range of ongoing challenges related to their displacement, livelihoods and food security as intimately connected to their mental health, and it is important to ascertain their priorities in order to focus on interrelated material and psychological needs.
Deepen understanding of mental illness among IDPs
Sole reliance on the Western psychiatric understanding of mental health is limiting. Practitioners seeking to address the problem of mental illness among IDPs need to take a nuanced approach that begins by seeking to understand the concept through lived experiences of IDPs in north-west Nigeria and considering world views in a respectful way. An approach aimed at considering IDPs’ mental healthcare preferences and ways of understanding mental health is recommended.
Involve IDPs in the design of mental health services
IDPs should be involved in the design of mental health services provided in formal camps for IDPs and provided to IDPs living outside formal camp settings. To ensure this, establish an Accountability to Affected Population mechanism. This mechanism would ensure that IDPs’ suggestions and contributions are constantly received and factored into the intervention design, and that complaints and feedback are collected regularly and acted upon to ensure that the feedback loop is closed. It would also provide the opportunity for those responsible for the services (the response team) to keep the IDPs informed of progress and resource management.
Ensure a well-coordinated humanitarian response that upholds core humanitarian standards
A well-coordinated humanitarian response, which upholds core humanitarian standards, is needed in place of the current ad hoc response to the humanitarian situation. While noting the commendable impact of the current response, we call for an outright acknowledgement of the humanitarian crisis by relevant local, national and international actors working in the humanitarian space. We also call for a commitment by these actors to work together in a coordinated manner with the affected communities to help them integrate all efforts to address the problems and achieve the best outcomes for all concerned. There are challenges to achieving this; for example, the considerable proportion of IDPs who are not living in formal camps for IDPs may be missed if they are not adequately planned for.
Address mental health challenges of displaced people
Psychological therapies and other interventions can be used to address the mental health needs of displaced people, as described in the brief. Capacity building is needed to expand the provision of mental healthcare. We propose that barriers to mental healthcare are carefully documented in this context and approaches put in place to overcome them.
Evidence also suggests that healthcare workers avoid communities affected by conflict,88 a situation that may further complicate displaced peoples’ access to healthcare generally, particularly mental healthcare. For this reason, task-shifting may be needed; a study looked at a mental health intervention involving task-shifting and found it to be effective in improving the mental health of IDPs in northern Nigeria.80
We recommend that humanitarian actors seeking to address the mental health challenges of IDPs in Nigeria’s north-west engage local traditional and religious healers currently providing mental health services in a respectful manner to ensure a partnership that works in the best interest of IDPs with poor mental health. The role of traditional healers is paramount as they are often the first responders available to support people with mental health needs. Capacity strengthening to build skills to handle cases effectively is critical to ensure they do no harm and avoid harmful healing practices. Mental healthcare task-shifting should seek to incorporate traditional and religious healers into the mainstream health system through mental healthcare training for non-medical personnel. Such collaboration should help traditional healers to identify and refer cases that they cannot manage to the right facilities in a timely manner.
References
- Wada, Y. H., Rajwani, L., Anyam, E., Karikari, E., Njikizana, M., Srour, L., & Khalid, G. M. (2021). Mental health in Nigeria: A neglected issue in public health. Public Health in Practice, 2, 100166. https://doi.org/10.1016/j.puhip.2021.100166
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Authors: This brief was written by Michael Kunnuji (University of Lagos) and Elizabeth Onitolo (UNICEF – in her personal capacity), with input from Catherine Grant (IDS).
Acknowledgements: This brief was reviewed by Narulita Ayu (International Organization for Migration – reviewed in personal capacity), Professor Hayley MacGregor (IDS) and Professor Melissa Parker (LSHTM). Support from Syed Abbas (IDS) and Megan Schmidt-Sane (IDS) is acknowledged. Editorial support was provided by Harriet MacLehose (SSHAP editorial team). This brief is the responsibility of SSHAP.
Suggested citation: Kunnuji, M., Onitolo, E. and Grant, C. (2024). Key considerations: Addressing the humanitarian needs of forced rural-to-city migrants in north-west Nigeria – focus on mental health vulnerability. Social Science in Humanitarian Action (SSHAP). www.doi.org/10.19088/SSHAP.2024.058
Published by the Institute of Development Studies: October 2024.
Copyright: © Institute of Development Studies 2024. This is an Open Access paper distributed under the terms of the Creative Commons Attribution 4.0 International licence (CC BY 4.0). Except where otherwise stated, this permits unrestricted use, distribution, and reproduction in any medium, provided the original authors and source are credited and any modifications or adaptations are indicated.
Contact: If you have a direct request concerning the brief, tools, additional technical expertise or remote analysis, or should you like to be considered for the network of advisers, please contact the Social Science in Humanitarian Action Platform by emailing Annie Lowden ([email protected]) or Juliet Bedford ([email protected]).
About SSHAP: The Social Science in Humanitarian Action (SSHAP) is a partnership between the Institute of Development Studies, Anthrologica , CRCF Senegal, Gulu University, Le Groupe d’Etudes sur les Conflits et la Sécurité Humaine (GEC-SH), the London School of Hygiene and Tropical Medicine, the Sierra Leone Urban Research Centre, University of Ibadan, and the University of Juba. This work was supported by the UK Foreign, Commonwealth & Development Office (FCDO) and Wellcome 225449/Z/22/Z. The views expressed are those of the authors and do not necessarily reflect those of the funders, or the views or policies of the project partners.
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