Implementing behavioral adaptation to curtail transmission and mental health impact of COVID-19 in Internally Displaced People (IDP) camp in Ethiopia

1. Project background, context and need addressed The world is facing unprecedented COVID-19 global pandemics. Africa is anticipated to be the next epicenter of COVID-19 pandemics according to the WHO. Given the fact; poor healthcare facilities and scarcity of resources, the COVID-19 outbreak can overwhelm the shaky health services (WHO, 2020). Ethiopia has reported 116 cases of COVID-19 so far by April 22, 2020. Though this number is quite small, it is doubtful to rely on as the number of daily testing is low and stringent preventive measures have not done. Thus, there would be a probable surge of COVID-19 up to 28 million infections in Ethiopia according to the ministry of health model prediction (Ethiopian Public Health Institute report, 2020). Ethiopia is the home to more than 3 million displaced people caused by conflicts which makes one of the leading countries with internally displaced people (IDP) (Relief web international 2019). More than 90,000 people were internally displaced in the Amhara region in 2019 due to longstanding conflict between the Amhara and Qemant communities (IOM displacement report, 2019). The majority have returned to their normal settlement with the peace-deal process between the two communities. Still, 15, 000 IDP are living in various local camps, communal accommodation sites, and collective sites with a high risk of protection concerns because of overcrowded shelter and poor living conditions. Among these, nearly 2,500 people are living in ten small clusters of temporary shelters ranging from 100 to 500 people in the Metema district. (Interagency Rapid Protection Assessment - Gondar, Amhara Region). The IDP's socioeconomic status may negatively impact their ability to take all precautionary measures against COVID-19 and to receive medical care if contaminated. IDP face immense barriers to accessing healthcare and preventative services like proper hand-washing and sanitation facilities. So, when an infectious disease hits, their risk is compounded and would result in catastrophic health and psycho-social consequences (IOM, 2020). Besides to prevention of the outbreak, particularly in highly vulnerable people like IDP's in the humanitarian setting monitoring and reporting rates of anxiety, depression, self-harm, suicide, and other mental health issues are crucial to understand and inform interventions. The rise in symptoms of anxiety and coping responses to stress are expected during these extraordinary circumstances, the number of people with anxiety, depression, and engaging in harmful behaviors (such as suicide and self-harm) will increase. (Emily A Holmes et al, Lancet 2020). The unprecedented occurrence of the COVID-19 pandemics and living with insecurity conditions could devastate the underlying psycho-social well-being of displaced people. Consequently, those highly vulnerable people require tailored responses both to the pandemics and mental health services. Implementing temporary behavioral adaptation, psychological first aid, and consultation to new ways of lifestyle such as emotional support, frequent hand-washing, sanitizer use, and social distancing measures would be helpful to prevent the outbreak of COVID-19 and associated mental health impairment in overcrowded settings. Furthermore, wearing a cloth face-covering may help to protect the most vulnerable from COVID19. Though face- covering cannot be equivalent to self-quarantine, social distancing, and medical face-masks; it may protect the transmission in an asymptomatic carrier of the corona-virus especially in overcrowded conditions (CDC, 2020). Refuge and humanitarian camps are under overcrowded conditions and vulnerable to a high rate of infection transmission. Therefore, in such inevitable circumstances, prevention of the outbreak and implementing feasible behavioral adaptation as voluntary public health measures like washable and reusable handmade face-mask use, frequent hand washing, and sanitizer use could be indispensable when resource-intensive public health measures are not affordable. 2. Aims or research questions being addressed The main aim of this study is to investigate the effectiveness of temporary behavioral adaptation as a voluntary public health measure to curtail the transmission and psycho-social impact of COVID-19 pandemics in IDP at the humanitarian setting in Ethiopia. The specific objectives include:  Explore the baseline behavioral practice and psycho-social status of IDP towards COVID-19 at their temporary camps  Provide comprehensive behavioral adaptation advice, sanitation logistic support, and psychological first aid  Document the number of people referred for tests, cases and mental health complaints of IDPs at the campsites  Evaluate the effectiveness of behavioral adaptation implementation and psychological support in IDPs to prevent COVID-19 outbreak 3. Study Design Study setting Metema is located 900 km away from Ethiopia's capital, Addis Ababa. It has an international boundary of 60 km between Ethiopia and Sudan. Its location makes it one of the high-risk areas to acquire the virus for the COVID-19 outbreak. Therefore, IDP living in the area is subjected to multiple risk factors such as living in overcrowded unsanitary camps, unstable seasonal Malaria areas with a high risk of Leishmaniasis co-infection. The majority (87.3%) of the displaced people have mobile phone devices (UNHCR Ethiopia report, 2019). This could make it easy to provide telephone reminders and weekly telephone consultations to comprehensive educational support, psychological reassurance, and intervention assessment. Method and Materials One small cluster camp of 100 IDP from the 10 camps in the Metema district will be selected randomly and enrolled in this action research project. Multifaceted interventional approach consisting of onsite behavioral training and logistics support, telephone reminders, weekly telephone consultation, and psychological support will be employed. In the first phase of the study, a combination of qualitative and quantitative approaches using descriptive and analytical study designs will be employed to explore the baseline understandings, extent and appropriateness of safety practices to COVID-19 prevention. An in-depth interview will be employed to generate information regarding their awareness, psycho-social status, and preparedness to personal safety measures to COVID-19. This prior assessment of the knowledge and practice gap will help to customize educational delivery and material support. In the second phase of the study, a customized 1-hour hands-on comprehensive adaptive behavioral awareness and training will be delivered at the campsite with some hygiene logistics support. Training on how to make cloth face-mask, wear, and wash for reuse will be provided. Then after, an individual automated telephone alarm before the call (a reminder of the disease transmission, safety measures, and practices), weekly telephone comprehensive advice, psycho-social first aid, and mental health support for those in need will be employed. Weekly telephone surveillance of symptoms for possible infection will be collected from onsite humanitarian workers and will link to the nearby COVID-19 test center. In the final phase of the project; the effectiveness of behavioral adaptation intervention as a voluntary public health measure to prevent the transmission, psycho-social and mental health impacts will be evaluated by predetermined quantitative checklists and qualitative methods. Generally; to conduct this multifaceted action research the following materials and logistics support will be prepared.  3-page COVID-19 brochure consisting of pictograms and factual data regarding COVID-19 mode of transmission, symptoms, safety measures, and social distancing instructions  Sanitizer, hand-washing soap, reusable and washable handmade face-covering mask  Capacity building training of data collector's and humanitarian workers  Mobile air time for a telephone consultation  The WHO standardized mental health status examination questionnaire, Quantitative behavioral adaptation checklists, and Qualitative informant questions 4. Approach used to maximize the impact of research outputs, to improve health and the research community While quantifying and generating practically tested evidence from this project, the multifaceted interventions comprised of comprehensive behavioral education, psychological support, and regular telephone alarming expected to prevent infection transmission and improve the health of the study participants. Furthermore, it involves health workers, psychiatry professionals, and humanitarian workers to provide behavioral support and training, psychological first aid, and gather evidence. The evidence of this study will be disseminated for the ministry of health, local health authorities, and to humanitarian organizations and international refugee agencies. This would be instrumental to provide a tested feasible behavioral adaptation model as a voluntary public health measure in the prevention of infectious disease outbreak in similar overcrowded and humanitarian settings. Finally, it will be published in the peer-reviewed journal for sharing the evidence with the scientific community and the wider public. 5. Expected outcomes  Humanitarian assistance (including behavioral education, psychological and material support) and inculcated behavioral adaptation practices for prevention and coordination of COVID-19 outbreak response in the humanitarian camp of IDP  The quantified measure of behavioral adaptation effectiveness to prevent transmission  The qualitative and quantitative measure of psychological support effectiveness to reduce mental health problems during a pandemic  Documentation of the frequent psychological and mental health problems in IDP  Epidemiological evidence and practical lessons of comprehensive interventional COVID-19 prevention from the small cluster of IDP perspective to the scientific community. 6. Role in the project I am the principal investigator who conceived the study and responsible for carrying most of out the activities under supervision. Among the roles, I am developing appropriate study design, prepare educational content and interventions. I will participate in recruiting and train humanitarian workers and data collectors to provide interventional education. I will also evaluate the intervention effectiveness, analyze and interpret data, disseminating the research output through presentation and feedback for relevant stakeholders. Finally, I will prepare and send the final manuscript for publication.