Piloting Community-based Mental Health Interventions for Flood-Affected Women in Sindh, Pakistan: An Intervention Feasibility Study (MeSH)

About the Project

Climate change is one of the most urgent public health challenges of the twenty-first century, driving more frequent and severe floods, cyclones, and droughts. Floods are damaging, leading to mass displacement, loss of homes and livelihoods, social disruption, health and prolonged economic insecurity, all of which are strongly associated with increased anxiety, depression, and post-traumatic stress disorder (PTSD), particularly among women, children, and marginalized groups. South Asia is highly exposed to these hazards, and Pakistan ranks among the most climate-vulnerable countries.

In 2022, unprecedented monsoon rains submerged almost one-third of the country, affecting over 33 million people, displacing around 8 million, and 2.2 million houses were damaged or destroyed, with Sindh province bearing much of the impact. The district of Dadu in Sindh was severely affected as thousands of households were inundated and tens of thousands displaced. Women were disproportionately burdened as they lost homes and possessions while maintaining caregiving roles in temporary shelters, and faced heightened risks of gender-based violence, poor maternal health, and deepening economic dependence. These gendered stresses, layered onto pre-existing poverty, low literacy, limited health care access, and restrictive norms, substantially increased their vulnerability to common mental disorders (CMDs) such as depression and anxiety. Pakistan's health system has historically given less priority to mental health, as mental health services are scarce, largely urban and tertiary based, and rarely accessible to rural or disaster-affected communities; hence stigma and the absence of routine screening within primary care further restrict help-seeking.

Global guidance has encouraged the use of community-focused, task-sharing models where non-specialist providers deliver basic mental health care under the supervision of specialists, as recommended by WHO through its Mental Health Gap Action Programme (mhGAP). Evidence from several low- and middle-income countries shows that community health workers can effectively identify CMDs, provide psychosocial support, and refer severe cases, thereby improving coverage and cultural acceptability. Pakistan's Lady Health Worker (LHW) Programme, with more than 90,000 LHWs embedded in communities, offers a strong platform for such approaches and has previously been used to deliver psychosocial interventions for maternal depression; however, these strategies have rarely been applied in post-disaster settings.

The 2022 floods in Sindh highlighted an urgent need for assistance, while also presenting a strategic opportunity to incorporate mental health services into primary health care through the involvement of LHWs. This feasibility study aimed to determine whether LHWs and physicians at primary health centers or Basic Health Units (BHUs) could deliver community-based mental health support screening, build resilience to climate change and its mental health impacts, and provide referral for women of reproductive age (WRAs) in flood-affected rural Dadu, Sindh; to assess the acceptability of this model to families, communities, and the primary health care system; and to generate preliminary evidence of its impact on anxiety and depression symptoms, measured using the Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9).

Project Objectives

Primary:

• To assess the feasibility, acceptability, and appropriateness of implementing a community-based mental health screening, referral, and resilience-building intervention for adult women of reproductive age (WRA) in a flood-affected rural community of the district of Dadu in Sindh, Pakistan.

Secondary:

• To assess the effectiveness of this community-based intervention.

Methodology / Approach

A mixed-methods, quasi-experimental design with a comparison group and pre-post assessments was employed to evaluate the feasibility, acceptability, and appropriateness of the intervention, as well as the knowledge, attitudes, and practices regarding mental health and resilience-building.

Participants were women of reproductive age (18–49 years) residing in selected households within LHW catchment areas and directly affected by the 2022 floods, including displacement, loss of property, or loss of livelihood. This population was targeted due to heightened vulnerability to the physical and psychological impacts of flooding, encompassing trauma exposure, adverse maternal health outcomes, and security challenges.

The intervention arm was implemented across four Union Councils (UCs) through LHWs, Lady Health Supervisors (LHS), and BHU staff in three phases: LHWs screened women of reproductive age using GAD-2 and PHQ-2, and those scoring ≥3 were referred to primary health care for further assessment with PHQ-9 and GAD-7; all participants attended group sessions to improve mental health awareness, resilience-building, and community support under LHW facilitation and LHS supervision; and screen-positive women received facility-based care, where mild-to-moderate cases were offered counselling while severe cases were referred to specialized services at Civil Hospital Larkana with the necessary support.

Both qualitative and quantitative methods were used to collect data. A qualitative formative phase was conducted to inform intervention design by exploring perceptions, feasibility, and relevance from multiple stakeholder perspectives, followed by a summative qualitative phase to assess feasibility and acceptability and to identify barriers and facilitators related to intervention uptake and implementation. Data were collected through focus group discussions (FGDs) and in-depth interviews (IDIs), guided by a Grounded Theory approach. In the quantitative phase, at baseline, trained community health workers conducted screenings of WRAs using the GAD-7 and PHQ-9 instruments, along with the collection of sociodemographic data in both arms, to assess the prevalence of anxiety and depression in the community. At endline, mental health screening was repeated using GAD-7 and PHQ-9 by health care providers to reassess levels of anxiety and depression among participants.

Data were analyzed using Stata 18.5 after cleaning and consistency checks, with descriptive statistics summarizing key variables. Primary outcomes (feasibility, acceptability, and appropriateness) were assessed descriptively, while secondary outcomes (anxiety and depression) were measured using GAD-7 and PHQ-9 scores. Intervention effects were estimated using multivariable mixed-effects regression and Difference-in-Differences (DID) analysis, adjusting for baseline characteristics and clustering at the LHW level. Qualitative data from IDIs and FGDs were translated and analyzed thematically using NVivo, ensuring rigor through established criteria.

The study was guided by Bronfenbrenner's ecological systems theory, which explains mental health and health care access across multiple interconnected levels. At the microsystem level, individual factors such as mental health, resilience, coping, and socioeconomic conditions were considered. The mesosystem highlighted gaps in mental health services and gender disparities. The exosystem focused on service delivery through the Lady Health Worker programme and the Sindh health department, particularly the integration of mental health services. At the macrosystem level, broader structural issues such as limited government funding, weak policies, and socio-religious barriers affecting women's access to care were examined. Finally, the chronosystem captured the impact of worsening natural disasters over time, combined with poverty and vulnerability, contributing to increased mental health challenges in the target population.

Study Location

Pakistan

Please Note: The study was conducted in District Dadu, Sindh Province, in a rural setting. Within Dadu, Khairpur Nathan Shah taluka, one of the most flood-damaged regions, was selected as the study site. Eight union councils (4 UCs in each arm) were selected using non-probability purposive sampling, based on flood exposure, accessibility, LHW coverage, availability of functional BHUs, and alignment with LHW catchment areas.

Target Population / Beneficiaries

Women of Reproductive Age (WRAs).

Project Team​

Principal Investigator

Dr Zulfiqar A. Bhutta Institute for Global Health and Development, Aga Khan University

Co-Principal Investigator

Dr Jai Kumar Das Institute for Global Health and Development, Aga Khan University

Co-Investigator

Fauziah Rabbani

Project Management and Coordination

Mushtaq Mirani

Other Key Team Members

Farhana Tabassum

Maira Niaz

Zoya Navid Ansari

Rekha Bai

Research Partners

Institute for Global Health and Development Aga Khan University

Brain and Mind Institute Aga Khan University

Supported By

The Hospital for Sick Children

Grand Challenges Canada Prime funder

Grant Status

Completed / Finished

Key Achievements

Expected Outputs / Deliverables

• Community-based interventions

Reports and Resources

Keywords

Climate Change; Flood Disaster; Mental Health; Gender Equality; Women of Reproductive Age; Resilience-Building; Implementation Research

Contact

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