Introduction

According to UNHCR, internally displaced persons (IDPs)  are "persons or groups of persons who have been forced or obliged to flee or to leave their homes and place of habitual residence, in order to avoid armed conflicts, violation of human rights, national disasters and who have not crossed an internationally recognized border" (UNHRC, 2018, p.4). These individuals have been reported to be at higher risk and vulnerable to mortality, physical attack, sexual assault, abduction, inadequate shelter, food, and health services compared to the general population. Their experience of these high-risk phenomena tends to limit their fundamental human rights ascribed to natural and international laws. Studies have also revealed that displacement is a global problem and that some of the creators of IDPs’ negative experiences on the African continent include but are not limited to the following:

1. Al-Shabaab (a militant group associated with al-Qaeda and operates in Somalia). 
2. Boko Haram (literal meaning - "Western education is forbidden" & a Sunni Islamist sect that also employs violent means to form an Islamic state in Nigeria).
3. Al-Qaeda in the Islamic Maghreb (AQIM) (a Salafi-jihadist militant group affiliated with al-Qaeda. The group operates in North Africa and the Sahel).
4. Ansar al-Sharia (militant group in Tunisia and Libya).
5. The Lord's Resistance Army (a Christian cult in Uganda).
6. Ansaru (were part of Boko Haram until they split away in 2012. They also randomly attacked the Nigerian military for some reason).
7. Ansar Dine (connected extremist organization in North Africa).
8. Al-Itihaad al-Islamiya (one of the many terrorist organizations that capitalized on the chaos and instability in Somalia during the 1990s).

In another study conducted by Hughes (2012), he revealed that some of the triggers of insurgency include but are not limited to social inequality, poverty, state fragility, food insecurity, and poor governance. Also, Akume & Godswill, (2016, p.146) noted that "Understanding the main cause of insurgency in Nigeria’s northeast will require a brief reflection on three theoretical perspectives which are the human development theory, Islamic state theory, and political feud/elite conspiracy theory" While other studies have revealed some of the consequences associated with extreme insurgency to include but not limited to different shape and forms of human right violation, violation of natural law/rights, and "different forms of humanitarian crises ranging from forced displacement, high rates of diseases and food crises, as well as many other health challenges" (Abbani, 2021, p.72).

In the Nigerian context, studies have revealed that Since 2009, North-eastern Nigeria, which consists of six states that include Borno, Adamawa, Yobe, Bauchi, Gombe, and Taraba, has largely been challenged by the internal displacement crisis" (Raji et al., 2021, p. 1). However, it is essential to note that IDP in Nigeria is not only triggered by the violent acts of the insurgents, like Boko Haram but also the "violence perpetrated by the government against some citizens with dissenting voices or by other causes such as communal clashes, terrorism, political or religious conflicts, natural disasters, government policy of urban renewal or outright discrimination" (Akume & Godswill, 2016, p.146). This shows that IDP is triggered by a comprehensive violent action of both the insurgents and governmental agencies.

Although many studies have been done on the causes, risk factors, and health consequences of IDP, minimal studies have been done on the mental health challenges of female internally displaced persons in Adamawa State, Northeast, Nigeria, and its Implications for State Policy. Therefore, this study sought to investigate the nature and dimension of mental health challenges faced by female IDPs in Adamawa State, identify coping strategies employed by female IDPs undergoing mental health challenges in Adamawa State and examine state and non-state response strategies for prevention and management of mental health challenges faced by the female IDPs.

Statement of the Problem

As at May 2022, more than 100 million people were forcibly displaced worldwide by persecution, conflict, violence, human rights violations or events seriously disturbing public order (UNHCR, 2022). At the end of 2021, the figure was 89.3 million, comprising 27.1 million refugees, 53.2 million IDPs and other categories of displacement. Displaced persons are regarded as one of the highest risk groups for mental disturbances.  It has been found that displacement can exacerbate pre-existing mental health conditions and contribute to new ones and that around 30 per cent of populations displaced by conflict suffer from depression or post-traumatic stress disorder (PTSD).  Using this figure, at least 14.4 million IDPs are likely to be affected (ReliefWeb, 2021).  This is because exposure to traumatic events, food insecurity, and the length of displacement leads to a higher likelihood of mental health issues among IDPs. Previous studies in Nigeria, Ethiopia, Georgia and Kenya all indicated that IDPs are more likely than the non-displaced population to have mental health conditions. In Ukraine, 25 per cent of IDPs suffered from depression compared to 14 per cent of the general population (ReliefWeb, 2021). Refugees and internally displaced persons (IDPs) may encounter additional stressors of poverty, discrimination, overcrowding, disconnection from their previous sources of social support and food and resource insecurity. Added to these challenges, the COVID-19 pandemic has led to widespread anxiety, fear and hardship. Consequently, these communities face adversity on multiple fronts, increasing their risk of developing mental health conditions (WHO 2021).

Hamid and Musa (2010) found that in Dafur, there was high prevalence of PTSD (54%) and general distress (70%) among IDPs and that female participants showed more somatic symptoms than their male counterparts. According to Amodu, Richter and  Salami (2020), numerous factors affect the mental health of internally displaced women in Africa. These include: excessive care-giving responsibilities, lack of financial and family support to help them cope, sustained experiences of violence, psychological distress, family dysfunction, and men’s chronic alcoholism.

In Nigeria, the armed insurgency has forced vulnerable individuals out of their native homes and means of livelihood to search for safety and security in safer zones.   The findings of a study in Maiduguri camps showed a high prevalence of PTSD (74.6%), depression (55.4%), suicidal ideation (33.8), and mental illnesses (26.3%) (Adegbola,   Bello,  Akinyoola&   Oginni, 2021).
Historically, humanitarian assistance programmes have often overlooked the need to incorporate mental health and psychosocial support services in response efforts—despite overwhelming evidence of heightened vulnerability among displaced communities to mental health conditions. To address this, UNHCR and WHO collaboratively worked  on an approach to mental health and psychosocial support (MHPSS) and identified  three core elements: the engagement of community leaders; the integration of support within the broader health system; and ensuring the quality of services provided through supportive supervision.

Against this background, this study sets out to investigate the nature and dimensions of mental health challenges faced by female IDPs in Adamawa State, identify their coping strategies   and examine state and non-state response strategies for prevention and management of mental health challenges faced by the female IDPs, toward policy formulation on mental health and psychosocial support within the humanitarian response.

Methods 

Study Location

The study was conducted in two IDP camps, namely, Malkoi and Fufore camps both in Adamawa State, of the Northeast, geopolitical zone of Nigeria. Adamawa State lies between latitude 9°19'60.00" N 12°29'59.99" E and covers a land area of about 36,917(Km²⁾ with a population of 4,504,337 people (2006 census projected figure). Adamawa has 21 local government areas and it is multicultural in nature with about 80 indigenous ethnic groups as well as three major religious groups, namely: Christianity, Islam, and African Traditional Religions. The major occupations of the people of Adamawa State are farming, fishing and commerce.

Participants

The participants studied were female IDPs in the Malkoi and Fufore camps located in Adamawa State and they were both young and adults ranging from 14 – 60 years old. Most of the participants were indigenes of Borno State, while the remaining participants were of Adamawa State origin. In addition, they acknowledged that they have a basic understanding of Adamawa State culture. Each participant was provided with information about the study in an oral format. The choice of the female IDP participants was informed by the goal of the research, which is to investigate the mental health challenges of female IDPs residing in camps. This became necessary as several studies have suggested that women are more affected by disasters than men (North, Nixon, Shariat et al, 1994 & 1999). In collecting data for the study, the authors used a confidence building process to enlist the trust of the participants. Through this, we were able to get both young and adult females who were IDPs and were residing in the two camps. Eight adult females and eight young females who have experienced mental health challenges were purposively selected and interviewed. In all, sixteen participants were interviewed (see the breakdown in the following table).

Table 1: Breakdown of the IDP participants interviewed through IDI guide.

Instruments

An In-depth Interview (IDI) guide was used to elicit the necessary qualitative data from the selected participants and a total number of sixteen (16) IDIs were conducted. The participants were asked questions based on the research questions raised in the study. Such questions covered issues such as the nature and dimensions of female IDPs mental health challenges and their coping strategies, the responses and the effectiveness of state and non-state in preventing and managing the mental health of female IDPs residing in camps. Face-to-face interviews were conducted with the participants from Tuesday 17 to Friday 18, June, 2022. The interviews were conducted from 10.a.m. to 12 noon, lasting 1 to 2 hour(s). These interviews were transcribed and codes were developed and later fused to central themes of the discourse. The findings were, then, thematically analysed and discussed.

Data Collection/Procedure

This study employed exploratory design and utilized the qualitative tools of data collection to extract data from participants who were selected using purposive sampling technique. The study employed purposive sampling technique because it was interested in those IDPs that were directly suffering from mental health challenges due to the shocks experienced from the terror attacks of the Boko Haram insurgents on their communities, which had forced them to end up in the government established internally displaced camp in Adamawa State. While participants were all purposively selected, they were reached through referrals and snowball methods. Through the knowledge of one of the authors residing in Adamawa State, we were able to reach the IDPs in the Malkoi and Fufore camps in the same state. 

Results and Discussion

In this section, the results of the study were teased out from the qualitative data collected from young and adult IDP participants on the research questions raised for the study. The results were discussed sequentially as follows:

Nature and dimension of mental health challenges of female IDPs in Adamawa State

The Boko Haram (BH) insurgency has exacted a tremendous and incalculable damage toll on several communities in the affected Northeastern states. IDP women are the most affected categories of people. Their traumatic experiences predispose them to different types of mental health challenges as found in this study which also affirms previous studies that have indicated that mental health is increasingly becoming an issue of concern among forcibly displaced people in Africa (Idemudia, William, Boehnke, Wyatt, 2013). This is also compounded by the fact that many IDPs live in dire conditions in informal settlements (European Commission, 2016). The violence leading to their displacement and the unhealthy conditions of the camps predisposes them to mental health challenges. The extant study unravels the gendering of mental health among young and adult female IDPs and the different mental health challenges they experience in the two camps studied. Findings arising from the qualitative data generated from selected female IDPs in both Malkoi and Fufore camps in Yola South and Fufore local government areas of Adamawa State respectively revealed the nature and dimension of the mental health challenges experienced by female IDPs which included: high blood pressure, suicide tendency, feeling of depression and frustration, irregular menstrual circles, withdrawal from people, low sexual drive, feeling of sadness, inability to sleep, constant headache and body pains, loss of appetite, nightmares and traumatic experience, and post-traumatic stress disorders (PTSDs).

Gendered Dimension of Mental Health in IDP Camps

As previous studies found out, the present study also found that female IDPs are more susceptible to mental challenges compared to their male counterparts. Of the sixteen (16) female IDPs interviewed, 11 indicated that they were undergoing mental health challenges. This finding is echoed in the statements credited to an adult female participant interacted with in Malkoi IDP Camp:

We the females are the most affected by mental health problems. Majority of the females both young and the old are suffering from one form of mental health problem or the other. For me, since my husband and two of our children were killed by Boko Haram, I have found myself in the camp here and I have not remained the same. I know for sure that most of the women in the camp here are distressed. Many of us have nightmares, having seen how our husbands and children were wickedly killed by the evil Boko Haram (Interview, 18/06/22, Hauwa Adam, 42 years). 

The above narration shows the female gendered dimension of mental health among female IDPs. According to the statistics obtained from the two camps, females (young and adult) constitute between 65 -70% of the IDPs’ population. The social, psychological and biological makeup of the female gender inherently makes them vulnerable to shocks and traumatic experiences. This finding is in line with previous studies which affirms that female IDPs suffer more from mental health challenges compared to the males as previous studies have indicated (Roberts et al., 2008; Richards et al., 2011; Makhashvili et al., 2014; Sheikh et al., 2015). Gender and age shape the health impact of internal displacement within IDP populations (Castañeda-Hernández et al., 2018; Villamizar-Pena et al., 2021; Rodriguez-Morales et al., 2019). Some studies have also reported high levels of PTSDs, especially depression and anxiety, in adult or mixed-age IDP populations - who are mostly from the female gender (Husain et al., 2011;Makhashvili et al., 2014; Elhabiby et al., 2015 and Roberts et al., 2019).

The study found that various types of mental health challenges were experienced by young and adult female IDPs. For instance, a female IDP from Fufore IDP Camp identified the different types of mental health challenges experienced by her peers and adult female IDPs:

Our experiences in the hands of Boko Haram insurgents and our residence in the camp here since 2014 have been very bitter and frustrating leading many of us to be suffering from mental health challenges such as sleeplessness, suicide tendencies, irregular and painful menstrual circles, low sex drive, high blood pressure, nightmares, shift in gender roles especially provision of livelihoods to the family and many more (Interview, 17/06/22, Asabe Abubakar, 47 years).

The above narrations point to the fact that a significant high number of the young and adult female IDPs in the two camps surveyed were suffering from different mental health challenges. A number of studies have reported that IDPs experience a wide range of health risks (Getanda, Papadopoulos & Evans, 2015). These include psychological distress such as depression, anxiety, sleeplessness and other mental issues (Roberts, Damundu, Lomoro, & Sondorp, 2009). They also experience somatic symptoms and physical illnesses, particularly hypertension, asthma, and chronic pain syndromes (Yehuda, 2002), which often occur because of their exposure to violence and loss of loved ones.

The striking mental health challenges experienced by IDPs in Malkoi IDP and Fufore IDP Camps are explained below:

Psychiatric Disorder

It was gathered from the participants that at least three (3) female IDPs were suffering from severe psychiatric disorder, one (1) in Malkoi IDP Camp who is about 17 years old and the remaining two (2) were in Fufore IDP Camp and they were in their mid-twenties. Participants from Malkoi Camp explained that young female IDPs suffering from severe psychiatric disorder developed the mental illness while she was about seven (7) years of age and since then she has been living with the condition. The other two female IDPs from Fufore Camp were said to have developed severe psychiatric condition due to the deep shock they experienced because of the killing of their family members and their sexual exploitation by Boko Haram insurgents. This finding is consistent with previous studies that have indicated common predictors of mental disorders among IDP populations to be common among the female gender (Roberts et al., 2008; Richards et al., 2011; Makhashvili et al., 2014; Sheikh et al., 2015; Madoro et al., 2020).

Low Appetite Occasioned by Depression and Stress

Participants also identified depression and stress as some of the mental health challenges common to the female IDPs studied in the two camps and this often affected their appetite. A participant explained below:

When we came to the camp newly and for several months, even as I speak to you,   many of the adult female IDPs, those married and widowed, including myself     have been having low appetite for food and a very low eating habit due to the fact    that we were depressed and stressed out. Most times we do not have the appetite for food (Interview, 17/06/22, Memuna Mohammed, 18 years). 

The above narration evinces the fact that many adult IDPs that are experiencing depression and stress have a challenge with their food appetite as they have low eating habit. This is traceable to their experiences of sexual exploitation by the insurgents, loss of their loved ones and their forced displacements from their communities, which have made them to be depressed and stressed out. Many of the IDPs are yet to overcome their traumatic experiences, as they are yet to come to terms with their present social and economic conditions, which continue to predispose them to nutritional problems. This is also compounded by the poor quality and low quantity of food provided for them, which is predisposing them to poor nutritional habits. This is consistent with previous studies like that of Martin-Canavate et al. (2020), which found that IDPs have the worst nutritional outcomes compared to other conflict-affected populations.

Mental Health Challenges Associated with Loss of Livelihoods (Psychosomatic Distress)

The forced displacement of IDPs from their communities also meant that they were uprooted from their sources of livelihoods, as the present study found that female IDPs were undergoing harsh economic conditions, which affected their mental health. Many of the widowed IDPs have been forced into taking up the role of bread winner of their families. Married women whose husbands are still alive were also not left out of engaging in livelihood generation activities to raise income for their family upkeep since their husbands could not adequately cater for their families. A middle-aged widow from Malkoi IDP Camp explained how she had been struggling to cater for her four (4) children:

Since my husband was killed about seven years back by Boko Haram, I have been the only one doing menial jobs and sometimes selling fried bean cake to    raise money for the upkeep of my children and myself. This has been very challenging for me to the extent that sometimes I get very frustrated and depressed because I do not know if I will be able to continue to handle this responsibility alone (Interview, 18/06/22, Zara Usma, 35).

The above statements of the widow speaks to the situation of many female IDPs and the shift in their gender roles, which have forced them to take up the role of the bread winners of their families. These changing gender roles of female IDPs compels them to take up livelihood generation activities. The additional responsibilities predisposes them to stress, anxiety and depression, thereby aggravating their mental health challenges. Consistent to this finding, many studies have indicated that women IDPs that experience a shift in gender roles experience psychosomatic distress in women because of the added financial responsibility to provide shelter, food, and security (Roberts, Ocaka, Browne, Oyok, and Sondorp, 2008).

The inability of IDPs to engage in livelihood activities can be a major source of distress and mental health challenges (See, Solow, 1995; Goldsmith, Veum, & Darity,1996; World Bank, 2015). It is also evident that people struggling with psychological distress may find it hard to take full advantage of the opportunities that development interventions offer (World Bank, 2015). Furthermore, recent studies on displaced persons affected by the Boko Haram insurgency in north east of Nigeria identified their lack of means of livelihoods to support themselves and their families (as they had previously been able to do) as a central cause of distress and other negative feelings (Giardinelli, Kios,Abubakar, Schinina & Hammen, 2015).

Coping strategies of female IDPs experiencing mental health challenges in Adamawa State

Adversity provokes distress, and distress affects emotions, thoughts and memories of individuals (Mullainathan & Shafir, 2013). These often have negative consequences for the daily functioning of victims of mental health and their wellbeing, with spill-over effects on their families, friends, community and the society at large. However, evidences have shown that IDPs are very resilient people despite the adversity or traumatic experiences they might have gone through whether those induced by violence, loss of their close relations or when forcibly displaced. Indeed, studies have echoed that individuals who have experienced traumatic events have the power to rebound back from the adversity and continue to live a positive life (Bernard, 1991; Bonnamo, 2008 and Taormina, 2015). Coping can be described as ‘an attempt to master, tolerate, or reduce internal or external stressors that an individual perceives as exceeding existing resources‘ (Folkman & Lazarus, 1980, 1991).  Qualitative data obtained from adult and young female IDPs who were interacted with show the different coping strategies employed by female IDPs to mitigate their mental health challenges. These coping strategies include developing of patience to overcome their condition; engaging in prayer; engaging in entertainment such as playing of Ludo, local draft called dara, drama, cultural activities; and engaging in livelihood activities to raise money for the upkeep of their families.

Prayer as A Coping Strategy for IDPs

One of the coping strategies used by female IDPs experiencing mental health challenges in the two camps studied is prayer. The participants interviewed confirmed the potency of prayers in coping with their mental health challenges. An adult female participant from Malkohi IDP camp, who is experiencing mental health challenge, she stated thus:

Many women like me in the camp always feel very sad and helpless because of our traumatic experiences. Our only consolation is that we constantly engage in   prayer to overcome our mental health challenges especially because we believe that Allah has the power not only to console us from our traumatic experiences    but he also helps us to develop the strength to overcome any challenge (Interview, 17/06/22, Fati Umar, 33 years). 

Prayer is a spiritual exercise and an act of supplication or intercession directed towards a supreme being or a deified ancestor. Studies have shown the potency of prayer as a coping strategy for overcoming mental health challenges of refugees and IDPs. For instance, Ai, Tice, Huang, and Ishisaka (2005) found that refugees used prayer as a way to cope with symptoms of PTSDs stemming from the Bosnian and Kosovo wars. Whittington and Scher (2010) found that religious practices like prayer enhance a person’s ability to make meaning out of life’s experiences. This meaning comes from the relationship a person forms in prayer with a deity (Whittington & Scher, 2010). For the female IDPs in Malkoi and Fufore camps, who were mostly Muslims, prayer helps them to regulate and change their negative emotional responses towards their stressful traumatic experiences. Studies have also confirmed the efficacy of Islamic prayers when used in conjunction with deep breathing exercises in helping either to reduce anxiety symptoms or as a way to cope with depression symptoms (Walker & Moon, 2011).

Sports and Entertainment as Coping Strategy for IDPs

We also found that IDPs engage in sporting activities and other entertainment activities to mitigate their mental health challenges. According to a young female IDP from Fufore Camp:

During most evenings when we are less busy, we young female IDPs come together to play Ludo or sometimes our local Dara game. We also engage in our      local dance and drama. Our engagements in these activities help us to calm down tension and stress (Interview, 18/07/22, Fatima Bukar, 21 years).

Further interviews held with the adult female IDP show that they also engage in similar sporting and entertainment activities during their leisure time and these activities help them overcome stress and forgetting their painful and traumatic experiences. Research has indicated that positive psychosocial benefits, and moderate-to-vigorous intensity physical activity can improve physical and mental health (Biddle, Mutrie & Gorely, 2015). The IDPs in both camps engage in sporting and entertainment activities not in a competitive manner, because evidence suggests that competitive sport may contribute to poor mental health (Bauman, 2016) and may also lead to specific stressors that hinder an athlete’s mental health optimisation (Donohue et al., 2007). The main goals of the IDPs engaging in sports and entertainment activities are to entertain themselves and bring back the good old memories of the times they were living together in peace in their communities. 

Livelihood Generation Activities as A Coping Strategy for IDPs

Another identified coping strategy of IDPs is the engagement of mostly adult female in income generation activities within and outside the camps. This is usually done in a bid to cope with their challenges by finding meaning or purpose to displacement and staying together (Almedom, 2004). IDPs in Malkoi and Fufore camps engaged in livelihood generation activities such as frying of bean cake and yam, making of rice cake (massa), farming activities, and tailoring. Interaction with an adult female IDP from Malkoi Camp reveals as follows:

Most of the women in the camp have lost their husbands and their livelihoods. This has compounded our sufferings and mental health challenges. Many of us have had to force ourselves to take up some livelihood generation activities such as farming, frying of beans cake and yam and massa, tailoring and other economic activities. These have helped us not only to be busy and able to feed our families but they have also helped us to reduce tension and distress and anxiety (Interview, 18/06/22, Hauwa Adam, 42 years). 

The plight of IDPs is apparently dire due to their socio-economic status (Wilkinson and Marmot, 2003). Hence the reason why livelihood generation activities remain one of the major determinant factors of IDPs wellbeing and mental health. Clearly, there is a significant relationship between the availability of livelihood generation opportunities and the mental health of IDPs. For the IDPs engaged in farm labour, the average daily pay rate is between N1,000 and N1,200, which is less than or about $2 USD, while normal labourers or non-IDPs are paid between N1,800 to N2,000, which is about $3 USD or slightly above, at N600 to $1 USD exchange rate. This goes to show that IDPs are paid lower wages than their counterparts in the general population and this brings about pay differentials between these two categories of workers. Their socio-economic conditions are often exploited by their employers and thereby making them cheap labour and the most economically, politically and socially marginalised group in the mainstream society. Unfortunately, the income they earn is largely insufficient and unable to meet their basic existential needs. 

Negative Coping Strategies Adopted by IDPs

More strikingly, the study also found that some female IDPs employ some negative coping strategies in their attempts to struggle to cope with their mental health challenges. This finding correlates with International Organization for Migration (2013) report that indicates that IDPs are confronted with negative coping strategies to their health challenges. Negative coping strategies refer to IDPs’ responses to difficulties or challenging situations that may provide a temporary means of survival or relief to their mental health conditions. This can seriously undermine their socio-economic and health conditions as well as their security.

Interactions held with female IDPs highlighted the different negative coping strategies adopted by some female IDPs in Malkoi and Fufore camps, which include stealing of money, food items and properties of other IDPs and property of the camp, engaging in substance abuse to calm down tension, self-medication/use of traditional herbs to treat their mental health challenges, selling of food and non-food items given to IDPs with the aim of having cash in hand to purchase medications, food items and other things they readily need. Some female IDPs owned up that some young girls and even married women engage in prostitution to raise cash, among other acts. All these negative coping strategies have connection with the mental health challenges of IDPs as they may either compound or alleviate them momentarily or may have negative repercussions on them in the long run. IDPs employ these negative coping strategies as survival strategies. Several publications have indicated the abuses and exploitation going on in the camps against IDPs in Borno, Yobe and Adamawa States. For instance, in 2016, The Guardian news reported as follows:

Sexual exploitation and abuse of vulnerable, powerless and traumatised persons,   especially children and women and harassment, sexual exploitation and violence against women and teenage girls in the camps of IDPs, allegedly perpetrated by security operatives and other officials of the state (sometimes by camp officials)…IDPs are coerced into sex through false marriage promises, and materials and financial aid…Women’s and adolescents’ livelihoods tend to be the most fragile, and females are at greater risk of engaging in negative coping mechanisms, such as sex work for food or other survival needs (The Guardian, 2016).

The harsh living conditions, the inadequate medical care and psycho-social services in IDP camps in Adamawa State will continue to negatively impact on the mental health and wellbeing of IDPs. Indeed, these factors have continued to encourage them to employ negative coping strategies to get round their mental health challenges.  

State and Non-state Actors Responses to Mental Health Challenges of Female IDPs
The health of IDPs, especially the female is critical and needs to be prioritised because they are usually the most affected in the context of violent conflict and they also play critical role in the sustenance of their families. It is for this reason that the UNOCHA (2014) stressed the importance of the health of IDPs as commonly cited among the top three needs of the displaced population in North-East Nigeria. Therefore, the present study identified the various responses of state and non-state actors in managing mental health challenges of female IDPs in Malkoi and Fufore Camps in Adamawa State. State and non-state responses cover areas such as psychosocial support services, livelihood support/skills acquisition and cash transfers.

Psycho-social Support Services

Majority of the female IDPs interacted with in the two camps agreed that they have been receiving psychosocial support services from some government agencies as well as non-state organisations. This has been helping them to overcome their mental health challenges. Psychosocial support services are part of the essential humanitarian services given to displaced persons suffering from mental health challenges and they are usually rendered by psychiatrists, psychologists or social workers. Its aim is to stabilise the emotional and mental health of IDPs such that they are able to function optimally. A young female IDP participant from Fufore IDP Camp stated thus:

Many IDPs, including myself have benefited from the psychosocial support services provided by the government and NGOs. We underwent many different therapies lasting for some weeks. Some females are still undergoing psychosocial treatments. These have helped us to overcome our fears and mental health challenges (Interview, 18/06/22, Mariam Mohammed, 23 years). 

IDPs in both camps have enormously benefited from the psychosocial support services provided by non-state organisations like International Office Migration (IOM), UNHPF, CARITAS and Save the Children Foundation.  The World Health Organisation (WHO) also operates a mobile clinic that provides psychosocial counseling for IDPs. WHO and IOM provide medical supplies to IDP clinics.

2. Livelihood Generation Activities

The study also found that there is a link between the availability of livelihood generation opportunities and mental health of IDPs. On one hand, IDPs that engage in livelihood generation activities have less cases of mental health while IDPs without livelihood opportunities are prone to increased mental health problems. Generally, the importance of livelihood support and psychosocial services in tackling the IDPs’ mental health challenges has been stressed by many studies including the one conducted by Inter-Agency Standing Committee’s (IASC) Guidelines on Mental Health and Psychosocial Support (MHPSS) in Emergency Settings, which recommends integrating MHPSS into livelihoods programmes, while further noting that livelihoods can act as key basic and community psychosocial support for everyone and, in particular, for individuals with mental health and psychosocial needs (IASC, 2007).

Both federal and state Ministry of Women Affairs provide livelihood support training for female IDPs such as soap and cream making, tailoring, bead and cap making. These support training are provided in order to enhance the income and livelihoods generating capacity of the female IDPs. A female IDP from Malkoi Fufore camp explained the types of livelihood support training she has undergone:

I have participated in many empowerment and support skills organized by the government and NGOs. I have learnt soap and cream making and so do many other female IDPs. We have also benefited from cash transfer programmes from NGOs. Many of us are now producing soap, cream, caps etc. and we supply these products to the local markets (Interview, 18/06/22, Zara Usman, 35 years). 

UN agencies such as IOM, UNCHR, UNHPF, CARITAS are the non-state organizations providing livelihood/skills acquisition trainings and cash transfer programmes to female IDPs in both Fufore and Malkoi camps. The female IDPs that benefited from the cash transfer programmes were given between N17,000 and N30,000 while some IDPs were placed on N20,000 monthly allowances. The skills empowerment and cash transfer programmes given to the female IDPs have taken away the usual anxiety and emotional stress associated with economic lack. As studies have shown, the economic roots of many IDP health problems point to a need for their economic empowerment (Amodu et al., 2020), through skills support cash transfer programmes, which helps to meet their basic needs (Falb et al., 2020). One major challenge observed in the intervention efforts of INGOs/NGOs towards managing the mental health challenges of IDPs is the fact that both the federal and Adamawa State governments are not adequately providing the funding support to complement their intervention efforts. In the event that INGOs and NGOs pull out from providing mental health treatment for IDPs, both the federal and Adamawa State governments do not have a well-thought-out sustainability plan in place towards ensuring the continuity of such interventions.

Effectiveness of State and Non-State Responses to Mental Health Challenges of Female IDPs

The study found that the intervention efforts of INGOs and NGOs are more impactful on the female IDPs’ mental health in comparison with the state actors’ responses that were considered grossly inadequate by the IDPs interacted with. They are effective because they were well-thought-out and scientifically implemented with strict adherence to global best practices.  According to an adult female IDP from Malkoi Camp:

The INGOs and local NGOs have really assisted us. If not for them, many of us would have either died or we would have been struggling to survive. Some of us now are business owners and can now assist our families. Thanks to the livelihood and skills acquisition programmes that we benefited from. The psycho-social services have also assisted us to stabilize and we are now more emotionally stable than when we newly arrived the camp (Interview, 18/06/22, Hauwa Adam, 42 years). 

The above narrative brings to the fore the effectiveness of the intervention efforts of state actors, which are believed to be more impactful on the female IDPs in terms of their economic wellbeing and also helping to reduce their mental health challenges. Studies have shown the direct correlation between livelihood and psycho-social interventions in the reduction of mental health challenges. Indeed, mental health is an important psychological capability that enables individuals to thrive in their livelihoods (World Bank, 2015). Similarly, the provision of psycho-social support through education on anxiety and coping skills appears most effective in relieving symptoms, and group therapy approaches appear to be most acceptable and cost-effective (Ekezie et al., 2020).

Most of the IDPs interacted with generally believed that both the federal and state governments have not done enough in assisting. They opined that they have continued to suffer from inadequate health care. They believe that government should be taking the lead in terms of caring for the needs of IDPs. As UNOCHA (2016) suggested, majority of the IDPs need health assistance and the scale and coverage of health services in conflict-affected states in the North-East remain below minimum standards. This is against the backdrop that, as a guiding principle under International Humanitarian Law, it is not the international community but national authorities that “have the primary duty and responsibility to provide protection and humanitarian assistance to internally displaced persons within their jurisdiction” (Principle 3(1) – (International Review of the Red Cross, No. 324, 1998).

The inability of the government towards effectively meeting the needs of IDPs has created many gaps in its humanitarian responses. Hence, the U.N. Office for the Coordination of Humanitarian Affairs OCHA (2017) has also said that 6.1 million IDPs in Northeast Nigeria lack protection, 3.4 million lack adequate nutrition, and 6.9 million lack access to health. OCHA (2017) also reported that, due to overcrowded settlements, IDPs in Nigeria suffer respiratory and other communicable diseases such as cholera and, diarrhea, etc. outbreaks of tuberculosis, dysentery, and u were reported in displacement camps in Myanmar (International Rescue Committee IRC. 2017).

Implications for State Policy:

Based on the result of this study, there is no doubt that IDPs in Adamawa State are doing a lot to combat the mental health symptoms associated with their displacement. For instance, some IDPs engage in creative livelihood and sports activities. Nonetheless, the federal and state governments need to change their policies toward enhancing coping skills for the mental health issues experienced by IDPs. This can be done by implementing legislation and procedures to ensure that the mental health of IDPs meets the standard set by World Health Organization, including the 1998 Guiding Principles on Internal Displacement. When implemented, these legislations and policies will help toward the development of resiliency skills for the female population in IDP sites.

In addition, the state government should urgently give due consideration to establishing a mental health institutional framework to be used in preventing and treating IDPs mental health conditions. This includes addressing and strengthening the hiring of well-trained mental professionals and establishing a licensing board for mental health professionals. The licensing board will be entrusted with the responsibility of providing and mentoring all the activities of licensed mental health professionals assigned to the IDP sites. Also, policies must address the lack of well-trained psychiatrists dealing with IDPs' mental health symptoms. 

Conclusion and Recommendations

The study investigated the mental health challenges of female IDPs in Malkoi and Fufore IDP Camps located in Adamawa State. The study revealed the gendered dimension of mental health among IDPs in the two camps. In this case, the female IDPs were found to be more prevalent to mental health challenges in comparism to their male counterparts in the two camps. The various mental health challenges faced by these female IDPs were also identified. These include: high blood pressure, suicide tendency, feeling of depression and frustration, irregular menstrual circles, withdrawal from people, low sexual drive, feeling of sadness, inability to sleep, constant headache and body pains, loss of appetite, nightmares and traumatic experience, and post-traumatic stress disorders (PTSDs).

Prayer, sports and entertainment activities as well as livelihood generation activities were identified as the coping strategies employed by females to manage their mental health challenges. Both the state and federal governments as well as INGOs and NGOs provided psychosocial support services, skills empowerment trainings and cash transfer programmers to female IDPs. These services are provided to empower and stabilise them to overcome their mental health challenges.

Based on the findings of this study it is recommended that government and other stakeholders should pay more attention towards ameliorating the mental health of female IDPs by improving access to better mental health care for them.

Also, government should come up with a sound sustainability plan for mental health care for IDPs in general. This plan should be properly funded and implemented. This will help to enhance the provision of effective mental health care for IDPs.

In addition, government should be deliberate in funding the training and re-training of care givers mental health medical personnel, who will be stationed in the IDP camp health clinics to handle and care for issues relating to depression and PTSDs.

Moreover, efforts should be made to create stronger coordination between government and INGOs and NGOs in the planning and execution of mental health care programmers for IDPs.