key: cord-0904813-ujepp139 authors: Sosa Lovera, Angelina; Ureña, Ana Jacqueline; Arias, Josefina; Araujo Rodríguez, Amarilis; Canario Guzmán, Julio Arturo title: Psychological helpline in response to the COVID‐19 pandemic in the Dominican Republic date: 2021-10-29 journal: Couns Psychother Res DOI: 10.1002/capr.12482 sha: 4f79bfa49ba2de3db62c070e5f8ab906e43aa48f doc_id: 904813 cord_uid: ujepp139 The global health emergency due to COVID‐19 is a disruptive event that has had various effects on mental health. Given this emergency, the Dominican Republic intervened to mitigate the negative impact of the pandemic, considering the physical isolation decreed in the country. In this context, the Autonomous University of Santo Domingo and the School of Psychology designed the UASD COVID‐19 Psychological Helpline. The objective of this article is to describe the development, implementation and evaluation of a programme of psychological first aid. The programme aimed to attenuate the impact of morbidity and mortality due to mental health issues associated with the COVID‐19 pandemic through mobile technology. There were 62 psychologists involved and trained to provide care, and a protocol was developed, implemented, monitored and evaluated. Over the course of four months, the programme assisted 497 people. The average age of the participants was 32 years, and 73% were women. The reasons for contacting the helpline included anxiety, stress, depression, domestic violence, suicidal behaviours and other behavioural problems. Following the intervention, most users reported feeling satisfied and having improved emotions. The first psychological aid in the country developed through telephone and chat messaging was an optimal resource since face‐to‐face interaction was not possible. It also reached more people and reduced the attention gap. On 31 December 2019, the World Health Organization (WHO) received notification of several cases of pneumonia from Wuhan, China. Later, on 30 January 2020, the outbreak of the novel coronavirus 2019-nCoV was declared a public health emergency of international concern (World Health Organization, 2020a, 2020b). On 28 February 2020, the Ministry of Public Health of the Dominican Republic reported the first cases of COVID-19 (Ministry of Public Health, Dominican Republic, 2020) . From 16 March, as in other countries, the government applied measures for social distancing and policies for citizen security, including the closure of educational, labour and leisure activities (Ministry of the Presidency, 2020). The Dominican Republic has not had drastic measures involving confinement and social distancing. Being a country with cultural activities that invite the masses and involve the social and emotional closeness of the people, the fear and dismay of the population was immediately noticeable. A crisis such as a health emergency, as in this pandemic, produces conditions for emotional instability in people as a result of exposure to high levels of stress (Pan American Health Organization, 2006a) . Studies report that in an emergency or disaster situation there can be a notorious increase in mental illness. Twenty-two per cent of people who have been affected by a disaster suffer from depression, anxiety or post-traumatic stress (World Health Organization, 2019) . Studies conducted during the pandemic suggest that important mental health implications are expected in the population, and that these may be long lasting, especially for those affected by the quarantine situation (Brooks et al., 2020) . Furthermore, there have been warnings of the increase of domestic violence and the exposure of children, adolescents and women to being victims of abuse and aggression (UNICEF, 2018) . This emergency needed interventions to mitigate the negative impact of the pandemic on the lives of this The model of care has focused on the care of people with serious mental disorders in large hospitals in the city, with the modality of hospitalisation and outpatient consultation, with a low capacity for care in the community and for those with psychosocial problems. Attention to child and adolescent mental health is much scarcer, with only three large hospitals in two provinces of the country serving children and adolescents, with limited capacity. Users of mental health services report significant barriers to access, such as limited time to attend consultations, difficulties in economic resources for transportation, the purchase of medications and difficulties in scheduling appointments (Caplan, Little, et al., 2018) . The country does not have national community research or surveys on morbidity due to mental disorders; studies of prevalence by demand in health services (Ministry of Public Health, 2019) are also limited. However, the National Epidemiological Surveillance System records that the most reported mental health issues are anxiety attacks, depression crises and alcoholism. Of concern is the steady increase in cases of suicide among adolescents and young people (Luciano et al., 2019) . In the pandemic, mental health services were closed, and only emergency services in major hospitals were open. There was no structure in place in the country to respond to mental health needs in health emergencies. The authors of this project have experience in the development of app-based mental health programmes, but intervention via the Internet or using mobile or residential telephony had not previously been implemented at a large scale by psychologists and therapists in the Dominican Republic. Therefore, this was a challenge for psychologists and therapists who wanted to develop an intervention at the national level. The development of medical health interventions based on technology is very low in the Dominican Republic; however, professionals identified some conditions that could facilitate the acceptability of the use of technological tools for health and mental health treatments. The first was to review international experiences of using a psychological helpline in an emergency, and the opportunities associated with the implementation (Hillers Rodríguez | 3 SOSA LOVERA Et AL. UASD COVID-19 Helpline Service to offer psychological first aid to the Dominican population. The objective of this paper is to describe the development, implementation and evaluation of this programme of care in psychological first aid. The programme was facilitated by technology and worked towards a goal: to reduce the impact of mental health morbidity and mortality due to the COVID-19 pandemic. This programme is the first national emergency helpline in the country. On 16 March, the government declared nationwide quarantine, and on 21 March, the UASD COVID-19 Helpline began operations as the first national mental health support resource. The helpline initially was only available to people linked to the University (students, professors and employees, more than 250 thousand people), For the formation of the second cohort, the university identified different psychology professionals, graduate students and other professors at the university from the health department who were interested in being part of the helpline. A selection was made through telephone interviews by a staff member in occupational psychology, who was also part of the management team of the helpline. Their eligibility relied on their professional profiles, their link with the university, the availability of support and voluntariness. In addition, the participants signed a contract for the confidentiality and security of information. In the second cohort, online training took place through the Google Classroom platform for care professionals, with the same topics and activities as described above. Also, through the Zoom platform, professionals developed subjects synchronously and conducted trials of helpful interventions. This second group added a service for people with hearing disabilities, through the use of a professional expert in sign language available via WhatsApp video call to assist this population. The psychologists used their mobile phones and Internet service to perform the intervention from home, besides contributing to the development of the intervention with their knowledge and time. Only three participants used mobile phones assigned from the UASD. In the other cases, the professionals used their personal phone numbers. All interventions were performed via calls to mobile phones, as well as video calls and messages through WhatsApp. Each professional who attended to a case was asked to report the general aspects of the case in a data record on the Google Drive platform. The information gathered included date and time of service, province, the reason for calls, gender and age, referral made, and detection of a situation of psychological risk (decompensated psychiatric crisis, suicidal behaviour, violence, anxiety crisis, depression crisis). As a way of safeguarding the mental health of participants, there were three working cohorts. The first cohort of 36 mental health professionals offered services from 21 March to 11 April 2020. The second cohort of 25 professionals provided services from 12 April to 23 May. At the end of this time, a third cohort was convened, consisting of 12 professionals who participated in the first and second cohorts and four new volunteers, from 24 May to 17 July. A management team was responsible for the supervision, monitoring and evaluation of the reporting of the cases. They were also responsible of the compliance with the protocols of action, the analysis of the data and the generation of weekly bulletins. Constantly, through a WhatsApp group with the entire team and personal communication, the reported cases were followed up and support was offered to the staff on the correct procedure in each situation and the timely reporting of cases was reiterated. At the end of each cohort, there was a closing meeting to debrief and provide emotional support for the staff. In addition, a specialist in Information and Communication Technology was involved to protect the telephone identity of the staff and reduce the likelihood of identity theft through the phone and WhatsApp. Each staff member obtained a certificate of recognition for their volunteer work on the UASD COVID-19 Helpline. The care protocol called for the identification of risk situations. In these cases, professionals referred the users to the mental health services of the local public network. The management team, coordinated with the National Department of Mental Health and the National Health Service, worked together to ensure the timely response to people identified as at risk. Within the protocol of action, the user was asked for authorisation to make a follow-up call. Within one week of receiving assistance through the helpline, a team of six psychologists made calls to the users who authorised the follow-up on their cases. These calls examinated the compliance with the protocol, as well as the improvement of the individual intakes and the detection of risk situations at home. The Dominican College of Psychologists covered the cost of the Internet for these calls. The staff completed an assessment survey once the interventions in the Helpline had finished. The survey allowed the coordinating team to identify the opportunities for improvement of the helpline's processes, as well looking at the remote teaching of the staff. During the four months of intervention, 497 people were assisted, with an average of eight interventions completed per day and 45 interventions completed per week, approximately. The average age of those receiving care was 32 years, with 73% of cases being women and 27% men. Fifty-four per cent of people who received assistance were from the National District and Santo Domingo; 14% of people called from abroad. The rest of the calls were from other provinces of the country (Tables 1 and 2 ). Eighty-three percent of the attention was called for the first time. The main reasons for the calls were because people had signs of TA B L E 1 Distribution of age groups and gender of the people who received care There was a total of 162 cases (32.5%) of high-risk reported, some identified as anxiety crises, depression crises, suicidal ideation and attempt, and domestic violence. WhatsApp (47%), followed by calls from local mobile numbers (39%), and then WhatsApp calls (24%) ( Table 3 ). A total of 192 feedback and service assessment surveys were completed by people who had received care through the helpline. More than 80% of users felt that psychologists paid a lot of attention and interest. Eighty-one per cent of respondents considered the recommendations given as useful, and 79% noted that their symptoms improved after the telephone intervention. Most people indicated they would call the Helpline again if they felt emotionally unwell (96%), and 97% said they would recommend it to other people (Table 4) . At the end of the operation of the helpline, a survey was carried out with the staff. Of the 46 people who responded to the survey regarding the training provided, the majority believed that the content was good (92%), the objectives of the training were met (98%), the material used was adequate (96%), and the medium used was good (96%). Regarding the care provided, they felt that the protocol provided was easy to use (94%), it was easy to communicate with users (98%), and they valued the use of technology for mental health care posi- When asked about the aspects they considered facilitated care, they pointed out that the protocol was very helpful. Other aspects valued positively were the systematic recording of information, the personal well-being of knowing that another person was supported, and working from home without leaving behind work and home responsibilities. They emphasised that the most complex situation is not being able to follow-up with people since, in most cases, they needed medium-or long-term mental health care, where the psychological first aid was not enough. In 57% of cases, the care staff believed that they improved their handling of technology after participating in the helpline. The majority (87%) believed that they will use technology to continue their clinical practice (Table 5 ). The UASD Helpline was the first emotional support resource available to the entire Dominican population following the impact of the pandemic. The helpline supported a proportion of the population, but it was not enough for the whole country, as many people were never able to access mental health services. The same happened in other countries, where the rate of use of helplines was very low (Michaud et al., 2020) . However, some elements that could help the development of a mental health helpline in future health emergencies stand out. During the training, some challenges arose, such as the availability of technological resources for the development of the helpline and the vulnerability of the personal data of the team. Since professionals were using private numbers, they were exposed to threats such as the hacking of WhatsApp accounts. There was also a barrier to access for people not having available minutes or Internet to access the service. In some situations, calls or chats were interrupted, and only staff who had funds available on their phone could return the call and continue the intervention. Another limitation is that there was no specific protocol for support in situations of violence or care for people at risk of suicide. Users identified situations of risk or that required a medium-or long-term intervention by mental health services that they could not access public services for, since the country was focusing hospital care on COVID-19 patients. Similarly, the helpline management team's efforts to establish collaboration with government entities were not successful. The data registrations were stored in free-to-use software, where each provider could modify the forms. Each cohort had different forms. Each working group had updated data records, which limited the homogenisation of the variables and indicators. In turn, this impeded the process of organisation and cleaning of data and its subsequent analysis. Very bad rating For the evaluation of the service, an analysis of the data could not be performed according to the demographic data of age, sex and locality, which could provide more insight into the responses service users. The UASD COVID-19 Psychological Helpline was a mental health support service developed as a rapid and timely response to the challenges that the COVID-19 pandemic imposed on the mental health of the Dominican population. The service was virtual and used telecommunications, facilitating the provision and access to psychological first-aid services. It became a national model of digital public health intervention that demonstrated the usefulness of digital media and the need to move towards sustainable types of mental health support. This is all the more important considering that a mental health service had never been developed in such a short time and with the use of digital technology in the country. This therapeutic modality has a cost-benefit that helps to reduce the gap in mental health care. The model improves the monitoring of health actions and outcomes and, above all, brings the service closer to those at greater psychosocial risk in the community. This closeness is vital because it includes populations highly vulnerable to violence and abuse such as children, adolescents and women. The authors of this article worked on the development of the Helpline described in this article and currently serve as directors and faculty of Psychology, Public Health, Bioethics, and Health Research, and declare no conflict of interest. Angelina Sosa Lovera https://orcid.org/0000-0002-1592-4180 The psychological impact of quarantine and how to reduce it: Rapid review of the evidence Mental health services in the Dominican Republic from the perspective of health care providers A feasibility study of a mental health mobile app in the Dominican Republic: The untold story Dominican Telecommunications Institute (INDOTEL). (2020a). Newsletter Dominican Telecommunications Institute (INDOTEL). (2020b). 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(Manual series is and Guides on Disasters UNICEF Helpdesk gender based violence in emergencies: Emergency responses to public health outbreaks Statement on the second meeting of the Emergency Committee of the International Health Regulations (2005) on the outbreak of the novel coronavirus (2019-nCoV). World Health Organization menta l-healt h-in-emerg encies World Health Organization, Pan American Health Organization, Ministry of Public Health She has published research on mental health, use of mobile apps for treating depression in primary care, forensic psychology and teenage suicide. She teaches undergraduate and graduate degrees in psychology, public health and health services management. She is currently developing research in the Dominican Republic with funds from the National Institute of Mental Health (NIMH) She is a professor of psychology. Currently, she is the Director of the School of Psychology of the Autonomous University of Santo Domingo. She is Co-author of chapter 8