key: cord-1034685-2u2xo3k4 authors: Ebuenyi, Ikenna D.; Gitonga, Isaiah; Tele, Albert; Syurina, Elena V. title: Unemployment in women with psychosocial disabilities during the COVID‐19 pandemic: Lessons from Tana River County, Kenya date: 2022-02-25 journal: J Int Dev DOI: 10.1002/jid.3638 sha: aff847e7e1cc5e8e18da0715459fb92aa62572ef doc_id: 1034685 cord_uid: 2u2xo3k4 In low‐income settings, the informal economy is a practical alternative to work and employment for persons with disabilities. However, the COVID‐19 pandemic negatively affected the informal economy. This study aimed to explore the experiences of women with psychosocial disabilities in Kenya during the pandemic. We found that the pandemic worsened their experiences of work and employment, and they did not receive any social welfare or support from the government. Our findings suggest that pandemic management must adopt inclusive and context‐sensitive approaches that support persons with psychosocial disabilities. Social welfare and protection for persons with disabilities are relevant for socio‐economic empowerment and inclusion. living with a mental illness can be disabling due to its impact on biological, psychological and social functioning (Wainberg et al., 2017) . As a result, the United Nations Convention on the Rights of Persons with Disabilities (UN CRPD) found it prudent to include persons with mental impairments in its definition of persons with disabilities (United Nations, 2006) . Psychosocial disability refers to disabilities that may arise on account of mental health conditions. Eaton and colleagues suggest that psychosocial disabilities "are those disabilities that arise from barriers to social participation experienced by people who have or who are perceived to have mental conditions or problems" (Eaton et al., 2021) . According to the Users and Survivors of Psychiatry (USP) Kenya, it "refers to persons who may define themselves in various ways: as users or consumers of mental health services; survivors of psychiatry or people experiencing mental health problems, issues or crises" (USP Kenya, 2017) . Persons with disabilities often experience discrimination that affects their access to education, healthcare and work or employment. These discriminations and disproportionate access to services means that they are denied rights to the very things that ensures their economic independence (Ebuenyi, Regeer, Ndetei, et al., 2019; Tele et al., 2022) . Among persons with disabilities, those with psychosocial disabilities experience greater work and employment barriers compared to those with physical disabilities in the general population Felix, 2021) . In Europe, the Organisation for Economic Co-operation and Development (2010) suggest that employment for persons mental disability is 30% and, in the United States, full time employment was 38.1% and 67% for those with serious mental illness and those without mental illness, respectively (Luciano & Meara, 2014) . Among recipients of social security benefits, persons with psychosocial disabilities are the highest. The nexus between mental disorders and poverty has been documented (Lund et al., 2011) . The impact of mental disorders on social and occupational functioning has dire implications for participation in work and employment, and conversely, lack of work and employment worsens recovery from mental illness (Saavedra et al., 2016) . Also, work and employment are important for social inclusion (Ebuenyi, 2019) . Work and employment are human rights and persons with disabilities require reasonable accommodation in work and employment (Ebuenyi, 2019) . Article 5 of the UN CRPD recommends reasonable accommodation to ensure equality for persons with disabilities and elimination of all forms of discrimination (United Nations, 2006) . In Article 27, the convention recommends that state parties should safeguard and promote employment for persons with disabilities through legislation that ensures and promotes the realisation of the right to work and employment. State parties such as Kenya that have ratified the convention are duty bound to implement their commitments to the articles of the convention (United Nations, 2015) . Among the commitments is to ensure inclusive work and employment, provision of adequate standard of living and social protection for persons living with disabilities, including psychosocial disabilities (Ebuenyi, Regeer, Nthenge, et al., 2019) . In low-income settings with preponderance of informal economy, self-employment serves as a practical alternative to formal work or employment (Ebuenyi, Guxens, Ombati, et al., 2019) . However, the current COVID-19 pandemic negatively affected the informal economy leading to widespread loss of income especially among whole population and especially vulnerable populations (Shupler et al., 2020) . A survey of Members of the International Commission for Occupational Health indicated that the COVID-19 pandemic extremely affected vulnerable populations and individuals in precarious employment and informal work (Tamin et al., 2021) . In Europe, Mental Health Europe advocated for renewed support for persons with psychosocial disabilities to mitigate the negative consequences of the COVID-19 pandemic (Mental Health Europe, 2020). Unfortunately, in Kenya and in most low-income settings, social welfare and protection are non-existent or suboptimal leading to greater challenges for vulnerable populations such as persons with psychosocial disabilities and women (Rohwerder et al., 2021) . The COVID-19 pandemic provided an opportunity to observe the pivotal role of social welfare and protection for unemployed persons and for persons with disabilities. Vulnerable groups including persons with disabilities were disproportionately affected by the unemployment experience of the COVID-19 pandemic. Previous study on employment for persons with psychosocial disabilities in Kenya highlights the work and unemployment challenges of persons with disabilities and the gendered pattern of the problem (Ebuenyi, Regeer, Ndetei, et al., 2019) . These work and unemployment challenges affect more women than men with psychosocial disabilities. The aim of this study is to explore work and unemployment experience of women with psychosocial disabilities in a rural Tana River community during the COVID-19 pandemic and its impact. It forms part of a larger study that adopts an action research methodology to improve work and employment opportunities for women with psychosocial disabilities (Gitonga et al., 2021) . Tana River County is one of the poorest counties in Kenya and ranks 43 out of the 47 counties in Kenya (Tana River County, 2020). The county is located at the coast of Kenya, approximately 300 km from the capital city. The rate of poverty in Tana River is 76.9%, which is higher than the national average of 45.9%. Starvation, inadequate access to healthcare, low literacy levels, unemployment and insecurity are common in Tana River. Also, there is high rates of early girl child marriages which limits education opportunities for women (Commission on Revenue Allocation, 2012). At the inception of this study, Tana River County did not have a psychiatrist or psychologist. There are no official statistics on the number of persons with psychosocial disability. Persons with psychosocial disability face high levels of stigma and discrimination in Kenya (USP Kenya, 2017). On acount of reduced access to formal health services, they largely rely on the informal/traditional services such as the traditional healing. We adopted an exploratory qualitative design in this study. This design was appropriate because it offers an opportunity for in-depth exploration of the actual experience of the study participants . The target population were women with psychosocial disabilities living in Tana River County, Kenya. We recruited a convenient sample of 25 women living with psychosocial disabilities who were clinically stable and not actively ill at the time of the study. Recruitment was done through a network of non-governmental organization that works with persons living with disability. A trained research assistant (RA) shared the informed consent forms with potential study participants and answered all individual specific questions. Only the participants who gave informed consent in writing or thumbprint participated in the study. The study was part of larger project that aimed to improve the employment opportunities for rural women with psychosocial disabilities (Gitonga et al., 2021; Tele et al., 2022) . Using a predesigned interview guide, we conducted in-depth interviews with each of the participants to better understand their experience with the evolving COVID-19 pandemic and regarding its impact on work and employment, coping and social assistance and services. The Kübler-Ross change curve (Metzger, 1980) was used to explore the experience and reaction of study participants to the changes on account of the pandemic. The Kübler-Ross change curve describes five stages of grief: denial, anger, bargaining, depression, and acceptance and can be adapted to describe the experience of the COVID-19 pandemic (Ray & Shklarski, 2021) . Data collection took place four months after the government had imposed nationwide lockdown and restriction of movements as a containment measure. These interviews were conducted by a trained RA conversant with the local language and who visited the women in their homes. Data saturation was considered to have been achieved when no new information emerged from the interviews (Gray, 2013). Data were analysed thematically . Thematic analysis was done through coding of key themes that were noted during the interviews. The initial coding of data was undertaken by IDE and shared with other members of the study team. The study team then met and discussed the identified themes to ensure they were comprehensive, and that the information gathered was accurate and a correct representation of the interviews with participants. A consensus was arrived on the final themes used in the manuscript. Representative quotes on impact and experiences of work and employment during the pandemic are listed below and categorised by emergent themes. The mean age of the participants was 36.6 years and ranged from 18 to 70 years. Close to half (48%) had primary level of education, 40% had no formal education, while 12% had secondary school level of education. In terms of their employment status, more than three quarters (84.0%) were unemployed, while 16.0% were self-employed. None of the participants was in formal employment. In terms of self-reported mental health conditions, bipolar disorder was the highest (n = 9; 36%), followed by schizophrenia and other psychotic conditions (n = 6; 24.0%), depression (n = 4; 16%), post-traumatic stress disorder (n = 1; 4.0%) and others (n = 5; 20.0%). Table 1 summarizes the socio-demographic and economic characteristics of the participants. More than three quarter (84%) of the participants reported to have been significantly affected by COVID-19 pandemic with 32% still being in shock, 44% in denial and 24% reporting frustration as per the Kübler-Ross change curve questions (Ray & Shklarski, 2021) . Majority (80%) of the participants of the participants indicated that food was their immediate need considering the pandemic, followed by financial support and protective equipment such as face coverings and clothing. None of the women reported to have received any form of social assistance or support Three interrelated themes emerged from the narrative interviews with each of the participants. These are economic impacts, psychological impacts and social assistance services and needs. Participants reported to have experienced major negative economic impacts because of the lockdowns and other pandemic restrictions that were enforced by the government. This worsened their experience of poverty as they, their caregivers and those they depended on lost their employment, which was mainly self-employment. It was worse for those who had no form of employment prior to the pandemic. We used to work in people's farms and get paid but since corona pandemic came, we don't even have those farm jobs. (Participant_25) According to the women, food was their top need. The pandemic containment demands such wearing of masks, which was an additional expense, made the situation even worse. I don't have even money to buy food let alone mask. (Participant_24) The pandemic had worsened their existing financial pressures and limited their ability to access any form of support, even from the neighbours or occasional wage labour which some relied on for subsistence. According to another participant, COVID-19 pandemic did not only affect work and employment but also availability of money: The biggest challenge is lack of money because most workplaces have been closed and people have no jobs. (Participant_10) In the face of the existing challenges faced by people with psychosocial disabilities and the inaccessibility of social assistance provision, the pandemic containment measures worsened participants' psychological well-being. The lockdowns and other restrictions caused much worry and distress for persons with psychosocial disabilities. Participants reported that they felt hopeless, helpless and depressed in the worst times of the crisis. Social distancing meant that participants could no longer rely on their usual support structures. In addition, their underlying psychological impairments made things more challenging if they were unable to follow the current restrictions as the authorities were not adequately aware of unintentional violations and possible accommodations.The responses to the Kübler-Ross change curve questions indicated that most of the participants were still in denial and shock, four months into the pandemic. Majority had no access to radios or television and therefore did not have access to appropriate information regarding the virus. I have just heard people talking about it, they say it is a dangerous thing I am in fear. (Participant_18) The lack of information led to reliance on others for information, uncertainty and misinformation. I don't know what it is, though we were told to buy masks and wear them. (Participant_20) Some participants were hopeless and resorted to prayer and religious beliefs as the only source of hope for their survival during the pandemic. When the virus came people were saying it wasn't treatable and just like death is final, so I felt that corona equals death because we inherited it from Adam and Eve. We were told that towards the end of the world a disease will come that will not be treatable and I think corona equals death because it is not treatable. Only God! The government will not give you any support. So, people should just pray to God so that he can lead the way. (Participant_13) The economic challenges indirectly caused the participants much distress and worry as they did not know how to provide for themselves and their families. For some, this had really serious consequences on their existing psychological difficulties. The lack of basic needs such as food and clothing resulted in the relapse for some people with psychosocial disabilities, thereby impairing their recovery journey. This was the perception of one of the women who stated: Corona has made life worse in everything, my health is worse. (Participant_24) 3.3.3 | Social assistance services and needs None of the participants had received any form of social protection assistance whether as existing social protection programmes or COVID-19 specific assistance. It is no wonder majority noted that basic needs such as food, clothing and personal protective equipment's such as masks were their top needs to help them cope with the pandemic. The aim of this study was to explore work and unemployment experience of women with psychosocial disabilities in a rural Tana River community during the COVID-19 pandemic. We found that that the pandemic had negative consequences for rural women with psychosocial disabilities in Kenya. These experiences worsened their existing work and employment challenges and psychological impairments. Despite these vulnerabilities, they did not receive any form of social protection from the government. Our findings are corroborated by the study by Rohwerder et al. (2021) that also reported on the deprivations faced by persons with disabilities in Kenya during the pandemic. The exclusion of persons with disabilities in the pandemic response reinforces the existing stigma and discrimination that persons living with disabilities continue to face in the society (Ebuenyi, Regeer, Ndetei, et al., 2019) . The participants suggested that COVID-19 pandemic and the measures by the government to curb its spread only worsened their pre-existing difficulties. They reported negative impact on work and employment, psychological well-being, access to social support and protection, among others. It is not surprising that majority of them were still in shock and denial and that access to basic supplies such as food and clothing were their priority needs. Access to income, livelihood support and social protection has been a major challenge for persons with disabilities; especially women with psychosocial disabilities even during the pre-pandemic times (Tamin et al., 2021) . All the participants in study started the pandemic not only from a point of psychological vulnerability because of their mental health conditions but also from a position of economic vulnerability due to unemployment, underemployment or insecure employment. This is a representation of the current disabling work and employment situation for people with psychosocial disabilities in Kenya and similar low resource settings (Ebuenyi, 2019) . It therefore means that the economic impact of the pandemic hit people with disabilities harder, because the informal sector was particularly affected by the lockdown and pandemic restrictions and also due to the absence of social welfare or protection in low-income settings compared to high-income settings (Ebuenyi, 2020; International Labour Organisation, 2020) . The burden was even worse for the rural women with psychosocial disabilities who face a double burden of anticipated and experienced stigma and discrimination in addition to poor awareness and lack of access to mental health services (Ebuenyi, Regeer, Ndetei, et al., 2019; Mutiso et al., 2018; Tele et al., 2022) . The level of disappointment, frustration, hopelessness and despair with the lack of social support and assistance provided by the government was evident. Despite evidence that people with disabilities were adversely affected by the pandemic, the government's response and interventions did not have a special package for this group as at the time of conducting this study. This reflects the wider policy and implementation gaps with the social protection response interventions and possible disability discrimination (Rohwerder et al., 2021) . Majority of the participants mainly relied on family support for survival which was inconsistent on account of the impact of the pandemic on the general population. Our study highlights the need for the government and wider disability movement to include special and vulnerable groups not only during pandemic response interventions but also their inclusion in the existing social protection policies in line with the social model of disability (Berghs et al., 2019; Ebuenyi, 2020) , that ensures a more humanistic and inclusive approaches to psychosocial disability (Degener, 2017) . In interpreting these results, it is important to note that these findings reflect the situation as it was three months (July 2020) after the declaration of the pandemic in Kenya. It is possible that as the containment measures eased, the response may have changed. Also, the challenges with registration and possession of a disability certificate are prerequisites for enjoyment of government benefits (Ebuenyi, Guxens, Ombati, et al., 2019) . Majority of the study participants do not have disability certificates which are often difficult to obtain especially for persons with psychosocial disabilities in Kenya. Perhaps, ownership of the certificate may have enabled the women to receive support from the government and spared them the dreadful experience during the pandemic. This highlights the need for urgent actions by government to prioritize measures that will ease the process and requirements for obtaining disability certificates in Kenya. We acknowledge that the use of convenient sampling as a recruitment method may be a potential source of bias in this study. Our study has shown that women with psychosocial disabilities faced and continue to face dire challenges during the pandemic and this has worsened their pre-existing economic and psychological predicaments. There is need for inclusive approaches in pandemic management that take into consideration the contextual challenges faced by persons with disabilities and devoid of any form of discrimination or bureaucratic limitations such as disability registration. Mental health, work and employment are human rights and relevant for survival and social inclusion. It is important that governments in low-and middle-income countries such as Kenya prioritise interventions for economic empowerment and livelihood support through increased awareness and skills provision to improve work and employment for persons with psychosocial disabilities. 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This project was supported by the Voice Empowerment Grant #507997. The authors declare that they have no competing interests. The study was approved by Maseno University Ethics Review Committee (MSU/DRPI/MUERC/00851/20). The data that support the findings of this study are available from the corresponding author upon reasonable request. https://orcid.org/0000-0002-3329-6296