Close to 19% of Somalia’s 16 million population are internally displaced and live in informal settlements where they are vulnerable to disasters and have very low resilience capacity. Humanitarian and other interventions that are grounded in evidence-based findings are needed to support these populations yet priorities and experiences of IDPs are often understudied. This study is unique for revealing the interrelationship between COVID-19 restrictions, livelihood, hand hygiene practicality and mental health and wellbeing in Somalia’s conflict-affected, displaced communities. Although knowledge and awareness of COVID-19 was relatively good at the time of the survey, practices such as regular hand washing with soap were not being practiced by 45% of the respondents largely due to difficulties accessing soap and water. Further, livelihoods and food security of these internally displaced communities were impacted in two ways. Firstly, social distancing directives aimed at restricting public gatherings negatively impacted daily earnings by limiting access to markets and led to the reduction of humanitarian food distribution at crowding points. Secondly, a sharp price increase in basic food items impacted people’s ability to buy these items. This study is the first to show that existing high levels of depression in Somalia’s internally-displaced communities were potentially compounded by COVID-19 restrictions such as prohibiting public gatherings. Further, it showed that people with severe or moderately severe depression (PHQ-9 ≥ 15) were less likely to practice good hand hygiene practices and more likely to cite difficulties buying food because of COVID-19.
COVID-19 overwhelmed the health systems of countries that scored well in the 2019 pandemic preparedness assessment [12]. In contrast, it was reported early in the pandemic that COVID-19 had a comparatively lower impact on less prepared African countries which reported lower cases, potentially due to younger populations, delayed pandemic spread, decisive response and other debated explanations [37]. Nevertheless, there was a significant socio-economic impact on the livelihoods of African communities that depend on daily earning wages [38], including in Somalia [39]. Livelihood concerns expressed by participants in this study are similar to those reported in recent studies conducted in Somalia’s conflict-affected and displaced communities that similarly reported livelihood interruptions, a decrease in household income, and failure to buy basic food items due to movement restrictions [40, 41]. This highlights the intrinsic vulnerability of the populations to multiple shocks and points to the need for future pandemic prevention strategies to specifically address displaced communities as they cannot observe movement restrictions that hobble their daily earnings for survival. Other researchers have recognized that such interventions duplicated international responses without being contextualized to local circumstances [41].
We report a relatively good knowledge of the pandemic by displaced communities in Somalia which corresponds well with other surveys conducted by humanitarian agencies [42, 43]. This is likely due to radio campaigns and distribution of translated posters by local governments and NGOs, aimed at improving awareness of COVID-19 and its prevention. Nonetheless, on the basis of their description of current practices, hand washing was deemed to be inadequate in nearly half of the respondents. Poor hand hygiene can be attributed in part to the general lack of adequate clean water; in 2022, Somalia’s Water, Sanitation, and Hygiene (WASH) cluster reports inadequate clean water for appropriate sanitation for more than 1.4 million displaced communities [44].
COVID-19 is associated with a high prevalence of depression and anxiety [45] which can be more precarious in low resource settings [46] such as conflict-affected communities in sub-Saharan countries that struggle to access primary health care [47]. Forcibly displaced children and youth are, in particular, considered amongst the most vulnerable to mental health impacts during the COVID-19 pandemic [48]. We report a high level of depressive symptoms among Somalia’s displaced communities and some evidence that mental health and wellbeing likely deteriorated further due to the pandemic and associated restrictions. Somalia’s median age is 16.7 years [49] which may explain why we found such high rates of depression in young and middle-aged people. This contrasts with a report of higher depression rates among older aged Rohinga refugees communities in Bangladesh during the pandemic [50]. Mental health and wellbeing has been neglected for decades in Somalia due to the prolonged conflict and lack of health care services [51]. This mental health burden should be a priority concern for policymakers and humanitarian agencies, particularly given potential negative knock-on impacts in terms of hand hygiene practice and ability to buy food. Similar mental health impacts of lockdowns have been reported in other conflict-affected countries such as Syria, where reduced ability to earn and provide food were all highlighted as the main concerns [52].
Importantly, we found evidence of inadequate hand hygiene practice particularly amongst people with high depressive symptomatology. This mirrors findings from a longitudinal study in China which reported a positive correlation between good hand hygiene and better mental health during the pandemic [53]. Similarly, a study in three South American countries revealed a relationship between poor mental health and inadequate handwashing in ordinary (pre-pandemic) times [54]. We did not explore possible mechanisms for this association in our study, however we speculate that a sense of apathy and/or despondency may mean people with depression are less likely to use soap and/or wash their hands. Indeed, people with depressive symptoms in this study were less likely to indicate that handwashing was difficult than those without such symptoms (data not shown). Alternatively, attitudes towards the importance of handwashing with soap may vary between people with and without depression. In Malawi, for example, vulnerable populations with poor mental health believed handwashing with soap is expensive and thus tended not to practice regular handwashing [55].
This study has a number of weaknesses and strengths which should be mentioned. We recruited only internally displaced people in the selected camps which limits our understanding of how the experiences of these people compare to the ways in which members of the host communities and refugees from other countries (like Yemen and Ethiopia) are coping with the pandemic. Nonetheless, the use of a sampling framework with random selection does mean that the findings are likely representative of and can be generalized to the wider IDP population in Somalia. Being a cross-sectional study, we cannot comment on how the impacts of COVID-19 evolved over the pandemic period, although the timing of data collection (December 2020 and March 2021) did coincide with a period of widespread transmission of COVID-19 in Somalia and thus we were able to document the impacts of the pandemic as they were occurring at that time. We did not ask participants if they had personal experience with COVID-19 (self or household members). This would have provided greater insight into household-level impacts of the pandemic, which may have varied between directly and indirectly-affected respondents. Lastly, even though the mental health tools used in this study have been previously deployed to internally displaced people [34, 56], there was no rigorous adaptation of the instruments to the Somali setting. Future research in Somalia would benefit from producing a context specific version of both WHO-5 and PHQ-9 tools.