Contextual vulnerabilities

Climate change is no longer a distant threat, but a present-day reality that adversely affects community health and well-being worldwide. In Pakistan, recurrent floods driven by climate change have emerged as one of the most devastating challenges, particularly for rural communities with limited access to health services. Amid focus on physical impacts, the mental health toll of disasters is often overlooked. As the fifth most affected nation by extreme weather, Pakistan’s rural communities face severe individual and systemic challenges. In 2022, Pakistan’s unprecedented floods affected 33 million people, caused US$30 billion in losses and left 8.2 million without basic health services, with over 2000 health facilities non-functional. ¹ Alarmingly, disaster-stricken areas suffer from limited psychological personnel and services, with certain areas not even possessing a single psychiatrist, along with pervasive stigma and low mental health literacy among local community members. ^{Reference Abdullah, Shaikh, Sikander and Sarwar2,Reference Yousuf, Mehmood, Aquil, Rija, Rahmat and Malikzai3} This paper sheds light on the mental health impacts of climate-driven floods on rural communities of Sindh and Balochistan in Pakistan using community voices, delivering integrated psychosocial care and recommending policy-driven solutions.

Community-based intervention for mental health and psychosocial support in humanitarian settings

During disaster emergencies, mental health response protocols are not adequately embedded into flood relief services and are often sparsely addressed within resource-constrained settings. By comparison with other South Asian countries, frequent natural disasters in Bangladesh have had a severe impact on the mental health of its people. However, despite the widespread consequences on well-being, post-disaster psychosocial support remains limited, underscoring the need for a community-based system. ^{Reference Nahar, Blomstedt, Wu, Kandarina, Trisnantoro and Kinsman4} In response, that country has implemented community-based mental health and psychosocial support (MHPSS) programmes using health workers and mobile health services to reach remote populations. ^{Reference Rahman, Hamdani and Awan5} Similarly, India has faced severe climate disasters, increasing anxiety and fear among affected communities, emphasising the need for mental health integration in disaster management. ^{Reference Rowe and Nadkarni6} It has begun efforts to incorporate telemedicine-based MHPSS into its national disaster plan, expanding access in underserved regions. ^{Reference Sharma, Patil and Sharma7} Moreover, in Nepal, the 2015 earthquake caused a surge in mental health issues among affected individuals. Response efforts focused on capacity building and community-based interventions to enhance resilience and integrate MHPSS into disaster response. ^{Reference Kane, Luitel, Jordans, Kohrt, Weissbecker and Tol8} Local efforts were made to train local volunteers in mental health first aid and psychosocial support, with community and family networks playing a key role in facilitating recovery and providing emotional support. ^{Reference Feldblum, Bhatia and Sim9,Reference Sherchan, Samuel, Marahatta, Anwar, Van Ommeren and Ofrin10} In Afghanistan, many face mental health challenges due to prolonged conflict, instability, poverty and natural disasters, prompting emergency relief organisations to integrate MHPSS into all healthcare facilities, with trained doctors, midwives and nurses providing counselling and treatment. ¹¹ Organisations such as the United Nations High Commissioner for Refugees (UNHCR) are expanding efforts nationwide, with mental health teams extending services to remote and conflict-affected areas, ensuring broader access to psychological care. ¹² Sri Lanka’s disaster response, shaped by the 2004 Tsunami, initially centralised mental health services, limiting access for remote populations. ¹³ Decentralisation efforts initiated MHPSS services into community settings, fostering resilience through local training and psychosocial support, leading to a significant expansion of mental health services in Sri Lanka. ¹⁴ These examples show the effectiveness of integrating mental health services during disaster relief efforts, and provide valuable lessons for Pakistan. They highlight the critical importance of community engagement, capacity building and the need to sustain these initiatives to enhance resilience and address climate-related psychological impacts.

Using Inter-Agency Standing Committee (IASC) guidelines on mental health and psychosocial support during emergencies, ¹⁵ and The International Federation of Red Cross and Red Crescent Societies (IFRC) MHPSS framework, ¹⁶ as a basis for climate action and lessons learned from MHPSS programmes in other South Asian countries, we devised an integrated approach to build psychological resilience among flood-affected communities. Based on the concerning impacts of the 2022 floods and emerging needs to address psychological adversities, ^{Reference Mushtaq, Ali, Ghosh, Jalal, Asghar and Dadhich17} six high-risk districts – three from each Sindh province (Khairpur, Nausheroferoz and Jacobabad) and Balochistan province (Lasbela, Jafferabad and Naseerabad) – were selected for the implementation of mental health camps to enhance access to MHPSS service delivery for flood affectees. Because mental health promotion through task-shifting methods has demonstrated success, ^{Reference James, Welton-Mitchell, Noel and James18,Reference Kiran, Mohan, Abhijith, Abraham, Anoop and Dinesh19} capacity-strengthening sessions were conducted for community health workers (CHWs) from these areas to leverage their influential role and community trust in enhancing the uptake of MHPSS services.

During the mental health camps, MHPSS services were seamlessly incorporated into other primary healthcare services. Trained CHWs used standardised tools to identify risk for depression among flood-affected residents (patient health questionnaire PHQ-9), anxiety (generalised anxiety disorder; GAD-7) and post-traumatic stress disorder (PTSD checklist, civilian version). For immediate psychosocial response, CHWs offered lay counselling services to screened individuals both during and after the screening process, to mitigate mental distress and create an open space for emotion and thought expression. Consequently, prompt referrals of high-risk individuals to specialised care were initiated using the telehealth model. ¹⁵ In addition to this, public advocacy on MHPSS can positively influence community cohesiveness and help-seeking efficacies during humanitarian crises. ^{Reference Rowe and Nadkarni6,16,Reference Riaz, Nayyer, Lal, Nawaz and Zil-e-Ali20} Of note, community-driven mobilisation and active engagement efforts were also undertaken, where CHWs and district health coordinators visited local households to provide health education, counsel caregivers, encourage MHPSS service utilisation and provide socio-emotional support. One of the female participants from Jacobabad district claimed:

Another participant highlighted the importance of such interventions for remote communities:

While community-based lay counselling services were found to be effective, access to telehealth specialised services was equally challenging. Residents from remote communities are often neglected and face health disparities that silently increase their psychological burden. In addition, lack of mental health knowledge, patriarchal decision-makers, restriction of women to accessing psychological treatment, inadequate digital infrastructure, economic inequities, rigid sociocultural norms and stigma, and meeting familial demands versus prioritising their own mental health further limit their engagement and adherence to telehealth mental services.

Survivors’ lived experiences

Exploring local flood-related experiences at grass-root levels is indispensable to adopting practices that respond to community mental health needs and contextualise the integration of MHPSS services across diverse socioeconomic groups. ^{Reference Wainberg, Scorza, Shultz, Helpman, Mootz and Johnson21} During our programme implementation, we briefly explored the perspectives of local people regarding the impacts of floods on their mental health and quality of life. The local community is largely affected by climate-induced anxiety because it has profoundly changed their narratives about rain:

The loss of loved ones and livestock, displacement, homelessness, limited access to essentials, disrupted health services and concerns for safety and the future contributed significantly to severe psychological distress and post-flood trauma. ^{Reference Palinkas22} Another participant narrated a powerful story:

Due to the detrimental effects of flood and inaccessibility of mental health services within remote regions, many flood-affected individuals experienced suicidal ideations and behaviours that further exacerbated their psychological problems and overall family dynamics:

Fig. 1 This image was captured during programme monitoring, showing floodwaters that remained even after 2 years and limited our access to the communities living on the other side. Image credit: Zainab Farid.

Future directions

The mental health impact of climate-driven floods among rural communities in Pakistan remains a silent crisis and must become a national priority. While IASC guidelines and the MHPSS framework are useful advisory tools, MHPSS services should be contextualised for efficient targeting of language barriers, cultural beliefs and stigma, community engagement, mental health literacy and the inclusion of people with lived experiences in intervention design, implementation and evaluation. Coordinated and multisectoral efforts via public–private partnerships are required to strategise supportive measures and map organisations nationwide, to effectively support the timely mobilisation of MHPSS services in remote regions during emergencies. The national and provincial disaster management plan must develop and incorporate emergency preparedness protocols for MHPSS implementation. The government should focus on linking disaster risk reduction strategies within MHPSS programmes to foster prevention, preparedness, response and recovery among affected individuals. Because the telehealth model may not be applicable to individuals within remote regions, a blended approach to implementing MHPSS services may be more feasible in enhancing equitable access to care. Integration of MHPSS services at the primary healthcare level, streamlining risk identification and referral strategies, adequate investments in improving health infrastructure and allocation of mental health personnel at these units all require greater focus. To prepare the community for future emergencies and promote well-being, social safety nets should be established. Local actors, religious leaders and community/tribal chiefs (Nawab/Sardar) can play a pivotal role in advocating for psychosocial support, reducing stigma and increasing help-seeking behaviours among community members. Innovative approaches and culturally appropriate information, education and communication materials in local languages should be widely disseminated to promote self-help and future disaster readiness. Steps should be taken for continuous capacity strengthening of local healthcare providers for MHPSS services, to increase service accessibility and increase community resilience. Evidence generation around climate-induced mental health severity for driving policy reforms and bringing quality improvements in community-based MHPSS programmes must be considered.