P ERSPECTIVES IN G LOBAL H EALTH Utilizing Distance Learning to Incorporate Global Mental Health Capacity Into Humanitarian and Post-Conflict Missions

Global Mental Health (GMH) is an emerging ﬁ eld of sci-enti ﬁ c education, research, advocacy, and intervention that takes a worldwide perspective of classi ﬁ able mental, neu-rological, and substance misuse disorders. 1 A sustainable and effective GMH service reduces cross-border threats and human security vulnerabilities while promoting resilience and capabilities of individuals and the wider community. For example, GMH professionals have successfully intervened to calm the escalation in domestic violence that typ-ically spikes in communities acutely stressed by post-con ﬂ ict environments. In addition to the direct harm domestic violence af ﬂ icts on its victims, it also leads to wider levels of criminal activity in the community and thus further impairs the community ’ s return to precon ﬂ ict baseline. 2

Global Mental Health (GMH) is an emerging field of scientific education, research, advocacy, and intervention that takes a worldwide perspective of classifiable mental, neurological, and substance misuse disorders. 1 A sustainable and effective GMH service reduces cross-border threats and human security vulnerabilities while promoting resilience and capabilities of individuals and the wider community. For example, GMH professionals have successfully intervened to calm the escalation in domestic violence that typically spikes in communities acutely stressed by post-conflict environments. In addition to the direct harm domestic violence afflicts on its victims, it also leads to wider levels of criminal activity in the community and thus further impairs the community's return to preconflict baseline. 2 It is becoming clear that a complex mix of biological, cultural, and psychological factors influences GMH. Religious tension, exclusion from political processes, wealth and resources inequity and human rights issues all directly impact an indigenous population's well-being, preempting civil unrest and escalation of violence. 3 The above scenarios are often apparent to deployed personnel on humanitarian and post-conflict missions, but difficult to quantify for resource allocation and planning purposes. Symptoms such as unreasonable behavior, illogical thinking, lack of cooperation, and hostility among indigenous populations do not necessarily fit conventional diagnostic classifications. Understanding such behavior requires cultural and language insights. However, this kind of indigenous population profile generates insecurity, impacts directly on peace keeping and health engagement initiatives on post-conflict missions yet has received little consideration in the literature.
Working with local stakeholders and building on existing infrastructure to scale-up GMH capacity is therefore key to understanding perceptions, motivations, performance, and expectations of populations and local organizations. Distance learning provides an effective, convenient, and costeffective tool to rapidly disseminate knowledge relating to skills needed to build GMH capacity, particularly among key deployed personnel. It can also be responsive to feedback and specific skill needs. Through distance learning it is possible to help health personnel to develop the key skills required to gauge the resilience of the local population and rapidly scale-up field research that will contribute to the healing of individuals and communities in conflict and global catastrophes.
The virtual classroom has proven itself to be an effective and popular vehicle for building work-based skill capacity among health care professions in low-resource situations. 4 It is particularly effective when scaled-up in conjunction with infrastructure to support faculty in their teaching and students in their learning. 5 This might take the form of expanding the faculty pool by connecting to partner or satellite education facilities, or the sharing of digital resources, or peer-led web-based learning in the form of electronic discussion forums and tutorials. In humanitarian and postconflict settings, this concept has been developed further to include clinical simulations and multimedia software, which have proved highly effective in facilitating learning and building capacity.
Distance learning has also been demonstrated to be highly responsive to newly emerging learning priorities during missions when they arise. 6 Human rights, for example, is a component of GMH that has been shown to be a significant concern among populations in post-conflict situations, whereas education and subsequent knowledge regarding individual human rights among personnel tends to be very limited. Instructors teaching online courses can rapidly adapt their content on human rights after receiving feedback from personnel in the field. The virtual classroom has also developed as a key forum to disseminate information between countries and governments in terms of health risks and the development of responsive strategies, to identify priority disorders that impact most significantly on communities and the identification of sources of funding.
Gauging an indigenous population's levels of resilience and response to conflict and humanitarian disaster, through monitoring the content of their interactions and decisionmaking, can increase community involvement with the mission. Such observations can be used in the formulation of mission strategy and for the successful outcomes and the prevention, care, treatment, and advocacy of those traumatized by conflict and humanitarian disaster.
Both medical and nonmedical personnel may find themselves negotiating with community leaders who have themselves experienced traumatic experiences, such as sexual violence, genocide, torture or loss of loved ones and been subjected to health and food insecurity, propaganda or the daily hassle of life in a refugee camp-all of which places individuals at high risk of developing emotional and behavioral problems. It is also important to integrate GMH knowledge into the mission toolkit as many individuals will not seek out mental health care, because they are either unfamiliar with the concept of mental health, or it is associated with stigma.
The rapid scaling-up of field research can be a challenge in post-conflict and humanitarian environments. Chaos, instability and a traumatized local population often characterize these environments; all of which generates suspicion, mistrust, and marginalization of communities. GMH research lends itself well to Snowball Sampling Method (SSM), 7 whereby one research subject provides a referral to the next subject and so on, like an enlarging snowball rolling downhill. SSM is a particularly effective tool when dealing with individuals, or groups who perceive their needs, goals, or interests as different to the next group across a broad arena (e.g., resources, trade, and land). Data yielded from this technique can be generated rapidly and shared with key decision-making personnel responsible for setting health priorities.
SSM is also supportive of a traumatized population, as it operates through a trusted network and promotes cooperation. Establishing communication and workable relationships with crisis affected and post-conflict populations have become critical to the engagement, participation, communication, accountability, and outcome of missions. However, consultation and engagement of the local population still remains an area for future development, particularly in terms of performance on the ground and the expectations and perceptions of the local populations. Competing factions on the ground including culture, political constraints, security, a lack of capacity, and internal and external influences make all of this more complex.

RECOMMENDATIONS
The authors suggest that mediation skills, in the form of conflict analysis and communication strategy, need to become an integral part of the GMH curriculum, irrespective of whether professionals set out to rapidly scale-up standalone mental health services for those with classifiable disorders, or integrated into the overall mission aims and objectives, as a supportive arm of wider humanitarian and post-conflict missions. Considered from a GMH perspective, conflict analysis and communication strategies can complement the skill base of the existing team, helping to gauge the morale, resilience, temperament, and well-being of the target population and the wider community. This strategy can establish trust and identify key elements of contention and common goals, while simultaneously gaining support of local power figures.
GMH skills can also assist by monitoring levels of neutrality and stress as the negotiations unfold and assisting in calming and stabilizing situations that might otherwise descend into chaos, preventing aggressive or impulsive behavior, which can jeopardize missions and leave communities vulnerable to hostile forces. This is best achieved through creating informed partnerships within existing infrastructure, ensuring sensitivity is upheld, developing relationships with policy makers, cultivating trust, and camaraderie necessary for long-term research collaborations and interventions that are sustainable and identify at risk groups. The Uniformed Services University has initiated a distancelearning course comprised of ten modules that provides basic principles and knowledge of GMH for the development of federal government and uniformed health workers.

CONCLUSION
Participation of GMH professionals in humanitarian and post-conflict missions can create heightened awareness of any given population's psychosocial profile, along with the subtle changes and nuances in mood and living conditions. Skills propagated by distance-learning modalities can provide insight and background information to monitor the impact of conflict in a culturally sensitive manner and awareness for more intensive GMH expertise and intervention.