Perspective Chapter: Global Health Security through Psychoeducation and Microfinance with At-Need Groups

Abstract

This chapter discusses and explores the relevance of microfinance with psychoeducation for the improvement of global health security. It specifically discusses the importance of microfinance interventions for vulnerable populations, with an accompanying emphasis on mental health. Depression is one of the greatest issues worldwide and currently causes the largest number of days of disability. Depression hinders health and development and is currently considered one of the most important health issues by the World Health Organization. Microfinance is a mechanism that can be directed towards low-income, at-need populations and address mental illness through group support and small loans.

1. Introduction

An estimated 250 million individuals suffer from anxiety disorders and 300 million experience depression worldwide. In addition to this, more than 80% of those suffering from anxiety and depression disorders live in low and middle-income countries. Moreover, those that live in low and middle-income countries are exposed to higher levels of hunger, food insecurity, social prejudice and marginalization, violence, trauma, stress, and poorer quality of life and psychosocial status. Generally, individuals living in poverty or extreme poverty have any underlying mental health disorders exasperated and are exposed to many severe stressors [1]. According to the World Bank, extreme poverty occurs when a person is living on $1.90 a day or less and it is estimated that almost 770 million people live at this level. Economic growth is a critical factor in poverty reduction. Micro-credit to those living in extreme poverty, and low-income women and children in rural areas reduces poverty, increases empowerment and improves positive mental health outcomes [2].

Microfinance was popularized in 1976 by the Grameen Bank in Bangladesh. The original intention with microfinance was to provide small quantities of money to low-income, at-need populations. These individuals worked as farmers or lived in village-type environments. The purpose was for them to use loan money to purchase essential items like food, or to grow and expand their businesses to improve their economic situations [2]. Since this time, the evidence has shown that providing increased access to food and ways to increase money-growing activities through microfinance loans, helps people increase their individual agency, well-being and empowerment [2] (The Association des Femmes du Mali pour la Solidarite el le Developpement, personal communication, July 15, 2023; Espoir des Femmes et des Enfants du Mali (EFEM), personal communication, July 15, 2023).

Microfinance loans, especially when accompanied with group support, not only empower individuals but can reduce depression by helping borrowers have hope for a better life. Hopelessness and disempowerment are key components of depression and low-levels of well-being. Therefore, microfinance when accompanied with group support and targeted towards impoverished female borrowers, has a very strong multiplying positive impact on some of the most disadvantaged regions of the world. However, the amount of money needed for microloans varies depending on the environment and local economy. For example, a microloan of $500 in Mexico may not go as far as a $500 loan in Mali, Africa. The economic situations of every country, and within various regions and places in countries differ, and so the most suitable loans for individuals are largely circumstance-specific and also related to the purpose of each loan [2] (The Association des Femmes du Mali pour la Solidarite el le Developpement, personal communication, July 15, 2023; Espoir des Femmes et des Enfants du Mali (EFEM), personal communication, July 15, 2023).

Cash transfer programs can also reduce trauma and depression by creating a safety net that help protect individuals from worsening depression and stress due to poverty. Wollburg et al. [1] identified the connection between poverty and poor mental health through an investigation of cash transfers on low and middle-income countries for mental health. This was done through an assessment of 4000 studies on cash transfers for the impact of stress, anxiety and depression and looked at adolescents and adults in poverty. A total of 26,794 participants and 17 studies were evaluated in sub-Saharan Africa, Latin America and South Asia were assessed. Cash transfers were found to positively impact depression and anxiety disorders, and this is very significant for overall global health security [1].

2. Microfinance and global health security

The landscape of global health security has changed in the last decades. In the past there was a major emphasis in the World Health Organization and in development initiatives on infectious disease, vaccinations and medical treatments. However, in the last decade there has been a shift towards chronic disease issues such as heart disease, cancer, diabetes, addiction and contributing factors such as obesity, age, lifestyle and well-being. In the most recent years, there has been a shift from physical disease to the importance of mental health issues. Right before the COVID-19 pandemic the WHO identified depression, suicidal ideation and isolation as some of the most pressing overall health concerns worldwide. However, COVID-19 only helped to exasperate and worsen the levels of every type of mental illness and contributing factors such as addiction, obesity, domestic violence, isolation, stress and economic instability. Although it is not properly documented to this day, it is estimated that the worst levels and highest prevalence of mental illness, (specifically anxiety and depression disorders) exist in low and middle-income countries. These regions also have a paucity of mental health literacy, knowledge, access and availability of treatment [3, 4].

Microfinance initiatives play an important role in empowering impoverished populations and vulnerable or disadvantaged groups such as women in rural areas. Empowerment here refers to in-need populations increasing their authority, status, agency and living standards. Since the 1990s, microfinance has demonstrated an ability to empower at need women to increase their quality of life and overall well-being. In addition to this, microfinance has created the development of micro-entrepreneurship. Micro-entrepreneurship refers to the creation and maintenance of small businesses for the poor to improve their economic circumstances. Micro-entrepreneurship through microfinance can reduce unemployment and its associated social and health problems [5] (The Association des Femmes du Mali pour la Solidarite el le Developpement, personal communication, July 15, 2023; Espoir des Femmes et des Enfants du Mali (EFEM), personal communication, July 15, 2023).

Core components of microfinance include that borrowers are from low-income groups, the loans do not have collateral, they are short in duration and given in small quantities. Microfinance loans are used for income generation and there is a high repayment rate, particularly among female borrowers. The role of women and microfinance in India has been transformational in eradicating poverty over the last 30 years. This is particularly true of women that lived in rural India in relative isolation and who lacked basic services. Microfinance groups help provide support women in these rural areas and empower them to improve their economic status. These groups also help support women in their household decision-making, welfare, improvement of gender-based norms, family’s health, individual health and access to non-formal education. However, in spite of the benefits, there is a major gap in supply and demand of microfinance loans and programs for those most in need [5] (The Association des Femmes du Mali pour la Solidarite el le Developpement, personal communication, July 15, 2023; Espoir des Femmes et des Enfants du Mali (EFEM), personal communication, July 15, 2023).

Micro loans of only $50–100 to those living on less than $2 a day, have been found to be an effective poverty reduction tool. Microfinance here refers to micro-credit, micro-savings, micro-insurance, and other approaches that empower entrepreneurs to create businesses and improve financial stability. Micro-credit and micro-savings generally have a positive impact on the health of the poor. This is in relation to the number of days of sickness, nutrition, physical well-being and greater investment in health care and health insurance. Microfinance and micro-savings also generally have positive impacts on food security and nutrition, as well as positive effects on housing, women’s empowerment and mental health (The Association des Femmes du Mali pour la Solidarite el le Developpement, personal communication, July 15, 2023; Espoir des Femmes et des Enfants du Mali (EFEM), personal communication, July 15, 2023) [6].

3. Traumatized populations, microfinance and psychoeducation

Microfinance and psychoeducation are powerful, effective interventions that can be applied to uplift and improve the health of many disadvantaged, traumatized groups. Microfinance here referring to small, micro loans with low-income, at-need populations intended to help improve entrepreneurship and economic empowerment capabilities. Psychoeducation here referring to education on mental health concerns for the self and others. Psychoeducation can provide awareness, self-help and group support. The lowest-income populations have higher rates of depression and trauma and need additional support aside from economic empowerment to improve their health, overall circumstances and well-being [7, 8, 9]. Trauma here refers to exposure to a traumatic or triggering event. This may be exposure to an actual or threatened death, serious injury, abuse, violence, or sexual violence. Trauma refers to events that cause threats to one’s survival or physical existence. It can refer to not only trauma from events that have occurred to individuals, but also to traumatic events such as violence or death to others of familial connection. Traumatic events are different from other stressful life events that create an emotional response. Stressful events do not contain a threat of injury, sexual violation or possible death [10].

Low-income populations are in general, more likely to experience trauma and Post-Traumatic Stress Syndrome (PTSD). They are also more likely to need microfinance intervention help and support. Many of these populations are living with undiagnosed and untreated PTSD, and often experience discrimination, poverty, and handicaps such as chronic mental or physical illness. Individuals with severe mental illness almost universally have trauma exposure to one or multiple traumas. This trauma and trauma treatment is greatly underdiagnosed and untreated worldwide. Individuals exposed to trauma, often struggle with other issues such as poverty, depression, chronic medical conditions and substance use disorders. These populations are globally underserved and less likely to seek assistance after a traumatic event. Mindfulness, Cognitive Behavior Therapy, mental health first aid, psychoeducation with cognitive restructuring, and exposure therapy are useful interventions for trauma [11].

Trauma psychoeducation is an increasingly popular intervention. However, it is important that it is provided in a human-centered, relationship-focused, culturally-sensitive way that emphasizes compassion, resiliency and strength-building. Psychoeducation on trauma can help someone understand how the trauma they experienced may impact their functioning and how they can manage those negative impacts. This psychoeducation can be used before or after exposure to a traumatic event. Important goals of trauma-focused psychoeducation include an increased understanding of common trauma reactions; building knowledge and skills to help normalize those reactions; and learning healthy mechanisms to reduce those reactions. There is very little research done on the impact of psychoeducation after a traumatic event. Psychoeducation on trauma is much more effective when resilience and recovery is emphasized, not only painful trauma symptoms. This education should help participants not view themselves as broken, or damaged, but to understand their trauma experience is connected to their trauma reactions [10].

Psychoeducation regarding trauma and mental health is more effective when focused on resilience, adaptation, self-care and self-compassion. Another important aspect of psychoeducation is building and maintaining supportive and trusting relationships. Individuals that have experienced threats, sexual assault, neglect and other types of abuse, have great difficulty forming supportive relationships. Positive, supportive, interpersonal relationships can help lessen the effect of stressors, difficult reactions and trauma responses. They can also provide a sense of connection and safety. Another important component of trauma psychoeducation is that it is more impactful when provided soon after the traumatic experience occurs; is provided repeatedly due to the time it may take to process what is being learned; provided in a culturally-sensitive and human-centered way, and to dispel common misunderstandings regarding trauma. Psychoeducation can also integrate practical tools like mindfulness, relaxation training, yoga, emotional support animals, music therapy and other forms of support [10].

4. The value of combined microfinance and psychoeducation interventions

Microfinance and health education programs are more effective than only microfinance or health education alone. This is particularly true if the intervention is longer in duration. Integrated approaches that combine multiple interventions into one, are necessary for achieving Sustainable Development Goals and for income and health equity. Progress was made towards the Millennium Development Goals from 2000 to 2015; however, more than one billion people continue to experience extreme poverty worldwide. In addition to this, the statistics on poverty do not clearly show the variation and inequality within country populations. In general, there is a heavier poverty burden on women, rural populations, and indigenous groups. These groups also have reduced access to income-generating activities and health care services. Microfinance is special in that it is a set of generally-defined financial services to help poor families, and in particular women, improve their economic status, livelihoods and financial security. It can be delivered through microfinance institutions, self-help groups, cooperatives, village banks or savings groups and is adaptable to most circumstances of the poorest [12] (The Association des Femmes du Mali pour la Solidarite el le Developpement, personal communication, July 15, 2023; Espoir des Femmes et des Enfants du Mali (EFEM), personal communication, July 15, 2023).

Structures that provide supportive groups such as self-help groups, microfinance institutions and savings groups, provide an opportunity for financial inclusion. These educational support groups provide opportunities such as health education, psychoeducation, financial or literacy support, and other types of support. These groups also provide platforms for psychoeducation and life-skill support. With these groups, women can also be informally educated, learn positive practices and health behaviors. The group support provides an essential layer of empowerment and an opportunity to increase the level of success beyond just the microfinance loans alone [12] (The Association des Femmes du Mali pour la Solidarite el le Developpement, personal communication, July 15, 2023; Espoir des Femmes et des Enfants du Mali (EFEM), personal communication, July 15, 2023).

Depression is one of the greatest health issues worldwide, and a significant part of depression is not only mindset and belief systems, but also a sense of lack of hope and future possibilities; also, not having power or control over your life and feelings of helplessness. Microfinance groups that support women can help improve depression by alleviating hopelessness and increasing levels of empowerment and support. Micro-finance and self-help groups provide reliable, low-cost and sustainable ways to support impoverished mothers and children. The health benefits of the microfinance groups include neonatal and material mortality reduction, improved child feeding, reduced child malnutrition, reduced child illness, reduced sexually transmitted disease, reduced gender-based violence and improved familial mental health [12] (The Association des Femmes du Mali pour la Solidarite el le Developpement, personal communication, July 15, 2023; Espoir des Femmes et des Enfants du Mali (EFEM), personal communication, July 15, 2023).

Our social, physical and economic environments that individuals live directly impact their level of mental well-being and inform the creation of mental illness. When individuals live in or grow up in poverty they are at much higher risk for mental illness. The World Health Organization (WHO) has been increasing highlighting the importance and interconnection between social determinants of health and global health security. Social determinant interventions make a major positive impact on mental health, physical health and suicide outcomes. Certain groups such as impoverished children, adolescents, women and elderly are at higher risk of mental illness due to poverty [13].

5. Successful global health security approaches

5.1 Inclusion of mental health in microfinance groups

Mental health is currently seen as one of the most important global health and international development issues. It has recently been included in the United Nations Sustainable Development Goals (SDGs) through the identification of how greatly mental illness contributes to the overall disease burden. The Movement for Global Mental Health is a network that has grown from the identification of mental health as being one of the most important issues of our time by the United Nations and the World Health Organization. Mental health and economic development became more highlighted on the global health agenda through the WHO in 2010 with the ‘Mental Health and Poverty Project.’ This report highlights the association between mental health as a significant health factor and its connection to poverty. Implementing psychoeducation and poverty reduction in a joint venture is addressed as an effective global health security intervention. However, before this report, the first Global Burden of Disease (GBD) studies were provided by the World Bank and the World Health Organization in 1991 and provided the initial foundation to assert mental health and poverty reduction initiatives as a WHO critical priority and part of the Sustainable Development Goals (SDGs) [14].

5.2 Inclusion of health education in microfinance groups

A majority of microfinance initiatives function through cooperative group dynamics that expand health and social well-being through accompanying health education. The phenomenon of combined microfinance and health education initiatives, have been poorly investigated. However, effective interventions that combine public health needs and economic empowerment are essential for progress and development. Microfinance impacts at least 200 million households worldwide through more than 3000 microfinance initiatives. It is a wide-spread mechanism to support the poorest populations with not only micro-loans but also fundamental health and social service needs. This is done through health education, health care, basic education, insurance and other significant concerns. Micro-finance interventions are uniquely suited to addressing complicated social and health issues among the poorest populations because of their already existing wide-spread, global reach. The addition of services into microfinance initiatives also makes them more effective as mechanisms to sustainably lift impoverished families out of poverty and to greater levels of health [15].

Although research is limited on microfinance initiatives that incorporate psychoeducation programs, case studies exist that demonstrate the effectiveness of health education with microfinance. In Mongolia for example, an HIV and sexual risk reduction curriculum combined with a savings-led microfinance program, proved effective in improving participant outcomes. This program was provided for sex workers, and demonstrated consistent positive effects. An intervention in Egypt improved working conditions of children through microfinance loans that provided training on workplace safety for children. In South Africa, a microfinance program implemented a participatory learning and action curriculum called Sisters-For-Life (SFL). The aim was to reduce the level of intimate partner violence and rape. This intervention resulted in reductions in intimate partner violence and sexual violence. An intervention in West Bengal, India with adolescent girls combined a microfinance initiative program with a non-formal education called Learning Games for Girls (LGG). The training provided financial, health and sexual health education to help prevent sexual violence and HIV/AIDS. It also resulted in positive outcomes for participants [15].

Another effective example occurred in Nigeria where a microfinance program integrated education on breastfeeding and maternal health with added songs, drama, and weekly text and voice messages through mobile phones. This intervention found improved maternal and child health outcomes. In Ghana, malaria education was integrated into microfinance initiatives with greater overall results [15]. A qualitative investigation of an agriculture and finance intervention in Kenya found that participants experienced significant improvements in farming practices, food security and nutrition, and protection from unplanned economic and weather-related issues. Food-security knowledge, skills and funding helped to improve overall outcomes [16].

Organizational strategies that combine health education with microfinance initiatives are more successful in improving health behaviors and their associated outcomes. Providing health education during microfinance loan meetings is the most used approach and requires the least number of resources. It is a low-cost, high-impact, sustainable approach to delivering health education. Systems that provide health education or microfinance as only stand-alone interventions are insufficient to address these borrower’s needs. However, when these two aspects are combined into one integrated approach, it consistently leads to positive health and social outcomes for poor, at-need communities [15] (The Association des Femmes du Mali pour la Solidarite el le Developpement, personal communication, July 15, 2023; Espoir des Femmes et des Enfants du Mali (EFEM), personal communication, July 15, 2023).

5.3 Inclusion of female borrowers in microfinance groups

Fadikpe et al. [17] examined 735 cases across 105 Microfinance Institutions among 26 countries in Sub-Saharan Africa from 2011 to 2017. This assessment was critical for understanding sustainability and longevity of microfinance programs. This evaluation found that the greater the number of borrowers, the better the financial return. In addition to this, an important component of repayment and sustainability was having a higher number of female borrowers enrolled in the microfinance programs than male borrowers. Female borrowers are essential for the sustainability of microfinance institutions as the female borrowers are much more likely than their male counterparts to repay these loans. The results of this continent-wide study propose that microfinance institutions intentionally increase the number of female borrowers enrolled in these initiatives. In addition to this, governments should increase support to microfinance institutions operating in at-need, impoverished regions. Thirdly, microfinance institutions should be specially trained to work with and support low-income, high need populations (The Association des Femmes du Mali pour la Solidarite el le Developpement, personal communication, July 15, 2023; Espoir des Femmes et des Enfants du Mali (EFEM), personal communication, July 15, 2023) [17].

6. Challenges in implementing sustainable, micro-finance programs for at-need groups

There are other specific challenges and vulnerabilities faced by different groups that receive microfinance loans in different environments throughout the world. These groups include refugees, survivors of violence, individuals living in poverty, minority groups, and particularly women in disempowered circumstances. A significant goal of these programs is to help support women in particular as they experience greater discrimination and poverty due to gender prejudices. The Mudra Yojana is a government-backed microcredit initiative that helps support female entrepreneurs begin a business or expand an existing one with lower interest loans. A study based on 417 female beneficiaries from West Bengal, India assessed the impact of these loans alone on the well-being of these women. This program targeted low-income women that were motivated to create a business or expand a current small business. The results of this quantitative study found that this program encouraged and supported female entrepreneurship, and increased their income, job skills and ability to obtain employment. In addition to this, the women in the study experienced increased financial, social, political and psychological empowerment. These women became active change-makers for themselves, their culture and family. Assisting women with these low-interest, no collateral loans had a multiplying impact that uplifted society [18].

Although there are major positives to targeting low-income, at-need female borrowers, there are also be challenges in this approach. Specifically, successful business endeavors by impoverished, uneducated women (especially those with children) can upset cultural and societal norms. This is due to the increased levels of female empowerment, power, decision-making control and buying power women can gain due to their business success. These positive changes for women can trigger domestic violence dynamics among male family members that feel threatened and disempowered by the female borrower’s success. As a result, the female borrowers may experience increased levels of physical, sexual, verbal, emotional or financial abuse from these male family members or male community members. The profits from the female borrowers, or their financial gains to be used for loan repayment, can also be confiscated by male family members due to their perceived loss of power. Another aspect that is problematic in the sustainability and longevity of these microfinance initiatives is political instability, crime, violence, and larger economic problems that disrupt local systems. Some regions have focused on helping support female borrowers with savings groups that have their own bank account which is not accessible by non-group members. These savings groups are meant to help female borrowers manage both wider societal and also destructive, familial destructive dynamics (The Association des Femmes du Mali pour la Solidarite el le Developpement, personal communication, July 15, 2023; Espoir des Femmes et des Enfants du Mali (EFEM), personal communication, July 15, 2023).

7. Important elements of psychoeducation and microfinance for at-need populations and groups

There are helpful tools to implement in psychoeducation for individuals involved in microfinance intervention programs. Some of the psychoeducation that is relevant to integrate with microfinance includes understanding how stress and trauma impacts our mind’s ability to function well. It also includes information on abuse, relationships and roles we may be engaging in that we are unaware of. The use of microfinance can interrupt these cycles and shift roles you may not know you are participating in, or to become aware of unhealthy, disempowering roles and dynamics you have been involved in. Additional relevant aspects to incorporate into psychoeducation for vulnerable populations include self-care and grounding exercises for support; education on understanding your window of tolerance for distress and increasing distress tolerance; understanding your triggers and trigger scale; education and understanding of role and re-enactments you may be involved in; and healthy versus unhealthy relationships [19].

Self-care for psychoeducation refers to conducting and participating in activities, mechanisms and strategies that help maintain, repair and develop individual health and well-being. Self-care helps individuals increase awareness of their needs and internal experience of stress and difficulty. Mindful awareness of internal states helps decrease distress, improve emotional regulation, stabilize and reduce trauma symptoms, and improve one’s experience of safety, security, competence and well-being. Trauma often occurs because the perpetrator’s desires came at the cost of another. Self-care helps with managing stressors, triggers, and emotional regulation so we can function at a higher level. Daily self-care is essential for improving well-being in vulnerable populations. Simple self-care activities such as practiced breathing, journaling, mindfulness practices, self-compassion reflection, exercise, time with friends, taking a walk, time in nature, mindful gentle yoga can all be supportive [19].

Other aspects to incorporate into psychoeducation for microfinance participants include education on what is termed the window of tolerance. The window of tolerance refers to the level of arousal or stimulation an individual can manage for daily stress and challenge. When one experiences trauma, the window of tolerance to stressors diminishes and it becomes much more difficult to manage stressors and everyday needs. Self-care practices can help improve the window of tolerance so that individuals with trauma can handle a greater number of stressors. Self-care is also supportive for managing chronic states of hyperarousal and hypo-arousal. Past trauma tends to easily activate the fight, flight or freeze response, therefore methods to manage these responses are important [19].

Psychoeducation on the existence of the window of tolerance, as well as ways to expand the window of tolerance is supportive as a tool in psychoeducation in conjunction with microfinance interventions. Another important aspect of psychoeducation is discussing the trigger scale. Trigger refers to internal or external phenomenon that remind the individual of their trauma and bring their trauma feelings forward. It is something that occurs in the present and brings up the fight/flight/freeze/or collapse survival response. The trigger scale assists individuals in slowing down, noticing and acknowledging their response to triggers. By mindfully noticing reactions, it creates a space to reduce activation and improve the sense of empowerment and choice regarding reactivity. Other psychoeducational points regarding the Trigger Scale are to ask clients if any symbols, images, ideas or words are associated with the trigger. Also, to ask individuals on a scale of “0” to “10” (with “0” being a state of calm), how triggered they are feeling in relation to certain issues [19].

In the case of microfinance initiatives, it is relevant to have psychoeducation on possible triggers while engaging in selling products or repaying loans. Additional psychoeducation interventions include mindfulness practices to help individuals see they are safe in the here and now and skills to help them notice the present and being calm in their bodies in the moment. Also, exercises to help someone identify that they are in the “there and then,” meaning back when they experienced the trauma. What thoughts, emotions, bodily sensations help to distinguish the present versus the trauma state? Are there any particular triggers that activate past traumas and bring the experience of distress into the present? [19].

Additional psychoeducational tools are educating individuals on aspects of the brain so they can better understand what they are experiencing in relation to their trauma. Specifically, the understanding that the brain has been hardwired for survival and to keep us alive. This can be useful for understanding and having compassion for survival reactions to past trauma and decrease self-blame and shame. In addition to this, the brain inherently has a negativity bias. This is also tied to survival so that we are aware of potential threats that could hurt us. However, it also means that negative experiences, negative beliefs and negative thoughts may seem more important than positive. Thirdly, the brain is flexible and plastic and can change continuously and heal itself throughout one’s lifetime. It is not only during childhood that the brain can be flexible and heal. Through the implementation of continual, conscious, mindful practices, the creation of new neural pathways can be created over time. Also, over time, integrating self-care, and soothing and calming mechanisms can aid in new, positive, neural pathway creation [19].

Other helpful psychoeducational interventions include understanding roles you and others may play such as perpetrator, rescuer, victim, neglectful bystander and what the patterns are in those. Creating your own business and engaging in microfinance interventions changes your normal role and perception of traits. It can be supportive to understand the roles you were formally playing and the roles you would like to play, as well as others in your life. Engaging in these roles is often tiring and unfulfilling as well as repetitive over time, and can interfere with succeeding in new, empowering endeavors. Therefore, education, awareness and consciously creating an authentic life by behaving as who you want to be, is also important in this process of awareness; also, education on self-esteem and boundaries, what they mean, and how trauma and stress can negatively impact both is valuable to include [19].

There is a difference between internally driven self-esteem and externally driven self-esteem. Internally driven self-esteem comes from inside, and from mindful presence of our own self-worth. Externally driven self-esteem comes from outside and is fragile and changing. Vulnerable populations benefit from education on internally driven self-esteem and focusing on how to make this better. Healthy self-esteem is relevant and important for being a successful entrepreneur or business owner, poor self-esteem of participants can negatively impact microfinance efforts and initiatives. Healthy self-esteem means having kindness for yourself in spite of imperfections, believing you are enough and valuable regardless of outside events. Healthy boundaries mean not allowing harmful people or situations into your life that can hurt your self-esteem, but still allowing connection as much as possible [19].

8. Case study of microfinance and psychoeducation intervention among Malian women

According to the World Health Organization (WHO), the population of Mali is over 18 million and at least 15% of the population is living with disability. However, due to the lack of health and economic empowerment data in Mali it is likely this number is much higher. At this time, there are little, if any, government programs to assist individuals with disabilities [20]. Depression is currently the leading cause of disability in the world and the greatest health burden from a collective perspective. Although data is very limited on impoverished, recovering regions like Mali, it is very likely that depression is also a significant concern in Mali along with economic poverty. Therefore, interventions that address both economic empowerment and group and family-based psychoeducation for trauma and depression are worthwhile and important to explore [20, 21, 22].

There are very limited interventions for improving child mental health and mental health in francophone West Africa and areas such as Mali. Interventions that only address behavior and mental health alone are insufficient for families living in absolute poverty and low-income regions. A randomized cluster study of children ages 10–15 years from 12 villages in francophone Africa (N = 360), found that psychosocial intervention that included all family members along with economic empowerment strategies was an innovative, effective approach for improving well-being of families living in extreme poverty. Close to 90% of the world’s children are in low and middle-income countries and the disease burden and disability from mental illness is growing in these regions. The 2030 U.N. Sustainable Development Goals included mental health and well-being as a priority concern. Global mental health prevention and poverty are of key global health concern, as well as finding effective interventions to address this. Training on livelihoods, 1–1 mentoring, family coaching that targeted all family members and seed grants were provided to help assist families with both psychoeducation and economic empowerment. These interventions found reductions in symptoms of depression, improved self-esteem and decreased symptoms of trauma. Interventions that conducted only economic empowerment or only psychoeducational initiatives alone, were not as effective in improving mental health and economic outcomes. The combination of the two together through family-based behavioral interventions is a potentially effective, innovative approach to prevent and address mental health concerns in low-income and poverty-stricken situations [20, 21, 22].

A case study of an early intervention in central Mali in the Bandiagara region also demonstrates early signs that the combination of psychoeducational group support with microfinance efforts for women living in absolute poverty, can be effective even after violence, trauma and worsening poverty has occurred (Association des Femmes du Mali pour la Solidarite el le Developpement, personal communication, June 16, 2023; Happiness Learned LLC, personal communication, June 16, 2023). On January 18th, 2012, the National Movement for the Liberation of Azawad (MNLA) attacked a small city in Northern Mali and many Malian soldiers at a Mali military camp died, the surviving soldiers were then executed. This began a civil war within Mali that went on for many years afterward and destroyed countless poverty and health intervention efforts that had been conducted previously [21]. However, a group of 43 extremely impoverished women were enrolled in the beginning of April 2023 into a program with combined microfinance and group psychoeducational support. These 43 women all survived by going to the garbage dump and landfill every day to find items within the trash to survive from or hopefully sell. They frequented Le Depot de Lafiabougou and Le Depot D’Ordures de Lafiabougou on a regular basis and survived in abject poverty (Association des Femmes du Mali pour la Solidarite el le Developpement, personal communication, June 16, 2023; Happiness Learned LLC, personal communication, June 16, 2023; Espoir des Femmes et des Enfants du Mali (EFEM), personal communication, July 15, 2023).

However, since the beginning of April, these women each received $100 in micro-loans, group support and psychoeducation on self-esteem, healthy relationships, abuse and strength-building exercises. As of mid-June 2023, all of these women no longer visit the landfill or garbage dump at all. All of these women are also highly engaged and active in the development of their new businesses. They have found psychoeducation to be extremely supportive and helpful in empowering and motivating them to continue the work they are doing. In only 2 months, all the participants express lower levels of depression and trauma symptoms and higher levels of hope, well-being and empowerment since before they received the microfinance and psychoeducational support (Association des Femmes du Mali pour la Solidarite el le Developpement, personal communication, June 16, 2023; Happiness Learned LLC, personal communication, June 16, 2023; Espoir des Femmes et des Enfants du Mali (EFEM), personal communication, July 15, 2023).

Since June 15th, of 2023, a second initiative in the Mopti/Bandiagara area of Mali has begun to assist an additional 75 women with micro-loans. All 75 women are highly motivated, and already have their own individual, small businesses. Through micro-loans of $50 each, group support, and psychoeducation, they are working to increase the viability of their businesses and expand their profit-making margins. This newest initiative is meant to empower and uplift not only themselves but their families, other women and their community. These two projects will continue to grow and be expanded on to include other regions and groups of women that could benefit in the area. The goal is to eventually include at-need women throughout all of Mali by mid-2024 (Association des Femmes du Mali pour la Solidarite el le Developpement, personal communication, June 16, 2023; Happiness Learned LLC, personal communication, June 16, 2023; Espoir des Femmes et des Enfants du Mali (EFEM), personal communication, July 15, 2023).

9. Conclusion

This chapter provides an overview of the relevance of microfinance initiatives for low-income, at-need populations. It also highlights the significant intersection of addressing both the mental health sector and economic empowerment sector synchronously for well-being improvement and development. Mental health or economic empowerment as stand-alone initiatives are not as impactful in helping these populations experience improved outcomes. Depression and trauma are significant worldwide problems, and those living in absolute poverty are at high risk of both. In addition, due to the mental health factors, economic empowerment alone is insufficient to adequately the needs of these populations. Interventions that incorporate multiple initiatives simultaneously are needed in the future to help uplift and improve the health and well-being of the world’s most vulnerable.

Acknowledgments

I would like to acknowledge The Association des Femmes du Mali pour la Solidarite el le Developpement (AFMSD), Espoir des Femmes et des Enfants du Mali (EFEM) and Happiness Learned, LLC for their invaluable contributions to this chapter.

Conflict of interest

“The authors declare no conflict of interest.”

Thanks

Thank you to both Happiness Learned, LLC, Espoir des Femmes et des Enfants du Mali (EFEM) and The Association des Femmes du Mali pour la Solidarite et le Developpement for your invaluable contributions to this chapter.