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Youth Ambassadors for Disaster Preparedness: Using Psychological First Aid in Times of Crisis

Introduction. COVID-19 has been declared as a pandemic by the World Health Organization. This global disaster has impacted people in various ways, such as the practice of physical distancing and the large-scale social restriction program implemented by the government. This situation of crisis also leads to mental health problems for those who are facing it. Method. We initiated a program with the goal of creating youth ambassadors for disaster preparedness, focusing on the mental health aspect of facing disasters. Nineteen undergraduate students with a psychology background were selected and given proper training on psychological first aid (PFA), which aims to help those affected by this disaster by fostering short and long-term adaptive functioning. Result. The youth ambassador team carried out multiple programs, such as psycho-education webinars held online multiple times. They also gave help to Indonesian students currently studying abroad in Italy in the form of interactive sessions. Discussion. The program gives promising results, with the training enabling the students to function as youth ambassadors and spokesperson on mental health during this disaster, gives them the tools they need to help others in the form of PFA. The training module could be implemented further to create more ambassadors working for this cause.


Introduction
The World Health Organization (WHO) has declared coronavirus disease 2019 (COVID-19) as a global pandemic since March 2020 [10] According to WHO as of 15 June 2020, there were 7,805,148 cases of COVID-19 with more than 431,192 deaths in many countries, including Indonesia [11] By 15 June 2020, there have been 39,294 confirmed COVID-19 cases in Indonesia and 2,198 deaths related to the disease [3]. In response to this disaster, Indonesia's president decided to implement a large-scale social restriction program (Pembatasan Sosial Berskala Besar) in cities and provinces [8]. The government also emphasises the need to stay at home for all Indonesian citizens and practice of physical distancing. The implementation of mass quarantine indicates that the situation has become severe and it needs a bigger effort to reduce the number of people infected with COVID- 19.
Mass quarantine or self-quarantine are making huge changes to the daily routines. People need to work from home, school from home, temporarily unemployed, and lack of physical contact with others. Adapting to these new lifestyles requires a big effort. Also, people need to manage the fear of contracting the virus and worrying about people close to us are challenging [5]. This response to the crisis could threaten mental health.
The threats to mental health issues are corresponding with the current situation. This crisis created confusion, anxiety, stress, and frustration. Most people are worried about getting sick or contracting COVID-19 [4]. On the other hand, they are also concerned about financial problems, jobs, the future, and conditions after pandemic [3]. This stressed and anxious feeling could lead to serious mental health problems. Especially for those who have a history of mental health problems or similar events. There even a suicidal case related to stress of the work terminations as consequences of pandemic [2].
In summary, the COVID-19 affected not only physical but mental health [15]. Several mental health issues related to pandemic including distress reactions (insomnia, anger, extreme fear of illness even in those not exposed), health risk behaviours (increased use of alcohol and tobacco, social isolation), mental health disorders (post-traumatic stress disorder, anxiety disorders, depression, somatization), and lowered perceived health [17]. Therefore, recent Lancet Psychiatry paper [16] calls for urgent advancement of mental health care due to coronavirus pandemic, including crucial and pressing goals of mental health assessment, support, treatment, and services. It is essential to provide support to those who are in need of care. In critical incidents and disasters such as pandemic COVID-19, there is a need to provide psychological support. One of the early psychological supports is called Psychological First Aid (PFA).
Psychological First Aid (PFA) can be used to provide psychological support ranging from minor stressor in daily life to traumatic events such as disaster [13]. It is an emerging crisis intervention of choice in the wake of critical incidents such as mass disaster [18]. It could decrease distress and negative health behaviour [19]. According to WHO [7] Psychological First Aid are supportive and practical assistance to fellow human beings who recently suffered exposure to serious stressor, and involves : 1) Non-intrusive, practical care and support, 2) Assessing needs and concerns, 3) Helping people to address their basic needs, 3) Listening others without pressuring people to talk, 4) comforting people and helping them to feel calm, 5) Helping people connect to informative, services, and social support, and 6) protecting people from further harm for himself or others. Therefore, PFA could make things get better quickly because it can give a sense of security, connectedness, calming, giving hope, give access to physical, emotional, and social support, and also help others to get back their sense of control.
There are several principles of PFA, consisting of prepare, look, listen, and link [8,6]. In preparation, participants of the PFA need to learn about the crisis event, availability of services and support. Then, they need to look or observe the situation and the people with obvious urgent basic needs and serious distress reactions. In the listen principle, the practitioner needs to make a contact, asking about the victims needs and concerns, also listening and helping people to feel calm. In the end, the practitioner needs to link and accommodate what the victims need. In detail, practitioners should help people to cope with their problems. Help them to prioritize their urgent needs and give practical suggestions. As practitioners, it is important to give accurate information about the disaster to decrease rumours. Last, as a practitioner of PFA, social support is also very important to recovery and make sure people know about how to access the service.
Generally, through training, it will result in greater competence in the performance and to create the change agent [9]. PFA is a basic "grassroots" psychological support provided for anyone in need by members of the general population not by mental health professionals [13]. PFA can be used as clinical intervention and can be done by either clinician or non-clinician [12]. It can be community based to build on the strengths of the community.
We aim to make a youth ambassador because we believe that they are able to receive and do this task properly. Adolescents cognitively have the ability to consider abstract ideas, the future, and various possibilities [14]. They are also able to debate various issues from a number of different perspectives and see how the issues are related to a larger set of social relationships. Therefore, they could receive and practice the content in the training. Emerging adulthood is an individual with age 18-25 years old. In this phase, individuals continue to explore their identities in many areas of life [14]. Emerging adulthood are marked by identity exploration, instability, focus on self, feeling in-between childhood and adulthood, and a focus on possibilities [20]. Therefore, this is the right time for us to form individuals with positive identity. Based on Erikson [21] psychosocial development, the psychosocial modality of emerging adulthood is to be oneself or not to be oneself. They are having a role confusion [21] Youths seek their true selves through their peer groups, clubs, religion, political movements, etc. These groups could provide opportunities for adolescents to try out new roles much in the way and someone might try on until finding a role that fits them. Based on the theory, we can conclude making the PFA community could help the youth to seek their own self or identity. By creating this community, adolescents could learn and internalize the skill and the culture in their identity This PFA training programme can be a tool to help young people strengthen themself and the community around them. It equipped the youth with psychological first aid skills and disaster or crisis knowledge. Furthermore, it could provide themself and society around them to prevent more severe mental health problems in the future.

Methods
Several stages were done in implementing this program, which are the preparation phase, implementation phase, and evaluation phase. The preparation phase consisted of content design and training module creation, the candidate recruitment process, and the training process.

Preparation Phase
•

Evaluation
• Training • Implementation The training module was used as a guideline for the training and interaction sessions. It has several contents, which were the impact of crisis, victim needs during and after crisis, priority scale in providing assistance, phases of disaster, psychological first aid principle, and ethical guidelines. These contents were divided into 3 subtopics: "Openness and Rapport Building", "Traumatic Events and its Impacts on Individual and Community", and "Relaxation Technique and Psychological First Aid Principle". Each subtopic was to be carried out in one day of training, with the total training period proceeding for three successive days.
Candidate recruitment for the training program was conducted simultaneously with the module and content design. An open submission electronic poster was created, consisting of the requirements, the date of training, the training fee (Rp. 50.000 for the certificate and food during the session), and the registration link. The call was for active first to third year undergraduates of the Faculty of Psychology from Universitas Indonesia, who were interested in disaster relief efforts and were willing to volunteer for communities in need. Those who were interested to be participants were required to fill out a form. The form consists of personal data (name, years of study, and organizational experience), their knowledge about psychological first aid, and their motivation in attending this training. First stage selections were document screening through the registration form. From 68 people who filled out the registration form, 38 candidates were selected to continue to the final selection stage, which was an interview. The interview was conducted for 3 days with 15 minutes for every session. Every session consisted of 2 interviewers and 1 interviewee. Based on the interview results, 19 participants were selected to take part in the training session. The selected participants then were required to attend the psychological first aid training. This training was conducted by four facilitators, which are all psychologists who are well versed in psychological first aid knowledge, and has numerous experiences giving aid in several disaster cases, such as Ambon, Seram, Lombok, and Karawang since 2010. The training was carried out for three days in late January 2020 for seven hours each day. The first day consisted of an introduction, sharing from one of the PFA practitioners, and making a river of life. Introduction started with an ice breaking and introduced names for each participant. Furthermore, the training continues with a sharing session from a PFA practitioner experienced in many disaster areas in Indonesia such as Lombok, Aceh, etc. This sharing session is held interactively with many of the question and answer activities. Subsequently, the first day training is closed with making a river of life within small groups settings. River of life is a visual method to help individuals describe an experience in the past, present, and the future through drawing. It helped the participants to valued themself for the whole things they have survived. After making the river of life, the participants will explain their visualisation in rotation. These activities aimed for participants to feel comforted, listened to, and given attention. Corresponding participants learned to be good listeners, give comfort to others, and give attention to others.
On the second day, the facilitators give a content of individual differences in response to crisis situations and the victim's needs in crisis situations. These contents are provided in a small group discussion. In groups, participants asked to write down the impacts and the needs in traumatic events. Impacts should consist of social, physical, and psychological impacts both for individual and community. Discussion result then presents and responds in the bigger groups.
On the third day, the facilitators provide relaxation techniques and PFA principles. People in crisis situations sometimes need the relaxation techniques to calm them. There are 2 techniques called square breathing and imaginary safe place. Participants practice in twos for 90 minutes. Moreover, facilitators continues the training with PFA principles, theory, and ethical guidelines. Finally, the facilitators wraps up the training with sharing. Participants share their experiences and insights during the whole training. Participants also give feedback for the facilitator and the training program in general using mentimeter.com. After going through this training period, the participants were acknowledged as Youth Ambassador for disaster preparedness.
The implementation phase has been carried out in the span of April-May 2020 and is still ongoing. The Youth Ambassador team has carried out multiple programs, such as psycho-education webinars held online, social media content, and online counselling. Periodic evaluations for each of these programs were also conducted to maintain the quality and improve upon the existing program. Since the formation of the Youth Ambassadors team in January 2020, they have shown a mastery over several contents, such as stress and coping strategy, physical and mental health, several relaxation techniques, and control in crisis situations. They also have an excellent interdependence, interaction, and bonding of each other. During the self-quarantine period of April-May 2020, the team carried out several support group sessions for each other that consisted of 5-7 persons for one group. Each group scheduled their own routine time for the support group activity. These groups aim to give each member emotional support, maintain connectedness to one another, keep in touch, and to stay coordinated in the current situation. These activities also helped the youth ambassador in implementing the contents of previous training within the team before finally creating a support group for other communities. Furthermore, the Youth Ambassador team also carried out multiple programs, such as online psychoeducation webinars, social media content creation, and online counselling through Instagram direct messaging system.  • "Hi, I want to ask about how to handle sadness and loneliness in this pandemic situation?" • "How to cope with overload tasks and managing priority scale?" • "Hi, in this pandemic, my overthinking worsened. What should i do?" • "How to cope with laziness in this pandemic situation?" • "How to gain productivity in this self-quarantine?" • "Hi, I want to ask about how to handle the victims of violence at home who are afraid to speak up and seek help?" • "What if we have difficulties having direct interaction with others?" Testimony about Webinar

Results
• "Thank you so much, this webinar helps me a lot, can i join for the next webinar too?" • "Thank you! I will be waiting for another mental health event from • "Thank you for the information, you are great!" • "Thank you so much! The information really useful, thank you" The youth ambassador team has held a total of 5 webinar sessions entitled "Mental Health 101: How to Manage Ourselves in This Challenging Time" aimed at college students in Indonesia and the public as the target audience. Every session consists of 5 facilitators from the youth ambassador team. These webinars are held for approximately 120 minutes including the interaction session through questions and answers session at the end presentation using google meets. The question and answer session are held in two kinds of options. Participants can immediately write the questions in the chat feature on google meets or participants can write the questions anonymously through the questions box in Instagram story feature. Questions on Instagram will be read anonymously by the facilitator in the webinar. These webinars gained a total number of 100-350 people participants in the room and live streaming with details of 20-60 participants every session.
In addition, starting April 2020, when the COVID-19 are claimed as pandemic by the World Health Organization (WHO), the Youth Ambassador team also intensely makes an infographic about suggestions and advice from WHO. They translated the information into Indonesian and informal wording for easier comprehension and uploaded the infographic through Instagram of Research of Community Mental Health Initiative (@rocmhi.id), official Instagram both of University of Indonesia (@univ_indonesia) and Faculty of Psychology University of Indonesia (@rocmhi.id). Furthermore, the youth ambassador team also released a podcast. This podcast was a collaboration project with Indonesian Student Association in Milan (PPI Milan). One member of the Youth Ambassador became the interviewees on "NGASO (Ngobrol Sore-sore)" podcast channel by PPI Milan. The content of the podcast is corresponding with the content of psychological first aid in times of crisis pandemic COVID-19. Furthermore, the youth ambassador team also makes a sort of publication containing a summary of frequently asked questions in the webinar through Instagram Research of Community Mental Health Initiative (@rocmhi.id). This compendium is intended for those who have similar questions could refer to this summary.
Furthermore, the Youth Ambassador team also provides online counselling through direct messages Instagram features. In the direct message feature through instagram Research of Community Mental Health Initiative (@rocmhi.id), there were several Instagram users especially high school who asked and consulted related to their problems during this pandemic. There are 6 people contacting us through direct messages for online counselling. Most of the participants are middle and high school students. The topic of their problems is also diverse. Starting from career counselling, overthinking, depression, toxic relationships, and the victim of an unsupportive family and bully. Most of them feel helped by the online counselling because they can gain information or options about how to handle and overcome their problems.
Moreover, all of these are the result of the training module and implementation. Most of the content of the training are beneficial to perform these multiple programs. The youth ambassador mainly said they are helped by the practical practice and role play in the training session. It helped them to understand the material better. Furthermore, they also learned that psychological first aid can be implemented in any conditions not only disaster but also on a daily basis, whether for ourselves or for others. The material about individual differences, active listening, coordination, and preparedness are the most beneficial component in helping the youth ambassador to implement these multiple programs. Hence, it changes their mindset in responding to people and a situation particularly in crisis situations such as pandemic COVID-19.

Discussion
Youth ambassador team program has been done in April to May 2020, and from the result we can conclude a good Youth Ambassador team is formed and performs quite well. It is shown as the students being a speaker on multiple mental health webinars. On the other hands there is a high level of enthusiasm from the webinar's participants. It is shown from the minimum of 20 persons participating in the webinar. There is also a high number of questions. Furthermore, there are 6 persons who consult about their problem through direct messages and there always consist of 5-15 questions every webinar. These achievements surely indicate the quality of the psychological first aid training and the module. Through the training, there are several skills gained by the youth ambassador team, such as active listening, accessing needs of others, relaxation technique, and giving social support that helped them to perform better as Mental Health Youth Ambassador in times of pandemic COVID-19.
The difficulties we met when we were trying to implement the plan were mostly the use of online methods. Firstly, the internet network of the students. Unfortunately, several students of youth ambassadors did not have enough resources to have a stable internet network in their place. The unstable internet networks mostly impact on the webinar activities. Secondly, the youth ambassador cannot see the non-verbal feedback from the webinar's participants. The limitation of reading the non-verbal feedback led to the confusion of appropriately responding and it is hard to adjust the audience needs.
We believe that this program has a good prospect in the future if we develop more activities, give another training for other communities in the future, and furthermore establish another youth ambassador. This program could develop the skill through the content psychological first aid and disaster preparedness training. Moreover, by gaining the skill, the youth ambassador could contribute more for other target audiences.
This positive program could develop the knowledgeable and capable youth ambassador to provide accurate and right information about disaster preparedness and mental health. They give contribution for them in need, so this program needed to be continued and maintained.