1. Introduction

An individual’s health has two components: 1) physical health, and 2) mental health; it has even been said that there is no physical health without mental health, which includes a person's bio psychosocial well-being, and affects thoughts, feelings and behavior when facing different life scenarios; taking care of mental health can preserve a person's ability to enjoy life, and this involves striking a balance between life activities, responsibilities and efforts to achieve psychological resilience. Conditions such as stress, depression, and anxiety, post-traumatic stress disorder can affect mental health and disrupt a person's routine (Chávez Baray & Escalante, 2021). According to the WHO in countries like Mexico, 76% to 85% of people with mental disorders do not receive treatment (Mental disorders, 2022).

Health inequities are mostly experienced by racialized ethnic underserved populations; race refers to the grouping that others assign to persons on the based physical characteristics, and the generalizations and stereotypes made as a result; ethnicity refers to people who share one or more characteristics, such as country of origin, language, religious/spiritual orientation, and/or cultural identity, disparities within mental health indicates that racial/ethnic minorities have less access to mental health services (Maura, 2017). Several factors contribute to the persistence of mental health inequalities, like distribution of and access to mental health providers, logistic factors, transportation, and stigma (Ramos, 2022).

Stigma is a complex process drove by psycho-sociological factors, including individual differences, community factors, cultural structures (DeLuca et al., 2022). In addition as a social process in which a person or group’s attribute, condition or status is identified as different, less desirable or dangerous (Douglass et al., 2022), and when is related to mental disorders is a barrier to quality mental healthcare (Gurung et al., 2022). If public stigma becomes internalized, it results in self-stigma (Shah et al., 2022) stigma as personally experienced can have a profound impact for a person with mental illness, who often do not seek professional help for several reasons: economic limitations, inadequate knowledge of support services, and fear of being stigmatized (Yu et al., 2022). Collaborative empiricism, cognitive restructuring, and behavioral interventions are distinguished as being useful in a contemporary multicultural approach for the anxiety, depression, stress, and other sequelae from marginalization due to a stigmatized identity (Hope, 2022).

2. Mental Health and COVID-19

The pandemic of COVID-19, is creating a mental health pandemic derived from the following factors: 1. Emotional: a) the increase of complicated mourning, due to the difficulty of performing a funeral ritual according to the culture and/or religion. Complicated mourning is the prolongation of the normal mourning process, the stages of this are stagnated, increasing the sense of loss and pain; also, the lack of emotional regulation leads to maladaptive behaviors such as prolongation of pain / discomfort, presence of clinical pictures such as depression, panic disorder and even psychotic outbreaks (Larrotta-Castillo et al., 2020). b) More than half of the health personnel who provide their services to COVID-19 patients develop post-traumatic stress (Martín-Aragón-Gelabert, 2020). c) The confinement and recovery from COVID 19 disease due to the traumatic experience of living a hospitalization generate post-traumatic stress in the population (Carrara, 2020). d) Loss of work or economic resources due to isolation measures; e) loss of social and family network due to isolation and fear of contagion; losses that are not processed can initiate depression or chronic stress in the individual; f) uncertainty of well-being and lack of control can generate anxiety and depression. In addition, 2. Physical factors: a) low oxygenation; b) clots that can generate cerebral infarcts; c) imbalances in minerals and chemicals derived from a long treatment (Joaquim et al., 2021; Robinson et al., 2020; Pfefferbaum, 2020; Bourmistrova et al., 2022; Xie et al., 2022).

Therefore, it is of utmost importance to reinforce knowledge and train in new prevention techniques, psychotherapeutic intervention, psychosocial intervention and neuronal rehabilitation, activation of brain plasticity to mitigate the impacts derived from COVID-19, as well as to raise awareness among the general population and generate policy changes (Chávez Baray & Escalante, 2021; Gruber, at al.,2021).

Addressing disparities is important from both a social justice standpoint and for improving overall population health. Many healthcare providers, public agencies, and service- and community-based organizations across sectors are committed to helping communities reduce health disparities that stem from widespread inequality (Gertel-Rosenberg et al., 2022). Individuals who require mental health treatment are not receiving appropriate services due to a variety of barriers, such as utilizing primary care providers to detect or provide care for mental health disorders; minimum or lack of training and supervision; community/lay health workers administrating psychotherapy for common mental disorders; and employing service users themselves (e.g., as peer support workers) to augment mental health interventions (Le et al., 2022).

3. THE PROGRAM

The Network of Organizations Dedicated to the Prevention and Care of Mental, Neurological, and Substance Abuse Disorders (ROTMENAS) began in 2017; under the coordination of the Mexico - United States Border Health Commission, outreach office in Chihuahua and the funding of Paso del Norte Health Foundation through the Thing Change Initiative. Currently, underway is the "Project to Improve Mental Health Care and Reduce Stigma Associated with Mental Illness in Ciudad Juarez". ROTMENAS has 46 institutions (academic, government, Organizations No Governmental [ONG], public and private sector) that are part of, participate in different activities, and in collaboration have been able to establish Mental Health Indicators in Ciudad Juarez, make changes in the legislation of the State of Chihuahua, initiate and strength the collaboration of different organizations with a single mission and strategic plan.

The vision of ROTMENAS is "To have a consolidated network, with defined strategies and actions, aimed at raising visibility, awareness, and training concerning mental health in the population, having as priorities the reduction of stigma and the improvement of access to mental health services"; and mission is “We are a multidisciplinary group made up of social, academic and governmental organizations, involved in improving mental health in our community, including substance abuse disorders. We do this through prevention and care strategies, with priority given to individuals, families, and vulnerable populations in Ciudad Juárez, with a comprehensive and binational approach” (ROTMENAS, 2022).

ROTMENAS´s objectives are:

1. To increase the technical capacity of health professionals and the awareness and knowledge of the population through education.

2. To reduce the stigma associated with mental illness and substance abuse.

3. To improve access to mental health services.

4. To implement and strengthen consortiums and coalitions with other groups and organizations.

The administrative group of ROTMENAS in Ciudad Juarez consists of a coordinator, 2 advisors, a program manager, a person in charge of media and an accountant; they recruited different entities that are dedicated to providing mental health care in Ciudad Juarez, through a letter of invitation the entities were asked to participate in an project informative meeting and then they were invited to be part of the net.

4. RESULTS

The members of ROTMENAS implemented four work teams (mesas de trabajo) mental health, investigation, public policies, and addictions. Every month, each work team meets between two to three times per month to advance in the proposed work activities that will be carried out throughout the year. The net has worked on several lines of action in the range of five years:

Between December 2016 - November 2017

MhGAP Intervention for mental, neurological and substance use disorders in non-specialist health settings trainings: To strengthen mental health workers technical capacity; increase their knowledge in mental health, the importance of promoting mental health in the community, to inform about different types of care and how to break in stigma. Two trainings were given to 116 mental health workers.

With the collaboration of EMERGENCE Health Network, the mental health authority in El Paso TX, the Mental Health First Aid trainings was provided to three groups of mental health providers, and 60 received the certification. To mitigate stigma and increase professionalization on mental health interventions, 22 organizations became members of ROTMENAS. The First Symposium on Suicide Prevention and Care on the Border was delivered to 260 professionals in mental health. In First Youth Forum on Suicide Prevention in Ciudad Juárez, 525 young people attended. The first Directory on Mental Health Services was developed and distributed in the community, containing the type of services, contact person, address, and phone numbers.

From December 2017 to November 2018

Two MhGAP trainings were imparted to 117 mental health workers.

A Mental Health First Aid training for 44 persons working in the field of mental health was conducted. A Second Symposium on Suicide Prevention and Care on the Border was delivered to 220 professionals in mental health. A presentation on the Trauma and Resilience on the Border Conference in El Paso TX was made. Members of ROTMENAS were invited to a workshop on Behavioral Health in Primary Care at the Texas Tech University at El Paso, Texas; 44 mental health providers from Ciudad Juarez participated.

Collaborative work was done between ROTMENAS and United Way El Paso, and a workshop on Play Therapy was imparted to 50 mental health professionals. Two research papers were completed: the first was conducted in Youth of the Community of Ciudad Juarez, with a sample of 1,300 adolescents, where risk factors associated with depression and suicide attempt were measured. The second study was carried out with 168 health professionals and a measurement instrument for stigma was used.

A collaboration between Dr. Judith Mc Farlan from the University of Women in Texas and ROTMENAS was done and a prevention tool and identification of violence against women was shared through a mobile app called FAST, and the Directory on Mental Health Services in the community was updated and distributed widely.

A Thanatological Coaching Conference focused on suicide was provided to 100 mental health professionals. Also, ROTMENAS worked with the Congress of the State of Chihuahua: 17 recommendations for amendments and new additions to the law were introduced, and 12 proposals to amend the law were approved by the State Congress and published in the official gazette of the federation. The First ROTMENAS Forum on Addictions and Associated Pathologies was done with 160 mental health providers in attendance. And participated in the Mexican Congress of Psychology with two topics.

December 1, 2018 to November 30 2019

The Fifth MhGAP training was imparted to 68 mental health workers.

Three Mental Health Fist Aid trainings were provided, certifying 93 mental health workers. The Update of the design and elaboration of the second version of the Directory on Mental Health Services was done. A workshop on Brief Motivational Detections and Interventions for Alcohol Abuse was provided to 53 workers on mental health.

Cognitive Behavioral Therapy Workshop for the Management of Depression was provided to 49 workers on mental health. Two workshops on Healthy Life without Smoke, and Theoretical and Methodological Resources in Smoking Prevention were provided to 125 workers on mental health. Cognitive Behavioral Therapy Workshop for adults with post-traumatic stress, and treatment of victims of violent events was provided to 60 mental health professionals. Workshop on clinical competencies for the management of suicidal behavior was provided to 50 mental health providers. Workshop approach to the management of homicide and suicide cases within the facilities was provided to 53 professionals on mental health. Workshop Ask, Persuade and Refer, three steps that anyone can learn for suicide prevention was provided to 30 professionals on mental health.

Workshop Evaluation and Management of Anxiety and Stress was provided to 60 mental health professionals. Workshop for women Healing Wounds Derived from Gender Violence was provided to 28 workers in mental health. First Healthy Life Smokeless Youth Summit in collaboration with the Healthy Smoke-Free Living Program was provided to 110 workers on mental health and community members.

Four workshops on the week of the Border Book Fair in connection with the First Economic Culture Fund and information about different mental health services in the community were provided to 300 workers on mental health and community.

The First Border Festival of Emotional Health ROTMENAS consisted of 26 trainings in different mental health topics that were provided to 1,150 persons from the community and mental health professionals. The first report of activities and presentation of indicators in mental health was presented to 101 participants

A Binational Consortium was established with Empower Change from the University of Texas at El Paso (UTEP) to strengthen the technical capacity of mental health professionals and the integration of the efforts made: 150 persons participated on four binational workshops.

Talk with the Expert on the topic of Human Rights and Mental Health was provided to 25 members of the public policy teamwork. The first ROTMENAS Forum on the stigma associated with mental health disorders on current panorama and public policies was provided to 130 workers on mental health.

The development of a website with information for the community on stigma, whose impact is based on documented scientific evidence, and the implementation of an inter-institutional reference and counter-reference system was done. The successful experience of the ROTMENAS Model was shared with other border states to replicate and benefit more border populations at the 2nd Border Health Symposium: The Power of Collaboration, held in Reynosa Tamaulipas.

From December 1, 2019 to November 30, 2020

Due to the start of the COVID-19 pandemic, ROTMENAS modified its way of working, to continue to influence the mitigation of stigma and the professionalization of mental health workers, increasing work on the Zoom platform and Facebook live.

Two online MhGAP trainings were provided in collaboration with the UNAM (Universidad Nacional Autónoma de México) and PAHO (Pan American Health Organization), to 68 mental health workers. Face-to-face Mental Health First Aid trainings was provided, certifying 13 mental health workers.

In the Second Border Festival of Emotional Health in virtual modality, 50 different courses and trainings were given 3 days, with an attendance of 5622 people and subsequent visits to the recordings (videos) of 22,021 viewers.

The second fase-to-face Report of ROTMENAS activities and monitoring of Mental Health and Stigma indicators in Ciudad Juárez with an attendance of 60 persons from diverse sectors was done.

Online Second ROTMENAS Forum on Stigma Associated with Mental Health Disorders: Stigma, Human Rights and Public Policy was provided to 110 partcipants and the recording was reproduced 471 times.

An update of the design and elaboration of the third version of the Directory on Mental Health Services was done. Two COVID-19 Response Training online were provided to 160 workers on mental health. An online course on Assertive Communication was provided to 87 workers on mental health. Online course on Psychological First Aid was provided to 98 persons. Mindfulness online course was provided to 76 persons. Online course Safety Plan in Times of COVID-19 was provided to 78 persons. Online Workshop Active Meditation with Mandalas was provided to 40 persons.

Five trainings in the management of the Psycho-educational Box in collaboration with CEAADIC (Comisión Estatal de Atención a las Adicciones by the name in Spanish) were provided face to face in small groups of a maximum of 10 giving a total of 45 persons trained.

Online, a series of training conferences on Gender Violence in connection with the Municipal Women's Institute was provided to 231 workers on mental health. Face-to-face conference on Mental Health and Cancer was provided to 40 workers on mental health. Online training on Acceptance and Commitment Therapy Strategies for the Treatment of Generalized Anxiety Disorder and other COVID-19 related conditions was provided to 92 workers on mental health.

Online training on Evidence-Based Prevention and Intervention Strategies for Managing Depression Generated by Isolation, was provided to 66 providers on mental health. Online Colloquium on Suicide Prevention at the Border was provided to 400 persons from the community and mental health workers.

Online Workshop on the Basic Fundamentals of Obsessive Compulsive Disorder was provided to 77 providers on mental health. Online workshop on Learning in Bereavement for Losses Caused by COVID-19, attended by 246 health professionals and community members.

Online training on Face the Stress and Post-Traumatic Stress Derived from COVID-19 was given to 77 ROTMENAS members. Development and dissemination of the Human Rights Booklet for People with Mental Disorders. The installation of the ROTMENAS Reference and Counter-Reference Committee. Launch of the ROTMENAS App was performed.

Face-to-face and online start of activities of the National Strategy against Addictions were carried out.

Two online diploma trainings in Fundamental Elements in Psychology of Addictions certifying 77 professionals on mental health, and each participant becomes a member of the International Society of Substance Use Prevention and Treatment Professionals (ISSUP). Participation with advice in the Consultation Forum for the Educational Model UACJ (Universidad Autónoma de Ciudad Juarez, by the name in Spanish) Vision 2040.

Involvement in the cycle of online dialogues Perspectives on Public Health and Substance Use with an attendance of 600 participants was done. The US- Mexico Border Health Commission in Laredo, Texas and the State of Tamaulipas Mexico, invited ROTMENAS to present the Model of the Network as good practices example in the Northern Border of Mexico; the event was attended virtually by 40 attendees.

ROTMENAS was invited to the State congress in Mental Health and Addictions in Coahuila, to present its practices as a Model; 600 attendees attended the event virtually. A face to face, Presentation of ROTMENAS results with the assistance of 60 members of the Network was given.

The campaign "Protecting Smiles" because of the shortage of facemasks ROTMENAS members distributed 2,960 free facemasks in the community to protect them from COVID-19. "Health Heroes" campaign, 350 COVID-19 protective kits with information, facemasks, gel sanitizer, granolas and beverages were distributed to hospital workers.

From December 1, 2020 to November 30, 2021

Two online MhGAP trainings were provided in collaboration with the UNAM and PAHO and 193 mental health workers were trained. The third Festival of Emotional Health, was done in mixed modalities online and face to face, with 1,570 participants and 5,800 subsequent reproductions of the recordings of the trainings.

Two fase-to-face Mental Health First Aid Training were given, where 53 school teachers were certified. The third forum on Stigma in People with Mental Disorders, with 60-in person attendees and 300 in virtual mode was done. Online workshop Learning in Bereavement for Losses Caused by COVID-19, attended by 140 health professionals and the community was given.

Fifty-five mental health practitioners attended online training in Advanced Strategies of Acceptance and Commitment Therapy for the Treatment of Anxiety Problems. Online workshop Humanistic Tools for the Professional Treatment of Depression attended by 43 mental health professionals was done. First Self-Care Meeting for 30 ROTMENAS leaders that attended the event in person. Online workshop The Presence of Absence: 25 mental health workers attended Psychosocial Care and Accompaniment in Cases of Disappearance. Online Training in the Brief Intervention Protocol for Adolescents who Initiate the Consumption of Alcohol and other Drugs (PIBA) was attended by 45 mental health professionals. Emotional Health Festival for Migrants, a face-to-face modality with 553 migrants served, was done.

Implementation of the ROTMENAS strategy-Specialized Units of Action in Suicidal Crisis (RUEDAS), training 43 teachers, 12 firefighters, and 80 public security officers. Update and dissemination of the website https://www.facebook.com/rotmenas which has 3116 followers and publications had a reach of 797,888 people. Tik Tok @ROTMENAS has 654 likes and posts had a reach of 5,321 people.

ROTMENAS contributed to the Modifications to the Basic Manual of Municipal Public Security. And, in person with Self-Care workshops for Municipal Public Security Officers were given, training 160 agents. Development of the Reference and Counter-Reference Manual for Mental Health and Substance Abuse Cases.

Development of a flowchart of the process of containment, attention and reference of people at risk of suicide. Continuity to the dissemination of the Human Rights Booklet for People with Mental, Neurological, and Substance Abuse Disorders. Continuity of the trainings of the net in the ROTMENAS referral and counter-reference system of patients in mental health was done.

Update of the design and elaboration of the fourth version of the Directory on Mental Health Services. Actualization of the ROTMENAS App. Presentation of indicators and report of ROTMENAS 2020 activities, face to face with 90 attendees, was performed.

Collaboration in the revision and updating of the Manual psychological care for women victims of violence, prepared by the Municipal Institute of Women. Participation in the Second Congress of Mental Health and Addictions of Coahuila State, with the presentation of the outcomes of the ROTMENAS Model, modality face to face and online. Application of the second phase of the Mental Health Indicators in Ciudad Juárez to 1573 persons was done.

At the moment 46 organizations are part of ROTMENAS Net and they are: Oficina de alcance en Chihuahua de la Comisión de Salud Fronteriza México – Estados Unidos; Organización Panamericana de la Salud/Organización Mundial de la Salud (OPS/OMS), Representación de México; Programa de Salud Mental Jurisdicción Sanitaria II; Dirección General de Centros Comunitarios Municipales; Dirección de Salud Municipal; DIF Municipal; Subsecretaría de Desarrollo Social de la Frontera Norte; Comisión Estatal de los Derechos Humanos; Comisión Estatal de Atención a las Adicciones; Fiscalía General de la República; Instituto Municipal de las Mujeres; Instituto Municipal de la Juventud; Ave Fénix; CATAA A.C; Centro de Atención Psicológica SURÉ UACJ; Centro de Atención y Asesoría para la Familia (CAAF); Centro de Consejería Familiar y Matrimonial; Centro de Evaluación Psicométrica y Atención Psicológica (CEPAP); Centro de Orientación y Asesoría Sexual S.C.(CEORASEX); Centro de Rehabilitación Dame la Mano A.C.; Centro Familiar para la Integración y Crecimiento A.C. (CFIC); Centros de Integración Juvenil; Colegio de Psicólogos del Estado de Chihuahua Sección Juárez; Coordinación de Orientación y Bienestar Estudiantil UACJ; CRECAVI A.C.; Cuerpo Académico No. 35 de la Universidad Autónoma de Ciudad Juárez; Cuerpo de Docentes en Psicología de la Universidad Autónoma de Ciudad Juárez; Estrategia Nacional para la prevención de adicciones (ENPA); Instituto de Logoterapia y Tanatología S.C.; Instituto Chihuahuense de las Mujeres; Mujeres Resilientes en Ciudad Juárez A.C.; Mujeres de Pacto A.C.; Red de Coaliciones Comunitarias México; Reto a la Juventud México I.A.P; SAADAR A.C.; Sistema Nacional de Protección de Niñas, Niños y Adolescentes; Salud y Bienestar Comunitario A.C. (SABIC); Secretaría de Educación del Estado de Chihuahua; Techo Comunitario A.C.; Tribunal de Adolescentes; Unidad de Hospitalización Centros de Integración Juvenil; Universidad Autónoma de Ciudad Juárez Coordinación del Programa del Doctorado en Psicología; Universidad Autónoma de Ciudad Juárez Coordinación del Programa de Maestría en Psicoterapia Humanista y Educación para la Paz; Universidad Autónoma de Ciudad Juárez Coordinación del Programa de Maestría en Psicología; Universidad Autónoma de Ciudad Juárez Coordinación del Programa de Licenciatura en Psicología; Universidad Autónoma de Ciudad Juárez Subdirección de Universidad Saludable; Volver a Vivir A.C.

5. DISCUSSION

ROTMENAS with its interventions and strategies has proven to be an innovative and model project that can be taken to other cities and states previously adapted to the region, to address mental illness with local resources, training and research. In addition to mitigate stigma so that the community will increasingly come forward to address their mental health. With the advent of the pandemic, both physical and mental health deteriorated at a dizzying rate, affecting the general population. ROTMENAS has also generated a unity among mental health professionals, which has translated into cooperation and support for both the organizations that are part of the Net and the community at large. ROTMENAS has made visible the mental health issues before and derived from the pandemic, so it has generated different intervention strategies to strengthen the collaborative work of organizations and institutions in Ciudad Juarez, efforts dedicated to the prevention and care of persons with mental, neurological and substance abuse disorders in order to promote the optimization of mental health services, reduce the stigma associated with mental disorders, improve the capacity of mental health care and promote policies aimed at improving the mental and emotional well-being for the community.

ROTMENAS has demonstrated that with leadership, collaboration and multi participatory work from persons from different professions but working on the mental health field services it is possible to offer mental health access to the entire community regardless of socioeconomic status, origin or culture.

ROTMENAS success relies on the offer of continuing education programs to the net based on mental health indicators, and the diagnosis of needs of the organizations that make up the NETWORK; the continuity of successful trainings based on scientific evidence such as the WHO mhGAP guidelines, Mental Health First Aid, suicide prevention and other therapeutic interventions. The design and dissemination of the Human Rights booklet for people with mental, neurological and substance abuse disorders, educating the community on stigma mitigation; consolidate the referral and counter-referral network among mental health agencies in Cd. Juarez, in order to make the existing resources in the community more efficient. To update and promote the ROTMENAS Directory of mental health providers in the community to inform and facilitate the access to mental health services. The measurement and dissemination of the Mental Health Indicators and other research derived from the Network to generate evidence-based and culturally sensitive strategies to tackle the mental health problems on Ciudad Juarez.

All this work has been done through meetings, workshops, lectures, trainings, certifications, festivals, forums, conferences and is well documented on web page: https://rotmenas.saludfronterizachihuahua.org/mision/

ROTMENAS steps to develop the Model:

1. To have a group of high-impact leaders with high values ​​respect, active listeners, civil responsibility, and community support with knowledge of mental health.

2. To secure funds.

3. To recruit partners.

4. To work on teams.

5. To develop together strategies to take.

6. To measure regional indicators of mental health.

7. To work on mitigation of stigma on mental health.

8. To professionalize mental health workers.

9. To evaluate community impact.

10. To document data, write reports and evaluate progress.

6. Conclusion

Around the corner, as a side effect of the COVID-19 pandemic we will be seeing a community with a range of negative psychological responses, mental health leaders must come together to promote mental health. Collaborative work between the different levels of professionals who work in the arena of ​​mental health is imperative. The knowledge and recognition of the work carried out by each entity in mental health is fundamental, to carry out the work of reference and counter-reference, as well as to optimize access to mental health care for all members of the community regardless of origin, culture or socioeconomic status. Public policies need to be changed to address more money to mental health care, education, and prevention. ROTMENAS has proven to be a successful model with high-impact practices to mitigate stigma, improve access to mental health services, and professionalize mental health workers in Ciudad Juárez.

Study Limitations

Some model limitations are worth mentioning. In order to duplicate the ROTMENAS model in another region, a prior study of mental health indicators and existing resources in the region is required. In addition to having funds. Despite this limitation, the ROTMENAS Model have several important implications for mitigating stigma on mental health, professionalization o mental health workers, research, practice, and policy.

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