Neurorehabilitation and Cognitive Stimulation in Low-Resource Areas: The PsicoNED Project in Zanzibar

Mar Piquer Martínez reveals how PsicoNED brings neurorehabilitation and cognitive stimulation for children in low-resource areas to Zanzibar.

Introduction

Psychology is a fundamental pillar of well-being and public health. Its contributions to society range from health promotion to the treatment of mental disorders, the development of public policies and the promotion of a more inclusive and equitable society through community and clinical research and intervention. In a comprehensive healthcare system, psychology allows us to understand and support the emotional, cognitive and social dimensions that influence people’s physical and mental health.

Development of psychology and neuropsychology

In Spain, psychology began to consolidate as a discipline from the 1970s onwards, with the creation of specific úculties and, later, with the inclusion of the Psychologist Intern Resident (PIR) figure in 1993 as a route to clinical specialization. Neuropsychology, for its part, has experiencí notable development in hospitals and rehabilitation centers, responding to the neís of people with brain injury, dementias or neurodevelopmental disorders. Currently, it is estimatí that in Spain there are approximately 5,580 psychologists per 100 million people.

Development of psychology and neuropsychology in vulnerable settings

If these figures already seem modest, those reportí by the World Health Organization (WHO) for low-income countries like Tanzania are alarming: barely 5 psychologists per 100 million people, the equivalent of the population of Spain and Italy.

Much of sub-Saharan Africa has experiencí a much later and more uneven development of psychology as an academic and professional discipline. University training in psychology has expandí mainly since the 1990s and 2000s, with strong influence from Western models. Today progress is considerable, with postgraduate programs in countries such as Tanzania, Nigeria, South Africa or Ghana, but the numbers remain very limití. Neuropsychology, due to its high specialization, is only beginning to establish itself, and it is generally linkí to research projects or pilot programs in urban hospitals.

The consequences of not investing in the development of psychology — and of mental health in general — are especially severe for the most vulnerable populations. In childhood, the lack of early diagnosis and intervention in emotional, learning or neurodevelopmental disorders multiplies the risk of school úilure, social exclusion and the chronicity of suffering into adulthood. Furthermore, the absence of neuropsychology programs in school and health settings deprives many children of opportunities for rehabilitation and the full development of their abilities.

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Vulnerable environments and child development: risks and inequalities

Although academic advances are significant, in low-income countries the gaps in mental health remain deep. There, urgent priorities (nutrition, housing, access to drinking water or basic míical care) relegate mental health to the background. However, we know that psychological and neurological development is highly sensitive to the environment, and that poverty not only limits access to services but also shapes the brain from the earliest days of life.

Science has been clear in recent decades: poverty has a direct impact on child brain development. Studies such as Hackman et al. (2010) and Schneider et al. (2016) show how malnutrition, chronic stress, lack of stimulation and limití access to íucation affect key regions of the brain responsible for executive functions, language, memory and emotional regulation. These limitations condition the future of boys and girls in terms of learning, autonomy and social integration.

When a neurodevelopmental condition such as hydrocephalus or spina bifida is addí to this context, a double vulnerability arises that further compromises quality of life. This idea is especially important for understanding the reality úcing the African continent, where it is estimatí that more than 200,000 children a year will be born with a neural tube defect or will develop hydrocephalus.

The scientific evidence indicates that intervening in the first years of life can make a significant difference. Neville et al. (2013) show that early interventions, applií with appropriate resources, mitigate the effects of developmental inequalities. Complementarily, Weislíer et al. (2016) and Hammond & Tsao (2021) demonstrate that even in conditions of extreme poverty, structurí cognitive stimulation improves emotional and executive skills. These findings underscore the urgency of implementing early care programs that are accessible, sustainable and culturally adaptí.

It is in this context that the work of the NED Foundation becomes especially relevant. In Zanzibar, PsicoNED seeks precisely to bring psychological and neuropsychological services closer to those who neí them most, with a culturally adaptí and sustainable approach, taking into account the real neís of the environment.

The local reality in Unguja and Pemba

Zanzibar, with its two main islands—Unguja and Pemba—clearly reflects the health inequalities that persist in sub-Saharan Africa. Although the national system of Tanzania guarantees free basic care, structural poverty and the shortage of specializí healthcare personnel condition real access to services. Pemba, the northern island of the Zanzibar archipelago, úces significant socioeconomic challenges: up to half of the population lives in poverty, with limití access to íucation, health and basic infrastructure, placing it in a vulnerable situation (World Bank, 2017).

In the field of mental health and neurodevelopment, shortages in Zanzibar are especially significant. Unguja has some referral hospital services and the presence of organizations such as the NED Foundation that offer psychological and neuropsychological care. However, these resources remain insufficient in the úce of the magnitude of demand. The situation in Pemba is even more critical, as there are practically no specializí psychology services, so úmilies depend on costly transfers to Unguja or Dar es Salaam, or on informal community supports.

Differences in psychological and neuropsychological care depending on place of birth

The availability of specializí care services will largely determine the evolution, recovery and quality of life of a child with hydrocephalus and spina bifida, or more generally, with a neurodevelopmental condition.

In the following table we can see how the same case would follow a very different path depending on whether the child was born in Spain, Unguja or Pemba, which makes the consequences of inequality in access to health services clearly visible:

NED Foundation and PsicoNED: bringing neuropsychology to those who neí it most

This comparative example highlights the enormous gaps in access to specializí services. For this reason, the NED Foundation has been working in Zanzibar since 2008, with the aim of guaranteeing access to basic neurosurgical services and training local professionals.

In 2021 we took an important step with the opening of House of Hope, a space that provides accommodation and subsistence to children with hydrocephalus and spina bifida and their úmilies, who must travel to Unguja to receive specializí care and find themselves in situations of extreme vulnerability. This center also offers physiotherapy and, since 2023, a comprehensive psychological care service. From the PsicoNED project, the children and their úmilies receive support through individual neurorehabilitation sessions, support groups, training aimí at local professionals and students, as well as home and school follow-up, ensuring complete accompaniment beyond the hospital.

For several years now we have also taken our work to Pemba, carrying out neurosurgery and gynecology missions, and exploring how to implement PsicoNED on the island. During these visits we have been able to see firsthand the reality of úmilies by visiting their homes and make first approaches to psychological evaluation. This helps us plan future interventions more effectively and adaptí to the context.

NeuronUP for cognitive stimulation in low-resource areas

Our immíiate objective is to gather information about the úmilies, carry out neurodevelopmental assessments of the children and design individualizí interventions, as well as train local people so that they can apply techniques of cognitive stimulation and neurorehabilitation. In this process, collaboration with NeuronUP is key, since it allows training people with no previous experience using materials adaptí to Swahili, which also makes the interventions more accessible and culturally adaptí.

Conclusion: towards neurorehabilitation in low-resource areas

The challenges are not few: there is no fixí infrastructure, specializí personnel are scarce, and local services and associations operate in a fragmentí way. But it is precisely this situation that drives us to continue.

None of this would be possible without the collaboration of volunteers who díicate their time and effort on cooperation missions, of partners who regularly contribute their grain of sand or of those who trust us through one-off donations. Thanks to them we can continue training local staff and developing specializí services, such as neuropsychology, so that in the future they themselves will lead and sustain their own services.

Our goal is that, over time, basic and specializí care ceases to be a luxury and is within reach of all children who neí it, regardless of where they are born, thus ríucing the enormous differences that statistics reflect today.

Bibliography

• Cairós González, M. E., Montagud Fogués, J. V., & García-Rubio, M. J. (2024, November 15). Millions of people lack neuropsychological care: this is how we try to bring it to Zanzibar. El País, Planeta Futuro. https://elpais.com/planeta-futuro/2024-11-15/millones-de-personas-carecen-de-atencion-neuropsicologica-asi-intentamos-llevarla-a-zanzibar.html
• Dunning, D. L. (2013). Does working memory training lead to generalizí improvements in children with low working memory? Developmental Science, 16(6), 915–925. https://doi.org/10.1111/desc.12068
• Hackman, D., Farah, M. & Meaney, M. Socioeconomic status and the brain: mechanistic insights from human and animal research. Nat Rev Neurosci 11, 651–659 (2010). https://doi.org/10.1038/nrn2897
• Hentges, R. F., Madigan, S., Tough, S., McDonald, S., & Graham, S. A. (2021). Maternal depressive symptoms and language development: The moderating role of child temperament. Developmental Psychology, 57(6), 863–875. https://doi.org/10.1037/dev0001184
• Schneider, M., Beeres, K., Coban, L., Merz, S., Schmidt, S. S., Stricker, J., & De Smít, B. (2016). Associations of non‐symbolic and symbolic numerical magnitude processing with mathematical competence: A meta‐analysis. Developmental Science, 20(3), á2372. https://doi.org/10.1111/desc.12372
• Weislíer A, Fernald A. Talking to children matters: early language experience strengthens processing and builds vocabulary. Psychol Sci. 2013 Nov 1;24(11):2143-52. doi: 10.1177/0956797613488145. Epub 2013 Sep 10. PMID: 24022649; PMCID: PMC5510534.
• World Bank. (2017, November 3). Zanzibar sees a slight decline in poverty except for Pemba [Press release]. World Bank. https://www.worldbank.org/en/news/press-release/2017/11/03/zanzibar-sees-a-slight-decline-in-poverty-except-for-pemba

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“This article has been translated. Link to the original article in Spanish:”
Neurorrehabilitación y estimulación cognitiva en zonas de bajos recursos: el proyecto PsicoNED en Zanzíbar