Neurorehabilitation and cognitive stimulation in low-resource areas: the PsicoNED project in Zanzibar

Mar Piquer Martínez shows us how PsicoNED brings pediatric neurorehabilitation and cognitive stimulation to low-resource areas in 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 research and community and clinical intervention. In a comprehensive health system, psychology makes it possible to understand and address 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 in the 1970s, with the creation of dedicated faculties and, later, with the introduction of the Resident Intern Psychologist (PIR) position in 1993 as a path to clinical specialization. Neuropsychology, for its part, has developed remarkably in hospitals and rehabilitation centers, responding to the needs of people with brain injury, dementia, or neurodevelopmental disorders. Currently, it is estimated that Spain has approximately 5,580 psychologists per 100 million people.

Development of psychology and neuropsychology in vulnerable settings 

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

Much of sub-Saharan Africa has experienced a much later and more uneven development of psychology as an academic and professional discipline. University training in psychology expanded mainly from the 1990s and 2000s onward, with a strong influence from Western models. Today progress is considerable, with graduate programs in countries such as Tanzania, Nigeria, South Africa, and Ghana, but the numbers are still very limited. Neuropsychology, because of its high level of specialization, is only just beginning to take hold, and it is generally linked to research projects or pilot programs in urban hospitals.

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

Vulnerable settings and child development: risks and inequalities

Although academic progress is significant, in low-income countries the mental health gaps remain deep. There, urgent priorities (food, housing, access to drinking water, or basic medical care) push mental health into 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 first days of life.

Science has been clear in recent decades: poverty has a direct impact on children’s brain development. Studies such as those by Hackman et al. (2010) and Schneider  et al. (2016) show how malnutrition, chronic stress, lack of stimulation, and limited access to education affect key brain regions responsible for executive functions, language, memory, and emotional regulation. These limitations shape children’s futures in terms of learning, independence, and social integration.

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

Scientific evidence indicates that intervening in the first years of life can make a significant difference. Neville et al. (2013) show that early interventions, applied with the right resources, manage to mitigate the effects of inequalities on development. In addition, Weisleder et al. (2016) and Hammond & Tsao (2021) show that even in conditions of extreme poverty, structured cognitive stimulation improves emotional and executive skills. These findings underline the urgency of implementing early intervention programs that are accessible, sustainable, and culturally adapted.

It is in this context that the work of the NED Foundation becomes especially relevant. In Zanzibar, PsicoNED aims precisely to bring psychological and neuropsychological services to those who need them most, with a culturally adapted and sustainable approach that takes into account the real needs of the setting. 

The fight for pediatric neurorehabilitation in Africa: interview with Mar Piquer, coordinator of PsicoNED

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 Tanzania’s national system guarantees free basic care, structural poverty and the shortage of specialized health staff limit real access to services. Pemba, the northern island of the Zanzibar archipelago, faces major socioeconomic challenges: up to half of the population lives in poverty, with limited access to education, health care, and basic infrastructure, which places it in a situation of vulnerability (World Bank, 2017).

In the field of mental health and neurodevelopment, the gaps in Zanzibar are especially significant. Unguja has some referral hospital services and organizations such as the NED Foundation that offer psychological and neuropsychological care. However, these resources are still insufficient given the scale of the demand. The situation in Pemba is even more critical, since there are practically no specialized psychology services, so families depend on costly trips to Unguja or Dar es Salaam, or on informal support within the community.

Differences in psychological and neuropsychological care by place of birth

The availability of specialized care services will largely determine the progress, 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 clearly shows the consequences of unequal access to health services:

	Spain	Unguja	Pemba
Initial hospital care	Relatively early surgery, postoperative care, neurological follow-up.	Surgery possible at the NED Institute Mnazi Mmoja or other referral centers, although with delays, dependence on external support, and possible complications due to a lack of specialized follow-up.	Very limited; there are no local hospitals with pediatric neurosurgery. The family would have to travel to Unguja or farther, facing cost, transportation, and logistical barriers.
Neuropsychology and rehabilitation	Early intervention: access to neuropsychologists, physical therapy, occupational therapy, and speech therapy. Multidisciplinary follow-up.	Partial: projects such as House of Hope provide physical therapy and neuropsychological assessment and intervention.	Practically nonexistent. No specific local infrastructure. Early intervention is difficult or late.
Educational support	Right to curriculum adaptations, support classrooms, specialized teachers, and early intervention programs.	High probability of early exclusion from school, schools unable to provide support, few transportation options, lack of awareness/specific training among teachers.	High probability of early exclusion from school, schools unable to provide support, few transportation options, lack of awareness/specific training among teachers.
Family/social support	Information, psychological guidance, social assistance, family support associations, coordination with social services; in many cases, health coverage and benefits.	Very limited support from the state; some local NGOs provide guidance; the family bears significant financial, physical, and emotional burdens.	Practically no institutional support; social isolation and lack of recognition of disability.
Service coordination	Multidisciplinary teams (neurosurgery, pediatrics, rehabilitation, neuropsychology, social work) with defined protocols in many regions; systematic follow-up.	Informal or occasional coordination; lack of clear cross-sector protocols; dependence on external funding and specific projects.	Very little coordination; services are not integrated; no clear protocols or care pathways; highly fragmented support, if any exists.

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

This comparison highlights the huge gaps in access to specialized services. That’s why 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 meals for children with hydrocephalus and spina bifida and their families, who must travel to Unguja to receive specialized care and are in situations of extreme vulnerability. This center also offers physical therapy and, since 2023, a comprehensive psychological care service. Through the PsicoNED project, children and their families receive support through individual neurorehabilitation sessions, support groups, training for local professionals and students, and home and school follow-up, ensuring comprehensive support beyond the hospital.

For some 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 families’ reality firsthand by visiting their homes and carry out initial psychological assessments. This helps us plan future interventions more effectively and in a way that is adapted to the context.

NeuronUP for cognitive stimulation in low-resource areas

Our goal now is to gather information about the families, carry out neurodevelopmental assessments of the children, and design individualized interventions, as well as train local people so they can apply cognitive stimulation and neurorehabilitation techniques. In this process, the collaboration with NeuronUP is key, since it makes it possible to train people with no previous experience using materials adapted to Swahili, which also makes interventions more accessible and culturally adapted.

Conclusion: toward neurorehabilitation in low-resource areas 

The challenges are many: there is no permanent infrastructure, specialized staff are scarce, and local services and associations operate in a fragmented way. But it is precisely this situation that drives us to keep going. 

None of this would be possible without the help of volunteers who devote their time and effort to cooperation missions, members who regularly do their bit, and those who trust us with one-time donations. Thanks to them, we can keep training local staff and developing specialized services such as neuropsychology, so that in the future they will be the ones leading and sustaining their own services. 

Our goal is that, over time, basic and specialized care will no longer be a luxury and will be available to every child who needs it, regardless of where they are born, thus reducing the huge differences reflected in today’s statistics.

References

• Cairós González, M. E., Montagud Fogués, J. V., & García-Rubio, M. J. (2024, noviembre 15). Millones de personas carecen de atención neuropsicológica: así intentamos llevarla a Zanzíbar. 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 generalized 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 Smedt, B. (2016). Associations of non‐symbolic and symbolic numerical magnitude processing with mathematical competence: A meta‐analysis. Developmental Science, 20(3), e12372. https://doi.org/10.1111/desc.12372
• Weisleder 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