PSYCHOSOCIAL TRAINING FOR HEALTH WORKERS FOR PUNTLAND

TRAINING REPORT

1.0 Executive Summary

TPO Uganda has been providing technical support in psychosocial programming to UNICEF Somalia LNGOs in the three zones (Somaliland, Puntaland and South central Zone) since August 2004. This followed a child protection study carried out in 2002 that revealed the dire need for psychosocial support services in the whole of Somalia. As part of implementing recommendations from this study, UNICEF Somalia invited TPO Uganda to provide technical support aimed at profiling psychosocial care in Somalia. One of the major objectives of this technical support as contained in the project cooperation agreement is to strengthen institutional and community capacity to respond to psychosocial needs of children and women affected by conflict and violence.

To this end, thirty (30) health workers in Puntland have been trained to ensure that psychosocial needs of target clients are catered for in the day-to-day delivery of health care services, establishing a holistic service delivery structure that enhances access to services. The overall objective of this training was that health workers are knowledgeable and skilled and can respond more appropriately and effectively to the psychosocial needs of patients approaching them at health care facilities. Participants to this training were drawn from MCH units, Pediatric section, the under five (5), OPD, community mental health represented by a social worker. The training was conducted at Puntland State University- Multipurpose hall between Dec 25th and Nov 5th 2006.

The main course content covered included the concept of psychosocial support, The Bio- Psycho- Social System, Child life cycle development, psychosocial support interventions, Loss, Grief and Bereavement, Coping and Resilience, Basic knowledge on mental health issues (Causes, signs and symptoms, prevention and management), Basic psychosocial support skills and attitude (the eleven steps in psychosocial helping), The role of health workers in promoting psychosocial and mental health care, skills for communicating and helping children, action plan.

The techniques used were participatory and included the following; interactive lecture and direct translation, small group discussions & presentations, sharing of experiences and ideas, use of case studies, buzz group discussions, questions and answers, role plays, demonstrations of skills and return demonstrations, field visit, reading and interpreting handouts. The tradition, culture and belief system of a given community have to be considered while planning for any activity. This particular training took into account unique belief system of the training group. Training methodologies were also used according to what is acceptable by the culture of the community.

The training report has also highlighted some of the achievements which include gaining an understanding of the concept of psychosocial support, acquisition of basic psychosocial support skills, understanding basic knowledge on mental health issues realizing the importance of positive helping attitude and core principles of health worker. In addition to this, participants acknowledged the importance off PSS services for normal and meaningful human development especially the psychosocial development of children. It is essential that health care systems should incorporate PSS interventions so that services become mainstreamed/ integrated and are offered in a holistic manner.

The different levels/ types of psychosocial and mental health interventions were discussed. It was further emphasized that these interventions should be chosen depending on the context, culture, capacity and available resources of the community.

The training was very well organized. The ministry of health and TPO worked together during the planning and implementation of the training. Thus there were no major constraints that could have affected the outcome of the training negatively. Few issues or challenges that came up were address immediately. Initially there were fears about language of communication, but this was addressed through translation into Somali language by the local trainer and a clinical officer from the ministry of health.

Besides, some important recommendations that can help strengthen psychosocial support services within the health sector have been highlighted in the report. These recommendations include mainstreaming psychosocial support into the primary health care system, monitoring, support supervision, follow-up and mentorship to the trained health workers, intensifying support to the local trainers, mainstreaming psychosocial support component into nurses training curriculum, refresher course, training more health workers in psychosocial support, initiate collaboration with the existing mental health centers, establishing psychosocial support spaces/rooms at MCH units, translating psychosocial training manual for health workers into Somali language, support to community based mental health services, and creating a section within the existing reporting formant being used by health workers to capture psychosocial cases assisted.

2.0 Training Process

2.1 Goal: Health Workers have basic psychosocial knowledge, skills and constructive attitude and are able to respond to the psychosocial needs of patients (Children & Adults) more appropriately and effectively.

2.2 Objectives:

To impart knowledge and build basic psychosocial support skills for working with patients presenting with psychosomatic/ functional complaints and offer appropriate support.

To discuss Psychosocial and mental health issues in order to identify and plan appropriate psychosocial and mental health intervention for patients in need of psychosocial care and support.

To prepare health workers to demonstrate a constructive attitude towards supporting patients and families in need of psychosocial care.

2.3 Methodology

The methods used took into consideration the culture and context of the Somalia people. The techniques used were participatory and included the following:

  • Interactive lecture and direct translation
  • Small group discussions & presentations
  • Sharing of experiences and ideas
  • Use of case studies
  • Buzz group discussions
  • Questions and answers
  • Role plays
  • Demonstrations of skills and return demonstrations
  • Field visit
  • Reading and interpreting handouts

3.0 Expectations and Fears:

Gain and knowledge and skills

Cascade the knowledge and skills learnt at community level.

Share ideas and experiences with colleagues and trainers.

Get certificate of attendance

To discuss more about psychosocial and mental health problems

Learning about corporation and coordination with local partners and other service providers

Fears:

Talking about Psychosocial problems will remind me about the past experiences which might interfere with my concentration in the training.

Having difficulty to understand some of the topics.

Trainers may not be able to cover all the planned topics.

Trainees may not get handouts.

Trainees may not be able to communicate well with trainers in English.

Trainers discussed the above list of expectations and fears with participants and the Director of training from the Ministry of health. Issues pertinent to the success of the training were clarified and agreed upon. The language of communication and instruction included both English and Somali. One local trainer and a clinical officer from the Ministry of health facilitated this process. They also facilitated small group sessions and planned for field visits to the hospital and a nearby IDP camp.

4.0 Achievements

  • The concept of psychosocial support was discussed in the training. Different aspects of human needs and development were identified such as the physical, emotional, social, spiritual and mental needs of a person. The training put emphasis on the importance of considering all the above needs which are important for meaningful human development more especially on child developmental stages. Participants also understood that psychosocial support and care are efforts by individuals, family and groups outside of the client’s usual social networks. It (PSS) is provided through interpersonal interactions that occur in caring relationship in everyday life, at home, health centers and in the community. This includes the love and protection that clients experience in family environments, as well as interventions that assist clients and their families in coping. This is a holistic approach to psychosocial care and support, which is important in everyday life.
  • The training also focused on basic psychosocial support skills that the health workers can use during their everyday work. This included empowerment, trust building (with patients/ clients), attentive listening, probing techniques, encouraging expression of feelings, providing emotional support and comfort, problem assessment and developing plan of action. These skills are important tools health workers can use to explore more information about the BIO-Psycho -Social status of patients in order to make appropriate diagnoses and treatment. These skills were taught, demonstrated and practiced in class and during field visit by trainees. Hence, the health workers returned to their work places ready to use those skills learnt in class.
  • An overview of Health and mental health problems was discussed during the training. The discussion centered on mental health and mental illness including epilepsy and mental retardation and other common mental disorders in childhood. Psychosocial problems related to the above common mental health problems were identified and discussed. These included social stigma and discrimination, family neglect and lack of care, sexual abuse as well as inadequate psychiatric services. Participants understood the common types of mental illness, epilepsy and mental retardation, their causes, management and preventive measures. Thus knowledge about mental health problems will help the participants to provide health education to clients, families and the general community. They will also be able to detect early childhood disorders and be able to support or refer for specialized services.
  • They were further able to relate this classroom knowledge to practical field/ real life situation during field visit to the hospital and the nearby IDP camp visited. They had the opportunity to experience interacting with children and adults outside health service delivery setting. Most importantly, they identified MH & psychosocial problems of clients, built helping relationship with them and provided emotional support to those they interacted with. They practically experienced that there are many people out there who need psychosocial support and that these psychosocial support services are not available within the health care services. Thus they realized the need to integrate psychosocial support into the health sector.
  • Psychosocial support is effective when caregivers portray a positive helping attitude and dignity for patients/ clients. Participants were taken through core principles of psychosocial support that guide them in their work and hold them accountable to clients, families and communities. These core principles are also part of the code of conduct for health workers, which include accountability, dignity, and confidentiality/ privacy. In addition, other positive helping attitudes/values such as compassion, empathy, being a good role model etc were emphasized. This helped the participants to review their attitudes towards helping their patients.

5.0 Lessons Learnt

  • The tradition, culture and belief system of a given community have to be considered while planning for any activity. This particular training took into account unique belief and value system of the training group. The trainers used training methodologies according to what is acceptable by the culture of the community.
  • PSS service is important for normal and meaningful human development. It is essential that health care systems should incorporate PSS interventions so that services become mainstreamed/ integrated and are offered in a holistic manner.
  • There are many levels/ types of psychosocial and mental health interventions. But these interventions should be chosen or used depending on the context, culture, capacity and available resources of the community.

6.0 Conclusion & Way forward

In general terms, the training objectives were met. The concepts of PSS and mental health issues were discussed and clarified in the training. The relationship between PSS and mental health was explained and understood by participants. The human component of BIO-Psycho-Social system and its relationship (connection) to the well being of a person was discussed. Possible physical, psychological and social responses to psychosocial problems were shared. Participants were able to understand the unique connections and share their work experiences. The training also focused on some basic psychosocial support skills and attitude that are essential in providing PSS and care to patients in the health care facilities. However, the following highlights some of the key ideas that were agreed upon with the participants as strategies that will help to strengthen further the PSS interventions within the health care services:

  • It was suggested that PSS be mainstreamed into the existing health care services (PHC). Human beings have varied and various need in order to develop and live a functional life. These needs should be provided in a holistic (integrated) manner. The Health Workers (who are already providing health care services) should integrate PSS into their daily work. These should include PSS services like Counseling (emotional support, problem solving, psychosocial awareness to patients and families), improve on the referral and advocacy systems, intensify education on common health issues as well as identify patients presenting with psychosomatic complaints (physical problems due to psychosocial problems) and offer appropriate support to them. They also need to improve on the support and care for the under – 5, children in their middle childhood and adolescents including their families.
  • Monitoring, support supervision and follow up system. Participants were exposed to new knowledge and skills during the training. For them to be able to transform the knowledge into practice effectively, it was agreed that a functioning monitoring and follow up system be established. This implies that the existing follow up system by the ministry needs to be strengthened in collaboration with TPO and other key stakeholders. The Director of training and local psychosocial trainers are particularly responsible for the monitoring and follow up of psychosocial support activities. Besides this, the local trainers need ongoing support and mentorship by TPO to be able to plan, implement and monitor psychosocial services effectively.
  • In relation to the above, it was further suggested that the local trainers should be exposed more to training activities and working closely with the TPO Technical Support Officer. This will help them practice their training skills and be able to plan and run trainings independently in the future. They further need to work as a team and support one another. For example, 2 of the local trainers in Busaso were able to organize and implement 5 day training for TBAs. This was excellent!
  • Integrating basic PSS knowledge and skills into the Nurse Training curriculum. Psychosocial support is a key component within the PHC services. For effective mainstreaming of PSS into health care system, trainees suggested that basic PSS knowledge and skills be incorporated into the existing training course for health workers such that they graduate with some knowledge and skills that they will be able to apply in their work. This means that the capacity of the Tutors to review the existing curriculum and be able to teach PSS topics needs to be enhanced. TPO is willing to work out this in collaboration with the MoH and UNICEF.
  • Refresher course for the initially trained Health Workers. The Health Workers are expected to apply the skills and knowledge learnt in class in their daily work. However, sometimes they may get difficulties in transforming the knowledge and skills acquired into practice correctly. Therefore, they suggested that there is a need to bring them together in refresher training so that they are able to discuss progress, lessons learnt, experiences, challenges related to PSS work and forge way forward for better management of patients. This can be planned after six (6) months from the initial training.
  • The Health Workers trained were selected from MCH (including under 5 sections), OPD, Community mental health department, and pediatric. The selection was such that only one person was identified from some of the above-mentioned sections to participate in this training. This meant that just a few of the Health Workers have received PSS training. Therefore, it was agreed that a similar training for another batch of health workers be organized in the future.
  • Support to Community based mental health services. Based on the discussions in the class and the situation on the ground, it is evident that there is need for intensive community based mental health care. The most common mental health problem identified in the area is mental illness manifesting in its different types. Young people (male) in their middle ages are the most affected group in the community. This is attributed to the abuse of drugs (mainly khat/ miraa, etc), consequences of war and displacement and related to depression and common disorders in children such as conduct disorder. There is already community mental health department in place but this is also constrained by limited human resource and logistical support to facilitate provision of mental health care. Thus, it was suggested that support (in terms of capacity building, drug supply and logistical support) to the community mental health department be scaled up in order to be able to reach out the beneficiaries. This intervention could go hand in hand with community education on the dangers of drug abuse and other related psychosocial problems like domestic violence, divorce, etc.
  • Translating the Health Workers Psychosocial & Mental health-training manual into Somali Language. This manual already exists, and the health workers requested that it would be useful if another version in Somali language is produced through translation of the existing one.
  • The health workers suggested that a section for reporting psychosocial related cases within the existing health workers’ monthly reporting format be created. This will support the monitoring system and improve on the follow up and mentorship of staff. It will also help the MoH to capture data on psychosocial cases supported by the trained health workers.
  • TPO is implementing child protection interventions through selected local NGOs, which are directly providing Psychosocial Support services to the Community. It was agreed during the raining that these local NGOs working with TPO such as Kaalo Relief and Development, Girls Development Association (GDA) and Action in Semi Arid Lands (ASAL) should try to work closely with the trained Health Workers and Teacher Mentors in their areas of operation. This can be achieved through establishing a Referral and Advocacy structure among the partners.
  • Health workers were able to design action plan as a strategy to mainstream psychosocial support into their daily work. This action plan reflected the common problems being observed with patients as they seek health care. A comprehensive support plan has been developed in order to respond to the psychosocial needs of these patients within the framework of health service delivery.

Appendix 1: List of participants