As a result of a humanitarian disaster, about 30-50% affected people develop signs of either moderate or severe psychological distress. This group would benefit from a range of social and basic psychological interventions that are considered helpful to reduce distress (World Health Organization, 2005a). According to the same source, in emergencies the population rates of mild and moderate mental disorders (mood and anxiety disorders) are expected to increase by about 5-10% and the rate of severe mental disorders may be expected to go up by 1-2% This group would need access to mental health care, which should be provided through general health services or through community mental health services within the health sector. Primary care is particularly appropriate because the primary clinic is easily accessible and provides a non-stigmatizing environment for the treatment of mental disorders (Ommeren at al., 2005).
Mental Health and Psychosocial Support (MHPSS) is reflected within a standard on mental and social aspects of health in the 2004 Sphere Handbook, which in general covers standards and indicators for the acute emergency phase of a humanitarian crisis (Sphere Handbook). According to the Sphere Handbook, care for urgent psychiatric complaints should be available through the primary health care system. Mental health training and supervision of available primary health care (PHC) staff is a key action of the minimum humanitarian response necessary to care for mental disorders in emergencies (Inter-Agency Standing Committee, 2007). According to Inter-Agency Standing Committee (IASC) guidelines, training should involve both theory and practice. It can begin at the outset of emergency (Budosan et al., 2007; Mahoney et al., 2006; Jones et al., 2007), and it should continue beyond the emergency as a part of a more comprehensive response (Ommeren et al., 2005; Inter-Agency Standing Committee, 2007).
Evidence suggests that in low and middle income (LAMI) countries, support for primary health care services with training, assistance and supervision by available specialist mental health staff, is also the best way to extend mental care to the population (Saxena et al., 2007). According to Lancet Global Mental Health Group (2007), good-quality mental health training in primary-care settings is one of the strategies to scale up services for people with mental disorders.
Appropriate training needs to be combined with continued supervision and support to achieve effective mental health care in primary-care settings (World Health Organization, 2008). According to Siddiqi et al. (2005), the effectiveness of interventions to change health professionals’ behavior and practices should be a priority area for researchers and international agencies supporting health system development in developing countries.
The great majority of studies that evaluated the effectiveness of mental health training for various groups of beneficiaries (residents, general practitioners, nurses) have been conducted in developed countries ( Hodges et al., 2001; Hodgins et al., 2007; Kroenke et al., 2000 ). The effectiveness of mental health training for PHC staff has also been tested in some developing countries (AbuZeid et al., 1998; Amira et al., 1996; Cohen, 2001; Harding et al.,1983; Lum et al., 2008), but very few have examined the issue in emergency settings. According to Patel and al. (2007), evidence for mental health interventions for people who are exposed to conflict and other disasters is still weak.
The mental health training program described here was initiated by International Medical Corps (IMC), an international non-governmental organization (INGO) working towards the integration of mental health into primary care in developing countries. A year after piloting its post-tsunami mental health program in Kalmunai in the North-East of Sri Lanka (Budosan et al., 2007), IMC took the same mental health training model per government request to the southern district of Hambantota, also hit hard by Tsunami.
The design of the capacity building programs were dictated to some degree by available national staff training time. This provided the opportunity to contrast the effectiveness of a less intense but longer mental health training intervention combined with on the job supervised work to a shorter but more intense theoretical training intervention only. The hypothesis was that longer and supervised training spread over time would be more effective and result in changing clinical practices of PHC workers.
The mental health training program was conducted in the district of Hambantota in the Southern province of Sri Lanka. The estimated population of 525,370 (World Health Organization, 2005) consists mainly of Singhalese (97%) and the remaining 3% is divided amongst Moors, Malays, Tamils and Burgers. It is estimated that between one-quarter to one-third of the population in the Southern province lived below the poverty line before the tsunami, with the numbers climbing exponentially after the disaster. Given their relative poverty, Hambantota residents were particularly vulnerable to the economic and psychological shock of the tsunami. The level of infrastructure in Hambantota is also below national standards. The Sri Lankan 2001 census classified 38% of all dwellings in the district as “temporary”, based on the use of non-durable construction materials- 11% higher than the national average. Anecdotal reports from PHC doctors interviewed in Hambantota reported that pre-tsunami, Hambantota presented the highest suicide and alcohol consumption rates on the island. According to the initial assessment through focus groups and in-depth interviews conducted at the outset of the training program, three most prevalent mental health problems in Hambantota were alcohol consumption, unexplained physical symptoms and depression.
At the time of the study, mental health services in Hambantota district were regularly provided only by two PHC physicians with some additional training in mental health. They were operating four outpatient mental clinics under the bi-weekly supervision of a consultant psychiatrist based in Colombo. Less than half of Hambantota’s population had local access to mental health services.
A longitudinal observational study design was used to contrast the effectiveness of two mental health training interventions for PHC staff.
The population of PHC doctors received less intense but longer mental health training combined with on the job supervised work from psychiatrists, while the population of mid-level public PHC staff received shorter, but more intense theoretical training only, from 10 trained PHC doctors. Altogether, 38 PHC doctors (27.14 % of all PHC doctors in Hambantota), and 499 mid-level public PHC staff (almost 100% of mid-level public PHC workforce in Hambantota) received some form of training intervention from July 2006 to January 2007. All PHC staff involved in training were responsible for provision of primary health care to Hambantota population.
The theoretical mental health knowledge was measured with multiple-choice tests before and after the training intervention, in both groups of trainees. The test for PHC doctors contained 30, and the test for mid-level public PHC staff 15 questions. The statistical index Cronbach alfa was used to measure the degree of internal consistency of knowledge tests (Wells & Wollack, 2003), and it was .84. Practical performance of PHC doctors was observed by psychiatrists and measured by using Mental Health On-the-job training Competency Checklist and Goal Setting Form. The detection rate of mental health problems was evaluated by reviewing data collection sheets and mental health assessment forms which also helped development of the case registry of mental health patients in Hambantota. These two measures were used only for PHC doctors. Socio-demographic and process variables, e.g. training attendance were noted. Performance of trainers was observed and evaluated by using scale with 9 tasks measuring the quality of presentation, presentation techniques, and participants’ satisfaction with presentation with a minimum of zero and a maximum of 9. Years of education and experience of trainers were evaluated on a point-scale, where one point was given for each year of trainer’s education and work experience.
The construct validity of all study instruments was determined by: a) the professional judgment of local experts, b) the available evidence on the use of similar instruments in similar situations, and c) general recommendations in the literature on questionnaire design. (Fathala, 2004).
The design of the mental health training program for Hambantota’s PHC workers followed IMC mental health training model already implemented in other parts of Sri Lanka (Budosan et al., 2007). The theoretical and on-the-job training of PHC doctors by psychiatrists was followed by the theoretical training of mid-level public PHC staff. A training of trainers (ToT) model was used in which the PHC doctors trained the mid- level staff. In a coordination with the local health authorities, a workshop model was selected as the best mode to deliver theoretical portion of the mental health training. Two-day workshops were the most feasible and realistic option for the majority of Hambantota PHC doctors, and one-day workshops for the majority of Hambantota mid-level public PHC staff. The best model for the mental health on-the-job training of PHC doctors was that they join the already existing mental health clinic closest to their work post. Altogether, 70 hours of theoretical training, and on average 7.7 on-the-job training sessions per participant were delivered to PHC doctors. 12 hours of intense theoretical training were delivered to mid-level public PHC staff.
The role of health workers within the existing primary health care system and their interest in mental health were the two most important conditions for the selection of training participants. Consequently, PHC doctors and mid-level public PHC staff employed within the primary health care system in Hambantota with a keen interest both to join the training and to implement newly acquired mental health knowledge/skills in their everyday practice were automatically selected. The training materials produced incorporated tasks of increasing recognition of the condition, confirming the diagnosis, and responding to the mental health problem (Murthy & Narendra, 1983). The mental health curriculum included several core elements that should shape the development and implementation of training curricula: 1) competence in listening and other communication skills, 2) training in properly recognizing mental health problems in a community, 3) teaching established mental health interventions, 4) providing strategies for problem-solving, 5) training in the treatment of medically unexplained somatic pain, and 6) learning to collaborate with existing local resources, e.g indigenous healers (Wein, S. & al., 2002).
Training staff resources for the training of PHC doctors included one international and three local psychiatrists. 10 local PHC doctors trained in mental health conducted the training of mid-level public PHC staff.
Active participatory approaches, didactic teaching and on-the-job training were equally used as teaching methods in the training of PHC doctors, while a didactic teaching method prevailed in the training of mid-level public PHC staff. On-the-job training was observed and supervised by local and international psychiatrists.
Important characteristics of two training interventions are summarized in Table 1.
The primary outcome measures were changes in test scores and practical performance after training interventions. The secondary outcome measure was a change in the detection rate of mental disorders among PHC doctors; in all measures higher scores indicate improvement compared to baseline measurements. All sets of ratings (baseline and end-point) were completed by an experienced psychiatrist, who was actively involved as a trainer in the training program.
Training attendance was coded as either complete for those participants who completed at least 70% or more training, or incomplete for those who completed less than 70% training.
The mean values of knowledge pre and post- tests were compared separately for both trainings with matched pairs t-test (p=.05) to show any improvement after each training intervention. The eventual difference between the group of PHC doctors and mid-level public PHC staff who passed the post-test was tested for statistical significance with the chi-square test (p=.05). 6
One-way analysis of covariance – ANCOVA (p = .05) was used to compare post-test results of two groups after removing the effect of their pre-tests. A stepwise approach was used to determine socio-demographic and process variables significantly associated with the outcome on the knowledge test. Those variables found by chi-square and Fischer exact test (p =.05) to be associated with the outcome were included in a binary logistic regression analysis (p = .05), to determine the impact of independent variables on the outcome.
The performance of trainers in both trainings were compared, and tested for statistical significance with t-test for two independent samples (p = .05). Correlation factor (r) was calculated for the relationship between trainers’ performance and their years of education/experience. The monthly average number of detected mental disorders post-intervention was compared with the monthly average number of detected mental disorders during the training and pre-intervention. The difference between groups was tested for statistical significance with one-way ANOVA test (p=0.05). The statistical tests were done by Sigma XL 5.3.4 package.
20 PHC doctors and 120 mid-level public PHC staff were randomly selected as a sample for this study. There was a significant difference in the number of female participants, years of work experience and the location of workplace between these two groups (see Table 2).
Comparison of outcomes
PHC doctors achieved a significant improvement ( t =10.88, p < .05 ) in the results of post-tests ( µ=24.25, SD=2.75 ) compared to pre-tests ( µ=19.30, SD= 4 ). Also, post-test results of mid-level public PHC staff ( µ =9.95, SD=1.83 ) were significantly better (t = 17.2, p < .05) than the results of their pre-tests ( µ = 8.62, SD = 1.69 ).The difference in the post-tests results of two groups persisted after adjustment for the results of their pre-tests [ F ( 1, 137) = 140.65, p < .001 , ANCOVA].
If pass/fail criteria were used with the cut-off point of 75% correct answers (Public Service Commission of Canada, 2006), there was a significant difference in the percentages of PHC doctors (85%) and mid-level public PHC staff (50%) who passed the test (χ2 (1) = 8.48, p < .01 ).
On-the-job training improved the practical skills of the PHC doctors, which were virtually non-existent before the training intervention. After the training, 85% of them were able to make correct diagnosis and take appropriate decisions regarding medication and the treatment of mental problems, 92.3 % were able to give correct information and advice about the drug, if prescribing, and all of them were able to provide clear instructions and explanations for the patient about his or her problem.
Age category, work experience and baseline test knowledge were associated with the outcome of post-test for PHC doctors in bivariate analysis (see Table 3), but not in multivariate analysis; age category (p = .83), work experience (p = .82) and baseline test knowledge (p = .24).
Age category was the only variable associated with the outcome of post- test for mid-level public PHC staff in bivariate analysis (see Table 4), but not in multivariate analysis (p = .35)
The performance of the psychiatrists as trainers of PHC doctors (µ = 8.25, SD=.96) was significantly better (t =2.8, p = .02) than the performance of GPs as trainers for mid-level public PHC staff ( µ = 6.5, SD = 1.08). Better educated and more experienced trainers performed better in training (r = .91 ).
PHC doctors in Hambantota showed a significant improvement in the detection rate of mental disorders after the training intervention (F = 10.14, p = .003). (See chart 1).
After the training program, the number of registered mental health patients increased in all health administrative areas of Hambantota district (see Chart 2).
The whole training program in Hambantota proved acceptable to the local community as indicated by the high level of engagement of PHC professionals over 6-month period of the program. Both training interventions took place in a primary care setting, but the differences in their implementation included both the duration and the comprehensiveness of the intervention, as well as trainers’ characteristics (education/experience) and performance in training. The training for PHC doctors was longer and more comprehensive. It included both theoretical and on-the-job training component and was conducted by specialists. According to Hodges et al. (2001), the duration of the intervention, the degree of active participation of the learners, and the degree of integration of new learning into the learners’ clinical context are the three most important variables that determine the effectiveness of an educational intervention. Hodgins et al. (2007) also argue that local “context-driven” training should lead to increased knowledge and reported change in practices by PHC doctors with mental health patients. According to Joukamaa et al. (1995), the ability among primary health care practitioners to detect mental disorders is associated with the quality and comprehensiveness of their mental health training.
The characteristics of trainers in terms of their years of experience in training and fieldwork is directly related to improving the outcome of the training process ( AbuZeid et al, 1998).
This study of the effectiveness of a mental health training program for PHC staff in one district of Sri Lanka supports these findings and adds to the limited evidence base on innovative strategies for delivering training as a part of a humanitarian assistance in post disaster and resource-poor settings in developing countries. It also adds to the evidence that a comprehensive mental health training intervention for PHC professionals is feasible in a challenging area, such as this part of Sri Lanka, and provides a template that can be replicated and adopted for use in similar settings.
According to the Lancet Global Mental Health Group (2007), innovative models of providing mental health services in primary health care need to be implemented in many LAMI countries. In these settings, there are usually insufficient trained mental health professionals, and building the mental health capacity of PHC staff through various training interventions is often the only effective way of providing mental health services to a large population. Such ToT model is often advocated as an appropriate method of disseminating training widely (World Health Organization, 2008).
The change in mental health knowledge of both categories of PHC workers and change in practical skills of PHC doctors after trainings in Hambantota were within the range of achieved improvements after similar trainings described in the literature (Budosan et al., 2007; Harding et al.,1983; Kroenke et al., 2000). The principal finding of this study is that the training of longer duration for PHC doctors spread out over time and combined with supervision provided by psychiatrists was effective not just in increasing mental health knowledge / skills, but also in changing mental health practices. The brief and intense theoretical training for mid-level public PHC staff delivered on its own by the trained PHC trainers did increase their knowledge, but not to the same degree as the combined training provided by mental health practitioners. This suggests that future trainings using a ToT model should ensure that such trainings incorporate practical components and that the skill set of the trainers is of a sufficiently high standard.
IMC mental health strategy advocates a comprehensive and longer training intervention combined with supervised on-the-job training targeting all health workers involved in the provision of primary health care in their communities. However, circumstances on the ground often force the use of different training approaches with different groups which allows for the comparison of different training interventions.
The study was not a randomized controlled trial, but was the most feasible design in the setting of an actual health service innovation in a resource-poor area. There were no comparison cohorts of PHC doctors and mid-level public PHC staff who received no training intervention.
This is because mental health was not practiced by PHC workers in Hambantota before the training intervention, and it was logical to assume that the changes in knowledge /skills and mental health practices would occur only by those PHC workers who completed the training. Another important limitation of the study is that the evaluation of the effectiveness of the training intervention was done by trainers, which introduces the possibility of bias in their reporting. The outcome measures used in this study focused on the results of mental health training. Therefore, although the study confirmed positive changes in clinical practices of PHC doctors, it was still unable to answer the important question as to whether their improved practices improved patients’ outcomes. Finally, the findings of this study are nested in the particular social and cultural milieu of one Sri Lankan district after the major disaster; the unique challenges and opportunities for the program may not necessarily generalize to other settings and other circumstances easily.
Strengths of the study and mental health training program
The study attempted to contrast two different training approaches with two different groups of PHC workers, and to compare their outcomes. To the best of our knowledge, this is the first study to examine the comparative outcomes of two different mental health training interventions for PHC staff delivered as components of a humanitarian assistance in a low-income setting after a major disaster.
The whole training program in Hambantota increased the overall mental health knowledge of Hambantota PHC professionals, and it was effective in changing the mental health practices of PHC doctors. It also confirmed the hypothesis that longer mental health training of PHC workers spread out over time and combined with supervision would result in change of their clinical practices. The strength of the training program was a result of several factors combined together: a) the change in Sri Lankan policy promoting integration of mental health into primary health care ( Democratic Socialist Republic of Sri Lanka, 2005), b) commitment of PHC professionals to implement the results of the policy, c) professionally designed mental health training in tune with the IASC guidelines being developed at that time ( Inter-Agency Standing Committee, 2007), d) timing of the program (after the major disaster), and e) cohesive work of all major stakeholders (government, WHO, local health authorities, local and international mental health professionals and Hambantota PHC staff).
Implications for future research
When evidence from randomized trials is not available, or is difficult to generalize, observational and interventional studies like this one provide useful information, but must be carefully interpreted (Buerkens et al., 2004). Nevertheless, both observational and intervention research is possible, and careful evaluation of ongoing practice and the lessons learned is valuable (Banatala & Zwi, 2000). Future randomized controlled trials (RCT) of both training for PHC doctors and mid-level public PHC staff should address the point made here for generating more scientifically credible evidence of the effectiveness of mental health training for PHC workers we have described in this paper. In recognition of the limitations of study reported here, we would recommend further studies of training interventions for PHC workers in other settings, and another follow-up study of outcomes of patients who were detected as a result of mental health training of PHC workers in Hambantota.
Future research could also address the issue of sustainability of mental health training intervention in Hambantota. It would be important to know if the positive trend in the detection rate of mental disorders by PHC doctors in Hambantota is sustained in the long term. Developing countries have limited resources, so it is particularly important to invest in health care that works and is sustainable in a long-term (Garner et al., 1998).
One other possibility for further research is to see how opportunities initially provided by post-tsunami relief efforts in Hambantota were used to develop mental health services in this Tsunami-affected district. According to Saraceno et al. (2007), professional understanding of effects of disasters, paired with post-emergency mental health interest, can provide enormous opportunities for mental health system development. Furthermore, mental health investments in primary care are important but are unlikely to be sustained unless they are preceded and/or accompanied by the development of community mental health services.
This study can also help stimulate further research in the field of mental health interventions in emergency settings. According to IASC Guidelines (2007), scientific evidence regarding the mental health and psychosocial support that prove most effective in emergency settings is still thin. Future studies could address the indications of the relative success of specific interventions for specific mental health conditions, for example interventions for depression delivered in primary care.
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