Improving mental health care in Sierra Leone

Although we’ve been quiet on the blog, the Connecting People Intervention project in Sierra Leone has been evolving over the past several months.

Since Meredith’s visit to Sierra Leone in July, we have been working on developing a model of practice rooted in the CPI and training programme for community-based nurses. The project considers how social interventions, developed in partnership with community members involved in mental health care, might increase the chance of recovery.

Meredith and Martin are now making plans to visit in May to meet with stakeholders in the Ministry of Health & Education, the Mental Health Coalition, the Ethics and Scientific Review Committee, and leaders at the University of Makeni. The purpose of this visit will be two-fold; firstly to continue developing our partnerships and ensure the projects meets equally defined needs, secondly to facilitate creative sessions to develop the culturally-relevant training programme. We will then return to Sierra Leone to pilot the training programme with community-based nurses and involving local research students.

This video was produced by The Centre for Chronic Diseases and Disorders (C2D2), based at the University of York. C2D2 is supported by a Wellcome Trust ‘Institutional Strategic Support Fund’ award, and funded the first phase of the Sierra Leone project, the feasibility study. The next stage of the project, including the development of a model of practice and the nurse training programme, is funded by the Maudsley Charity.

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International perspectives on Connecting People

Sierra Leone Flag

Sierra Leone Flag

WAN TIK Nכ DE MEK FכRεST
Krio proverb meaning: one tree does not make a forest

Researcher Meredith Newlin has just returned from a two-week visit to Sierra Leone where she was evaluating the feasibility of adapting the Connecting People Intervention model to address the mental health treatment gap in low and middle-income countries we first spoke about here.

Funded by the Wellcome Trust and the University of York via the Centre for Chronic Diseases and Disorders (C2D2), this visit allowed Meredith and colleague  Dr Susie Whitwell from King’s Centre for Global Health, to visit Sierra Leone in July 2013 to explore how social interventions can help to meet the needs of people with mental health problems. During their visit, Meredith and Susie conducted interviews, focus groups and observations in a variety of mental health service settings and with a number of key stakeholders in the three largest cities, Freetown, Makeni, and Bo.

University of Makeni

University of Makeni

IMG_3375

Like many post-conflict societies, Sierra Leone lacks capacity in its health and social care workforce. Where an estimated 13 per cent of the adult population suffers from a mental disorder and there exists only one trained psychiatrist for a population over 4 million, the lack of mental health training and supervision represents a significant barrier to addressing mental health needs.

Although training has begun for 21 psychiatric nurses, focus has been placed on the medical model, which is problematic in a country with poor access to medications. Upon graduating this autumn, the nurses will be based in district hospitals across the country with referral pathways reaching into the rural communities. Training in psychosocial approaches is greatly needed both at district and community levels in order to strengthen the care available to adults with mental health problems.

Psychiatric nurse training at Enabling Access to Mental Health (EAMH)

Psychiatric nurse training at Enabling Access to Mental Health (EAMH)

Meredith and Susie joined the psychiatric nurses for three days of training where they discussed principles of social capital and strategies they currently use to build relationships with patients, and spent time reviewing difficult cases. This gave us an opportunity to analyse the difference between actual symptoms of mental disorders and stereotypes associated with unusual behaviour in a context where people with mental health problems are highly stigmatised and vulnerable. Time spent with the nurses also enabled us to better understand the manifestations of illness from a sociocultural perspective. For example, the nurses explained they see young women suffering more from “frustration” (Krio for depression) due to the immense pressure placed on them to marry and have children, which may be over-diagnosed as psychosis given the prevalence of stigma in the community.

Susie discussing case studies with the psychiatric nurses

Susie discussing case studies with the psychiatric nurses

Feedback from stakeholders on the adaptation of an intervention model was positive, highlighting specific elements of social capital within the cultural context:

  • Building of trusting relationships between the health worker and service user
  • Deepening connections in the community, particularly with family members
  • Enhancing public awareness of mental health thereby minimising stigma
  • Traditional beliefs of mental illness impacting perceptions of recovery
Sierra Leone Psychiatric Hospital in Kissy

Sierra Leone Psychiatric Hospital in Kissy

From the data collected in this feasibility study, the research team will continue to collaborate with stakeholders in Sierra Leone to enhance the psychosocial skills of mental health workers through adaptation of the intervention model and development of a training programme.

Training Community Health Officers in Bo

Training Community Health Officers in Bo

Connecting People goes global!

This week the Centre for Mental Health Social Research at the University of York announced funding for a new project to explore the feasibility of adapting the Connecting People Intervention model for use in Sierra Leone. The project is funded by the Wellcome Trust and the University of York via the Centre for Chronic Diseases and Disorders (C2D2).

The grant will fund the Connecting People study researcher, Meredith Newlin, in collaboration with Dr Susie Whitwell from King’s Centre for Global Health, to visit Sierra Leone in July 2013 to explore how social interventions can help to meet the needs of people with mental health problems. The study will use ethnographic methods to evaluate the feasibility of adapting the Connecting People Intervention model and developing a sustainable training programme.

Early discussions with the Government of Sierra Leone, the Ministry of Health and Sanitation, service providers, NGOs, and the Mental Health Coalition, indicate the need to strengthen skill training in Sierra Leone to support existing services with evidence-based solutions. Findings from the study will be used to enable us to co-produce interventions with collaborators in Sierra Leone, which will ensure that Western approaches are not imposed where they may be inappropriate.

There is increasing evidence to suggest that the application of knowledge in developing countries is failing. A gap exists between what is known from research and what is done to apply it. To address this gap we aim to evaluate the knowledge transfer of psychosocial interventions for adults with mental disorders in low and middle income countries using a systematic review and preliminary data from this feasibility study in Sierra Leone.

The World Health Organisation has long been concerned about the gap between the high numbers of people with mental health problems and the limited availability of medication. This treatment gap is particularly large in low and middle income countries. However, Western medicine and therapy is arguably not universally appropriate.

Social interventions can help to fill the treatment gap for people with mental health problems in low and middle income countries. They receive a low priority from funding bodies, but have the potential to improve the quality of life, social participation and well-being of people experiencing mental distress. Our exploratory work will determine whether or not it will be possible to adapt the Connecting People Intervention and co-produce a version for the local context in Sierra Leone. Working with collaborators in Sierra Leone led by Dr Carmen Valle (University of Makeni), we aim to see if this is possible.

This first project for the new Centre for Mental Health Social Research at the University of York is an international collaboration involving Dr Elizabeth Hughes (Mental Health and Addictions Research Group, Department of Health Sciences, University of York), Dr Oliver Johnson (King’s College London), Professor David Morris (University of Central Lancashire)  and Dr Lynette Joubert (University of Melbourne, Australia).

International reach of the Connecting People Intervention

I am very fortunate to hold two roles with the Connecting People Intervention: one, as the full-time London based research worker on the pilot study, and two, as a part-time PhD student exploring the international scope of the intervention model.  To address the wide gap in global mental health implementation research and to promote capacity building of researchers in lower-and middle-income countries, I am working on expansion of the Connecting People Intervention to under-developed contexts that currently lack critical resources and skills.

Juggling two roles is not unfamiliar to me, for several years I have pursued my career in psychology research whilst also serving as a director for the small African development charity, SpanAfrica.   But until very recently these two passions for me—the drive to inform evidence-based research and to support meaningful change in underdeveloped countries—have not converged.  This is precisely the reason I jumped at the opportunity to explore the feasibility of taking the UK-based Connecting People Intervention to low- and middle-income countries (LAMICs).

I believe the Connecting People Intervention model has great potential to enhance health and wellbeing of vulnerable populations in LAMICs, especially with its focus on social participation.  I see the intervention as an opportunity to enhance social relationships between individuals whilst also developing the local community through existing services.  But most importantly the intervention model we have developed in the UK cannot simply be imposed on communities across the globe, instead my PhD will explore the ways that the CPI can be adapted to fit the local context.

With a background in health psychology and experience working in severely disadvantaged areas of Africa, I am often challenged by the varying approaches to addressing health inequalities through sustainable development.  We see blanket approaches where non-governmental organisations and international institutions will address seemingly similar issues exactly the same across vastly different countries or regions.

A story comes to mind of an NGO who visited a small rural town and asked male leaders what they needed most for their community. They responded, “a water well” because the women had to walk miles each day to access clean water.   The well was constructed but shortly after installation many people in the community fell ill and they determined it was the new well. What the male leaders didn’t understand was how important that daily walk was for the women.  It was their time for socialising, peace, and exercise.  One woman missed that time so much that she began contaminating the well water just to have that time back.  This is a story that reminds us the importance of truly addressing the needs of the entire community. Whilst the NGO had good intentions, and even worked with the local leaders, it wasn’t sustainable to the entire community.  Of course clean water is vital but perhaps the NGO could have consulted the entire community and in addition to providing clean water also considered opportunities for social participation.

Integral to conducting research in LAMICs is the need to establish strong relationships with key stakeholders to capture a realistic description of the challenges faced by vulnerable adults in the community.  Recently I have been collaborating with individuals from the King’s Centre for Global Health to explore the possibility of piloting the Connecting People Intervention in Sierra Leone.  The connections we are making now will enable us to reach individuals across health and social care systems in Sierra Leone to engage with community-based organisations, medical professionals, religious and community leaders, other mental health researchers, policy makers, and importantly, service users.  Connecting with these individuals in the research development stages, we seek to find the critical balance between addressing local needs in Sierra Leone with the innovative approaches that have been found effective in the UK.

We have developed a multinational research network that draws expertise and skills from diverse disciplines including social work and social policy, social and health psychology, medicine and nursing, global health policy and international development.  As a team we are scattered across the United Kingdom, Sierra Leone, and Australia with connections around the globe in these diverse fields of research and practice.

In order to assess the feasibility and acceptability of the CPI in Sierra Leone, we are arranging travel to Sierra Leone to engage with local stakeholders and gain a better understanding of the mental health services available as well as identify where significant gaps exist, forming the foundation for a needs assessment.  Drawing upon the extensive network of our international research team members in Sierra Leone we will use ethnographic methodology to gain a comprehensive description of the local context. This work will establish the potential for the model to benefit the outcomes for service users and inform the planning the protocol for a future pilot study.