Category Archives: Sierra Leone

Latest news on our work in Sierra Leone

Meredith Fendt-Newlin has just returned from a visit to Sierra Leone where she met with the nurses we trained in April to see how the Sababu model and intervention has impacted their practice. Here are her reflections on her visit.

 “The training greatly helped me to know to connect myself and my clients to other people or organisations for support.” – Sierra Leone Mental Health Nurse

Developed over the past three years, Sababu is a culturally adapted mental health social intervention that we’re currently piloting with mental health nurses in Sierra Leone. Meaning “connections that may bring benefit” in one of the local languages, Sababu incorporates elements of enhancing a service user’s social capital such as building trusting relationships, communication skills with service users and families, assessing an individual’s assets in addition to their needs, and networking in the community.

Click here to read Martin Webber’s first impressions of mental health services in Sierra Leone, 2014.

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Sababu Intervention model

In April we ran a five day training workshop with 20 mental health nurses, after which they returned to their posts in each of Sierra Leone’s 14 districts. Last week we brought the nurses back to Freetown for refresher training, supervision and a chance to hear how the Sababu model has impacted their practice.

Using case examples from the past three months we discussed ways in which the nurses have been using the Sababu model in their practice during a peer supervision activity. Splitting into small groups of three we asked one nurse to present a difficult case, one to play the role of the supervisor, and the third person to observe and provide feedback on what the nurse could do to improve.

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Sierra Leone Mental Health Nurses presenting cases during peer supervision

This activity illuminated some of the many challenges currently faced by the nurses. In Port Loko, still an Ebola “hot spot”, fifteen young people experiencing mental health problems were recently found in a camp held by a local traditional healer, chained to small huts and with little opportunity to move or interact. Health authorities removed the individuals and the nurse in Port Loko is now working to reintegrate them back into the community. She spoke of skills learned in the Sababu training that help her to draw upon the local networks and build relationships to support the recovery of these young people. Her peers made suggestions about which services in the community she might be able to access and offered to be available for peer support as she manages this influx of difficult cases.

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Disused signs from the former Ebola Treatment Centre at Jui Hospital, Freetown

Read more here about how the EVD outbreak has impacted our work in Sierra Leone.

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One of the Mental Health Nurses, an EVD survivor, describing her recent experience with the disease

The role of traditional healers is still very strong in most of Sierra Leone, especially in the rural districts where they have been the main source of treatment for many years. One nurse based in an Eastern province struggled to be trusted by the community when she first arrived as a mental health nurse. During role play she shared the process she needed to take in her district to build relationships with the District Medical Officer, the traditional healers, and families by working in collaboration to support service users in the community.  As we learned in April, giving the nurses an opportunity to practice new skills during role play is an effective way to translate theory into practice. And the nurses are brilliant actors!

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Nurses during role play

With only 20 newly trained mental health nurses across the country the referral systems are yet to be fully established; in many areas more advocacy and promotion of services is needed. One of the nurses trained a small group of hospital-based general nurses in mhGAP and aspects of Sababu so they could recognise symptoms and refer to her as appropriate. The establishment of a skilled workforce through such ‘link nurses’ enables the mental health nurse to spend more time with service users and their families.

Click here to view a BBC video with Mental Health Nurse Jennifer Duncan, talking about ways to support people affected by Ebola

 People have known for thousands of years that the best way to understand a concept is to explain it to someone else. “While we teach, we learn,” said the Roman philosopher Seneca. Feedback from the April training indicated the nurses wanted to have more experience, skills and resources to train others in the District Mental Health units (DMHUs).

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Visiting the DMHU at Connaught Hospital, Freetown

 With this in mind, we obtained funding from the University of York Learning and Teaching Forum to create a series of short training videos that will enable us, and the nurses, to teach others about Sababu and how to adapt evidence-based social interventions for use with service users from diverse cultural backgrounds. The training videos include interviews with the nurses and their supervisors role play and other training activities, and visits to DMHUs in Freetown.

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Presenting nurses with Certificates of Attendance for the training; Researcher Meredith Fendt-Newlin wearing a dress that was a gift from the nurses for “Africana Friday”

The next stage of the research includes publishing the videos (check back on the ICMHSR blog for updates!), analysing and reporting findings from the evaluations, and looking at ways we can further adapt Sababu for use with social workers and Community Health Officers (CHOs) in Sierra Leone.

Piloting the Sababu Intervention in the wake of Ebola

By Meredith Newlin

The Ebola outbreak, which reached Sierra Leone in May 2014, quickly became a global health crisis and caused significant psychosocial distress and a disintegration of communities across West Africa. The case numbers are now dropping and Sierra Leoneans talk about the “aftermath” and a shift toward recovery phase. However, amid a resource-limited system there is still an urgent call to address the psychosocial needs of individuals and families by enhancing the skills and capacity of the existing workforce.

Our research in Sierra Leone began in 2012 with a feasibility study and development of a culturally sensitive social intervention to mobilise community resources and connect individual service users to supportive networks. In light of the Ebola outbreak, iterations to the intervention were made to address the changing needs of communities. Funded by the Maudsley Charity and one of several projects undertaken by the International Centre for Mental Health Social Research (ICMHSR), Martin Webber and I travelled to Freetown last week to pilot the intervention and determine its application and effectiveness during a humanitarian crisis.

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It had been nearly one year since we had been in Sierra Leone, and two years since seeing most of the nurses we’d be training. We were starting the week establishing relationships and coming together to learn from the intervention and model of practice we’d co-produced during that time. During the introductions I was given a Krio name, Mame, and was told this is a sign of respect. But I knew that earning the respect and understanding of this group wouldn’t be as easy as a name; that it would come over time, throughout the week.

The Sababu Training Programme offers techniques for training mental health workers within a social intervention framework. In Krio, ‘sababu’ means connections with other people, in particular, benefiting from connections with other people. Suggested as a suitable name for the training programme by members of Sierra Leone’s Mental Health Coalition and one of our partners, sababu relates to the notion of social capital, describing the connections among people and the shared value that arises from such relationships.

Over the week our group dynamic shifted. Using Tuckman’s theory we could see how each stage was experienced: forming, storming, norming, and performing. The week was not without challenges but each day we left feeling more energised and connected than the previous day. This group of 20 nurses has worked together for several years. Though now placed in each of Sierra Leone’s 14 districts to lead mental health services across the country, they come together quarterly for supervision and possess a wide variety of experience. Coming in as outside trainers meant that we needed to learn the group dynamic and assert our place with it.

In Sierra Leone there is a culture around receiving that is most often viewed in terms of tangible items. Mental health practitioners experience this as a barrier to their credibility in the community because most Sierra Leoneans are accustomed to getting ill with a short-term disease, with malaria, for example, going to hospital and receiving a tablet or treatment with an immediate cure. Mental health, contrastingly, is often longer course and infrequently treated with medication as supply is drastically limited. The nurses are up against this belief in their day-to-day practice.

We observed this week how the idea of tangible incentives carries over into learning and what the nurses expect to obtain from training. Questions arose about what the incentive of our training would be when knowledge was not immediately seen as a take-away. International aid organisations have plagued the training culture with per diems and financial incentives taking precedence over knowledge gained. It took us time to develop mutual understanding around the purpose of the Sababu training and how it could be seen as an opportunity to enhance practice, to better support the work they’re doing.

In many of the UK trainings Martin and I have done together we use a great deal of experiential learning, sharing difficult cases and success stories to relate the model to practice, building upon that knowledge from peers. But what we encountered in Sierra Leone is that the nurses didn’t feel there was learning happening if it came from peers and their own experience: they wanted to see what knowledge and expertise we as trainers could impart on them.

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Like many African cultures, Sierra Leone teaching is often characterised as using a didactic style. The teacher or trainer is seen as an authority figure with expertise to pass down to participants who listen and observe (typically in lecture format, powerpoint as preference). Coming to training the nurses expected new knowledge to be given and that they could sit as passive recipients. Which, unfortunately, translates to the need for “no sleeping” to be listed in ground rules!

Although it wasn’t immediately welcomed, our style of interactive training, with a great deal of practice through role plays and encouraging the quiet nurses to be actively involved, was eventually appreciated by most members of the group. Understanding their preconceptions of what training should look like, we didn’t need to drastically change our plans but found activities that would meet their needs whilst offering dynamic interaction. It did also help us to think critically about the pitch. We needed to ensure the nurses would walk away with specific strategies and tools to use in their practice so they felt they had learnt something.

During introductions one day, most described themselves first and foremost caregivers, thinking often of how to support others but very little about how to address their own problems. Reflective practice was a new concept to them and we found it was necessary to provide a step-by-step process in how to analyse their own problems, reflect on what they could have done better in their past experiences, and begin to apply such learning to new situations.

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We also spent a full day on social network mapping, first getting the nurses to write down their own networks and support systems. When it came time to practice using this approach with service users, it was clear that writing is not always possible—stationery may be unavailable, service users may be illiterate—and thus an approach of using one’s hand to discuss social networks was deemed more appropriate. We asked them to list five supportive figures, one on each finger, on the palm to imagine enjoyable activities and the wrist as a place to imagine a comforting proverb. We then needed to break down the specific questions they could ask a service user to elicit information about their assets and resources to access in the community. By repeating these questions in role play we hope the nurses turn this new approach into tacit knowledge and make changes to their usual practice.

I noticed a pattern in each role play, it would start with the family member discussing why they had brought their son or daughter to see the nurse, the nurse addressing the family member first, sometimes speaking as if the service user wasn’t even present, and only after the family member had shared their story would the nurse turn to the service user. I could see that part of this approach was to show respect to an elder, but on the other hand it undermined the service user and inhibited trust building.

One of our local trainers, George, paused the role play to put a rule in place: speak only to the family if your relationship with the service user has broken down. We could see this was a major shift for some nurses. Changing the tacit knowledge in how they’ve always practiced is not an easy shift. But this is why role play seemed to be one of the best training methods we used, it’s necessary for them to practice the concepts we were teaching. And in a storytelling culture they are all brilliant actors, usually keen to be the difficult/unresponsive service user or the loud angry parent!

On the final day of training the nurses were asked to complete evaluation forms to assess their reaction and satisfaction with the training, the extent to which their knowledge has been enhanced, and to gain feedback about how to improve the training in future iterations. I will return to Sierra Leone in July and October to evaluate the extent to which the nurses have been able to put this new knowledge into practice. At that time we will also offer refresher training sessions and create videos to be used in teaching this approach of social intervention development to social work students and practitioners, funded by University of York’s Teaching and Learning Rapid Response Fund.

 

Impact of Ebola on our work in Sierra Leone

Last week the World Health Organization (WHO) issued an international health emergency as the Ebola outbreak in West Africa has claimed nearly 1,000 lives since it was first detected in Guinea in February 2014. Ebola is a severe viral illness, transmitted by bodily fluids, with mortality rates of between 60 and 90 percent. The WHO said the outbreak is an “extraordinary event”.

Discussing how the outbreak has affected our research in Sierra Leone, ICMHSR researcher Meredith Newlin was interviewed by BBC York reporter Elly Fiorentini on Friday (listen here - start at 1.04.30). During the interview, Meredith explained how our research plans have changed in recent weeks as the country responds to the outbreak.  We had planned to visit Sierra Leone in September to deliver the co-produced training we developed with stakeholders during our last visit. However, when the Ministry of Health and Sanitation issued a state of emergency and began restricting travel, it became clear that it would not be possible to bring the nurses together from their posts in district hospitals across the country and we decided to postpone the training.

During the interview, Meredith discussed the importance of addressing psychosocial issues around the outbreak. As we saw during our visit in May, Sierra Leone’s health facilities have a shortage of doctors, nurses and infrastructure, and were struggling to cope even before this outbreak. Whilst public health information has been consistent, an “epidemic of fear” in Sierra Leone has led to suspicion and fear surrounding the disease and contributed to its spread.

Our partners in Sierra Leone, Enabling Access to Mental Health Sierra Leone (EAMH) and King’s Sierra Leone Partnership (KSLP) have held emergency response training for the 21 psychiatric nurses. The nurses are now focussed on providing mental health support to families and communities in some of the worst affected areas, an essential component of the country’s response to the outbreak.

Keeping in mind the safety of our research team and the nurses we will resume plans to deliver the training at a later date and in the meantime look for ways that we can support the mental health response.

Mental health social interventions in Sierra Leone

post by Meredith Newlin
Martin Webber and I have been in Sierra Leone to follow-up from my last visit in July 2013 when I conducted a feasibility study to explore the potential for developing social interventions with mental health workers. The initial visit, funded by the Centre for Chronic Diseases and Disorders (C2D2), was an opportunity to meet with a variety of stakeholders to better understand current practice and explore the extent to which principles social capital are relevant to the communities in Sierra Leone. The second visit, funded by Maudsley Charity, was focussed on co-producing a culturally appropriate social model and training programme for the nurses with local partners, as well as exploring the acceptability of this model of practice.

Findings from the feasibility study indicate enthusiasm for the potential of social interventions to promote meaningful involvement for adults with mental health problems, aiding in their recovery and enhancing social inclusion. Mental health services on the whole are extremely under-resourced and there is significant need for training in low-cost psychosocial approaches to mental health care at both the district and community levels. Findings from the feasibility study were developed into a short film, which can be viewed here.

Based on reflections from the feasibility study, we identified 21 trained psychiatric nurses as the most appropriate group to work with in future training, as they have strong mental health experience but are still limited in how they might be able to apply the biomedical model in which they were largely trained. Through conversations with our partners, King’s Sierra Leone Partnership (KSLP), EU-funded Enabling Access to Mental Health (EAMH), and the Sierra Leone Mental Health Coalition (MHC), we recognise gaps in their current practice around the social aspects of mental health, particularly the capacity for nurses to engage with service users social support networks such as family members and the wider community.

The 21 nurses received extensive training from the College of Medicine and Allied Health Sciences (COMAHS) and EAMH over the past two years. We acknowledge that new skills must fit into the training they have received, and this not meant to be replacement training but rather supplemental. It’s important that training modules and activities for interactive learning also serve as refresher to what they have already learnt. For example, nurses were trained in the MHGap Intervention Guide, the World Health Organization’s (WHO) flagship programme on mental health for scaling-up interventions by general health practitioners in low- and middle-income countries. The nurses have a strong foundation in diagnosing mental illness but what we suggest is an extension of their initial training in which we integrate practical application of social methods, enabling nurses to work in the most under resourced settings.

We heard from stakeholders the importance of teaching nurses about other community-based models of mental health services in African contexts. We will use the limited evidence available to ensure the training programme is in-line with strategies found to be effective in other West African countries. Also in regards to sharing good practice, we recognise the challenges faced by the nurses as they have been posted across the country in all 14 districts, thus peer support approaches are important to ensure the nurses learn from one another.

It is our hope that is in the future the model and training programme could be a useful tool and product for cross-disciplinary training. From the conversations we’ve had, the capacity for its use in other health sectors has been made clear; it might be useful in future training of social workers, PHU staff, CHO’s or primary care doctors. We plan to make the training bespoke for the variety of contexts the nurses are working in. For example, the nurses from the Sierra Leone Psychiatric Hospital in Freetown have different challenges and capacities to an outpatient hospital in Bo, and a community-based clinic in Kono District, but there are ways to take this approach to all these contexts.

Read Martin’s first impressions on mental health services in Sierra Leone here.

Connecting People in Sierra Leone

Recent estimates from the World Health Organisation (WHO) report an increase in the global burden of disease attributable to mental disorders.  However, about four out of five people in low- and middle-income countries (LMIC) in need of mental health services do not receive them.

Social interventions have the potential to fill the treatment gap for people experiencing mental distress in low and middle-income countries. As we are learning from the UK-based pilot study of the Connecting People Intervention (CPI), social interventions can improve the quality of life and community engagement for people with mental health problems. Previous work exploring social capital interventions in India and Malawi suggests the CPI could benefit low-income communities where enhancements to mental health services have potential to boost community development thereby decreasing health inequalities.

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Univeristy of Makeni 

International research is an opportunity to share knowledge across boundaries to evaluate social interventions in different international social, cultural and economic environments. To address this need we are exploring ways in which the social capital principles of the CPI can be adapted and translated to LMIC.

In Sierra Leone, 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, we have begun working with collaborators from King’s Sierra Leone Partnership to address significant barriers to mental health care.

Psychiatric Nurse TRaining
Psychiatric nurse training

Funded by the Wellcome Trust and the University of York via the Centre for Chronic Diseases and Disorders (C2D2), ICMHSR researcher Meredith Newlin and colleague  Dr Susie Whitwell from King’s Centre for Global Health, visited Sierra Leone in July 2013 to explore how social interventions can help to meet the needs of people with mental health problems. Preliminary findings from the feasibility study indicated significant need for psychosocial skill training to strengthen the care available to adults with mental health problems.  Feedback on the adaptation of the CPI was positive and will continue in the second phase of our work in Sierra Leone.

Training Community Health Officers in Bo

Training Community Health Officers in Bo

The second phase of the research, funded by the Maudsley Charity, will be to continue building an evidence base for the translation of social interventions to low-resource settings. To ensure an iterative approach we are working collaboratively with key stakeholders in Sierra Leone to adapt the CPI model to the local communities and build capacity of mental health workers through a co-produced training programme.

Back in the UK, C2D2 are funding the creation of a short film about this project which will be premiered at our next ICMHSR seminar on 26th September when Meredith will talk about her recent trip to Sierra Leone. More information about this free seminar can be found on our events page.