Perspectives and concerns of clients at primary health care facilities involved in evaluation of a national mental health training programme for primary care in Kenya.

0.21 MB·English

by  Othieno, Caleb

Othienoetal.InternationalJournalofMentalHealthSystems2013,7:5
http://www.ijmhs.com/content/7/1/5
RESEARCH Open Access
Perspectives and concerns of clients at primary
health care facilities involved in evaluation of a
national mental health training programme for
primary care in Kenya
Caleb Othieno1, Rachel Jenkins2*, Stephen Okeyo3, Julyan Aruwa3, Jan Wallcraft4 and Ben Jenkins5
Abstract
Background: Acluster randomised controlled trial (RCT) ofa national Kenyan mental health primary care training
programme demonstrated a significant impact on thehealth,disability and quality oflife of clients, despitea severe
shortage ofmedicines inthe clinics (Jenkins et al. Submitted 2012).As focus group methodology has been found
to be a useful method of obtaining a detailed understanding of client and health workerperspectives within health
systems (Sharfritz and Roberts. Health Transit Rev 4:81–85, 1994),theexperiences of theparticipating clients were
explored through qualitative focus group discussions inorder to better understand thepotentialreasons for the
improved outcomes inthe intervention group.
Methods: TwoninetyminutefocusgroupswereconductedinNyanzaprovince,apooragriculturalregionofKenya,
with10clientsfromtheinterventiongroupclinicswherestaffhadreceivedthetrainingprogramme,and10clients
fromthecontrolgroupwherestaffhadnotreceivedthetrainingduringtheearlierrandomisedcontrolledtrial.
Results:Thesefocusgroupdiscussionssuggestthattheclientsintheinterventiongroupnoticedandappreciated
enhancedcommunication,diagnosticandcounsellingskillsintheirrespectivehealthworkers,whereasclientsinthe
controlgroupwereawareofthelackoftheseskills.Confidentialityemergedfromthediscussionsasasignificantclient
concerninrelationtothevolunteercadreofcommunityhealthworkers,whoseonlytrainingcomesfromtheir
respectiveprimarycarehealthworkers.
Conclusion:Enhancedhealthworkerskillsconferredbythementalhealthtrainingprogrammemayberesponsiblefor
thesignificantimprovementinoutcomesforclientsintheinterventionclinicsfoundintherandomisedcontrolledtrial,
despitethegeneralshortageofmedicinesandotherhealthsystemweaknesses.Thesefindingssuggestthat
strengtheningmentalhealthtrainingforprimarycarestaffisworthwhileevenwherehealthsystemsarenotstrongand
wherethemedicinesupplycannotbeguaranteed.
Trialregistration:ISRCTN53515024.
*Correspondence:[email protected]
2WHOCollaboratingCentre(MentalHealth),InstituteofPsychiatry,King’s
CollegeLondon,London,UK
Fulllistofauthorinformationisavailableattheendofthearticle
©2013Othienoetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative
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Othienoetal.InternationalJournalofMentalHealthSystems2013,7:5 Page2of7
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Background system approach. The content of training is informed by
Mental disorders are common in primary care across the above earlier qualitative and quantitative studies and
the world. A few specific interventions for single disor- closely aligned to the generic tasks of the health workers
ders or single client groups in low income countries on child health, reproductive health, communicable and
have been evaluated but it remains challenging to scale non-communicable diseases, and the training delivery
up for all the usual mental disorders and client groups integrated into the normal national training delivery sys-
within existing human and financial resources [1,2]. At tem [19,20].
present, in African countries, on average only 0.7% of This mental health continuing professional develop-
the health budget is spent on mental health services and ment (CPD) training programme (known as the KMTC
national health budgets in Africa are often only around mental health CPD training programme) is a 5 day 40
10 USD per capita per year [3]. This means that there is hour programme conducted through theory, discussion,
a need to develop interventions that are affordable in role plays and videos, and consists of 5 modules, with
the context of wider priorities and the current low the first covering core concepts, the second core skills,
resource situations prevailing in low income countries. the third common neurological disorders, the fourth
There is evidence to suggest that general integration of psychiatric disorders (content based on the WHO pri-
specialist programmes into general health systems mary care guidelines for mental health, Kenya version
achieves better outcomes than more targeted disorder 2006) and the fifth module covering health sector and
specific narrow integration[4]. other sector system issues of policy; legislation; links be-
Over the last 12 years, the Kenyan and Tanzanian go- tween mental health and child health, reproductive
vernmentshavecollaboratedwiththeWHOCollaborating health, HIV and malaria; roles and responsibilities;
Centre, Institute of Psychiatry, and key stakeholders in health management information systems; working with
nationalsituationappraisal,includingepidemiologicalsur- community health workers and with traditional healers;
veys and stakeholder consultations and assisting develop- disaster planning (included after the 2007 Kenyan con-
ment of national policies, strategic implementation plans flict, and consistent with the IASC guidelines [21]) and
and integration of mental health into national health integration of mental health into annual operational
sector reforms [5-7]. This previous work includes: a plans. Each participant has to complete over 27 super-
detailed situation appraisal of context, needs, resources, vised role plays on different topics in the course of the
provision and outcomes using the mental health country week, and to observe and comment on 27 role plays
profile [8]; a household survey exploring the conceptual conductedbycolleagues.
model underlying the views of the general population The KMTC mental health CPD training course was
about mental illness [9]; a focus group study of 60 tra- developed and piloted in three courses in 2005; it was
ditional healers in Maseno District exploring their views contributed to by colleagues from primary care, the
of mental illness, aetiology and treatment [10]; a national Ministry of Health respective health programmes, Uni-
survey of views of district level staff about mental illness versity of Nairobi, and the professional and regulatory
[11];studiesinTanzaniaandKenyaofattitudesofprimary bodies for nurses and clinical officers. The course has
carestaffaboutmentalillness[12,13];epidemiologicalsur- been approved by the Kenya Nursing Council and the
veysofmentaldisordersintwosamplesof1000peoplein Clinical Officer Council of Kenya for 40 hours continu-
urban Dar es Salaam,Tanzania [14-16], and in Maseno, a ing professional development, now mandatory in Kenya.
town in a rural district near Kisumu [17,18]; and adapta- Role play scenarios are derived from real Kenyan clinical
tion of the World Health Organization primary care cases.
guidelinesforKenyaandTanzania. In 2010 the research project conducted a phase 2
Kenya, like a number of sub Saharan African coun- exploratory trial as a pilot cluster RCT testing the
tries, has a complex layered primary care system effect of an affordable low cost training intervention -
(described in detail elsewhere [6]), with the first level integrated with the national health sector reforms -
representing the community, the second level represent- intended to be accompanied by routine supervision
ing dispensaries, the third level health centres, and the from district staff, routine availability of medicines in
fourth level district hospitals and their outpatient clinics. the clinics, and provision during the training
Since 2005, the Kenya Ministry of Health has conducted programme of WHO primary care guidelines adapted
a programme to train 3000 level 2 and level 3 primary for Kenya: (i) on the competencies of primary care
health care staff across Kenya in collaboration with the staff to recognise mental disorders, treat and make
Kenya Medical Training College (KMTC), Kenya Psychi- appropriate referrals to the scarce specialist service;
atric Association, and the WHO Collaborating Centre, (ii) on recovery (improved health and social outcomes
Institute of Psychiatry, funded by Nuffield International and quality of life) of clients. The trial was conducted
Foundation and using a sustainable general health in a real clinical field setting, using local trainers
Othienoetal.InternationalJournalofMentalHealthSystems2013,7:5 Page3of7
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(who had been trained in 2006, received a refresher The focus group discussions were held in August
course in 2009 and had delivered several such courses 2011, eight months after the end of the randomised con-
per year since 2005) to train health staff in the inter- trolled trial, during a residential two days in a small
vention group. The project did not exert any special hotel at Chulaimbo, near Kisumu, which was easily
influence on the usual local availability of medicines, accessible by all those invited. They were conducted by
district supervision or local health management infor- CO assisted by RJ, and each lasted 90-120 minutes.
mation systems. During the course of the trial Kenya, Discussionswere conductedmainlyinEnglish,butalso
and especially Nyanza Province, experienced a severe in the local language where participants could not
shortage of medicines, and this was reflected in the understand English or found it easier to express them-
research findings on medicine availability in the selves in Luo. Avoice recording of all the sessions was
clinics participating in the trial. Nonetheless, the trial made, and both RJ and JA took written notes which
found significant improvement in the clients of the were used to help clarify the transcript material where
trained health workers in the intervention group com- necessary.
pared with those in the control group [22]. Therefore, at
the request of the funder (the UK Department for Inter- Instruments
national Development) we conducted focus groups with Thediscussionswere guidedbythefollowing questions:
some health workers and clients from the trial to better
understand their perspectives and experiences. Focus 1. Could youdescribetousyour experience in
groupmethodologyhasbeenfoundtobeaneffectiveway attending the health centre?
to explore health worker and client views within health 2. Describe theresponseyougetwhenyoupresentan
system contexts [23]. This paper reports the experiences emotionalproblem tothe health worker.
of the clients, and an accompanying paper reports the 3. Whatisyour viewregarding the communication
experiencesofthehealthworkers. between youandthe health workers:
4. Doyoufeelunderstood?
5. Doyoufindthehealthworkerhelpful?
Methods
6. Howmuchtimedoyouspendwiththehealthworker?
During the randomised controlled trial, we had followed
7. Areyougivenan opportunitytoaskquestions?
up for 3 months 12 clients positive on the General
8. Doyougeta satisfactoryexplanationaboutyour
Health Questionnaire in each of 100 clinics. For the pur-
condition?
pose of the focus group study we contacted one such
9. Whatfurther informationwouldyoulike?
client from each of 10 intervention clinics, and 10 con-
10.Whattreatmentoptions didthe health worker
trol clinics, selected at random. We invited them to take
provide?
part in one of four ninety minute focus groups (10 clients
11.Wereyoureferredanywhere else?
from the intervention clinics and 10 clients from the con-
12.Pleaserateyour satisfactionwith theservices
trol clinics). We paid respondents’ transport and subsist-
13.Haveyounoticedanychangesinthewayyouare
ence for the day they came for the interviews. No
treated atthe health centre?
additionalpaymentsweremade.Therewasnocommunica-
14.Whatimpact hasithad onyour health?
tionaboutthestudybetweenthedifferentgroupsofpartici-
15.Doyouhaveanyother concerns?
pantsbeforetheirrespectivefocusgroupswereheld.
The guideline questions were used to structure the
Ethicalconsiderations,explanationandconsent conversation. However the clients were allowed to dis-
Ethical approval was obtained from Kings College cuss issues which they felt were important to them.
London ethical committee and the University of Nairobi Thus issues that were not explicitly spelt out in the
ethics committee. An explanatory information sheet guideline questions came up. In the analysis as stated
was given to each client in English and Kiswahili, and common themes were grouped together. For example
read out to those who could not read. We explained questions 2 – 9 were brought up issues concerning
verbally in English, Kiswahili and Luo to the partici- communication. Questions on satisfaction with the
pants the purpose of the meeting and asked for their health services, other concerns (questions 12 – 15) led
individual consents. They were reassured of confiden- to discussions on confidentiality, and the need for more
tiality and told that we wanted to learn from their frequenthomevisits.Treatmentoptionsandreferralissues
experiences. We then assigned each participant an (questions 10 – 11) arediscussed under coordination. The
identification number. They were told that the con- patient’s experiences of taking emotional problems to the
versations would be taped but they would not be clinics (1) brought up issues of recognition of mental
identified by name. healthproblemsandtreatmentsoffered.
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Dataanalysis Some clients in the control group reported major con-
The recordings of the discussions were transcribed and cernswith theway theywere communicatedwith during
translatedintoEnglishwherenecessary.Thevoicerecord- childbirth:
ings and the transcripts were analysed for common
themes emerging in response to the guideline questions. “Firstly,whenyousee awoman whoisinlabour
Matrices werecreatedtohelp facilitatethe comparison of struggling,youdonot tellher shocking things.For
textacrossthedifferentcategoriesofinformant. example,ifthebaby isstucknexttoherheart and
these arethingswhichfrightenus.Hencewhenyou go
Results of client focus group discussions totheclinic,youfeelyou willbedead. You(nurse)
All those invited attended, namely 10 clients from the shouldjustkeep quieteven whenthechildiscoming
intervention group and 10 from the control group. Each outbythelegs.You(nurse)shouldjusttellher ‘keep
wasfrom adifferenthealthcentre. cool mamathingswill be alright’.”Client4,control
group.
Healtheducation
The patients in both intervention and control groups
reported receiving general educational talks in the “Another onecancheatwomen that ‘mamathetimeis
clinics, which involved mainly nutrition, HIV informa- not yetjustbepatientthere’andyetthewatershave
tion andhygiene: started pouringout.”Client6,control group.
“What Icansayabout ourclinicisthat we arebeing “Sometimesyouareharassed,beatenand evenabused
taught.Ontheclinicdaysall patientsare assembled and thesethingsmake you feelbad.”Client8,control
togetherandtaught about food...we aretaught we group.
shouldnot justeatfishand meatbut alsoconsider
having vegetables.”Client3,control group. “When Iwastaken toBondoin2006forablood
transfusion,the veinscould notbe traced andthe
They requested to be given more education on mental doctortoldme,‘woman,you havenoluck’.If youare
health:
told youarenot lucky,youare automaticallygoing to
die. Youwilldie because youhavelosthopeofliving.”
“Ijustwantedtoask,thisstresswhichoftencomesto
Client4,control group.
me,whydoesitcome,becauseIthinkalot?”Client6,
controlgroup.
There were also complaints from clients in the control
group abouttheway people with HIVwere treated:
Communicationskills
Clients in the intervention group reported a welcoming
“That sisterwhenshediagnosedyouthat youhave the
reception in the clinic while the control group described
disease(HIV),andwhenyou gotothehospital,she
poor reception and even rudeness. The patients in the
caneven abuse youthat youhave AIDS.When she
control group were generally less satisfied with the treat-
findsoutthat youarenot taking theARVs
ment offered in the health facilities. In particular they
accordingly,she alsoabusesyou infront ofothers,even
were dissatisfied with the way they were handled by the
if youdidnot want other people tohear...There are
health workers.
othersalsowhoharasspeople.”Client7,control
“Wewouldliketobetalked tosoftly andeducated.” group.
Client3,control group.
Recognitionofadultmentalhealthproblems
“Patientsshouldnotbe neglected oravoided even These were poorly recognised in the control group and
whentheyareterminally ill.”Client5,control group. one patient narrated how she had taken anti-malarial
tablets and paracetamol repeatedly for headache without
The clients from the intervention clinics had better improvement. When she consulted a doctor, she was
relations with the health workers and could easily talk to tested and treated for typhoid and she is still unwell.
them: Others described common mental disorders which had
not been offered appropriate treatment or referral. One
“Inmy areaitiseasyformetodiscusswith thehealth client wantedtoknowwhyshe hadstress,shesaid “Why
workers.Theywelcome usandmakeusathome,soit does it come and make me think a lot?... When many
iseasytoexplainmyproblem.”Client9,intervention things come my head stops functioning”. Another client
group. experiences frequent headaches, right in the middle of
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the head. It is aggravated by noise. She also feels pains “Attimes,patientsdonothaveadequatefinancesto
all over her body. She said, “I behave like someone buymedicineandwhentheygoonthatotherside
alreadydead”. (thegovernmentclinicpharmacy)theyareagainchased
away.Soaccordingtomethedoctorsshouldtrytofind
outinasofterapproachhowmuchmoneythepatients
Recognitionofchildren’smentalhealthproblems
have.Supposingtheydonothavesufficientmoney,can
Problems identified by the intervention group included
theybeallowedorhelped?”Client3,control group.
school refusal due to school phobia or anxiety; somatisa-
tion; substance abuse – illicit brew (chang’aa) and canna-
(b)Coordination
bis(bhang).Theclientsinbothgroupsrequestedpractical
Clients in the control group felt that more coordination
informationonhowtheycouldcopewiththeirchildren:
was needed when making referrals so that they are not
sent to and from the pharmacies, only to find that no
“Somechildrencouldbe fearing school.Some would
medicineswereavailable.
pretendthat theyare sick. Theorphans mightbe
mistreatedbytheirguardianwhichmay affectthem. “There aretimeswhenyougo toadoctor,he
Such childrenmay pretendtobe sick. Suchachild
prescribesmedicinesand hegivesyouprescriptionto
may needtosee thedoctor.”Client8,intervention
taketothepharmacist. You gotothepharmacist and
group.
you aretoldthere arenomedicines.What Iam
wondering, doestheprescribing doctor knowthat itis
Clientsviewsonareaswhereclinicimprovementis thereornot?”Client,control group.
needed
Moreareasneedingimprovementwerehighlightedbycli- “Doctorsshouldconsiderthe socio-economic status of
entsinthecontrolgroupthanintheinterventiongroup. thepatientswhenprescribingmedications andoffer
appropriatehelptoneedy patients.”Client,control
group.
(a)Communicationskills
The patients in the control group wanted better doctor
(c)Homevisits
patient relationships, respect for patients, not to be
The patients in the intervention group suggested that
blamed,abusedandassaultedbyhealthcarestaff,oreven
they shouldhavemorefrequenthome visits bythe cadre
chased away by them. The health care staff should learn
of volunteer community health workers as it was easier
how to break bad news to patients, involve them more in
todiscusssomeissues whentheywere athome.
management especially when making referrals, and not
neglect patients when they are seriously ill. Patients
“Communityhealth workers(CHWs)shouldvisitmore
shouldalwaysbegivenhope.
frequently toknowourproblems. Bydoing this,we
coulddiscussmore. Itiseasierwhentheycometoour
“Theyshouldbe taught onhowtospeakgentlytothe home.”Client,interventiongroup.
patientsbytelling themtoput Godfirstintheir
treatmentregardlessofthepatients’sicknesses. They (d)Confidentiality
shouldnot tellthepatientsthingswhichgivethem
However, they felt that the community health workers
shockssuchasdeathswhichcanfrightenthem.”
shouldobserve confidentiality.
Client,controlgroup.
“There are someCHWswhoarenot experienced
“If I may add a bit on the doctors following what enoughtouseconfidentiality. Thismayleadtostigma
my other sister has said,‘beatings’. There are some becausethesepeoplemaystart spreading.”
people who do not know how to talk to patients.
Patients should not be given sad news but they Incaseswhereconfidentialitywasnotreliablyobserved,
should be talked to politely by telling them to patients preferred travelling to hospitals far from home
believe in their God because he is a better healer wheretheycouldnotbeeasilyidentifiedbytheircommu-
than the doctors. Whether you are going to die you nitymembers.
should be talked to in a polite manner rather just
neglecting you.”Client,controlgroup. “Like inmycase,Idiscussedmy problems with the
community healthworkersand it spreadout.Now I
In addition they would like more help in situations feelmore freeexplaining tothehospitalsthan the
where theycannotaffordtobuymedication. community healthworkers.”
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Discussion with identifying risk and stabilising illness rather than
This is the first qualitative focus group study of clients helping recovery. UK clients do not have to contend
involved in a randomised controlled trial of primary care with shortage of medicines, nor do they generally report
training on mental health in Kenya. The study was con- verbal and physical abuse. Nonetheless there is still a
ducted in Nyanza province, Kenya, in the public sector mismatch of expectations and concerns at the primary
primary care system, and the study findings are limited care level between clients and health workers in the UK.
to this group, although are likely to havewider relevance Recent NICE (National Institute for Health and Clinical
for Kenyan primary care as a whole. Further limitations Guidance) guidelines and quality standards on patient
of the study include the fact that most of the research experience has set out the principle that high quality
team for the focus group study were also involved in the client experience should be at the heart of good clinical
randomised controlled trial. The use of both clients and care [30], and the data reported here indicates that cli-
health workers (see accompanying paper [24]) affords ents consider this principle to be just as relevant in
some triangulationofthe findings. Kenya asitiselsewhere.
From the focus group discussions it seems that the cli-
entsinclinicswherestaff hadbeentrainedintheKMTC
mental health programme experienced better reception, Conclusion
communication and overall support than clients in These focus group discussions suggest that the clients in
clinics wherestaff hadnotbeen trained. the intervention group noticed and appreciated enhanced
Since the drug supply was poor in both the control communication, diagnostic and counselling skills in their
and the intervention groups it is likely that these respective health workers, while clients in the control
enhanced psychosocial skills in the health workers, group were aware of the lack of these skills. These
noticed by both themselves (see accompanying paper enhanced generic health worker skills conferred by the
[24]) and their clients, are the factors that contributed to mental health training programme may be at least partly
better recovery in the clients in the intervention group, responsibleforthesignificantimprovementinoutcomeof
compared to those in the control clinics in the rando- patients in the intervention clinics where staff had
mised controlled trialreportedelsewhere[22]. receivedthetrainingprogramme,comparedtothecontrol
Thesestudyfindingsconcurwiththosefoundinaran- group,despitethegeneralshortageofmedicinesandother
domisedcontrolledtrialofthesametrainingprogramme healthsystemweaknesses.
in Iraq, where research observers found better diagnosis
and communication skills in staff trained in the pro- Competinginterests
Theauthorsdeclarethattheyhavenocompetinginterests.
gram, compared tocontrols[25].
These findings support the value of strengthening
Authors’contributions
mental health training forprimarycarestaff;the valueof
COthienochairedthefocusgroupdiscussions,suppliedthetranscriptionof
including major emphasis in the training on the core dataandthemainanalysisoffindings,andwrotethefirstdraftofthepaper.
generic psychosocial skills, and on the links between RJwasresponsibleforoveralldesignofthestudy,obtainedfunding,co-led
thefocusgroupswithCalebOthieno,andwrotethesubsequentdraftsof
mental health, malaria, HIV, child and reproductive
thepaper.SOsupervisedthelocalimplementationofthestudydesign.JA
health; and indicate that such training is worthwhile coordinatedtheinvitationsofclientandhealthworkers,andtooknotesof
even where health systems are not strong and where the thefocusgroupdiscussions.JWcheckedthequalitativemethodologyand
contributedtoUKcomparisonsofthediscussion.BJadvisedonthespecific
medicine supply cannot be guaranteed. The findings
contentofthefocusgroups,andorganisedtheaudiotapingofthe
suggest that such training would benefit from more discussions.Allauthorscontributedtoandapprovedthefinalversionofthe
emphasis on client confidentiality especially in relation paper.
to the volunteer cadre of community health workers,
Funding
whose training is generally delivered by primary care
UKDepartmentofInternationalDevelopment.
health workersinregularweeklytalks.
When comparing this Kenyan experiential data with Authordetails
1DepartmentofPsychiatry,UniversityofNairobi,Nairobi,Kenya.2WHO
that reported by clients and primary care doctors and CollaboratingCentre(MentalHealth),InstituteofPsychiatry,King’sCollege
nurses in the UK, where there is also an agenda to take London,London,UK.3GreatLakesUniversity,Kisumu,Kenya.4Universityof
people and their lived experience into account to deliver Birmingham,Birmingham,UK.5Zacchaeus2000Trust,London,UK.
more effective services [26,27], UK focus groups have
Received:31August2012Accepted:10November2012
found that clients see primary care as the corner stone Published:23January2013
of their health care [28,29] but, like the Kenyan clients,
perceive that primary care professionals give more prior- References
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