"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.
VISIONS OF THE FUTURE: Building Tomorrow's Community Health Workforce
As part of the ‘Symposium on CHWs and Their Contribution Towards the Sustainable Development Goals’ (link is external)Makerere University (Uganda), CHW Central, Nottingham Trent University (UK), and World Vision are supporting a series of interviews with academic leaders and experts in international health development and delivery fields to provide their vision of the future of CHWs in a new light.
We will explore: How can CHWs create lasting impacts in the era of the Sustainable Development Goals? What steps need to be taken to scale up, empower, and create changes within in our global workforce?
The interviews will be posted on CHW Central over the next weeks as part of the preparation for the Symposium taking place from February 21st-23rd in Uganda. Past interviews will be posted on the CHW Hub.
Read our fourth interview with Dr. Alison Schafer below.
Dr. Alison Schafer is trained in clinical psychology specialising in Mental Health and Psychosocial Support (MHPSS). Her experience includes humanitarian responses to Sierra Leone’s Ebola crisis, the protracted Syria conflict and in the occupied Palestinian territories of West Bank and Gaza. She has conducted research into cross-cultural mental health issues facing people in South Sudan, as well as mental health and psychosocial programs in China, Sri Lanka, Haiti, Darfur, Kenya and Uganda, amongst others. She has been directly involved in development of key methodologies for MHPSS including Psychological First Aid for humanitarian responses, Interpersonal Psychotherapy Groups in emergencies and Child Friendly Spaces. Alison represents World Vision on the Inter-Agency Standing Committee (IASC) mental health and psychosocial support reference group and is rostered as a mental health expert for the WHO. Alison is a Board Director of REPSSI, a Southern Africa non-government organisation, who are working towards being specialist responders to children’s psychosocial needs in Africa. As a clinician, Alison has worked in private practice, community and family mental health services, and works as crisis and suicide telephone counsellor.
To access Alison Schafer’s publications through PubMed click here.
To download Psychological First Aid and other key WHO resources for mental health click here.
To learn more about REPSSI click here.
What is your vision of how ‘tomorrow’s CHWs’ could be working better in the domain of mental health?
We know that reducing the current gap of mental health care is going to require fundamental elements of task shifting, whereby specific tasks, such as mental health treatment, care and support, are ‘shifted’ to those with fewer qualifications and minimum-standard training. With 20% of the world’s population experiencing mental disorder at any point in time (one in five persons), less than 20% of these receive any form of evidence-based mental healthcare treatment. The majority of those lacking treatment are in low and middle income countries, where psychiatric, psychological and clinical social work personnel are extremely insufficient. In order to reach more people with evidence-based mental health care, community-based and community-facing approaches are going to be essential. Evidence is now well-established that CHWs can be trained in evidence-based mental health treatments (e.g. WHO's Problem Management Plus [PM+] and Thinking Healthy), ultimately task-shifting mental health care to a lower cadre of health worker and easing the load on scarce mental health professional resources. One of the greatest benefits of such approaches is that individuals with more common mental health problems are treated in a low-cost but still evidence-based way at the primary or community level; which further reduces the load on limited professional mental health services and personnel allowing their attention to be offered to the most severe and complex cases of mental disorder. To deliver such mental healthcare coverage moving forward, CHWs are going to be the key to achieving this outcome.
Why CHWs? What is the unique contribution of this cadre to mental health?
CHWs have such a unique opportunity to contribute to improved mental health care. CHWs usually visit clients in their homes and are well trusted in the communities. They know their clients individually and the relevant members of their client families. They routinely visit clients for health issues; and in this process might be the first to observe that certain clients are not coping well, are showing impaired functioning or psychological distress. As frontline health workers, CHWs can offer first line support where needed and help to facilitate the mental health care individuals require. This would normally involve a fairly basic assessment, which they could be trained to undertake themselves, or simply a referral for assessment. Depending on the problems and mental health treatment required, CHWs may be able to provide:
- direct treatment (e.g. WHOs Problem Management Plus [PM+] is a brief 5-session evidence-based intervention for common mental health problems, which can be provided by non-professional mental health workers, such as CHWs)
- support and follow-up to ensure clients attend mental health referrals (e.g., for assessments or treatment);
- treatment compliance, such as encouraging clients to attend regular treatments and/or take prescribed medication;
- monitoring of individuals living with mental disorder and ensuring their conditions do not become worse, and if so, support them to review their treatment needs; or
- community engagement and social support, helping ensure the inclusion of individuals living with mental disorder to be better involved in community activities;
- support linkages for clients to other community services, such as protection, legal, financial, livelihoods and other programs.
No other cadre of health worker has the opportunity to offer all these aspects of support. Unlike CHWs, most health workers are not personally familiar with individuals and their lives, the activities and supports within the community, nor have the chance to always be in regular contact with individuals. With just minimal training, CHWs have the potential to care for individuals living with mental disorder and contribute to their treatment needs, whether that is by providing direct treatment (e.g., PM+) or referral support.
What are the best ways that CHWs could work to contribute to the “prevention and treatment” and promotion of “mental health and well-being” described in target 3.4?
Prevention of mental disorder and promotion of mental health are two sides of the one coin. Across the lifespan, promotion of mental health can begin before life begins, with mothers encouraged to prepare their bodies well for pregnancy, and then to receive the best possible ante natal care for optimal growth and development of their babies. From birth, the intricate relationship between mother, father and caregivers and the infant, as well as opportunities for newborns, and in their first 5 years, to receive strong social, emotional, physical and neurological care is one of the best known ways to help prevent disorder later in life. Naturally, the mother’s mental health and wellbeing is directly correlated to these early childhood development years. CHWs can therefore play a huge role in supporting families to raise children in ways that are likely to support mental health in the long term. Further to this, CHWs can be trained to identify and possibly treat common and less severe mental health problems before they worsen – be that in the parents, the children, or others in the community, such as youth. It is a known fact that early identification and intervention for mental health problems can contribute to more severe mental disorder and help prevent future relapse. CHWs are at the frontline of community health and best placed to be the first to identify and intervene where needed.
What resources, skills and policies will be needed to see this change come about?
One of the great global debates today is whether it is realistic, fair and just to be asking CHWs to continue working on what is mostly a ‘volunteer’ basis. Their benefit to community health, including mental health, is increasing and thus more pressure is being placed on CHWs to undertake more work and dedicate more time to their volunteer commitments. As such, resolution about embedding CHWs as a formalised and fairly paid cadre of health worker, in most LAMICs, must be examined. One of the additional advantages of treating CHWs as a paid workforce rather than a volunteer workforce is that it would become easier to ensure their skills remain updated and stronger supervision for quality of interventions could be established. Although consideration to pay a CHW in health systems would incur substantial government health investment, the returns would irrefutable in the long term, resulting in healthier communities and less burden of healthcare at the primary, secondary and tertiary levels.
What specialised and generalist approaches have already been evidenced to work effectively with CHW cadres?
Multiple evidence-based approaches are now known to be effective in working with CHWs to identify and treat common mental health problems. Four major approaches, with strong evidence and publication by WHO as part of their mental health gap series. These include:
- mhGAP: an intervention that encourages mental health care and support at the primary health care level, however, CHWs have been shown to be critical to the success of mhGAP by being trained in the early identification of cases that may require primary healthcare mhGAP support;
- Thinking Healthy: A targeted intervention for mothers with postpartum depression, shown to be effective when delivered by CHWs in reducing common symptoms of depression and increasing their functional capacity to care and provide optimal early childhood development opportunities for their infants;
- Problem Management Plus (PM+): A brief (5 x 90 min session) individual treatment for common mental health treatments can be effectively delivered by trained and supervised CHWs to reduce common mental health symptoms and increase daily functioning. The advantage of PM+ is that individuals do not require formal diagnoses to be identified for treatment and it may address multiple conditions at the same time (e.g., depression, anxiety, posttraumatic stress disorder).
- Interpersonal Psychotherapy for Groups (IPT-G): Possibly the longest known evidence based intervention for small groups of individuals with depression; and known to also support those with other mental health conditions such as anxiety, harmful alcohol/substance use and traumatic stress. CHWs are trained and supervised to deliver 8 or 16 week IPT-G programs to small gender disaggregated groups of 10-14 people.
The WHO and global mental health community are continuing to assess the effectiveness of multiple other approaches with a focus on task shifting for the delivery of mental health care and treatment. The trend for CHWs to provide evidence-based care for individuals with mental health problems will continue to evolve and grow in the coming years.
Mental health services at the primary and secondary care levels are often lacking in developing nations – should these be in place before we can work with MHPSS at community level?
Context is an essential part of ascertaining community-based mental health care needs as is the full mapping of the wider services available. Wider services may be formal (e.g., health services) or informal (e.g., local community legal processes, or faith groups) and each are as important as the other. While formal secondary care levels of service may be lacking in developing countries, informal supports will always be there in some shape or form. As such, it is generally viewed that formalised mental health services do not need to be in place before we can work with MHPSS programs at the community level. However, the level and extent of care that can and should be provided needs to be carefully considered as part of determining what MHPSS services are implemented. For instance, in a community with zero referral options the focus on wider community mental health promotion and prevention of disorder might be a better aspect of focus than training CHWs to identify more complex cases of mental disorder. Given MHPSS is one of the fundamental social determinants of health, some MHPSS and promotion is likely going to be beneficial at the community level to support the health of its constituents.
How do you see the demographic need for MHPSS changing over the next 15 years?
Improvements to the early identification of mental, neurological and developmental disorders in childhood will be a growing feature and need for effective MHPSS in coming years; with evidence now showing that about half of all mental disorders have an onset before the age of 14 years. As such, early identification and intervention will help reduce the long-term burdens of mental healthcare and disease. Further to this, early identification and treatment will lead to high education and financial productivity and ultimately contribute to reducing systemic and/or cyclic (e.g., within families) poverty. Linked to this is the likelihood of growing needs for youth mental health promotion and care. Currently around the world, suicide is estimated to be the second leading cause of death amongst 15-29 year olds. As such, the world needs to begin focusing on MHPSS as a life-saving need, of equivalent importance to water, food, shelter and basic health care; and a commitment to greater funds for MHPSS is going to critical to meeting this need.
Another demographic need for MHPSS over the next 15 years will be a focus on individuals living in fragile situations, such as those exposed to chronic crises, conflict and extreme poverty – all known risk factors for mental disorder and its cyclic impacts.
Any final thoughts and comments?
Surprisingly, despite the demand for child and youth interventions in MHPSS, these are largely lacking, with current evidence-based approaches being focused on adult populations. This is likely a consequence of the inherent challenges of undertaking MHPSS research with minors, but this is going to be an investment essential for future MHPSS work. In line with the need for more evidence-based approaches, high and some middle-income countries are focusing on technology as a means for improving access to mental health care. For example, online treatments via smartphones and tablets, particularly for common mental health problems like depression or anxiety. Whilst there is solid evidence for such interventions, the reality of these reaching the most vulnerable of all is unlikely (e.g., in South Sudan, CAR, or Chad). As such, research for evidence-based interventions must also account for the current disparity of access to technological solutions as there remains a risk for the most vulnerable being left further behind the rest of the world.
Another important element in MHPSS emerging now is the need for “scaling up”. Many innovative and effective approaches have now been determined in the MHPSS field – particularly those engaging CHWs for mental health prevention and treatment of disorders. However, innovation after innovation is not yet tackling the wider and more difficult task of ‘scaling up’. Once an approach is deemed ‘evidence-based’ there is a temptation to move to the next innovation for the next demographic or delivery solution; ultimately failing to have the wider impact and yield the potential of established innovations by spending time, funds and effort in embedding these approaches into government policy, plans and strategies. In line with this, there is also the need to see how such innovations can be more effectively integrated to both existing health services, but also wider community initiatives, such as livelihoods opportunities, protection services, legal services and social supports.
The need for increased MHPSS prevention, mental health promotion, early identification, treatment and care for individuals living with mental disorder is now irrefutable. However, it’s a complex area that people are often tempted to set aside, believing there is not enough technical capacity to make a difference or that MHPSS is a luxury and not a life-saving need. And yet, when we look at research and evidence, it is clear that MHPSS can be implemented with only small technical inputs, and in light of growing suicide rates and the impacts of mental disorder of lifelong potential, including economic, educational and productivity potential, we can no longer view MHPSS as a luxury. This is a global need and an urgent one at that.
All CHW Visions interviews have been conducted and compiled by Polly Walker.
Polly Walker has provided technical leadership to World Vision’s community health worker (CHW) program portfolio over the 5 years. During this time she has overseen their expansion of CHW support growing from 70,000 in 2011, to over 220,000 CHWs in 48 countries. She is the co-author of Timed and Targeted Counselling: a comprehensive course for community health workers, now operating in 38 countries. Over the last 12 years of her career she has focused on CHWs, authoring over 20 CHW training modules, designed mHealth applications used in 7 countries, written various publications on ICCM, quality assurance and supportive supervision, as well as the Core Group’s CHW Principles of Practice in 2013. Polly is known for her work as an advocate for government-led harmonization and scale-up, as well as for her work in developing innovative family inclusive psychosocial approaches to community health care.