By: Polly Walker, Megan McGrath, and Alison Schafer, World Vision International
Maternal psychosocial concerns, which include depression, anxiety, and psychosocial problems in the home such as intimate partner violence (IPV), serve as significant risk factors to healthy child development. In their daily work, Community Health Workers (CHWs) commonly encounter families experiencing these problems, but on the whole CHW trainings don’t include any comprehensive training in these areas. Research has found that CHWs can be trained in simple psychosocial interventions which are found to be effective in reducing symptoms of maternal depression and anxiety, in addition to the distress related to IPV. In turn, such interventions play a role in enhancing children’s health and development.
“I had lost hope even in terms of my business because it had failed and I did not think it could be revived. But when the CHW taught me the skills, I realised I could solve my own problems and my attitude towards life changed.”
– Client of World Vision CHW PM+ program in Kenya
CHWs work with women and families on a daily basis. They hold a position of trust with those individuals and may be the first to become aware of a serious issue within a family. Furthermore, those families and communities who depend most heavily on CHWs in low-middle income contexts are in fact those most vulnerable to psychosocial risks. So, it is not a question of ‘if’ CHWs will work with families experiencing depression, anxiety, or IPV. Reports from the field show that CHWs are already encountering these issues on a regular basis, but often have no basic orientation on how to deal with families in these circumstances.
But should CHWs be trained to address these problems? Arguably, CHWs, with limited training, are not qualified to provide diagnosis or therapeutic interventions. They are often already overwhelmed with the scope and number of issues they must address in the household. Furthermore, many of the countries where CHWs have the most critical roles in providing basic health care have little or no mental health or social services that can support referrals or provide adequate back-up and supervision. Depression is the leading cause of global disability, and women, especially during the years of pregnancy and parenting, are particularly affected. In developing countries, up to 13% of women experience an anxiety disorder during the perinatal period and 19.8% of women experience postnatal depression after childbirth, which has negative outcomes for both the health and development of the baby. Studies also show up to 28% of women are physically abused during pregnancy by an intimate partner, and the risk of IPV increases during the pregnancy and post-partum period. These rates can be especially high in areas where cultural norms, stigma, and expectations of women prevent women from seeking care and support when it is needed.
Evidence is emerging that positive parenting and psychosocial support in low-middle income settings can be effectively conducted by CHWs. Community health workers caring for pregnant women can be taught to recognize signs of psychosocial distress and employ supportive listening techniques, provide education about stress reduction techniques, as well as making a referral to specialist support if required, and indeed, available.
“The CHWs deal with these kinds of issues every day of their work, it’s just that at the moment, they don’t know how to respond.”
– Kenya MOH representative, during Psychological First Aid Training for Timed and Targeted Counselling, World Vision Kenya, 2014
“This training changes the way we think about health, and helps them understand the social-emotional model of health and wellbeing.”
– Raymond Owusu, World Vision Ghana, Ghana National CHW TOT, 2016
World Vision’s approach: equipping CHWs with basic skills
To address these issues, World Vision has included training on perinatal mental health and IPV within its maternal and child health CHW curriculum, Timed and Targeted Counselling (TTC). World Vision adapted, with permission, the WHO model of psychological first aid (PFA) for use in non-emergency settings, applying the ‘look-listen-link’ action principles to supporting a client in difficult circumstances. TTC teaches about signs and symptoms of distress/mental health problems, referring for specialised support, and promoting family and social support for mental health and wellbeing during the pregnancy and post-partum period. TTC lso look at how to help individuals and families identify positive coping strategies such as stress reduction techniques, exercise, sleep, and social support, all of which have proven benefits in reducing symptoms of depression and anxiety. Whilst this doesn’t constitute a therapeutic intervention, it focuses on compassionate care, supportive listening, and connecting clients to support systems and coping strategies accessible to them.
Since releasing TTC-2 in 2015, we have trained health teams in 10 countries. Following the multi-country training in 2015, the materials have been included as part of the Kenya MOH national curriculum revision and the new Ghana National CHW programme, supported by World Vision; the One Million CHW Campaign also includes the methodology as part of pre-service training. The method is currently being field tested and adapted for use in several fragile contexts including Mauritania, Chad, Sudan, and South Sudan.
“Through the training my relationship with the family is improving. Before the children would come and find me lying on the couch looking sad and it would also make them sad. But nowadays they often find me happy and feel good too.”
– CHW trainee following a 3-day training in mental health using the PM+ model with World Vision Kenya
“At least 20% of the Palestinian population experience mental health problems. We started training CHWs in PFA and mental health support so they can now screen for maternal depression, counsel, support, and refer through enhanced TTC. It was the CHWs that asked us for this training, as they were supporting mothers in distress so often, and sharing stories, so we know this is really important for their work.”
– Hana Rabadi, World Vision Jerusalem West Bank and Gaza
A more comprehensive mental health and psychosocial support model, Problem Management Plus (PM+) trialled in several low-middle income country settings, was field tested by World Vision Kenya with CHWs from urban slum settings. PM+ serves as an in-service specialised training for CHWs taking 3-4 days, and is more suited to CHWs who are operating at a higher level, or working in more challenging conditions. In our Jerusalem, West Bank and Gaza TTC programme, our health team have successfully trained and deployed 160 CHWs across the region over the last 3 years, and recently completed a 3-day in-service training in mental health and psychological first aid, in which they are trained to detect and refer mental health problems, and apply the psychological first aid technique to situations common in this challenging setting. In Sierra Leone during the Ebola crisis, World Vision Sierra Leone ran psychological first aid training, which emerged as an important skill for Ebola contact tracers and burial teams alike. Early responses to these trainings have been highly rated by participants and by government representatives alike; many participants report that the training has proved useful not only in supporting their clients, but also in managing their own difficulties and those of their families.
These models and tools are still evolving, and each country we approach has a very different response and approach to talking about mental health and violence against women. But what we do know, is that these approaches are breaking new ground, and Ministries of Health the world over are waking up to the importance of mental health, especially in the most vulnerable communities. They are also recognising that in the circumstances “where there is no social worker,” a skills-based approach through CHWs can help CHWs and their clients navigate difficult issues and circumstances. So, we are taking a first step, integrating mental health across our maternal health CHW programmes, but also in developing and testing specialised models for CHWs working in the most challenging circumstances.
Polly Walker is World Vision International’s CHW Programming Advisor
For more information about World vision’s Global CHW Portfolio visit http://www.wvi.org/health/map/world-vision-chw-global-programme, email: firstname.lastname@example.org or follow Polly Walker on Twitter: @DjennaBu