Innovation summary

Communities were severely affected by the 2014-2015 Ebola Virus Disease (EVD) outbreak in West Africa, in a variety of ways: many people experienced the death of loved ones, were separated from loved ones, or had to cope with quarantine and separation, and many who survived had to learn to cope with long-term physical consequences. Health care providers were overloaded and stressed, and a disproportionate number were counted among the victims. Social stigma increased towards people affected by EVD, worsening distress and isolation. Ultimately, whole communities experienced the fear and suffering that often accompany disease outbreaks.

This program aimed to reduce psychological trauma associated with EVD by providing psychological and social support to those affected by the outbreak in Sierra Leone, as well as preventative psychosocial interventions aimed at children and their families.  Building on an existing programme in-country, this innovation decentralized services and aimed to make MHPSS support available in all areas and all sectors of the population.  

An associated programme worked to ensure that messages for prevention of EVD were accessible to all communities, by working with different marginalised groups like persons with disabilities to develop their own messages that overcame the usual barriers they experience.

Impact summary

  • Functioning District Mental Health Units created in all 14 districts of the country, run by 20 mental health nurses providing consistent care to an average of 20 patients per month
  • Supervision of and referral point for more than 300 health professionals trained in Psychological First Aid and 150 health professionals trained in basic mental health care provision.
  • Cross-sectoral mental health care provided to:
    • Persons with mental health conditions in all the districts
    • Nurses, doctors and personnel of the ETCs
    • EVD patients and their relatives
    • Persons in the quarantined homes
    • Members of the burial teams
    • Members of the Ebola hotline (117 number to report Ebola cases)
    • Children in Child Protection custody
    • EVD survivors 

“When the Ebola crises struck, we were ready to act”

 

- Sahr Mortatay Momoh, Mental Health Nurse, Sierra Leone

Innovation details

Enabling Access to Mental Health in Sierra Leone (EAMH)

This innovation builds on EAMH, an EU funded project in which CBM worked, in partnership with GIP and 3 local agencies, over 5 years in decentralizing and strengthening mental health systems in Sierra Leone, to shift from a scenario where there was only one psychiatric hospital in the capital city with very limited resources, to one that included professionals in every district of the country (District Mental Health Units) capable of providing care to those who needed it during the EVD outbreak. Due to the poor conditions and lack of awareness prior to the implementation of the innovation, this was only possible by combining three elements of work:

Advocacy: The creation of the Mental Health Coalition of Sierra Leone (MHC-SL) was key to break through the limitations and lack of political will by strongly advocating for MH to be a reality in the country and by working very closely with the Government of Sierra Leone, specifically Ministry of Health and Sanitation, in providing support, encouragement and drive. Thanks to these efforts the Mental Health Policy and Strategic Plan was launched in 2012;1 4 annual MH conferences were held,2 bringing together national and international stakeholders; the first organization of persons with psychosocial disabilities was created;3 the MH Steering Committee of the Ministry of Health and Sanitation was created and strengthened.

Capacity Building: The first national curriculum for psychiatric nursing was created in 2011 and the program trained the first cohort of mental health nurses (18 months diploma for nurses) in the country, as well as 150 health workers from Peripheral Health Units in a basic course in mental health with a strong focus on identification and referral of cases from the community and follow ups. This training was further strengthened with quarterly sessions for further training and peer support and field supervision.

Awareness Raising: none of those efforts would work without the population recognizing and making use of MH services, and shifting discriminatory attitudes. This is being achieved by producing materials such as posters, leaflets, and booklets; producing radio programs and jingles; and very importantly, bringing MH to the community by organizing Community Forums with Traditional Healers, Religious Leaders, and Non-State Actors, where a fruitful dialogue about MH was established.

MHPSS for EVD Outbreak

As soon as the Ebola outbreak was declared in the region, the actor networks strengthened by the EAMH programme were in a unique position to advocate, move resources and bring organizations together in recognizing the importance of a MHPSS element of the response. This allowed, for example, to quickly support the adaptation of WHO’s Psychological First Aid guidelines to make them useful for the EVD outbreak.4 The different components of work in EAMH were adapted to the situation in a timely manner and CBM was able to quickly commit further support in an established infrastructure.

Advocacy: MHC-SL became a founding member of the national MHPSS Working Group to support all activities from organizations working in the response. As the main local organization with previous experience in MH, MHC-SL provided essential inputs in the development of the MHPSS for EVD strategy5 and associated MHPSS for EVD basic packages;6 in the adaptation of PFA for EVD guidelines and their piloting for the Sierra Leonean context;7 in ensuring referrals to national resources those NGOs providing MHPSS; etc.

Also, and key to the provision of MHPSS for those affected by the outbreak, the MHC-SL strongly pushed for the MH Nurses to be deployed in all districts of the country, and CBM allocated funds to support the District Hospitals in setting up MH Units. This advocacy effort made it possible to create, with very little resources (12,000EUR) 14 District Mental Health Units (DMHU) all across the country, by identifying spaces at the hospitals and refurbishing them, and deploying at least one psychiatric Nurse to each of them.  The establishment of a strong collaboration with WHO allowed the provision of further materials and support.

Capacity Building: Prior to being deployed to the newly created DMHU, all the MH nurses received further training to be able of responding to the needs of those affected by the crises:

  • mhGAP module on conditions specifically related to stress8
  • Stress management, self-care and group care for frontline workers in ETCs
  • Child and Adolescent Mental Health: how to support the personnel at the Child Friendly Spaces
  • Training of Trainers on Psychological First Aid for EVD (in collaboration with WHO)

The training was strengthened by a supervision plan and by the MHC support in linking with other organizations, such as those at the Ebola Treatment Centres, and the creation of a strong referral system for other organizations of the Ebola response to be able of referring adequately (e.g., social mobilization teams identifying persons in distress in the quarantined homes, personnel of the ETCs identifying EVD patients with MH complications, personnel of the IOCC identifying children with difficulties)

Through these efforts the nurses were capable of providing the only specialised care available in the country for:

  • Persons with mental health conditions in all the districts
  • Nurses, doctors and personnel of the ETCs
  • EVD patients and their relatives
  • Persons in the quarantined homes
  • Members of the burial teams
  • Members of the Ebola hotline (117 number to report Ebola cases)
  • Children in Child Protection custody
  • EVD survivors 

Key drivers

  • Existing infrastructure (though newly developed) in place before disease outbreak
  • National MH Steering Committee coordination
  • National MH Coalition in place with enthusiastic organisations ready to collaborate

Challenges

  • Initial lack of recognition of the relevance of mental health at all levels in the country’s health and social systems
  • Weak services prior to the implementation 

Continuation

By definition this was a specific emergency relief response programme, but the mental health system infrastructure in place was further strengthened by the experience.  Personnel, for example nurses will be well placed to respond to individuals who have experienced trauma, and to any future wider emergency that might take place.

Lessons were learnt in the emergency, and deliberate process of review and evaluation of the specific programme and the overall MHPSS response has allowed these to be carried forward for future emergencies.9

In addition, tools developed during the emergency can be used in future, for example the adaptation of the Psychological First Aid guideline for Ebola outbreaks allowed to train professional in the affected countries and in the whole region. As part of this specific project, CBM provided training on PFA to health workers in Togo, as part of the preparedness plan of the country. 

Evaluation methods

One mid-project evaluation and one external evaluation (end of project) by an independent consultant were carried out to assess EAMH. This used a mixed methodology approach using logical framework indicators, and according to standards and expectations of donor (European Commission). For the crisis project/innovation, CBM Regional Office for West Africa provided regular monitoring and evaluation via monthly reports and CBM’s Global Advisor for Mental Health visited the project in May 2015. Further analysis of subsequent M&E data is being conducted for the final report and a research project is being done in the awareness-raising and community engagement component.

Cost of implementation

The pre-crisis (EAMH) programme establishing integrated service cost EUR 200,000 /year.

The crisis programme/innovation cost less than EUR 60,000 for nationwide coverage.

The fact that mental health practitioners were in place in decentralised locations dramatically reduced service user costs for access to such care.

Impact details

  • Over 2000 beneficiaries accessing care in one year
  • Functioning District Mental Health Units created in all 14 districts of the country, run by 20 mental health nurses providing consistent care to an average of 20 patients per month (Max.= 45 patients/month. Min= 6 patients/month)
  • Supervision of and referral point for more than 300 health professionals trained in Psychological First Aid and 150 health professionals trained in basic mental health care provision
  • Cross-sectoral mental health care provided to: health professionals at Ebola Treatment Centres, members of the burial teams, survivors, member of the Ebola hotline, persons with EVD, relatives of persons with EVD, quarantined communities, and patients suffering long term mental illness
  • Supported 12 Ebola Treatment Centres and served as mayor referral point for organizations responding to the emergency and identifying mental health issues
  • Provision of care in 5 Survivors Clinics

References

  1. http://www.mindbank.info/collection/country/sierra_leone
  2. http://enablingaccesstomentalhealthsl.com
  3. http://blog.cbm.org/you-have-the-will-you-have-the-power/
  4. http://www.who.int/mental_health/emergencies/psychological_first_aid_ebola/en/
  5. Government of Sierra Leone, Ministry of Social Welfare, Gender and Children’s Affairs. Mental Health and Psychosocial Support (MHPSS) Strategy for Sierra Leone 2015-2018
  6. Government of Sierra Leone, Ministry of Social Welfare, Gender and Children’s Affairs. Mental Health and Psychosocial Support (MHPSS) Service Packages, 2015
  7. Government of Sierra Leone, Ministry of Social Welfare, Gender and Children’s Affairs. Psychosocial Support for Ebola-Affected Communities in Sierra Leone. Training Manual, 2014
  8. http://www.who.int/mental_health/emergencies/mhgap_module_management_stress/en/
  9. Valle, C. (2016). A Model for Psychosocial Support in Emergency Epidemics: An Adjunct to Existing Guidelines Based on Feedback from Locals and Responders. In J. Kuriansky (Ed.). The Psychosocial Aspects of a Deadly Epidemic: What Ebola Has Taught Us about Holistic Healing. Santa Barbara, California: ABC-CLIO/Praeger

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