Training Lay Health Workers: when etic meets emic
Urvita is a student of Global Mental Health at the London School of Hygiene and Tropical Medicine, and has drawn upon her experiences in working as an intervention facilitator for non-specialist health workers in SHARE, Goa, India. For more information on SHARE, visit: http://www.sangath.com/details.php?nav_id=232
Otherwise known as Non-Specialist Health Workers, Lay Health Workers (LHWs) play a unique role in mental health service delivery in low resource settings, and hence nurturing them is of crucial importance. One of the ways to nurture LHWs is through quality training and supervision, by involving specialists (e.g. mental health professionals). Whilst capacity building remains the central focus of training and supervision, it is equally crucial to be mindful of and respond to the resourcefulness of the LHWs. Below is a summarization of experiences that support this point, emphasising lessons for trainers for their engagement with the non-specialist workforce. These experiences formed an integral part of a project in India where non-specialists called “sakhis” (meaning friend in the vernacular) were trained to deliver a psychological treatment for perinatal depression. The sakhis had no previous training in mental health, and belonged to the local community, thereby sharing similar experiences as members of target population (i.e. women experiencing perinatal depression). They played a key role in integrating mental health care within the community context. Essentially, their involvement was envisaged to expand the reach of quality mental health care to women affected by perinatal depression, who may otherwise receive no treatment (due to situation-specific challenges including availability and accessibility of mental health services).
An empty board and native wisdom
The essentials of a contemporary training classroom include a whiteboard, flipcharts, markers, etc. During the first few days of training the sakhis in Goa, we realised that sometimes it is valuable to keep the whiteboard aside and to create an atmosphere that contributes to shared learning; by incorporating discussions and role-plays that are related to everyday experiences. For the trainer, doing so involves adopting an open and flexible stance, in a way that learning becomes a two-way street. As the sakhis were typically from the same community where they were expected to engage with patients, they possessed unique experiences and skills that had the potential to play an important role in the treatment’s success. These experiences and skills included, but were not restricted to, shared real-life struggles, an intuitive understanding of the norms and behaviours in the cultural context, communication skills unencumbered by technical jargon, and established social relationships within the community. These experiences, when combined with the specialist lens can bring immense value to the therapeutic context. Hence, a trainer must deliberately make efforts to formulate training content that is grounded on these personal experiences in order to maximise learning outcomes; and create opportunities to connect their personal experiences to the basic principles that come into play in a counselling relationship.
A dual focus
Whilst the training of sakhis was focussed on building conceptual knowledge required to deliver the psychological treatment, it was equally important to strengthen their own qualities required for a positive therapeutic alliance. This combined focus requires the trainer to keep aside the hat of a “teacher” and to instead be a “facilitator”. It is particularly important to acknowledge that the latter (which includes qualities such as empathic understanding, reflective listening, etc.) is largely innate; and hence the facilitator should create a learning environment where LHWs are given opportunities to engage in self-reflection and good quality supervised practice. The further development of existing non-specific skills in the LHWs creates the foundation for a “good therapist”; and makes them more adept in dealing with situations within the therapeutic context. For the sakhis, our efforts to foster their specific and non-specific skills resulted in a well-rounded skill set, which gave them the confidence required to begin and sustain work in their communities.
Jackfruit and integration
An experience that I hold very close to my heart is one during a supervision session with two sakhis. It was a regular day at work, and I was drawing to a close a scheduled supervision session at one of the sakhi’s homes. As I made my way out of her house, one of the sakhis quickly went to the garden and presented me with an item wrapped by a newspaper. She prompted me to take a peep, and I curiously did so. I was taken aback for a moment when I found a jackfruit in there! Pre-empting my next response, she added, “you cannot refuse to take this home, it is a token of appreciation, and I want you to relish it.” My heart melted. On my way back home, and when I shared the jackfruit with my colleagues at work, I reflected on this experience. I felt warm and contented that we developed a meaningful connection in the common pursuit of community-based work. This made me deeply appreciative of the fact that LHWs wish to integrate us (trainers/researchers) into their lives, and are motivated to engage in community-based work with a genuine drive to connect with and contribute to their communities. Consequentially, they present as a rich resource for empowering and strengthening communities, whilst emphasising better mental health.