Innovation summary

Kazakhstan, a former Soviet Republic in Central Asia, is the largest landlocked country on the globe. It is a high burden country for multi-drug resistant TB (MDR-TB): 26% for newly diagnosed cases and 53% for previously treated TB cases. Reducing mortality and preventing drug resistance and morbidity associated with TB is among the essential goals of national TB/HIV collaborative activities to meet SDGs. PIH has worked in the country since 2009, when Kazakhstan’s Ministry of Health—citing PIH’s track record of combatting MDR-TB in neighbouring Siberia—invited PIH to support care for patients with MDR-TB in prisons and civilian sectors of six pilot sites. Expansion of those efforts now has PIH fighting TB in the entire country, or 20 regions of the Republic of Kazakhstan. Today, PIH Kazakhstan works with the national government and international aid groups to bolster TB services country-wide. In 2020, PIH Kazakhstan launched the Many Voices Project to reduce adverse mental health experiences and suffering of patients who are receiving TB treatment. This means that Kazakhstan could ultimately become a model in the global health community for the treatment of drug-resistant TB, as well as the illnesses that so often accompany it—HIV, mental illness, substance abuse and more—placing PIH at the forefront of work that shapes global policy and treatment practices for decades to come.

Impact summary

  • Between July 2021- December 2022, the team conducted 3900 mental health visits
  • From 2020-2022, PIH Kazakhstan provided psychological support to 290 people enrolled in the MDR-TB program with mental health conditions primarily (90%) depression.
  • By 2022, 555 medical workers had been trained in PFA

Innovation details

The PIH Kazakhstan mental health program started in 2020 to provide mental health treatment, monitoring, and social support to MDR-TB patients in outpatient settings. The team collaborates with the department of public health and NGOs to provide mental health services and social support to MDR-TB patients, strengthen capacity of non-specialists (task shifting), improve patient follow up, and train medical workers and psychologists in relevant psychotherapy approaches. As of 2023, the team carries out mental health activities in the cities of Almaty and Karaganda for TB patients on M/XDR treatment, TB patients and family members, and TB doctors and psychologists. Since the program launched at the onset of the COVID-19 pandemic, emergency response and social support are integral to the team’s work. The team is planning to continue expanding the program through psychotherapy trainings, strengthening services and interventions, and continued collaboration with the national government.

The team is piloting a project to improve prevention activities to reduce alcohol and substance use among for youth with the aims to;

  • Maintain a peer-to-peer group on alcohol substance use prevention among student youth
  • Expand community engagement towards substance use prevention.

Key drivers

Capacity building: The team adapted and translated materials on PFA to train healthcare workers. Psychological services were also adapted for remote-based care, and psychologists practiced weekly phone calls with patients as the primary method of communication, with supplemental in-person visits as needed. The project team carries out advocacy activities to support clients. Project staff members are engaged in consulting for the project clients on obtaining free medical services from the Primary health clinics (PHC) system, consulting on obtaining a pension from the state for the period of TB treatment, referral services to the NGO partners for obtaining legal services.
 

Close collaboration: The team works closely with many partners, including the Department of Public Health, Center for Mental Health, Inter-district TB Dispensary, and NGOs that address co-morbid TB, HIV and mental health conditions. From the start of project implementation, emphasis was placed on collaboration with healthcare authorities of Almaty City. The Almaty City TB Dispensary provided valuable practical assistance in selecting and maintaining communication between patients and providers.

Skilled Workforce: The project team consists of a project coordinator, six psychologists, and one social worker. In May of 2021, the Cross-Site Mental Health Team trained 13 consultants in CETA. Psychologists address patient’s thoughts, feelings, and behaviour using comprehensive psychotherapeutic approaches, and advise patients on how to receive benefits and free medical care from the public state health system and link them to legal advice as needed. The team created new forms and adapted existing patient registration forms from other PIH care delivery sites, taking best practices from sites that focus on TB/depression care such as PIH Lesotho and Socios En Salud (PIH Peru).

Challenges

Integrated system of care/training providers: Healthcare providers already have limited time and many tasks; therefore, the team is working to integrate mental health services while alleviating the burden of added work for providers. PIH Kazakhstan is developing referral pathways to mental health specialists and social workers to make their system of care more efficient.

Social support: People affected by co-morbid TB and other health conditions often face additional barriers to care other than the availability of medication. Given that mental health conditions can exacerbate pre-existing health issues, social support is a necessary and often neglected aspect of care that help alleviate the additional barriers to improving physical and mental health, adhering to treatment, and living a healthy life.

Continuation

Expand Impact: The team is eager to expand the scope of its target enrolment and treatment populations to also include people living with HIV (PLHIV), substance use disorder, and co-addiction. The team is addressing alcohol and substance use in partnership with the local State University in Almaty by establishing preventive peer support groups and utilizing an innovative curriculum. PIH Kazakhstan plans to continue enrolling clients at both sites, integrate mental health care into other services, and further develop their remote methods of providing treatment, such as tele-PFA. With structured clinical supervision for those who participated in a virtual CETA training in June 2021 and the development of electronic medical records, the team is excited to continue piloting CETA and provide social support for vulnerable populations.
 

Strengthen Partnerships: PIH Kazakhstan will continue its strong partnership with the government,and increase advocacy efforts with local health authorities and NGO partners to gain support in addressing and providing services for those affected by mental health conditions and MDR-TB. Along with continuing to strengthen services for people with co-morbid TB and depression, the team aspires to pilot an adolescent mental health intervention focused on suicide prevention and school outreach. In January 2023, PIH-KZ signed a Memorandum of Understanding with the Al-Farabi Kazakh National University on prevention of substance use and reduction of alcohol use among the students.

Partners

  • Department of Public Health
  • Center for Mental Health
  • Inter-district TB Dispensary (including Almaty City Dispensary)
  • Partners In Health
  • Sanat-Alemy NGO
  • Doverie (Hope) NGO
  • Shapagat NGO
  • Daua 2050 NGO
  • Al-Farabi Kazakh National University

Funders

Evaluation methods

The team utilizes specially developed checklists and internal reporting forms and is planning to integrate mental health into their existing electronic medical record (EMR) system. In addition, after the initial CETA training in May 2021, the team of consultants agreed to continue to learn the CETA approach under the guidance of the local supervisors from among the participants themselves and trainers from the Johns Hopkins University team. The supervision process includes theoretical issues as well as practical implementation feedback from the trainers.

After the training, the mental health team used CETA forms to accurately assess client’s mental health status, make a diagnosis and start treatment.

For the duration of the treatment sessions, clients fill questionnaires to keep track of their depression scores and functioning, throughout the psychological treatment sessions. Recently, the PIH-Kazakhstan MH team developed a project to provide preventive work among university students to alcohol and substance use. Under this project, questionnaires and other tools have been developed to assess SU situation and the progress of the project.

Cost of implementation

N/A

Impact details

Given that the PIH Kazakhstan mental health program launched a few months before COVID-19, the emergency response was a key component of the work. The team conducted psychological first aid sessions for primary health care workers and adapted training materials that were translated into Russian for the local context. Psychological services were also adapted for remote-based care, and psychologists provided weekly phone calls to patients as the primary method of communication, with supplemental in-person visits as needed.

The PIH-KZ MH team collaborates with the local NGOs to expand services to the project beneficiaries. Through collaboration between PIH-KZ and StopTB Partnership, the PIH Kazakhstan MH team has provided training for the employees of the local NGOs and representatives of the TB community.

Despite the challenges of COVID-19 quarantine restrictions, by the end of 2022, 555 medical workers have been trained in psychological first aid (PFA). The PIH Kazakhstan team has distributed 4,500 food certificates. The entire PIH Kazakhstan mental health team has successfully been certified in CETA, essential to support people with co-morbid depression, TB, and substance use. Through collaborations between the PIH Kazakhstan and Cross-Site Mental Health teams, the PIH Kazakstan team has been able to record the progress of 136 clients in electronic medical records (EMR) within the last year.

Research

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