Developing village-based community mental health care in southern Malawi

The origin of the Mental Health in Zomba (MHiZ) Project stems from work on a 2005-6 British Medical Association (BMA) Humanitarian grant funded project to pilot the teaching of mental health care to staff posted at health centres around Zomba in southern Malawi.  These health professionals – nurses, clinical officers, medical assistants – were updating their mental healthcare skills, skills they rarely utilised in the midst of challenges besetting the low resourced and overstretched health centres, compounded by the priority afforded to physical health problems of communicable disease and mother and infant health.  The evidence of mental health problems contributing to the global burden of disability, and how the physically unwell and their carers are among the most vulnerable to mental health problems, was only beginning to emerge.  Two things were challenging – HOW to design and deliver mental health training that would be effective and accommodate the social and cultural context of rural Malawi and secondly, WHERE best to target these efforts.

Health Surveillance Assistants (HSAs) are a group of Malawian health workers closest to the communities they serve.  While based at a health centre, they attend there only once or twice a week but spend most of their time promoting health in the villages – directing efforts to providing vaccinations, monitoring children and mothers’ health, supporting the treatment of malaria, TB and HIV, monitoring and promoting community efforts at water and sanitation facilities and tracing outbreaks of infectious disease.

Mental health was not included in their training to become an HSA and yet at the teachings HSAs would describe ‘people experiencing madness’ (“anthu a misala”) and other mental health and development difficulties such as learning disability, epilepsy, low mood and suicide.

Though previously untested, the accessibility of HSAs within the communities made them the ideal staff group to be supported to promote mental healthcare for people closest to their homes.

However, what type of assessment and intervention should be promoted? In the past, initiatives in low income countries have tended to focus on enhancing the often sparse psychiatric service, with the intention that the ‘expert’ knowledge of mental illness from institutions filtering through the interventions and provision of effective care to the public.  The knowledge espoused too would be based upon that evidenced from other (usually high resourced) countries – with the assumption of universal applicability and appropriateness.  While there appears to be an agreement that throughout the world people experience mental distress, the way that these experiences are understood, lived, and ‘treated’ differ according to cultural context.  A decade of experience working with colleagues in rural Malawi – where there are rich traditional African and other religious responses to what might be described as mental health problems, together with its mixed picture of effectiveness and an absence of western psychiatric thought – meant we wanted to tread carefully by introducing a determinedly ‘healthcare’ response to people suffering distress that was also conducive to Malawian social and cultural mores.

To develop such a mental health curriculum that would assist HSAs in recognising and responding to the range of mental health problems they witness in their communities, a mixed group of Malawian and UK health professionals, academics, users of mental health services and HSAs themselves was convened.  Through a series of workshops and deliberations a three day training programme was designed and prepared.

The curriculum acknowledged multi-factorial pathways to experiencing mental health problems, accepting the personal value and significance of people’s own attribution beliefs (stress, the use of drugs, bewitchment, the ‘will’ of God etc.) and offering a ‘health model’ as a way of responding to the distress.

Although, within the community, ‘bewitchment’ was the most common attribution for a person experiencing what may be termed a mental health problem, so too was ‘stress’ which provided HSAs with an ideal opportunity to pose a ‘stress-vulnerability’ model to understand the psychological ‘distress’ as a health problem.   Instead of identifying psychiatric diagnoses, a client- and HSA-assessed adjudication of ‘psychological distress’ and ‘risk to self or others’ was sought,

together with a Human Rights framework utilised to determine prioritisation and acceptability of an intervention against a person’s consent.

The response and interventions from HSAs too emphasised the mobilisation of support locally from within the family or wider community, with the health centre available for the most severely disturbed people.

The curriculum was successfully piloted in 12 health centres between 2010 and 2012 and involved training 271 HSAs and the current MHiZ Project is now scaling–up that programme to the whole of Zomba District which includes 32 health centres and serves a population of 550,000.  In a development from the pilot project, to support the integration and sustainability of mental health within the role of HSAs further, a one day training course on mental health using the same model was also provided to 240 health professionals based at the 32 health centres in order to acquaint them with the HSAs new role and enlist their support managing mental health problems at health centres.

In 2013, once a ‘training of trainers’ programme was completed, nine Malawian trainers delivered ten three day training programmes to more than 450 HSAs.  The third day was delivered six to nine months following the first 2 days to incorporate an opportunity for HSAs to review and discuss their new mental health roles.  A pre- and post-training assessment of each individual HSA’s knowledge and confidence in tackling mental health issues was also undertaken, with increases in both recorded on follow-up.

In the 18 months since the trainings, the small MHiZ team have provided monthly supervision to HSAs at their health centres, reviewing their interventions with individuals and families and also the huge number of mental health promotion activities the HSAs have facilitated.  A record of both HSAs’ mental health care activity with individuals and their families and their mental health promotion activity is being collated.  Records show people are presenting to HSAs with a range of life-problems: bereavement, abuse, marital problems, epilepsy. Carers attend to see the HSA describing clients ‘abnormal’ behaviours such as ‘wandering’, not eating, not sleeping, dizzy, talking to self and smoking ‘chamba’ (marijuana).  The HSAs describe people challenged by difficult social contexts including death of loved ones, abuse, physical illness and relationship problems, with more than 1 in 10 people feeling suicidal.  HSA interventions range from providing information, emotional support and reassurance, communicating with extended family or community to mobilise support, advice on medication or referral onto the health centre.

To date, records of over 800 mental health promotion activities have been collected, with over 40,000 persons attending these events – including public meetings, meetings of village health committees, consultations and support groups for patients and carers.   This demonstrates the huge reach HSAs have within their communities and the potential this has for public mental health promotion and sensitization.

As the project nears its end in March 2015, we look towards sustainability and summative evaluation.  In September last year the Project financed and hosted an Award Ceremony at Matiya Health Centre, Zomba District, to celebrate their efforts as the top performing health centre and the mental health work of individual HSAs.  The event, attended by local stakeholders and national press, has helped to draw attention to the potential of HSAs and to generate interest within the Malawi Ministry of Health and more widely in developing this or similar initiatives. To inform this too, the MHiZ Project team is currently analysing data to determine both successes and ongoing challenges in developing this innovative approach to community mental health care.

In the coming weeks, we are looking forward to testing the degree to which the MHiZ Project has developed a way of increasing primary mental healthcare that is responsive to local understandings and experiences of distress and provides humane and effective care for some of the most vulnerable people in society.