FaCilitator Manual Introduction to Agitation, Delirium ......Introduce the family and...

English-haiti

Introduction to Agitation,

Delirium, and Psychosis

Curriculum for Community health Workers

FaCilitator Manual

Introduction to Agitation, Delirium, and Psychosis Curriculum for Community Health Workers

IPartners In Health | FaCilitator Manual

Partners in health (Pih) is an independent, non-profit organization founded over twenty years ago in haiti with a mission to provide the very best medical care in places that had none, to accompany patients through their care and treatment, and to address the root causes of their illness. today, Pih works in fourteen countries with a comprehensive approach to breaking the cycle of poverty and disease — through direct health-care delivery as well as community-based interventions in agriculture and nutrition, housing, clean water, and income generation.

Pih’s work begins with caring for and treating patients, but it extends far beyond to the transformation of communities, health systems, and global health policy. Pih has built and sustained this integrated approach in the midst of tragedies like the devastating earthquake in haiti. through collaboration with leading medical and academic institutions like harvard Medical school and the Brigham & Women’s hospital, Pih works to disseminate this model to others. through advocacy efforts aimed at global health funders and policymakers, Pih seeks to raise the standard for what is possible in the delivery of health care in the poorest corners of the world.

Pih works in haiti, russia, Peru, rwanda, lesotho, Malawi, Kazakhstan, Mexico and the united states. For more information about Pih, please visit www.pih.org.

Many Pih and Zanmi lasante staff members and external partners contributed to the development of this training. We would like to thank giuseppe raviola, MD, MPh; Père Eddy Eustache, Ma; rupinder legha, MD; tatiana therosme; Wilder Dubuisson; Ketnie aristide; leigh Forbush, MPh.

this training draws on the following sources: Manual for Health Counselors, sangath (goa, india: sangath); Mental health response in haiti in the aftermath of the 2010 earthquake: a case study for building long-term solutions, giuseppe raviola, Eddy Eustache, Catherine oswald, and gary s. Belkin (harvard review of Psychiatry 2012;20:68–77); national institute of Mental health, http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/; An Introduction to Mental Health: Facilitator’s Manual for Training Community Health Workers in India, Basicneeds (Warwickshire, uK: Basicneeds), 2009; Weissman, Myrna and lena Verdeli, IPT-EST for Depression in Haiti: for Patients Who Have Screened Positive for Depression (copyrighted unpublished manual, May 2012). national institutes of health (nih): www.nlm.nih.gov/medlineplus; Promoting Mental Health: Concepts, Emerging Evidence, Practice, World health organization, Dept. of Mental health and substance abuse, Victorian health Promotion Foundation, and university of Melbourne (geneva: World health organization), 2004; The Manas Model for Health Counsellors: A Program to Improve the Care for Patients with Common Mental Disorders in Primary Health Care, 1st edition, sangath society for Child Development and Family guidance (goa, india: sangath), 2011; The World Health Report 2001: Mental Health: New Understanding, New Hope, World health organization (geneva: World health organization), 2001; World health organization, http://www.who.int/features/qa/62/en/index.html; Eapen, V., graham, P., & srinath, s. (2012). Where There Is No Child Psychiatrist: A Mental Health Care Manual. rCPsych Publications; Mental illness Fellowship Victoria. (2013). Understanding psychosis; raviola, Kahn, Jarvis. (2015). World health organization. (2010). Mental Disorders Fact Sheet 396, http://www.who.int/mediacentre/factsheets/fs396/en/.

We would like to thank grand Challenges Canada for their financial and technical support of this curriculum and of our broad mental health systems-building in haiti.

© text: Partners in health, 2015 illustrations: hesperian health guides, Jonathan Case, and Jesse hamm Photographs: Partners in health Design: Elizabeth Martin and Partners in health

II


Partners In Health | FaCilitator Manual

This manual is dedicated to the thousands of health workers whose tireless efforts make

our mission a reality and who are the backbone of our programs to save lives and improve

livelihoods in poor communities. Every day, they visit community members to offer services,

education, and support, and they teach all of us that pragmatic solidarity is the most potent

remedy for pandemic disease, poverty, and despair.


IIIPartners In Health | FaCilitator Manual

Table of Contents

Introduction to Agitation, Delirium, and Psychosis

introduction ..........................................................................1

objectives .............................................................................2

time required ......................................................................4

Materials ...............................................................................5

Session 1: introductions, Pre-test and Confidentiality ............6

Session 2: What is Mental health? ........................................9

Session 3: introduction to Psychosis ....................................14

Day 1 Review: Participant Presentations ..............................19

Session 4: identifying and approaching People with agitation, Delirium and Psychosis ........................................20

Session 5: triage and referral for People with agitation, Delirium and Psychosis ........................................................26

Session 6: Counseling Patients and Families about agitation, Delirium and Psychosis ........................................31

Day 2 Review: Ball toss .......................................................38

Session 7: Conducting home Visits .....................................39

Session 8: Community Education activities .........................46

Session 9: review, Post-test and Feedback ..........................50

IV


Partners In Health | FaCilitator Manual

Annex

Pre-tests and Post-test ........................................................57

Pre-test and Post-test answer Key ......................................62

Psychosis Care Pathway .......................................................67

agitation, Delirium and Psychosis Checklist .........................68

initial Visit Form...................................................................69

ZlDsi Form .........................................................................70

referral Form .......................................................................71

Follow-up Form ..................................................................72

Education Cards (7) .............................................................73

Community Education activity Checklist ..............................80

stigma assessment activity .................................................81

training Evaluation Form .....................................................82


Partners In Health | FaCilitator Manual 1

Introduction to Agitation, Delirium, and Psychosis

INTRODUCTION

Being healthy does not simply mean that a person has no diseases, such as pneumonia, malaria,

or tuberculosis. True health is a state of complete physical, mental, and social well-being. People

are physically well if they have no diseases, or if their diseases are being treated. People are

socially healthy if they have good shelter, food, clothing, schooling, and economic opportunities.

People are mentally healthy when they can realize their own potential, handle the normal

stresses of life, work fruitfully, and make contributions to their communities.1

Maladi Pèdi Bon Sans — otherwise known as psychosis — is a severe illness. It can be caused

by medical illness or mental illness. People suffering from this illness may hear voices other

people do not hear or see things other people do not see. They may say things that do not

make sense or have a hard time functioning. Sometimes they can become violent. Family and

community members may fear individuals with psychosis because they do not understand it

and do not know where to seek treatment. They may even abuse or mistreat these individuals

to control their behavior. Furthermore, they are often not properly identified as mental health

patients and therefore do not receive treatment. For these reasons, people with psychosis and

their family often experience stigma and discrimination.

In this training, participants will review the impact of psychosis and will examine its associated

stigma and discrimination. Participants will learn to identify, respond to, and follow-up with

individuals with this illness, and they will also learn how to teach the community about it. Last,

participants will learn how their efforts combined with the efforts of nurses, physicians, social

workers, and psychologists create a system of care in the Central Plateau and Artibonite Valley.

This system of care has the power to help people with psychosis receive effective treatment and

live rich, fulfilling lives — but it cannot operate without the help and support of community

health workers.

1. World health organization, http://www.who.int/features/qa/62/en/index.html.

2 Partners In Health | FaCilitator Manual


ObjeCTIveS

By the end of this training, participants will be able to:

Session 1:a. Establish ground rules that create a respectful and trusting environment.

b. Demonstrate prior knowledge of the training topic.

c. Explain the importance of confidentiality.

Session 2:d. Define mental health.

e. Describe basic interviewing skills and their importance.

Session 3:f. Identify participants’ current and past attitudes surrounding severe mental illness.

g. Define psychosis, its causes and prognosis.

h. Explore common misconceptions of psychosis.

i. Explain the psychosis burden of disease.

j. Describe the impact of stigma and discrimination on families and communities.

k. Introduce the family and community-based approach to treating psychotic patients.

Session 4:l. Describe the Psychosis Care Pathway and its importance.

m. List the key roles for CHWs in psychosis management: case identification, triage, referral, follow-up and documentation, and psychoeducation.

n. Describe common symptoms of psychosis and how to identify someone with psychotic symptoms.

o. Explain how to approach patients with psychosis in a therapeutic and supportive way.

Session 5:p. Identify the difference between when to make an urgent referral and emergency referral.

q. Successfully complete the Referral Form.

r. Successfully complete the Initial Visit Form.

s. Explain which information to report to psychologists/social workers when making a referral.

Session 6:t. Explain when the ZLDSI should be administered to a patient’s family members.

u. List the four groups of psychoeducation messages and when each should be used.

v. Utilize Education Cards to counsel patients and families.



Session 7:w. Explain when and how to conduct home visits for psychoeducation and follow-up.

x. Successfully complete the Follow-Up Form.

Session 8:y. Conduct successful community education activities about psychosis using the Community

Education Activity Checklist.

z. Facilitate community members’ completion of the Stigma Assessment.

aa. Assess community members’ understanding of stigma and discrimination through the Stigma Assessment activity.

Session 9:ab. Review all unit objectives.

ac. Demonstrate learning through a post-test.

ad. Give feedback on the training.



TIme ReqUIReD 3½ days (16 hours and 15 minutes of training sessions)

DAy 1: 4 hours of training sessions

Session Content methods Time

1 Introductions, Pre-Test, Confidentiality • Facilitator presentation• icebreaker• assessment

1 hour 30 minutes

2 What Is mental Health? • large group discussion• Carousel activity

1 hour

3 Introduction to Agitation, Delirium and Psychosis

• large group discussion• reflection Journey• assessment• role Play

1 hour 30 minutes

DAy 2: 5 hours and 30 minutes of training sessions


Review of Day 1 • group Presentations 30 minutes

4 Identifying and Approaching People with Agitation, Delirium and Psychosis

• large group discussion• Facilitator presentation• role Play

1 hour 30 minutes

5 Triage and Referral for People with Agitation, Delirium and Psychosis

• Facilitator Presentation• role Play

1 hour 30 minutes

6 Counseling Patients and Families about Agitation, Delirium and Psychosis

• Facilitator Presentation• role Play

2 hours

DAy 3: 4 hours and 30 minutes of training sessions


Review of Day 2 • game 30 minutes

7 Conducting Home visits and Follow-Up • role Play• large group discussion

2 hours

8 Community education Activities • large group discussion• small group work

2 hours

DAy 4: 2 hours and 15 minutes of training sessions and review


9 Review, Post-test and Feedback • assessment• Evaluation

2 hours 15 minutes



mATeRIAlS NeeDeD

materials for All Sessions

� Facilitator Manual

� Participant handbooks

� PowerPoint Presentation

� Education Cards

� Flip Chart

� Projector

� Markers

� tape

� Post-it notes

� anonymous Question Box

� Copies of initial Visit Form, referral Form, Follow-up Form (1 copy/participant)

� Ball (1 per every 7–10 participants)



SeSSIon 1: Introduction, Pre-Test and Confidentiality

methods: Facilitator presentation, icebreaker, assessment

Time: 1 hour 30 minutes

materials:

� PowerPoint (agitation, Delirium, and Psychosis), slides 1 – 4

� Pre-test (1 copy/participant)

� Flip chart or chart paper

� Markers, pens

� tape

� Post-it notes

� Box for anonymous question box

Preparation:

• Post a blank sheet of paper on the flip chart and title it “goals & Expectations.”• Post a blank sheet of paper on the flip chart and title it “training rules.”• Photocopy the pre-test (see appendix).

• review PowerPoint (agitation, Delirium and Psychosis), slides 1 – 4.

Objectives:

a. Establish ground rules that create a respectful and trusting environment.b. Demonstrate prior knowledge of the training topic.c. Explain the importance of confidentiality.

StePS

45 minutes

1. Show Slide 1. Introduce yourself and this training.

2. Pass out one Post-It note to each participant. Ask participants to take a minute and write down one goal or expectation that they have for this training. Then, have all the participants introduce themselves and share their goal. After each person speaks, post their Post-It note to the flip chart entitled “Goals and Expectations.”

3. Assure participants that many of these goals and expectations will be met during the training. Others will be addressed through monthly meetings and ongoing communication with participants.



4. Explain that in order to ensure an effective training, the group will follow some ground rules. Invite participants to brainstorm ground rules. Write the ground rule on a sheet of chart paper and keep it posted during the training. Ground rules can include: punctuality; confidentiality; participation in discussions and activities; respect for different opinions; cell phones off.

5. Explain the concept of confidentiality. Then ask:

• What could happen if you told confidential information about one of your patients to someone else?

• How would you feel if someone shared confidential information about you with other people?

• Why is it so important to maintain confidentiality?

ConFiDEntiality

Confidentiality is one of the most important parts of being a clinician. you must keep everything that family members tell you, and everything that you know about their condition, confidential. you should only share such information with other clinicians when needed. you should not share this information even with the person’s spouse, siblings, or children, or your own spouses, siblings, or children.

some of you may reference confidential patient information during the training. you must share or ask in a way that maintains confidentiality. For example, do not use the person’s name, say where she or he lives, or give any other information that would reveal the person’s identity. also, you must not talk about confidential information outside of this training.

6. Introduce the anonymous question box. Explain that at any point during the day, participants are welcome to write down any questions they may have but do not want to ask aloud in front of the group, and put them in the box or envelope. The questions can be about particular cases or any other issue. At the end of the day, the facilitator will review and answer questions from the box, either with the group or privately as needed.

30 minutes

7. Distribute the pre-test and explain how it should be completed. Read the questions and possible answers aloud one by one if needed.

8. Collect the completed pre-tests.

9. Explain that the participants will take a post-test at the end of the training in order to measure what they have learned.



15 minutes

10. Explain to the participants that they have materials and resources that will be referred to throughout the training. The materials and resources will also be a resource to them once the training is over. Tell them that they can refer to the training materials when they are seeing patients or need clarification on the topics covered in the training.

11. Show the participants the Participant Handbook and show the agenda for the training. Tell them that the training is divided into a series of sessions as they can see listed in the agenda.

12. Ask the participants to turn to their handbook to the “Objectives” page. Tell the participants that each session has learning objectives associated with it. Tell them that the learning objectives represent what they should learn during each session of the training. Encourage the participants to re-visit the learning objectives for each session to assure that they are meeting the expectations for the training.

13. Remind the participants that they are responsible for their own learning in some ways. As such, encourage the participants to ask questions throughout the training, especially if they do not feel like they are able to fulfill the training objectives.

14. Turn on the projector (or uncover its lens).

15. Show Slides 2 – 4: “Learning Objectives.”

16. Animate and read each objective (ask a participant to read the objectives aloud or do so yourself). Tell the participants that these objectives will be covered by the training in the next three and a half days.



SeSSIon 2: What Is mental Health?

methods: large group discussion, carousel activity

Time: 1 hour

Participant Handbook page: 3

materials:

� Flip chart

� Markers

� tape

Preparation:

• review the definitions below.• Write the following titles on separate flip chart pages:

– “Confidentiality” – “show Empathy” – “active listening” – “religion” – “asking open-Ended Questions” – “What not to do”

Objectives:

d. Define mental health.e. Describe basic interviewing skills and their importance.

StePS

20 minutes

1. Tell participants:

Over the past two years, we discussed mental health and your role as community health workers in helping people to achieve good mental health and get help for mental disorders. We will start with a review of this discussion, focusing on the definitions of good health and good mental health.

2. Ask participants the following questions and take a variety of volunteer responses:

• What does it mean to have good health?

Responses may include: you are not sick; you are not malnourished; you do not have any infections or diseases such as pneumonia, tuberculosis, malaria, or HIV; you are strong and able to work; you do not need to go to the health center; you do not need medicines.



3. Ask participants to find the definition of health in their participant handbooks. Ask a volunteer to read the definition aloud.

Definition of health: Health is a state of complete physical, mental, and social well-being. Health is not simply the absence of disease.2 Part of being healthy means having good relationships with family and friends in the community. It means being able to engage in meaningful activities such as going to church or working. It also means being treated equally, and not facing stigma and discrimination from others.

4. Explain that this is how the World Health Organization (WHO) defines health. The WHO is an organization of health professionals dedicated to improving health around the world.

5. Ask participants:

• How is this definition similar to what you have just said about good health?

• How is this definition different from what you have just said about good health?

6. Ask participants the following questions and take a variety of volunteer responses (refer to Facilitator Notes as needed):

• As we have seen, having good mental health is part of having good health. What does it mean to have good mental health?

Responses may include: you can think clearly; you are not sad or depressed; your mind is clear; you are not confused. You are functioning well in your family and community.

7. Write the definition of mental health on the flip chart. Explain that this is how the World Health Organization defines mental health. Ask a volunteer to read the definition aloud.

Mental Health: Mental health is a state of well-being in which a person can realize her or his own potential, cope with the normal stresses of life, work fruitfully, and make contributions to her or his community.3


• How is this definition similar to what you have just said about good mental health?

• How is this definition different from what you have just said about good mental health?

9. Tell participants:

As we have seen, good mental health is part of good health. If a person does not have good mental health, we say that the person has a mental health disorder or mental health problem.

2. World health organization, http://www.who.int/features/qa/62/en/index.html.3. World health organization, http://www.who.int/features/qa/62/en/index.html.



There are different kinds of mental disorders, and you will learn about one of them, psychosis, during this training. We will discuss what causes psychosis, how it affects individuals and communities, and how you can support patients with psychosis. We will also discuss how supporting patients’ families and communities is an important part of their treatment.

40 minutes

10. Tell participants they will now spend some time reviewing best practices for how to interact with community members. Explain that interviewing skills are an important competency of community health workers, and so the participants will spend this next activity reflecting on successful interviewing techniques.

11. Hang up the six already-labeled flip chart pages around the room. Explain that:

• Participants will be broken up into small groups, and each group will be placed at a flipchart.

• The participants will have 2 – 3 minutes at each flipchart to discuss and write down their ideas related to the title of the flip chart.

• After two minutes, the facilitator will announce “move”, and all groups will finish writing, and travel in their groups to the next flip chart paper to the right.

• Once at the new flip chart, the groups will have the opportunity to read what has been written, and add any additional ideas (if a group agrees with an idea that has already been written, they can put the “+” sign to signal agreement next to the specific points).

• After two to three minutes, have participants move again in their groups to the next flip chart to the right, and continue the process until all flip charts have been visited by all the groups.

Participants should ponder the following questions during their time at each flip chart page:

• How would you describe this interviewing skill?

• Can you write down an example of this skill or how to do it?

• Why is this skill important?

12. Once the groups have traveled to each flip chart, they will sit down and the facilitator will summarize the key points written on that flipchart aloud for the class. The facilitator can add key points below:

a. Confidentiality

Speak with the person in a place that promotes confidentiality and makes the person feel safe. Provide a calm, private setting in which the persons feels safe enough to open up and share. This is an important part of establishing trust between you and the person.



b. Show Empathy

Empathy means to let yourself experience what the person is feeling and to let the person know that you understand what she or he is going through.

Showing empathy is a powerful healing tool. It helps the person to feel more supported and understood, and less alone. Empathy also makes it easier for the person to express uncomfortable feelings, such as anger, envy, sadness, or guilt.

Showing empathy does NOT mean that you express pity, give advice, or tell the person what you think is the right solution for her or him.

To show empathy:

– Try to understand the type and intensity of the person’s feeling. (Is the person sad or angry? A little angry or very angry?)

– Acknowledge the person’s feelings. (For example, say, “I can imagine how angry that might make you.”)

– Use phrases such as, “You seem to feel…” (“You seem to feel discouraged.”); “It sounds as if…” (It sounds as if you are very sad).

c. Active Listening

This means paying attention to what the person is saying and showing through your posture, your attentive expression, and occasional questions that you are interested in what she or he says. Paying attention through active listening is another powerful healing tool.

To listen actively:

– Face the person and look at her or him.

– Pay attention and do not let your mind wander.

– Show that you are listening by using appropriate facial expressions and nodding your head.

– Encourage the person with small comments such as “yes, uh-huh,” etc.

– Ask questions for clarification.

– Do not interrupt.

d. Religion

Follow the patient’s lead about religion. If the person brings up religion, show respect for the religion and explore how it relates to her or his depression. For example, does the person feel comforted by her or his beliefs? Forsaken? If a person’s faith offers a source of personal strength and social support, this can be used to support the person’s treatment. For example, engaging with the church community could help the person to feel more peaceful and less isolated. Some religious leaders may tell a person who is depressed, “God will take care of everything, do not worry.” It may be helpful to tell the



person that, yes, faith can help, but many people may also need other help, for example, counseling, medication, etc. Other religious leaders may tell the person, “This is hap-pening to you because God is punishing you.”

It is important to learn how the person understands her or his depression. Does the person think that it is her or his fault?

Without contradicting the person’s religion, reassure the person that she or he can get help, and that this happens to many people. If the person wants to seek the advice of a traditional healer, you may tell the person that she or he can do this, but that it would also be a good idea to go to the health center.

e. Asking Open-Ended Questions

Ask questions that will help you to understand the problems that the person is having in her or his life. The information that someone tells you depends on the way in which you ask the question. Ask open-ended questions to encourage the person to share and answer from her or his own perspective. Open-ended questions ask for more information than just a yes or no answer. Open-ended questions usually use what, how, when, who, where, why, and which — these words ask for more information than just yes or no.

Examples of open-ended questions:

– When do you think your depression began? Tell me about it.

– Why have you felt so sad this week?

– Who are the important people in your life?

– Who did you see this week?

f. What not to do

– Making decisions for the person

– Judging the person as a good or bad person

– Interrogating the person

– Blaming the person

– Preaching or lecturing to the person

– Making promises that you cannot keep

– Imposing your own beliefs on the person

13. Begin the activity: divide participants up into groups and assign each group to a flip chart page. Reiterate the instructions and use the prompts listed above to spark conversation.

14. Conclude by emphasizing that appropriate interview techniques in contribute to community health workers’ success in the community.



SeSSIon 3: Introduction to Agitation, Delirium and Psychosis

methods: large group discussion, reflection journey, assessment, role play



materials:


� Flip chart

� Markers

� tape

Preparation:

• Practice implementing the reflection Journey.• review PowerPoint (agitation, Delirium and Psychosis), slides 5 – 11.

Objectives:

f. identify participants’ current and past attitudes surrounding severe mental illness.g. Define psychosis, its causes and prognosis.h. Explore common misconceptions of psychosis.i. Explain the psychosis burden of disease.j. Describe the impact of stigma and discrimination on families and communities.k. introduce the family and community-based approach to treating psychotic patients.

StePS

30 minutes

1. Explain to the participants that the group will begin to discuss psychosis, which is the mental illness that is the topic of this training.

2. Tell the participants that you will now take them through a ‘Reflection Journey — some quiet thinking before a large group discussion. Ask participants to begin by closing their eyes or putting their heads down.

3. Once the participants are ready, lead them through the following ‘Reflection Journey’. Be sure to pause for 5 – 10 seconds after each question to allow the participants to reflect. Keep in mind that you do not need to ask every question (and you may add any questions that might be more relevant).



Think back to a time when you were very young:

• How did you learn about psychosis? What were your thoughts or feelings about it?

• What words did you hear and use related to psychosis?

• What did you think or feel about people with psychosis?

Think about your life since then:

• How have your thoughts about psychosis changed?

• What events or experiences changed the way you think or feel about psychosis?

• In what ways have your ideas about psychosis remained the same?

• What stigmatizing ideas about psychosis might you still have?

4. Ask participants to open their eyes. Invite a few volunteers to share their thoughts (maintaining patient and family confidentiality), and lead a brief discussion during which you discuss participants’ past and current experiences with psychosis. Discuss common explanatory models of psychosis in Haiti.

5. Show Slide 5: What is Psychosis?

Give the definition of psychosis and explain its biological, psychological, and social causes. Explain to the community health workers that it’s very important for them to understand these causes because often times patients and families feel more comfortable sharing their history with community health workers rather than psychologists and social workers.

6. Show Slide 6: Psychosis Prognosis

Proceed to line graph “Outcomes for Persons with Psychosis Compared to Healthy Person.” Explain that psychosis is a chronic illness that affects individuals’ ability to function. There are different phases. Sometimes it is more acute, other times it is more stable. Some people recover fully. Others do not. Therefore, it is usually a chronic, life-long illness.

• The healthy person is the green line. This person functions 100% normally.

• The red and blue lines represent two cases of psychosis. In the acute phase, both function very poorly. Both stabilize, however, psychotic patient A is less sick than psychotic patient B. In the long term, psychotic patient a can end up functioning similar to a normal person, while psychotic patient B may never reach the same level of recovery.

7. Show Slide 7: Causes of Psychosis

Ask the community health workers whether psychosis only affects the patient or whether it affects the family and community. Invite them to explain in what ways psychosis can affect families and communities.

Emphasize that major medical problems can produce symptoms similar to psychosis. However, when psychotic symptoms appear due to medical illness (such as HIV/AIDS related infections, TB, infections, medications), the condition is known as delirium, not



psychosis. If someone is experiencing delirium the patient needs to be identified and referred to be treated by a physician for the underlying medical problem. A patient with a medical delirium is not considered to have a mental health problem.

8. Show Slide 8: Impact of Psychosis in Haiti.

Explain that because the impact of psychosis in Haiti extends to families and communities, the treatment for psychosis must take place on all three levels. In the coming sessions, community health workers will learn their important roles in providing care at all three levels.

20 minutes

9. Ask participants if people with mental illness are treated differently, whether in their homes and/or in the community. Allow the participants to respond.

Explain that poor treatment of people with mental illness is usually because of stigma. Stigma refers to negative or prejudicial thoughts about someone based on a particular characteristic or condition, in this case, someone with psychosis.

Continue, explaining that stigma can often lead to discrimination. Sometimes, people who have stigmatizing beliefs about others treat them poorly or deny their rights. This is discrimination.

10. Explain to the participants that both community health workers and clinicians often feel stigma toward people with certain conditions. This can lead to discrimination — unfair or low-quality treatment of patients. Highlight the fact that, as CHWs, it is not acceptable to have stigmatizing thoughts or behaviors toward people with psychosis. It is the responsibility of CHWs to overcome any stigmatizing beliefs they may have in order to treat community members with dignity and respect.

11. Ask participants to close their eyes or lower their heads again, and to consider the following questions:

Think about the community members you visit:

• What are some stigmatizing beliefs families and communities may have about psychosis?

• How do these stigmatizing beliefs affect the person with psychosis?

• As a CHW, how can you respond to stigmatizing beliefs families and patients may have?

12. Ask participants to open their eyes. Invite a few volunteers to share their thoughts (maintaining confidentiality), and lead a brief discussion.

13. Remind participants the importance of building a therapeutic relationship — a relationship of trust that allows community members to express their thoughts and feelings honestly. Remind participants that in the last training, they discussed interview and counseling skills as well as other strategies for building trust with community members.



14. Ask the following question and hold a brief discussion and move around the room to encourage participation from different people:

• What are some ways CHWs can respond to patients, families or community members who demonstrate stigmatizing beliefs about people with psychosis?

20 minutes

15. Invite three volunteers to come the front of the room to complete a role play about stigma and patient communication (in participant handbook and Facilitator Notes below).

16. After the role play, ask the following questions:

• What did the community health worker do well?

• What could the community health worker improve next time?

• What are the next steps for the patient?

17. Thank the groups for their performances.

18. Explain that stigma and discrimination are not only unfair and unjust, but can lead to poor-quality treatment for individuals with psychosis.

Sometimes, communities, families and even community health workers can have stigmatizing thoughts about patients with psychosis, which can hinder access to high quality treatment and management.

Stigma and discrimination can also cause people with psychosis to suffer from other mental health problems such as depression, suicidality and alcohol addiction.

20 minutes

19. Ask participants the following questions:

• How many people would you estimate have psychosis worldwide?

• How many people with psychosis receive treatment?

Wait for participants to respond.

20. Show Slide 9: Treatment Gap.

Tell participants that over 81 million people in the world have a severe mental disorder. Ask participants:

• What is your reaction to these numbers?

• Why do you think the psychosis treatment gap is so high?



21. Explain that there are many people with psychosis in Haiti, and part of the participants’ job is to identify these individuals. Identifying cases of psychosis in the community is a critical first step for developing a system of care to treat psychosis in Haiti. We will discuss how to identify cases later.

22. Show Slide 10: Reasons for Treatment Gap.

23. Show Slide 11: Consequences of Treatment Gap.

Reiterate that stigma and discrimination can lead to poor access to treatment for people with psychosis. It is CHWs’ responsibility to treat people with psychosis and other mental health conditions with respect and dignity, to ensure that everyone who needs it receives appropriate medical care, and to educate the broader community.

24. Ask participants what questions remain and thank them for their work.

FACIlITATOR NOTeS

STIgmA ROle PlAy

Participant #1 plays the role of an adult with psychosis; Participant #2 plays the role of the ChW; and Participant #3 plays the role of a neighbor.

Adult with psychosis: talking to himself on the road outside of his house. Even though motos are close to hitting him, he doesn’t notice. he is wearing dirty clothes and is very thin. it appears he has not bathed or eaten recently.

CHW: the ChW moves toward the person to direct him back to his home. he places his hand on the psychotic person’s shoulder to direct him.

Neighbor: the neighbor shouts at the ChW to not touch the patient because she might catch psychosis from the patient.

Key POINTS

• the ChW should help the patient and move him away from the street so he is not in danger.

• afterward, it is important to speak to the community member patiently and respectfully. Key messages include:

– Psychosis is not contagious. it is due to an illness in the brain, but cannot be transmitted between people.

• a neighbor can help someone who may be psychotic and is in danger by finding a family member to be with the patient. the neighbor can also explain to the family that the illness is not contagious.

• ChW should follow up with the patient and can also follow up with the neighbor to assess a change in stigmatizing beliefs/behaviors.



DAY 1 RevIew: Participant Presentations

methods: group presentations

Time: 30 minutes

materials:

� Flip chart � Markers

StePS

30 minutes

1. Explain to the participants that they will be reviewing yesterday's sessions by participating in group presentations.

2. Tell the participants that they will be divided into small groups and will be assigned a topic from yesterday. The groups will have 10 minutes to create a three to five minute presentation summarizing the most important information from their assigned session. Each group will be given a piece of flip chart paper and markers — participants are free to draw, create a map, or write an outline to present their information to the audience.

3. Divide the participants into groups of four to five participants. Distribute the flip chart paper and markers. Assign one of the following sessions to each group:

• ZLDSI

• Initial Visit Form, Referral Form, Follow-Up Form

• Treatment Gap

• What is psychosis?

• Discrimination/stigma

• 6 Interviewing skills

4. Read the following questions aloud to the participants to guide their work:

• What were some of the key points raised of this topic?

• What ideas and suggestions are you taking away from this training?

After 10 minutes, invite each group to the front of the room to present. Instruct the timer to time each group so that no group goes over the five minute time limit. Thank each group after they have presented.



SeSSIon 4: Identifying and Approaching People with Agitation, Delirium and Psychosis

methods: large group discussion, facilitator presentation, group work, role play



materials:


� Flip chart

� Markers

� tape

� Education Cards

Preparation:

• Draw a table on a flip chart page with the following headings: thinking, other symptoms, haitian Creole sayings, functioning, safety.

• Draw a table on another flip chart page with the following columns: biological, psychological, social.

• review PowerPoint (agitation, Delirium, and Psychosis), slides 12 – 13.

Objectives:

l. Describe the psychosis care pathway and its importance.m. list the key roles for ChWs in psychosis management: case identification, referral,

triage, follow-up and documentation, and psychoeducation.n. Describe common symptoms of psychosis and how to identify someone with

psychotic symptoms.o. Explain how to approach patients with psychosis in a therapeutic and supportive way.

StePS

50 minutes

1. Ask participants to turn to the psychosis care pathway in their participant handbook.

2. Show Slide 12. Explain that the effective care of psychosis patients requires close collaboration between many members of the health care system. This collaboration is represented in the psychosis care pathway.

3. Ask participants to look at the pathway as you explain its different parts. Highlight the important roles of CHWs — case identification, triage, referral, documentation and psychoeducation.



4. Ask participants what questions they have about the pathway and answer briefly.

5. Ask participants to now turn to the Agitation, Delirium and Psychosis Checklist in the annex of their participant handbook. Tell the participants that this checklist outlines the major responsibilities of all the providers of care in the Zanmi Lasante mental health system: physicians, psychologists/social workers, nurses and CHWs.

6. Tell participants that they will now take a few minutes to read through it in pairs. Divide participants into pairs. Try to respectfully ensure that a CHW who is more comfortable reading is paired with a CHW who may be less comfortable doing so.

7. After a few minutes, when most pairs look done reading, ask what questions or concerns they have about the checklist. Tell participants that this checklist will be used by the CHWs and their supervisors alike.

8. Show Slide 13: “Psychosis System of Care Responsibilities.”

Explain this is a summary of the checklist responsibilities for each cadre. Introduce the CHW’s roles and responsibilities.

9. Ask participants to refer to their participant handbooks as you discuss the first role: case identification.

10. Ask participants the following questions and lead a brief discussion:

• What is case identification?

• When have you heard about or been responsible for case identification?

• Why is case identification important?

11. Summarize participants’ ideas and supplement with the following information:

• Case identification is a crucial part of CHWs’ work.

• Through case identification, CHWs identify individuals who otherwise would not have access to the care and treatment they may require.

• Many people with psychosis do not receive adequate assessment and treatment; through CHWs, these individuals are referred to psychologists and physicians for further evaluation.

Reiterate to participants: anyone who is suspected of being psychotic must be referred to a psychologist and a physician immediately for further evaluation.

Go to the pre-made flipchart with five categories (thinking, other symptoms, Haitian Creole sayings, functioning, safety) and explain there are five categories of symptoms/ findings that community health workers should keep in mind when trying to identify possible cases of psychosis.



12. Ask participants the following questions and then confirm, correct or supplement based on the information below. Tell participants they can refer to the same supplemental information in their participant handbooks.

• What are the thinking signs of psychosis?

– Strange thoughts about people harming him/her, about having great powers

– Thinks that mind is being controlled (di parol ki dwol/ki pa fè sans)

– Cannot think well (pa ka panse byen)

– Thinking/speaking does not make sense

• What are the other signs of psychosis?

– Speaking a lot/speaking too little/speaking to oneself (leve kouri, pa domi)

– Hears a voice telling him/her what to do (pale pou kont li oswa pale anpil, paka domi, kouri, tande/we bagay ki pa la)

– Sees things that are not there

• What are the functioning signs of psychosis?

– Unable to go to school/work

– Does not take care of self (bathing eating)

– Does not take care of children/family

– Does not do other activities (go to church, work the land)

– Isolated from family

– Being alone

• What are the Haitian Creole phrases used to describe psychosis?

– Maladi lalin

– Maladi pèdi bon sans

– Moun fou

– Tèt pati

– Tèt chò

• What are the safety concerns with psychosis?

– Aggressive

– Violent

– Suicidal

– Cannot take care of children/other vulnerable people



13. Tell participants to turn to their Education Cards. Have participants go to Education Card #1 and see that the messages they just learned are on the card. Tell participants that they will use the Education Cards to communicate psychoeducation messages to the community.

40 minutes

14. Tell participants to continue looking at the flipchart with the signs and symptoms used to identify psychotic patients. Tell the CHWs you want them to think about how to approach these patients in order to keep them calm and to make them feel supported. Remind them that psychotic patients cannot think well, are often scared that other people might harm them, and cannot process information well.

15. Tell participants that they will now view a role play performed by the facilitators. Two facilitators will perform a role play demonstrating how NOT to treat a person with psychotic symptoms.

DIReCTIONS FOR FACIlITATORS PeRFORmINg THe ROle PlAy

• one facilitator should be the ChW, while the other facilitator should be a community member with psychotic symptoms.

• the facilitator playing the ChW should do the opposite of what ChWs should do to manage patients with psychotic symptoms. (e.g. they should blame the patient, challenge his delusional beliefs, respond to his strange thinking, not take the knife away from him, not manage the crowd, not decrease the stimulation, etc.).

• the role play should take no more than 3 minutes.

16. After the “how not to treat a person with psychotic symptoms” role play has ended, ask the participants to identify what went wrong. Help them identify better ways to approach a person who may have psychosis, using the facilitator manual and participant handbook. Ask if there are any questions.

Add additional key points as needed:

How to Approach the Psychotic Patient:

• Do not blame the patient.

Psychosis is a medical illness. It is not the patient’s fault.

• Do not challenge the patient.

Do not challenge the strange ideas they share — it will provoke them. Focus on being kind and maintaining safety.



• Treat the patient very well.

Make eye contact. Speak softly. Be very kind and patient, even if the person yells at you. Never yell back.

• Speak slowly, softly and clearly in simple, short sentences.

When a person is psychotic, they cannot think clearly. Do not overstimulate them by talking to them too much. Focus on supporting them and insuring their safety.

• Never see the person alone. Remove dangerous objects.

Make sure a family member is present, and make sure there are no dangerous objects accessible. Psychotic patients can be violent.

• Avoid crowds and noise.

Make sure no crowds are gathering to watch the person and to yell at him/her. Take the patient to a place where they can be alone with a family member. Make sure there are no loud noises and no one is watching or shaming the patient.

• Share important information with psychologists.

Remember the biopsychosocial nature of psychosis. Share all biological, psychological, and social causes of psychosis.

17. Tell participants that they will now participate in a different role play, modeling the proper approach when working with a patient with psychotic symptoms. Ask for four volunteers. Tell the volunteers that the role play shouldn’t last more than 3 minutes.

ROle PlAy

Participant #1 will be the ChW; Participant #2 will be the patient; Participant #3 will be the patient’s father; Participant #4 will be a neighbor.

CHW: the ChW has been asked to visit the home of a 25-year-old man who may be psychotic.

Patient: this 25-year-old man has been carrying a knife with him because “bad spirits are after him.” he is unable to work and does not bathe. he spends all day walking around looking for the bad spirits.

CHW: When the ChW arrives to where the patient is, there is a large crowd of neighbors watching the patient.

Patient’s Father, Neighbor: the father and neighbor are yelling at the patient calling him “moun fou.”

Patient’s Father: he feels angry with and frustrated by his son’s behavior. he has tied up and beaten his son before.

Neighbor: he is trying to help the father by threatening to beat the son again.



18. After the role play has ended, ask the audience members what the CHW specifically did to manage the patient. Ask the audience if there is anything they would have done differently.

19. Add any additional key points as necessary:

• The CHW should politely ask the crowds to leave.

• The patient should ask the neighbor to not yell at the patient and should ask him to leave.

• The CHW should ask the father not to yell at the patient and to explain that they can get help at a local Zanmi Lasante clinic.

• The CHW should be very kind to the patient, speaking softly and making eye contact.

• The CHW should not blame or challenge the patient’s false beliefs.

• The CHW should focus on safely removing the knife by asking the patient to put it down and then taking it from him.

• The CHW should work with the father to move the patient to a calmer environment. The CHW should use short, simple sentences to help the patient do this.

20. Before closing ask the CHWs to reflect on the best way to approach patients who may be psychotic. Ask them to think about how they would teach families to approach a family member who may be psychotic. Ask for participants to share any ways they have managed people with psychotic symptoms in the past (and if they would have done it differently).



SeSSIon 5: Triage and Referral for Agitation, Delirium and Psychosis

methods: large group discussion, facilitator presentation, group work, role play



materials:


� Flip chart

� Markers

� tape

� slides

Preparation:

• review PowerPoint (agitation, Delirium and Psychosis), slides 14 – 19.• Make copies of the referral Form (1 copy/participant).• Make copies of the initial Visit Form (1 copy/participant).

Objectives:

p. identify the difference between when to make an urgent referral and emergency referral.q. successfully complete the referral Form.r. successfully complete the initial Visit Form.s. Explain which information to report to psychologists/social workers when making

a referral.

StePS

1 hour

1. Explain to participants that once a person with psychotic symptoms has been identified, the community health worker’s next responsibility is to triage and refer.

2. Explain to the participants that they must refer all patients with psychotic symptoms to psychologists/social workers and physicians. “Triage” determines how quickly they must make the referral. Some people with psychotic symptoms need to be referred immediately as an “emergency” while others can be referred “urgently.”



3. Show Slide 14: Triaging Cases

Explain to participants the following information. Encourage them to follow along in their participant handbook.

Emergency situations — patients facing these situations must be brought to the clinic or hospital immediately:

• New psychosis (for any patient but especially for mothers who are pregnant or who have just given birth)

• Agitation

• Violence

• Suicidal ideation

• Medication side effect (fever, dystonia)

Urgent situations — patients facing these situations must be evaluated by a psychologist and physician within 24 hours:

• Patient has confirmed psychosis but is not taking medication or does not have medication.

• Patient has confirmed psychosis and is pregnant but the doctor does not know.

• Patient has confirmed psychosis and is breastfeeding but has not told the physician she is breastfeeding.

• Patient has problems from psychosis medications which she cannot tolerate.

• Psychotic symptoms are getting worse.

4. Shows Slides 15 – 19: Which type of referral?

Proceed through the next few slides, which present possible situations. Ask the participants to tell you whether the situations are urgent (referral within 24 hours) or are an emergency (referral immediately/same day).

Explain to participants that when an urgent/emergency referral is happening, you need to remember to include the family in your communication plan. Ask participants:

• Why do we need to communicate with the family when a referral is happening?

• What should we specifically check with the family about?

Write participants’ answers on the flipchart. Add the following additional information if not mentioned:

• Communicate with the family to:

– Make a plan for the safety of the patient’s children and other children in the household.



• Check with the family about:

– Family’s socioeconomic burden of the illness.

– The wellbeing of the patient’s children (school, food, proper supervision, abuse).

– Depression, trauma, and stigmatization of family members. Family members may need a ZLDSI and a referral to see a psychologist/social worker.

5. Tell participants that community health workers will refer a person with psychotic symptoms to the nearest health facility with a psychologist/social worker. CHWs will record their referral on the Referral Form.

6. Ask participants to turn to the Referral Form in the annex of their participant handbook. Invite participants to take five minutes to quietly review the form. Then, go through the form question by question, asking participants if anything is unclear. The facilitator should discuss which information should be entered into each part of the form.

7. Tell participants that if it is the first time that the CHW is seeing this particular community member, they should also fill out the Initial Visit Form. Ask participants to turn to the Initial Visit Form in the annex of their participant handbook. Invite participants to take five minutes to quietly review the form. Then, go through the form question by question, asking participants if anything is unclear. The facilitator should discuss which information should be entered into each part of the form.

8. Explain that a third key form to utilize with people with psychosis is the ZLDSI. This screening tool, which has been taught to community health workers in previous trainings, is important in understanding if a psychotic patient is also suffering from depression.

9. Tell participants that sometimes they might not be able to capture all the information needed for the Referral Form, Initial Visit Form or ZLDSI because of the emergency state of the patient. If the patient is not able to provide basic details about themselves, then ask neighbors or family members to get the needed demographic information.

10. Tell participants that once they fill out the Referral Form and/or Initial Visit Form and/or ZLDSI, they must help the patient get to the health facility. Once the patient and community health worker are at the facility, the community health worker is responsible for sharing information about the patient with the psychologist/social worker and physician to help them make a medical or mental health diagnosis.

Ask the participants:

• How often do patients and families tell you things that they do not tell the psychologist/social worker?

• What type of information do they share with you that they might not share with the physician or psychologist/social worker?



11. Once participants have answered, return to the flip chart page with the terms ‘biological’, ‘psychological’ and ‘social’ causes/contributors to psychosis. CHWs should alert psychologists if they learn that a patient who may have psychosis experiences the following:

bIOlOgICAl PSyCHOlOgICAl SOCIAl

� hiV/aiDs

� infections

� alcohol/drugs

� head injury

� Death/grief (partner, child/baby, parent)

� Failure/loss (test, job)

� other trauma

� unemployment

� Poverty

� Migration/exploitation (Dominican republic)

12. Tell the participants that many of the causes of a patient’s psychosis might be revealed to you, rather than a physician or psychologist/social worker. It is an important part of the community health worker’s role to communicate information surrounding the patient to the clinicians.

30 minutes

13. Tell participants that they will now participate in a role play to practice identification, triage and referral skills. Ask for four volunteers and assign each a role. Give the volunteers a few minutes to prepare. The role play should not last longer than 5 – 7 minutes.

ROle PlAy

Volunteer #1: Community health worker; Volunteer #2: Patient (Jessica). Jessica is a 28-year-old woman who is 3 months pregnant; Volunteer #3: Patient’s mother; Volunteer #4: Psychologist/social worker at health facility.

Patient’s mother: runs up to ChW hoping that the ChW could help her.

Community Health Worker: asks what is wrong.

Patient’s mother: Explains that daughter was raped and is having a crisis.

Community Health Worker and Patient’s mother: rush to Jessica’s house.

Patient: locked in her bedroom screaming. she is agitated and psychotic, her behavior is disorganized, and when she talks, she does not make sense.

Community Health Worker: identifies the situation, triages, fills out referral form, notifies psychologist/social worker at hospital.

Community Health Worker, Patient’s mother, Patient: go to health facility together.

Community Health Worker and Psychologist/social worker: ChW gives referral form to psychologist/social worker, communicates important information.



14. Pass out copies of the Referral Form and Initial Visit Form. Tell the audience that during the role play they should fill out the Referral Form and Initial Visit Form as though they were the CHW, too.

15. Begin the role play. Once the role play has finished, ask the audience the following questions:

• How did we know this person was psychotic? What were her symptoms?

• Did this patient receive an emergency referral or urgent referral? Why?

• What key information was communicated to the psychologist/social worker by the community health worker?

16. Then, as a group, go over the Referral Form and Initial Visit Form. Ask participants what they filled in and why. Clarify any questions as needed.



SeSSIon 6: Counseling Patients and Families about Agitation, Delirium and Psychosis

methods: Facilitator presentation, role plays

Time: 2 hours


materials:


� Education Cards

Preparation:

• review PowerPoint (agitation, Delirium and Psychosis), slides 20 – 28.

Objectives:

t. Explain when the ZlDsi should be administered to a patient’s family members.u. list the four groups of psychoeducation messages and when each should be used.v. utilize Education Cards to counsel patients and families.

StePS

1 hour

1. Explain to the participants that they will play a very important role in supporting families and educating them so they can take care of their family members. This role is a critical part of the psychosis care pathway.

2. One of the first ways to support family members is by supporting their mental health. Often, caregivers of people with mental illness experience stress, fatigue, and feelings of anger, shame or helplessness. It is important to screen caregivers and family members for depression using the ZLDSI. If caregivers and family members are depressed and not treated, they are more likely to contribute to a negative home environment for the person with mental illness.

3. Explain to participants that the ZLDSI should be administered to a patient’s family members after a stressful event, such as when a person is displaying psychotic symptoms. The ZLDSI should also be administered as needed to family members during follow up visits. If there is a score of concern, the family member/caregiver should be referred to the psychologist/social worker.



4. Show Slide 20: 4 Groups of Psychoeducation Messages.

Tell the participants that there are 4 different groups of psychoeducation messages that a community health worker can present to a patient and their family.

Tell participants that each of these groups of messages will be used at different times, because the messages are specific and targeted to how that patient/family might be feeling/thinking in that moment.

Ask participants:

• Why might you give different psychoeducation messages at different times?

• Looking at the four groups of psychoeducation messages on the slide, how might the messages in each group be different?

5. Show Slide 21: Psychoeducation: Diagnosis Unconfirmed

Read the points on the slide aloud, adding additional information if needed:

• Psychosis/agitation is a medical emergency that must be treated immediately.

– It can be caused by an illness in the body that affects the brain. It can be fatal. Therefore, the person must go to see a psychologist and physician immediately (the same day).

• Do not blame the person. Do not challenge the person. Treat the individual kindly and with respect.

– The illness is not the person’s fault. They do not mean what they say. Yelling and blaming will make the illness worse. Challenging the strange things the person says will make the illness worse. Be gentle and kind. Give simple commands. Focus on keeping him/her safe and getting him/her medical care.

• Do not tie up, beat, or burn the person

– Doing this will harm the person and make the illness worse, not better.

• Avoid crowds/noise.

– If the patient becomes agitated, move him/her to a quiet, isolated place. Make sure there are not too many people and too much noise. Make sure there are not lots of people watching and yelling.

• SAFETY: Never leave the person alone or with children/other vulnerable individuals.

– Never leave the person alone with babies, children, the elderly or a pregnant woman. When people are psychotic they can become violent or they can be negligent. Make sure a responsible family member or neighbor is with him/her at all times.



• SAFETY: Remove dangerous objects.

– Make sure all objects that can be used to harm oneself or another person (knives, ropes, poison) are removed or locked up. A person who is psychotic is high risk for harming himself /herself and others.

• Find family members and neighbors who can help.

– Psychosis affects the person. But it also affects the family. When a family member is psychotic, the family members need help to manage the patient and to take care of the rest of the family, especially the children.

6. Tell participants to turn to their Education Cards. Have the participants turn to Education Card #2, to see that the messages on this card are the same as what they just learned about. Tell participants these Education Cards will be used to help the community health worker communicate these important psychoeducation messages in the community.

7. Explain that participants will now look at a case together to review the psychoeducation messages to give to a family/patient who has psychotic symptoms but has not been diagnosed yet.

8. Show slide 22: Case – Diagnosis Unconfirmed.

Ask for one participant to come up and do the case as a role play with the facilitator. The participant will be the community health worker, and the facilitator will be the father. Give the participant and facilitator a few minutes to prepare, and invite them to begin the role play. Tell the participant that he should use his Education Card to assist him during the role play when he is giving psychoeducation.



CASe

Participant #1 (volunteer): Community health Worker; Participant #2 (facilitator): Father.

ROle PlAy: DIAgNOSIS UNCONFIRmeD (ReFeRRAl)

• you are a ChW.

• you visit the home of a 25-year-old man who may be psychotic.

• this 25-year-old man has been carrying a knife with him because “bad spirits are after him.”

• he is unable to work and does not bathe. he spends all day walking around the community looking for the bad spirits.

• a concerned community leader has asked you to meet with his father, who has resorted to tying up and beating his son. he also takes him to a hougan for treatment.

• the son is not at home but the father is.

NOTeS FOR FACIlITATOR’S ROle AS ‘FATHeR’

Father: says that the illness is a curse sent from a neighbor and needs treatment from a hougan, not a Zanmi lasante clinician.

Father: says he ties up his son when he gets violent because he does not know what else to do.

Father: says he is very angry with his son because his illness prevents him (the father) from working the land and his mother from doing commerce.

Father: says he has a 3-year-old and five-year-old child.

9. Begin the role play. All the audience members should be following along with their Education Cards. Once the role play has finished, debrief, highlighting important messages and takeaways from the role play.

10. Show Slide 23: Psychoeducation: Confirmed Diagnosis (Visit 1)


• Make sure the patient is taking the medication properly.

• Make sure that a family member is keeping the medication and giving it (checking the patient swallowed).

• Check for major side effects (fever, rigidity, restlessness).

• Make sure patient has follow-up appointment scheduled and is planning to go in the next month. Make sure patient has enough medication to last until next appointment.

• Explain to families the importance of sharing all information with psychologist/social worker (medical illness, alcohol/substance abuse, past trauma; see biopsychosocial diagram).



• Ask the family to tell you the illnesses’ impact on them. Look at economic impact, stigma from the community, and neglect of children. Check for depression and do ZLDSI for family members. Explain to the family that during the next visit you will explore ways to diminish this impact.

11. Show Slide 24: Psychoeducation: Medication

Read the points on the slide aloud, adding additional information if needed.

12. Tell participants to turn to their Education Cards. Have the participants turn to Education Card #3 and #4, to see that the messages on these cards are the same as what they just learned about.

13. Explain that participants will now look at a case together to review the psychoeducation messages to give to a family/patient who has psychotic symptoms and has been diagnosed with psychosis.

14. Show Slide 25: Case – Confirmed Diagnosis.

Ask for 2 new participants to come up and do the case as a role play with the facilitator. One participant will be the community health worker, the second will be the patient, and the facilitator will be the father. Give the participant and facilitator a few minutes to prepare, and invite them to begin the role play. Tell the participant that he should use his Education Card to assist him during the role play when he is giving psychoeducation.

CASe

Participant #1 (volunteer): Community health Worker; Participant #2 (volunteer): Patient; Participant #3 (facilitator): Father.

ROle PlAy

you refer the 25-year-old man to the psychologist and physician.

• they find he has no major medical problems. they diagnose him with psychosis.

• the doctor prescribes risperidone 1mg by mouth each night.

• you are asked to follow-up with the patient and his father the following week.

NOTeS FOR FACIlITATOR’S ROle AS ‘FATHeR’

Father: Begins asking a lot of questions about medications. the father should say he gives two pills, rather than 1 pill (as prescribed) to make the patient get better faster. the father should add that he wants his son better immediately so the rest of the family does not suffer.

Father: reports that sometimes the patient has “ko rèd” and then refuses to take the medication.

Father: Emphasize the illness’ socioeconomic burden on the family and how the other children in the family are being neglected. Discusses stigma from other family and community members.



15. Have the participants begin the role play. All the audience members should be following along with their Education Cards. Once the role play has finished, debrief, highlighting important messages and takeaways from the role play.

1 hour

16. Show slide 26: Psychoeducation: Confirmed Diagnosis (Visit 2)


• Give hope about the illness.

Explain that psychosis is just like any other illness. It can be treated, just as hypertension (high blood pressure) or other illnesses can be. However, it is a chronic illness (like hypertension or diabetes) and requires lifelong treatment.

• Challenge hope and helplessness by explaining to family what they can do to help the patient.

– Explain that if patients go to the psychologist and doctor, the patient can receive medication and can get better.

– Explain that patients have control over the patient’s illness. They can make sure the patient takes the medication. They can also create a “supportive environment” at home.

– They can make a “relapse prevention drill” to prevent the patient from getting very sick again.

• Discuss with the family how to create a supportive environment.

– No blaming/criticizing the patient

– No anger towards the patient

– Resolving family conflict (related/unrelated to illness) by talking

– Keeping home environment calm

• Discuss the role of the family in supporting the patient’s treatment (medication, appointment, activities, daily schedule).

– Giving medication and making sure patient takes it.

– Making sure patient goes to psychologist/physician appointment (at least monthly) with one family member).

– Daily plan/schedule for patient (sleeping, eating, activities).

– Encouraging the patient to participate in activities (hygiene, work, social) and not treating the patient like a child.

17. Tell participants to turn to their Education Cards. Have the participants turn to Education Card #5, to see that the messages on this card are the same as what they just learned about.



18. Show slide 27: Psychoeducation: Stable or Improved.


• Check whether family has identified other family/neighbors who can help

– Psychosis impacts the family a great deal. It’s important to have friends and neighbors who help.

• Check whether family has created a supportive environment at home.

– No blaming/criticizing the patient

– No anger towards the patient

– Resolving family conflict (related/unrelated to illness) by talking

– Keeping home environment calm

• Check whether the family is supporting the patient’s treatment.

– Medication, appointments

– Daily schedule, activities

19. Show slide 28: Psychoeducation: Relapse Prevention Drill

Tell participants that the purpose of the relapse prevention drill is to prevent patients from becoming sick after they stabilize. It helps the family prepare for this possibility. During a relapse prevention drill, the CHW discusses ways for the family to help the patient prevent relapse (through a daily schedule, by taking medication, by going to appointments, and by doing various activities). Family members also identify early signs of psychosis, as well as people who can help them.

20. Tell participants to turn to their Education Cards. Have the participants turn to Education Card #6 and #7, to see that the messages on this card are the same as what they just learned about.

21. Close by asking CHWs whether they have any questions about psychoeducation for agitation, delirium and psychosis. Remind them that their responsibilities include:

• Referring anyone from the community whom they suspect may have psychosis to the hospital.

• Counseling families and community members about psychosis, especially the important role of family in supporting and caring for the patient.

• Conducting community education sessions about psychosis, decreasing stigma and discrimination.



DAY 2 RevIew: ball Toss

methods: game

Time: 30 minutes

materials:

� Ball (about 1 for every 7 – 10 participants)

StePS

30 minutes

1. Explain to the participants that they will be reviewing yesterday’s sessions by participating in a game.

2. Open the game by reviewing the titles of the three sessions covered the day before.

• Session 4: Identifying and Approaching People with Agitation, Delirium and Psychosis

• Session 5: Triage and Referral for People with Agitation, Delirium and Psychosis

• Session 6: Counseling Patients and Families about Agitation, Delirium and Psychosis

3. Invite participants to take 3 – 5 minutes to look over their notes and participant handbook chapters on these sessions, reviewing quietly some of the most salient points or new pieces of information learned.

4. After 5 minutes, ask for participants to stand come stand in one large circle or make multiple circles depending on class size (7 – 10 people is ideal for a circle; if there is more than 10 people, create another circle with a separate ball and facilitator).

Tell participants that during this activity you will begin by announcing which session you want to review (4, 5 or 6). You, the facilitator, will begin by holding the ball and sharing a fact or new piece of knowledge you learned yesterday. Then, once you have stated your fact, you will throw the ball to a participant in the circle, who will then have to say another, dif-ferent fact learned the day before from that session. Once the participant has received the ball and has contributed a fact, they should put their hands behind their back, to signal they have participated. This participant now throws the ball to a third person in the circle, who will have to share another new fact. Ask participants to not repeat the same piece of information that another participant has already mentioned. The ball should ultimately be thrown to each person in the group once, so everyone has an opportunity to contribute.

5. Once everyone has shared one fact for the chosen session, begin the game again, this time focusing on a different session. Continue until all participants have spoken about all sessions.



SeSSIon 7: Conducting Home visits and Follow-Up

methods: role play, large group discussion

Time: 2 hours


materials:

� initial Visit Form (1 copy/participant)

� referral Form (1 copy/participant)

� Follow up Form (1 copy/participant)

Preparation:

• Photocopy the initial Visit Form, the referral Form and the Follow-up Form.• review the Patient Education role Plays.• review the Education Cards.

Objectives:

w. Explain when and how to conduct home visits for psychoeducation and follow-up. x. successfully complete the Follow-up Form.

StePS

1 hour

1. Remind participants that the CHW’s key roles are: case identification, triage, referral, documentation and psychoeducation. Explain that in this session, they will practice home visits, related counseling and follow-up.

2. Tell participants that effective follow-up is just as important as case identification and referral. Once a person with psychosis has been triaged and referred to the health facility for consultation with a psychologist/social worker, the community health worker will continue to support the patient when they return to the community. Depending on the severity of the patient’s diagnosis, and recommendation by the clinicians at the health facility, the community worker will visit the patient at their home with frequency.

3. When the community health worker visits the patient, the community health worker will provide psychoeducation to the patient and their family (as learned about in previous sessions). The community health worker will record their actions with the patient on the Follow-Up Form.



4. Have all participants turn to the annex in their participant handbook to the Follow-Up Form. Go over the Follow-Up Form step by step to teach how it should be properly completed. Answer questions as they are raised by participants.

5. Distribute the Initial Visit Form, the Referral Form and the Follow-Up Form to the participants.

6. Explain to participants that they will have about 30 minutes to practice conducting two patient and family education sessions through role plays. Each role play should be about 5 minutes long. During the role play, participants should consider:

• What questions to ask the patient and family

• How and when to share key messages

• How and which forms to complete

7. Tell participants that after 30 minutes, various groups will be invited to the front of the room to perform the role plays and receive feedback.

8. Divide participants into groups of three to four. Assign each group two role plays that can be found in their participant handbooks. It is fine if some of the groups perform the same role play.

9. Circulate as participants work through the role plays, answering questions and providing feedback. Identify a few groups whom you will invite to the front of the room to perform.

1 hour

10. Ask participants to stop working. Invite the first group to the front of the room to present a role play. After the presentation, ask the audience:

• In the role play, what did the CHW do, or say, well?

• What could the CHW improve next time?

• What are the next steps for the patient and the family?

• Which is the appropriate form to use in this scenario, and which information is recorded there?

• Which step in the psychosis care pathway is represented in the role play (case identification, triage, referral, documentation or psychoeducation)?

11. Repeat this process for each of the groups you invite to perform (you do not need to invite every group).

12. After thanking the groups for performing, summarize key learning points and ask participants what questions still remain.



FACIlITATOR NOTeS

ROle PlAy 1

THRee ROleS

• gerard is a 30-year-old man who has recently been sharing strange thoughts with his family. he thinks he is a messenger from god. he cannot function: he stopped working 6 months ago. also, sometimes he is aggressive. he hit his mother two months ago. he has never been evaluated by a psychologist/social worker or physician at a Zanmi lasante clinic, and has never been diagnosed with psychosis.

• amelie, his mother, fears that a spirit is punishing him because she argued with her neighbor last month. she has taken him to a traditional healer, but the illness has continued and she does not know what to do.

• the ChW notices that amelie seems worried and down. the ChW does a home visit to learn more.

Key POINTS

• role #1: Case identification

– gerard has thinking symptoms of psychosis (strange thoughts); functioning symptoms (he cannot work), and safety issues (he has been violent). refer gerard to the psychologist.

• role #2 and #3: triage and referral

– gerard has never been diagnosed with psychosis, so this may be a new diagnosis. he must be referred to the psychologist/social worker and physician immediately. this is an emergency. remember that in an emergency, one can never neglect the family. the ChW should check about the socioeconomic burden of the illness, make sure that all children/vulnerable family members are safe, and do a ZlDsi to see if amelie is depressed.

• role #4: Documentation – use initial Visit Form

– Fill out initial Visit Form

– use the ZlDsi to screen for mental health comorbidities, especially suicidal/homicidal ideation.

– give initail Visit Form and ZlDsi to psychologist/social worker directly.

– Fill out referral Form (be sure to coordinate with psychologist/social worker) and give to patient or family members (referral Form needs to be given to clinic/hospital).

– the mother may be depressed. Do a ZlDsi and follow the depression care pathway for her.



ROle PlAy 2

TWO ROleS

• annette is a 40-year-old woman who is in her first trimester of pregnancy. she has already been seen by a psychologist/social worker and a physician at a Zanmi lasante site. they diagnosed her with psychosis and started her on the medication haloperidol. she has been stable for 6 months. however, her doctor does not know she is pregnant.

Key POINTS


– the patient is already an established psychosis patient

• roles #2 and #3 : triage and referral

– she is a pregnant patient with psychosis but her physician does not know she is pregnant. this case is urgent (do not wait for the next appointment). she must go to the hospital/clinic within 24 hours.

– Ensure follow-up with psychologist/social worker and physician.

– Document in Follow-up Form:

• Whether psychotic symptoms are improving.

• ZlDsi and mental health comorbidities, especially suicidal/homicidal ideation.

• adherence to medication; also side effects.

• re-screen any family members that you once offered the ZlDsi to during the first visit. if family members ZlDsi scores raise a concern, encourage them to see a psychologist at the clinic.

• give Follow-up Form and ZlDsi to psychologist directly.

• role #4: Psychoeducation: Psychosis stable/improved. relapse Prevention Drill.



ROle PlAy 3

THRee ROleS

• you are completing a follow-up visit for Pierre, anita’s 21-year-old son who has psychosis. Pierre has already been evaluated by a psychologist/social worker and a physician at a Zl site. he was diagnosed with psychosis. his psychosis has stabilized with medication, and he has no side effects. he has been stable for three months.

• you visit Pierre and his mother after the psychologist/social worker asks you to do follow-up for him.

• you learn from anita that Pierre stopped taking his medication one week ago. today he reported wanting to kill himself.

Key POINTS


– the patient is already an established psychosis patient.

• role #2: triage

– Pierre has stopped taking his medication and he is suicidal. this is an emergency. he must be referred to the psychologist/social worker and physician immediately.





• Check evolution of symptoms.


• role #4: Psychoeducation – relapse prevention drill.

– the ChW should help anita review the plan she developed when Pierre was stable. the ChW can also recall skills related to managing a psychotic patient (do not blame/challenge the patient; treat the patient very well; speak slowly and simply; remove dangerous objects; avoid crowds and noise; share information with the psychologist).



ROle PlAy 4

TWO ROleS

• Jean is a 55-year-old man whom you identified as a possible psychosis case. he was previously hospitalized at Mars and Klein hospital. you referred him immediately to see a Zanmi lasante psychologist and physician. he was diagnosed with psychosis and started on risperidone 1mg on week ago.

• you return to see Jean’s wife to continue psychoeducation.

Key POINTS


– the patient is already an established psychosis patient.

• roles #2 and #3: triage and referral

– the ChW can assume that Jean is doing well, is taking his medication, and there are no safety concerns. the ChW should make sure he has follow-up scheduled and enough medication to last until his appointment.

– Document in Follow-up Form




• Check evolution of symptom.


• give Follow-up Form and ZlDsi to psychologist directly.

• role #4: Psychoeducation for psychosis using Education Card (visit 2).



ROle PlAy 5

TWO ROleS

• Evelyn is a 45-year-old woman with a lifelong history of psychosis. she has never been stable nor has she taken medication regularly. you identified her as someone with psychotic symptoms and have referred her to a Zanmi lasante psychologist/social worker and physician. they started her on haloperidol.

• Evelyn’s daughter calls you to tell you her mother has a high fever and rigidity.

Key POINTS


– the patient is already an established psychosis patient

• roles #2 and #3: triage and referral

– the patient has a high fever. this is an emergency, and the patient must be referred to a psychologist and physician immediately. high fever and rigidity after starting an antipsychotic can be deadly.

– usually the ChW would ensure follow-up with psychologist and physician but this is an urgent case, patient must be brought to hospital/clinic immediately.

– usually the ChW should check to see if the patient has enough medication to last until next appointment. But in this case, this is not necessary because the patient is experiencing a life-threatening side effect.

– usually the ChW should do psychoeducation. however, since this case is an emergency, the ChW should focus on getting the patient to the hospital immediately.

– accompany the patient to the clinic/hospital because this is a life-threatening issue.


• Whether psychotic symptoms are improving

• ZlDsi and mental health comorbidities, especially suicidal/homicidal ideation

• adherence to medication; also side effects

• Check symptom evolution




SeSSIon 8: Community education Activities

methods: large group discussion, small group work

Time: 2 hours


materials:

� Education Cards

� Flip chart

� Markers

� tape

Preparation:

• Photocopy the initial Visit Form, the referral Form and the Follow-up Form.• review the Patient Education role Plays.• review the Education Cards.

Objectives:

y. Conduct successful community education activities about psychosis using the Community Education activity Checklist.

z. Facilitate community members’ completion of the stigma assessment.aa. assess community members’ understanding of stigma and discrimination through

the stigma assessment activity.

StePS

30 minutes

1. Explain to participants that part of their role is to complete Community Education Activities about many topics, including agitation, delirium and psychosis.


• By a raise of hands, who has ever seen a presentation or community event that they really enjoyed?

• By a raise of hands, who has seen a presentation or community that could have been improved (or wasn’t very good)?

Explain that community activities can be really great (if done well) and very boring (if not done well).

3. Invite participants to brainstorm for three minutes with the person sitting next to them the elements that make a presentation engaging, interactive, and overall, successful.



4. After three minutes, invite the pairs of participants to share their ideas, calling on each pair one by one to quickly summarize their thoughts.

5. Write down participants’ answers on the flip chart.

6. Once all pairs have presented, ask participants:

• How might you use some of these interactive teaching methods in your psychosis community education activities?

Allow for participants to respond.

1 hour

7. Ask participants to review the Community Education Activity Checklist in the participant handbook. Call on different participants to read the checklist steps aloud.

8. Ask participants if they have any questions, concerns or additions to the checklist. Note these questions, comments and suggestions on the flip chart.

9. Tell participants they will now spend some time becoming comfortable with the first four steps on the checklist:

a. Introduce yourself to the group.

b. Explain the goal of the meeting and introduce the main subject (agitation, delirium and psychosis).

c. Assess the baseline knowledge of the subject (through asking the audience general questions).

d. Use Education Cards and participant handbooks to provide key information about the main subject (agitation, delirium and psychosis):

– Define the disease.

– Explain symptoms with concrete examples.

– Explain how the disease develops, if it is contagious, prevention methods, where and how to be treated, and recovery.

Tell participants that they will spend the next 5 – 10 minutes discussing points three and four with a partner. Participants should specifically brainstorm:

– What questions they would ask the audience to elicit information for checklist point #3.

– What key points about agitation, delirium and psychosis they would present at a community activity for checklist point #4.



10. Divide participants into pairs and begin the activity. Circle through the pairs, answering questions as needed.

11. Once ten minutes has passed, ask for a volunteer to come to the front of the room to demonstrate the first four steps of a Community Education Activity about agitation, delirium and psychosis. Explain that the volunteer should only speak for 5 – 10 minutes, and the audience should pretend to be community members and respond.

12. After the participant has completed the presentation, thank him/her for her presentation. Ask the following questions and lead a brief discussion:

• What did the community health worker do well?

• What could be improved next time?

13. Invite another volunteer to present if time allows.

30 minutes

14. Explain that part of the CHW’s responsibility during a community education activity includes assessing and recording the level of stigma that community members have related to mental health issues like agitation, delirium and psychosis. This falls under steps 5 and 6 on the Community Education Activity Checklist.

15. Explain that community members will complete the Stigma Assessment before they receive education about stigma and discrimination from CHW, and then after. This assessment will help the CHW and Zanmi Lasante learn about the impact of their community education activities.

16. Ask participants to turn to the Stigma Assessment in their participant handbooks. Read the questions on the Stigma Assessment aloud. Ask participants to consider their answers to each of the questions.

17. Tell participants they will now work in small groups for 10 minutes to brainstorm what messaging around stigma and discrimination they will give to community members during the activity.

18. Divide participants into groups of three to four. Give each group a piece of flip chart paper on which they can record their brainstorm. Prompt participants to discuss:

• What messages or education around stigma would you give during a community education activity?

• Besides for key messages and the Education Cards, what might be other interactive ways to present information to community members? (Stories, myths vs. facts, role play, etc.)



19. After 10 minutes, bring the participants back together, and invite a representative from each group to summarize their brainstorm. Ask participants to take no longer than 1 minute when presenting their ideas.

20. Ask participants what remaining questions they have about community education activities.



SeSSIon 9: Review, Post-test and Feedback

method: Case studies, assessment, evaluation

Time: 2 hours 15 minutes


materials:

� Flip chart

� Markers

� Post-test answer Key (downloaded on the computer to be projected)

� training Evaluation Forms (1 copy/participant)

� Post-test (1 copy/participant)

Preparation:

• review the case studies ahead of time.• Photocopy post-tests and training evaluation forms.• Create three flip chart pages, each individually titled:

– how will you share what you’ve learned? – What strategies will you use to ensure collaboration with other team members? – When i’m unsure or struggling i will…

Objectives:

ab. review all unit objectives.ac. Demonstrate learning through a post-test.ad. give feedback on the training.

StePS

1 hour

1. Explain to the participants that they will discuss case studies as a way to review both the management of patients with agitation, delirium and psychosis and to become familiar with the forms and tools that are available to help with patient management.

2. Divide the participants into small groups of three or four people.

3. Have them turn to the case studies in their participant handbook. Assign each group a case study; it is OK if more than one group has the same case study. Tell the participants they will have 40 minutes to complete the case study questions.



4. Remind the participants to reference the tools and forms with which they have been provided. Encourage them to think about the system of care more broadly and their roles within the system. Ask the participants to consider how they should best work with psychologists/social workers, nurses, and physicians.

5. After 40 minutes, ask everyone to join the larger group again. Review the case studies by asking the groups to present each case and their answers. Use the questions included in the case studies to guide the discussion.

6. Answer any questions that arise.

Post-test

40 minutes

7. After the case study discussions have finished, administer the post-test to the participants (verbally if necessary). Allow them 30 minutes to complete the post-test.

8. Once the post-test has finished, and all tests have been collected, project the post-test answer key. Go over each question and the correct answer. Answer any questions that arise from the participants.

Reflection exercise

20 minutes

9. Hang up the three pre-written flip chart pages on three separate walls in the training space.

10. Tell the participants they will spend a few minutes reflecting on this training. Go to the first flip chart page on the wall and ask participants to reflect a moment on how they would answer the question posed in the title.

11. After a minute, begin a discussion, and scribe participants’ ideas.

12. Repeat this activity for the remaining two flip chart pages.

13. Conclude by summarizing the key points about knowledge-sharing, team work, and reaching out for support when needed.

evaluation

15 minutes

14. Explain that you would like to gather participants’ comments and feedback on this training, in order to revise and improve future trainings if needed.



15. If you wish to conduct the evaluation orally, post the evaluation questions, ask them one at a time, and record answers on notebook paper.

16. If you wish to have participants complete the written evaluation, give participants the form. Read the evaluation questions aloud and then ask participants to complete the evaluation. As participants work, circulate and help as needed.

17. Save the responses from the oral evaluation, or collect and save the written evaluation forms.

18. Congratulate participants on having completed this training. Thank participants for their participation. Distribute certificates if appropriate.

FACIlITATOR NOTeS

Use the Psychosis Checklist as you complete the following activity.

CASe STUDy 1

you are a ChW and you are completing a follow-up visit for a couple, henri and Belle. henri has psychosis, and he has been meeting with a psychologist and physician at a Zl clinic for years. Belle explains that for the last six months he has been stable, but this past week he stopped taking his medication. When you are meeting with Belle, you hear henri yelling, threatening his neighbors.

How do you respond in the moment, what do you teach family members, and what are your next steps?

Appropriate response:

• the first step is to manage henri because he is psychotic and possibly unsafe

• Do not blame the patient

• Do not challenge the patient

– treat the patient very well.

– speak slowly, softly and clearly in simple, short sentences.

– never see the person alone. remove dangerous objects.

– avoid crowds and noise.

– share important information with psychologists.

after you move henri to a quiet room in his house and calm him, you proceed with your other roles: case identification, triage and referral, documentation and follow up, and psychoeducation.

What would you do during each of those steps for this case?


– henri is already an established psychosis patient.



CASe STUDy 1 (continued)

• roles # 2 and #3: triage and referral

– henri has stopped taking his medication and he is threatening people. this is an emergency, and he must see a psychologist and physician immediately. never forget the family in this emergency situation. Make sure you check in with Belle about herself, her children, etc.

• role #4: Documentation in Follow-up Form

– Whether psychotic symptoms are improving.

– ZlDsi and mental health comorbidities, especially suicidal/homocidal ideation.

– adherence to medication; also side effects.

– Check evolution of symptoms.

– re-screen any family members that you once offered the ZlDsi to during the first visit. if family members ZlDsi scores raise a concern, encourage them to see a psychologist at the clinic.

– give Follow-up Form and ZlDsi to psychologist directly.

• role #5: Psychoeducation

– Because this is an emergency, the ChW should focus on getting the patient to the clinic to see the psychologist/and physician. the ChW should, however, review the relapse prevention drill to help Belle remember the plan for managing this situation.

CASe STUDy 1b

you arrive at the clinic with henri and Belle, and the psychologist is not there. you are unable to find the social worker.

What do you do?

• if a ChW shows up to a clinic and no psychologist/social worker is present, the ChW should call the psychologist/social worker of the clinic/hospital and bring the patient to see a physician. if the ChW is unable to reach both psychologist and social worker, they should call their supervisor.



CASe STUDy 2

Jean Pierre, a 75-year-old man, is acting strangely. he sees things that are not there, and he worries people are chasing after him. he has begun to run out of the house into the streets. he is also sometimes urinating on himself. he has never been this way before. a worried family member asks you to come see him. When you arrive, Jean Pierre is sleeping.

What would you do during each of the following steps: case identification, triage and referral, documentation and follow up, and psychoeducation?


– this is possibly a new case of psychosis. refer him to a psychologist and physician immediately.


– since this is an elderly man who has never been psychotic before, he may be medically sick. this is an emergency. refer him to the psychologist and physician immediately.

– assure follow-up with psychologist and physician.

• role #4: Document in Follow-up Form

– Whether psychotic symptoms are improving (less frequent); note date of last episode.

– ZlDsi and mental health comorbidities, especially suicidal/homicidal ideation.

– adherence to medication; also side effects.

– Check evolution of symptoms.

– re-screen any family members that you once offered the ZlDsi to during the first visit. if family members ZlDsi scores raise a concern, encourage them to see a psychologist at the clinic.

• role #5: Psychoeducation:

– the ChW should try to provide basic education for possibly case of psychosis (Education Card 1), understanding that he is sleeping.

CASe STUDy 2b

the family lives very far away from the hospital, so you call the psychologist first to schedule an appointment. you call and text the psychologist four times in two days but cannot reach her.

What do you do?

• as outlined in the policy regarding collaboration with psychologists, if you cannot reach the psychologist, you should then contact the social worker.

• if you cannot get in contact with both psychologist and social worker, you must then call your supervisor so that she can assist you.



CASe STUDy 3

Junior, a 16-year-old boy, is doing poorly in school. his teachers have reported that he’s always getting into fights and arguments with his classmates. he gets distracted easily and spends most of his time in a corner alone speaking to himself. he doesn’t have any friends nor does he participate in any afterschool activities. his parents encourage him to study but his performance becomes worse and worse. a community member tells you that they have recently heard that Junior often runs away from his house.

What would you do during each of the following steps: case identification, triage and referral, documentation and follow-up, and psychoeducation?

Appropriate response:


– Because this case raises concern for psychosis, the ChW must refer Junior to the psychologist/social worker.


– this is probably Junior’s first psychotic episode. he must go to the clinic/hospital that day because a life-threatening medical problem could be causing the episodes.

– assure follow-up with psychologist/social worker and physician.

• role #4: Documentation in initial Visit Form

– Do ZlDsi (sometimes not effective for children).

– also do ZlDsi for Junior’s parents.

– Check for mental health comorbidities, especially suicidal/homicidal ideation.

– give referral Form, initial Visit Form and ZlDsi to patient/family to present to psychologist/social worker.

• role #5: Psychoeducation for possible case of psychosis

– Meet with the family. Explain to them that children who are doing poorly in school may have a medical or mental health problem. give support. understand how they are feeling.

– speak with Junior. gently ask him about what he is experiencing and try to understand how he is feeling. show care and empathy.

56 Partners In Health | FaCilitator Manual | Annex

Annex

57Partners In Health | FaCilitator Manual | Annex

� PRe-teSt � PoSt-teSt (check one)

Name: Date:

Site: Supervisor:

1. What are the elements that comprise good health? (Choose one) ( / 1 point)

a. Well-being

b. ability to realize one’s potential

c. Work fruitfully

d. Make contributions to the community

e. Cope with the normal stresses of life

f. all of the above

2. What are the causes of psychosis? (Choose one) ( / 1 point)

a. Biological causes, such as genetics

b. social causes, such as unemployment

c. Psychological causes, such as past trauma

d. all of the above

3. What are common symptoms of agitation, delirium and psychosis? ( / 1 point) (Choose one)

a. Fast heartbeat, foaming at the mouth, inability to walk.

b. seeing things that aren’t there, hearing voices in their head, not being able to think clearly.

c. low functioning in work or school, poor hygiene, having strange thoughts, is often alone/isolated.

d. B and C

4. What level of functioning do people with psychosis typically have? (Choose one) ( / 1 point)

a. low, most people with psychosis don’t have good personal hygiene or meaningful conversations.

b. Medium, there are some barriers to working but many people with psychosis can function in the community.

c. high, often people with psychosis can do the exact same things as people without psychosis.

d. it depends on the person and the type of treatment they receive. some people with psychosis can recover and be high functioning, while others will always be low-functioning.


5. severe mental illness affects how many people worldwide? (Choose one) ( / 1 point)

a. 5 million people

b. 81 million people

c. 500 million people

d. 25 million people

6. What are the ChW’s main responsibilities in the psychosis care pathway? ( / 1 point) (Choose one)

a. identification, triage and referral of patients with psychosis/psychotic symptoms.

b. Provide psychoeducation and counseling to patients and their family members.

c. Perform follow up with patients through household visits.

d. host community educational activities to education people about psychosis.

e. a and C

f. all of the above

7. if you find a community member displaying psychotic symptoms and ( / 1 point) threatening her husband with a knife, would you? (Choose one)

a. refer and accompany the woman to the health facility immediately; the situation warrants an emergency referral.

b. refer and accompany the woman to visit the health facility within 24 hours; the situation warrants an urgent referral.

c. ask the woman’s family when she has time this week to visit the health facility; make a referral to visit this week.

d. give no referral; the situation does not warrant a referral.

8. Psychosis is defined as: (Choose one) ( / 1 point)

a. a mental illness marked by alternating periods of elation and depression.

b. a mental illness in which people lost contact with reality and cannot think nor function well.

c. an anxiety disorder that develops after exposure to a terrifying event.

d. an acute, disturbed state of mind that occurs in fever, intoxication, and other disorders and is characterized by restlessness, illusions, and incoherence of thought and speech.


9. a woman is taking medication to control her psychosis. she finds out she ( / 1 point) is pregnant. you know, but her physician doesn’t. What do you do? (Choose one)


b. refer the woman to visit the health facility within 24 hours; the situation warrants an urgent referral.

c. ask the woman’s family what time this week they can visit the health facility; make a referral to visit this week.


10. some psychoeducation messages to give to a person and their family with ( / 1 point) undiagnosed psychosis include: (Choose one)

a. Psychosis is not a punishment, a curse, or spirit possession.

b. Psychosis/agitation is a medical emergency that must be treated immediately.

c. Psychotic people can be dangerous so you can tie them up if needed.

d. a and B

e. all of the above

11. some psychoeducation messages to give to a person and their family with ( / 1 point) diagnosed psychosis during your first visit include: (Choose one)

a. Patients must take their medication every day, even if they are feeling better.

b. Medications for psychosis can take weeks or months to work.

c. Families should be alert for side effects from the medication, and should tell the physician and psychologist/social worker if the patient is experiencing side effects.

d. a and C

e. all of the above

12. some psychoeducation messages to give to a person and their family with ( / 1 point) diagnosed psychosis during your second visit include: (Choose one)

a. giving hope about the illness

b. sharing the fact that, realistically, the patient with psychosis will not recover

c. Discussing with the family how to create a supportive environment

d. a and C

e. all of the above


13. some psychoeducation messages to give to a person and their family ( / 1 point) with psychosis that is stable or improved include: (Choose one)

a. the patient must continue to take his medication every day (if he is currently taking medication).

b. it is important to continue going to appointments and seeing the physician and psychologist/social worker.

c. the family should continue to be supportive of the patient, even if he doesn’t look ill.

d. B and C

e. all of the above

14. What is a relapse prevention drill? (Choose one) ( / 1 point)

a. it is something practiced in the hospital by physicians if a patient is psychotic.

b. it is a tool that the ChW uses to facilitate a conversation with a patient’s family members about what to do if the patient relapses, to ensure there is a plan in place.

c. it is a type of therapy practiced by the psychologists/social workers.

d. it is a document that the ChW fills out and returns to the psychologists/social worker detailing the family’s psychosis management plan.

15. the initial Visit Form is used when: (Choose one) ( / 1 point)

a. you are seeing a new person in the community for the first time.

b. the psychologist has formally diagnosed a person with psychosis and you are visiting the family for the second time.

c. the physician is seeing the patient. the physician fills out this form because it is the first visit with the patient.

d. all of the above.

16. the referral Form is used when: (Choose one) ( / 1 point)

a. a psychologist/social worker is referring the patient to receive medication from the physician. the psychologist/social worker will fill out the form.

b. a family member wants to refer their family member to a psychologist/social worker. the family member will fill out the referral form themselves at the hospital.

c. a ChW believes that a patient should be referred to receive mental health services. the ChW will fill out the form and ensure that the psychologist/social worker at the hospital receives the form.

d. a nurse encounters a patient with psychotic symptoms in the waiting room. she will fill out the form to give to the Mental health team.


17. When should the community health worker use the ZlDsi? (Choose one) ( / 1 point)

a. When a patient displaying psychotic symptoms has calmed down, before their referral to the hospital.

b. During a home visit, when a patient with psychosis who has been stable reveals he is feeling particularly depressed.

c. With the family members of a patient who has been diagnosed with psychosis; to see if they might be feeling depressed or stressed.


18. When should the community health worker use the Follow up Form? ( / 1 point) (Choose one)

a. Every time a community health worker visits a patient for relevant follow up.

b. When the patient is not taking their medication and needs to be referred to the physician.

c. When the family calls you to come follow up with the patient because the patient is not doing well.

d. When the psychologist tells the community health worker to do a specific follow up visit.

19. What is the purpose of the stigma assessment? (Choose one) ( / 1 point)

a. to inform people that they are being discriminatory.

b. to measure how much stigma community health workers have towards their patients.

c. to serve as a tool to measure community members’ level of stigma towards people with mental illness.

d. to test people’s knowledge of the diagnosis and prognosis of psychosis.

20. What are the main components of psychosis community education activities? ( / 1 point) (Choose one)

a. introducing the information about psychosis.

b. assessing baseline knowledge of psychosis through asking questions.

c. using Education Cards to provide key information about psychosis.

d. administering the stigma assessment.

e. all of the above


PRe-teSt AnD PoSt-teSt AnSweR KeY

Name: Date:

Site: Supervisor:

1. What are the elements that comprise good health? (Choose one) ( / 1 point)

a. Well-being

b. ability to realize one’s potential

c. Work fruitfully

d. Make contributions to the community

e. Cope with the normal stresses of life

f. All of the above

2. What are the causes of psychosis? (Choose one) ( / 1 point)

a. Biological causes, such as genetics

b. social causes, such as unemployment

c. Psychological causes, such as past trauma

d. All of the above

3. What are common symptoms of agitation, delirium and psychosis? ( / 1 point) (Choose one)

a. Fast heartbeat, foaming at the mouth, inability to walk.

b. seeing things that aren’t there, hearing voices in their head, not being able to think clearly.

c. low functioning in work or school, poor hygiene, having strange thoughts, is often alone/isolated.

d. b and C

4. What level of functioning do people with psychosis typically have? (Choose one) ( / 1 point)

a. low, most people with psychosis don’t have good personal hygiene or meaningful conversations.

b. Medium, there are some barriers to working but many people with psychosis can function in the community.

c. high, often people with psychosis can do the exact same things as people without psychosis.

d. It depends on the person and the type of treatment they receive. Some people with psychosis can recover and be high functioning, while others will always be low-functioning.


5. severe mental illness affects how many people worldwide? (Choose one) ( / 1 point)

a. 5 million people

b. 81 million people

c. 500 million people

d. 25 million people

6. What are the ChW’s main responsibilities in the psychosis care pathway? ( / 1 point) (Choose one)

a. identification, triage and referral of patients with psychosis/psychotic symptoms.

b. Provide psychoeducation and counseling to patients and their family members.

c. Perform follow up with patients through household visits.

d. host community educational activities to education people about psychosis.

e. a and C

f. All of the above

7. if you find a community member displaying psychotic symptoms and ( / 1 point) threatening her husband with a knife, would you? (Choose one)

a. Refer and accompany the woman to the health facility immediately; the situation warrants an emergency referral.

b. refer and accompany the woman to visit the health facility within 24 hours; the situation warrants an urgent referral.

c. ask the woman’s family when she has time this week to visit the health facility; make a referral to visit this week.


8. Psychosis is defined as: (Choose one) ( / 1 point)

a. a mental illness marked by alternating periods of elation and depression.

b. a mental illness in which people lost contact with reality and cannot think nor function well.

c. an anxiety disorder that develops after exposure to a terrifying event.

d. an acute, disturbed state of mind that occurs in fever, intoxication, and other disorders and is characterized by restlessness, illusions, and incoherence of thought and speech.


9. a woman is taking medication to control her psychosis. she finds out she ( / 1 point) is pregnant. you know, but her physician doesn’t. What do you do? (Choose one)


b. Refer the woman to visit the health facility within 24 hours; the situation warrants an urgent referral.

c. ask the woman’s family what time this week they can visit the health facility; make a referral to visit this week.


10. some psychoeducation messages to give to a person and their family with ( / 1 point) undiagnosed psychosis include: (Choose one)

a. Psychosis is not a punishment, a curse, or spirit possession.

b. Psychosis/agitation is a medical emergency that must be treated immediately.

c. Psychotic people can be dangerous so you can tie them up if needed.

d. A and b

e. all of the above

11. some psychoeducation messages to give to a person and their family with ( / 1 point) diagnosed psychosis during your first visit include: (Choose one)

a. Patients must take their medication every day, even if they are feeling better.

b. Medications for psychosis can take weeks or months to work.

c. Families should be alert for side effects from the medication, and should tell the physician and psychologist/social worker if the patient is experiencing side effects.

d. a and C

e. All of the above

12. some psychoeducation messages to give to a person and their family with ( / 1 point) diagnosed psychosis during your second visit include: (Choose one)

a. giving hope about the illness

b. sharing the fact that, realistically, the patient with psychosis will not recover

c. Discussing with the family how to create a supportive environment

d. A and C

e. all of the above


13. some psychoeducation messages to give to a person and their family ( / 1 point) with psychosis that is stable or improved include: (Choose one)

a. the patient must continue to take his medication every day (if he is currently taking medication).

b. it is important to continue going to appointments and seeing the physician and psychologist/social worker.

c. the family should continue to be supportive of the patient, even if he doesn’t look ill.

d. B and C

e. All of the above

14. What is a relapse prevention drill? (Choose one) ( / 1 point)

a. it is something practiced in the hospital by physicians if a patient is psychotic.

b. It is a tool that the CHW uses to facilitate a conversation with a patient’s family members about what to do if the patient relapses, to ensure there is a plan in place.

c. it is a type of therapy practiced by the psychologists/social workers.

d. it is a document that the ChW fills out and returns to the psychologists/social worker detailing the family’s psychosis management plan.

15. the initial Visit Form is used when: (Choose one) ( / 1 point)

a. you are seeing a new person in the community for the first time.

b. the psychologist has formally diagnosed a person with psychosis and you are visiting the family for the second time.

c. the physician is seeing the patient. the physician fills out this form because it is the first visit with the patient.


16. the referral Form is used when: (Choose one) ( / 1 point)

a. a psychologist/social worker is referring the patient to receive medication from the physician. the psychologist/social worker will fill out the form.

b. a family member wants to refer their family member to a psychologist/social worker. the family member will fill out the referral form themselves at the hospital.

c. A CHW believes that a patient should be referred to receive mental health services. The CHW will fill out the form and ensure that the psychologist/social worker at the hospital receives the form.

d. a nurse encounters a patient with psychotic symptoms in the waiting room. she will fill out the form to give to the Mental health team.


17. When should the community health worker use the ZlDsi? (Choose one) ( / 1 point)

a. When a patient displaying psychotic symptoms has calmed down, before their referral to the hospital.

b. During a home visit, when a patient with psychosis who has been stable reveals he is feeling particularly depressed.

c. With the family members of a patient who has been diagnosed with psychosis; to see if they might be feeling depressed or stressed.

d. All of the above.

18. When should the community health worker use the Follow up Form? ( / 1 point) (Choose one)

a. every time a community health worker visits a patient for relevant follow up.

b. When the patient is not taking their medication and needs to be referred to the physician.

c. When the family calls you to come follow up with the patient because the patient is not doing well.

d. When the psychologist tells the community health worker to do a specific follow up visit.

19. What is the purpose of the stigma assessment? (Choose one) ( / 1 point)

a. to inform people that they are being discriminatory.

b. to measure how much stigma community health workers have towards their patients.

c. To serve as a tool to measure community members’ level of stigma towards people with mental illness.

d. to test people’s knowledge of the diagnosis and prognosis of psychosis.

20. What are the main components of psychosis community education activities? ( / 1 point) (Choose one)

a. introducing the information about psychosis.

b. assessing baseline knowledge of psychosis through asking questions.

c. using Education Cards to provide key information about psychosis.

d. administering the stigma assessment.

e. All of the above


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Department of Mental Health & Psychosocial ServicesInitial visit Patient Form – Community Health Workers

visit Date:

_____ / _____ / _____ DD MM yyyy

Chart Number:

Patients’ Demographic Data What did you observe?

name:

nickname:

sex: M F

address: is it a urgent matter that needs immediate attention? yes no

seizure

thinking about suicide

thinking about harming othersPhone:

Date of Birth: DD/mm/yyyy

age:

Which illness do you think the patient suffers from? What did you do:

anxiety

Psychosis

Epilepsy

Depression

Check symptoms

same day therapy session

give advice

relaxation

ask if patient is out of medication

yes

no

Patient is not on medication

Psychoeducation Did you: Did you use the ZlDSI form?

Explain the illness to the patient

give him/her hope

give him/her the sick role

Encourage the patient to participate in activities that makes him/her happy

Bring patient to hospital?

send patient to hospital?

Encourage the family?

Encourage the patient?

yes

no

What is the ZlDsi score: _____ / 39

What are some other problems that the patients’ family say he/she have?

Name of CHW


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Department of Mental Health & Psychosocial ServicesReferral Form – Community Health Workers

visit Date:

_____ / _____ / _____ DD MM yyyy

thomonde

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Verrettes

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Patients’ Demographic Data Reason for the Referral

name: Why are you referring the patient?

Depression – ZlDsi score ______

Epilepsy

seizure

Psychosis

is the person taking any medications?

yes no

if yes, specify:

is it urgent? yes no

seizure


thinking about harming others

nickname:

last name:

sex: M F

address:

Phone:


age:

Who do you refer the patient to:

Zanmi lasante

Psychologists

social Worker

Mobile Clinic

Date:

__ __ / _ ___ / ____ DD MM yyyy

Members of the Community

Community leader

other Community health Workers

others (specify):

Remarks

Information on the person who referred the patient:

name:

last name:

nickname:

Phone: address:


Department of Mental Health & Psychosocial ServicesPatient Follow-up Form – Community Health Workers

visit Date:

_____ / _____ / _____ DD MM yyyy

Chart Number:

visit Number:

Patients’ Demographic Data What did you observe?

name:

nickname:

last name:

sex: M F

address: is it urgent? yes no

seizure


thinking about harming others

Phone number:


age:

How do you think the patient is feeling? What did you do:

Patient is better now

Patient is doing worse

Patient is the same

Check symptoms

same day therapy session

give advice

relaxation

ask if patient is out of medication

yes

no

Patient is not on medication

Psychoeducation Did you: Did you use the ZlDSI?

Explain the illness to the patient

give him/her hope

give him/her the sick role

Encourage the patient to participate in activities that makes him/her happy

Bring patient to hospital?

send patient to hospital?

Encourage the family?

Encourage the patient?

yes

no

What is the ZlDsi score: _____ / 39

What are some other problems that the patients’ family say he/she have?

Name of CHW


What does psychosis look like?

seeing things that are not there

speaking to oneself

hearing voices

not taking care of selfCard 1

What are the thinking signs of psychosis?• strange thoughts about people harming him/her, about having great powers• thinks that mind is being controlled• cannot think well • thinking/speaking does not make sense

What are the other signs of psychosis? • speaking a lot/speaking too little/speaking to oneself• hears a voice telling him/her what to do• sees things that are not there

What are the functioning signs of psychosis?• unable to go to school/work• does not take care of self (bathing, eating)• does not take care of children/family• does not do other activities (go to church, work the land)• isolated from family• being alone

Identification of Psychosis

Card 1


Card 2

What is psychosis?

Do not tie up, beat, or burn someone who might have psychosis.

Find friends and neighbors to help.

Psychosis is not a punishment, a curse, orspirit possession – it is a medical emergency!

• Psychosis is not a punishment, a curse, or spirit possession.

• it is not contagious.

• Psychosis/agitation is a medical emergency that must be treated immediately.

• Do not blame the person. Do not challenge the person.

• treat the individual kindly and with respect.

• Do not tie up, beat, or burn the person.

• avoid crowds/noise.

• SAFeTy: never leave the person alone or with children/other vulnerable individuals. remove dangerous objects.

• Find family members and neighbors who can help.

Unconfirmed Case of Psychosis

Card 2


Card 3

How to care for someone with psychosis

Psychosis affects the whole family.

taking medication is important.

share information with the psychologist/social worker.

Card 3

Confirmed Diagnosis of Psychosis (visit 1)• give psychoeducation messages about medication.

• Check adherence to the medication; check for side effects of medication.

• Check follow-up with psychologist/social worker and physician.

• ask families to share all information with psychologist/social worker.

• Check the impact of the illness on the family.

• if there is enough time, proceed to the psychoeducation messages for Visit 2.


Card 4

Taking medication and potential side effects

the medication that the patient is taking for psychosis can have secondary effects.

Medication can have dangerous side effects.

Card 4

• Patients must take medications everyday, exactly as the doctor prescribed.

• Families must choose one person in the family to be responsible for keeping medication and for giving it to the patient.

• a family member must watch the patient take the pill and swallow it.

• if the patient refuses medication, the family must take the patient to see the psychologist and physician.

• Medications for psychosis can take weeks, even months to work.

• if the family member becomes pregnant or is breastfeeding, take her to the psychologist/doctor immediately but do not stop the medication.

• Families should tell the psychologist and physician about side effects.

• Dangerous side effects include:• Muscle rigidity (potentially including: eye muscles, throat, neck, tongue, back).• Confusion, delirium, stiffness (rigidity), sweating, hyperpyrexia, autonomic instability,

drooling; death.• rashes, jaundice.

medication


Continue adherence and follow up

a supportive family environment will help the patient.

there is treatment for people with mental illness.

it’s important to adhere to medication.

Card 5

Card 5


• Check follow-up with psychologist and physician.

• separate the illness from the person.

• give hope about the illness.

• Challenge hope and helplessness by explaining to family what they can do to help the patient.

• Discuss with the family how to create a supportive environment.

• Discuss the role of the family in supporting the patient's treatment (medication, appointment, activities, daily schedule).

Confirmed Diagnosis (visit 2)


Card 6

Card 6

Continuous support of patient and family

Continue a supportive environment.

Continue supporting the patient's treatment. identify family/neighbors who can help.

Follow up with physician and psychologist/social worker.


• Check follow-up with psychologist and physician.

• Check whether family has identified other family/neighbors who can help.

• Check whether family has created a supportive environment at home.

• Check whether the family is supporting the patient's treatment.

• Plan relapse prevention drill.

Stable or Improved


Relapse prevention drillPrevent Relapse:

Card 7

Depression

suicide Psychosis

Card 7

Relapse Prevention DrillRelAPSe PReveNTION DRIll

1. name four things family can do to prevent illness: a. b. c. d.

2. list four signs your family member may be getting sick again: a. b. c. d.

3. What is your plan if the patient stops taking medication?

4. What is your plan if the patient becomes agitated/violent?

5. Which people will help you with this plan? take the patient to the clinic/hospital take care of the children

other people who will help: a. b.


COmmUNITy eDUCATION ACTIvITy (CeA) CHeCKlIST

guidelines:

• ChWs conduct CEas once a month.

• CEas are approximately 1–3 hours long.

• local leaders will announce the sessions on the appropriate day; ChWs will conduct sessions at a place where people are gathered (church, school, etc.).

• ChWs will record information about the CEas on the stigma reduction Form and attendance sheet.

• ChWs should arrange water, snacks and soda for participants.

• ChWs should use visuals such as Community Education Cards and the participant handbook as much as possible during the sessions.

steps:

o introduce yourself to the group.

o Explain the goal of the meeting and introduce the main subject.

o assess the baseline knowledge of the subject (through asking the audience general questions).

o use Community Education Cards and the participant handbook to provide key information about the main subject.

oDefine the disease.

o Explain symptoms with concrete examples.

o Explain how the disease develops, if it is contagious, prevention methods, where and how to be treated, and recovery.

o assess community members’ understanding of stigma and discrimination through the stigma assessment activity before giving information, and again after.

o Explain the damage that stigma and discrimination can cause to families and communities.

o allow participants to ask questions throughout the presentation.

o Continuously ask questions to assess understanding. give a small incentive to participants who answer correctly.

o remind participants that if they or anyone they know are facing any of the topics being discussed, they should speak to the ChW. the ChW can give a referral to the hospital or other experts.

o Distribute the snack, such as soda or cookies.

o if time allows, practice a specific skill:

o Practice doing a consultation, completing the referral form, using the ZlDsi, etc.


PART 1totally

disagree Disagree neither agree

nor disagreeagree totally agree

People choose to live like this and can change if they want

the problem is that he has a weak mind or little brain

this problem is not really a medical problem

this person is dangerous

it is best to avoid people with problems like this so you can avoid having the same problem

you never can tell what a person acting like this will do

if i had a problem like this, i wouldn’t tell anyone

i would not like to work with someone with this problem

i would not choose this person as a leader

PART 2yes no

Would you like to be the neighbor of this person?

Would you like to spend time with or date this person?

Would you like to develop a friendship with this person?

Would like to work closely with this person?

Would you like it if someone like that married a member of your family?

sadrak is a 22 year old man. he is terrified of the dark and refuses to sleep alone at night. he believes that someone is coming to get him the minute that he shuts his eyes and because of that sadrak always sleeps with a knife under his pillow. Ever since the age of 17 sadrak has shown signs of a mental illness. he often sees and hears things that are not present and spends majority of his day talking to himself or throwing rocks at people. Because of that, sadrak doesn’t have any friends and everyone in the community is afraid of him.

STIgmA ASSeSSmeNT ACTIvITy


evAlUATION FORm

What training activity did you like the most? Why?

What training activity did you like the least? Why?

What did you learn that was valuable and that you will use in your work?

Was there anything you did not understand? give specific examples.

What are your recommendations to improve this training? What would you change? (For example, what activities, illustrations, etc. would you change?)

What additional comments do you have?

Thank you for completing this evaluation.

Partners In Health888 Commonwealth Avenue, 3rd Floor, boston, mA 02215 www.pih.org

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