Menatl Health - Training the Trainer Programme Sri Lanka - Facilitators Guide - KAMHA.ORG

8/8/2019 Menatl Health - Training the Trainer Programme Sri Lanka - Facilitators Guide - KAMHA.ORG

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MENTAL HEALTH TRAINING FOR PHC STAFF IN SRI LANKA

CONTINUING PROFESSIONAL DEVELOPMENTCONTINUING PROFESSIONAL DEVELOPMENT

FACILITATORS GUIDEFACILITATORS GUIDE

FACILITATORS GUIDE 1


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CONTENTSCONTENTS

1. Rationale for in service training course 2. How to use the manual.

3. Assessment and Evaluation Methods4. Guidelines for preparing to run the course5. Preparing the venue, Welcome and Packs6. Starting the course and pre-test.7. Unit 1 core concepts.8. Unit 2 core skills..9. Unit 3 common neurological disorders..10. Unit 4 common mental disorders.11. Unit 5 Policy, legislation, roles and responsibilities, mental health and HIV,

malaria, child health and reproductive health; HMIS community health workers,traditional healers

12. The way forward..13. Post test..

RATIONALE FOR INSERVICE TRAINING COURSE ON MENTAL HEALTHRATIONALE FOR INSERVICE TRAINING COURSE ON MENTAL HEALTH

Mental health is as crucial for all of us as physical health. Mental illness and neurologicaldisorder account for 10-15% of the global burden of diseases worldwide, and a quarter of years of life lived with disability. At least 1 in 10 of the adult population has a mentaldisorder at any one time, but many suffer in silence and only a few of those who needtreatment get it. A number of factors contribute to this situation including stigma at alllevels, inadequate knowledge of the conditions in patients, family, community and health

professionals, inadequate resources meet the needs of the clients. The situation is worsein low-income countries like Sri Lanka.

In the primary care setting, every third or fourth patient seen has some form of mentalhealth disorder. Therefore primary care staff needs to be strategically prepared to serveclients with mental health problems. Integrating mental health into Primary Health care isessential if the population is to have equitable access to care.

It is therefore the aim of this training workshop to equip primary health workers withknowledge, skills and attitudes for promoting mental health, preventing illness and for caring for clients and families with mental health problems within their area of work. Theduration of the course is one week. Participants are expected to be health professionalsworking in primary care, including clinical officers and nurses with no specialist trainingin mental health, although they will have had some exposure during basic training, andwill also have accumulated much exposure to mental health problems during their dailywork.

HOW TO USE THE MANUALHOW TO USE THE MANUAL



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The manual is a resource reference for facilitators and tutors conducting mental healthtraining workshops for primary care workers in Sri Lanka. The aim of this guide is toassist facilitators to run the course smoothly with minimal difficulties. The manual gives

.

Overall rationale for courseHow to use the manualGuidelines for preparation of courseGuidelines for running the course

The manual is divided into five units, each on a different theme, with an indicationof how long each might take. Each unitbegins with a summary,lists the topics to be covered and the teaching objectives,indicates the facilitators role in the teaching and learning process.

The manual is accompanied byo Teaching slideso Role playso Group Discussionso The timetable for the week, indicating the time allocated to each topic

The timetable is a crucial aid to managing the course within the time allowed,finding the relevant role plays, and ensuring everyone gets to have lunch on time!

ASSESSMENT AND EVALUATION METHODS

There is a pre-training assessment to explore the basic knowledge that participants comewith to the course, and post training assessment on the last day to determine howmuch participants have achieved from the course.

Continuous assessment is done throughout the course in terms of participation andcontribution from participants.An overall evaluation is conducted at the end of the course. Participants andfacilitators will evaluate the effectiveness of the training workshop in terms of strengths, weaknesses and suggestions for improvement.

GUIDELINES FOR PREPARING TO RUN THE COURSE Ensure all participantsinvited and have confirmed-fill any gaps, as an empty space wastes precious training

resource Book venue, coffee, lunch, tea and supper Book accommodation Book audiovisual aids-computer, projector, video Check all hand out packs are complete-it is very frustrating for

participants if they cant find something (see below) Name tags-? Sticky labels and pen Set up teaching slides



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Check all arrangements in person Ensure the week before that the room will be open and ready by 7.30am

on day 1. Check where main keys, and back up keys, will be held. Ensure the week before that the refreshments will arrive on time so as not

to disrupt the timetable Review allocated budget guidelines, retain all invoices, and account for

all monies spent, per person and per course

DAY 0Facilitators arrive on Sunday evening

DAY 1

WELCOMEAs a facilitator you need to prepare yourself and resources well in advance:Go to venue at 7am and ensure it is unlocked, well set and with proper ventilation

Ensure room unlocked 30 minutes before start in mornings Ensure all technology working 30 minutes before start All photocopying to be double sided, and slide handouts 6 to a side

Set out the Packs for each participant

Curriculum Timetable for week Pre-test,WHO primary care guidelinesSri Lanka Mental Health LegislationUnit 2 Core skillsPost testBlank note paperPenFolderName tag

Set out the Teachers pack Facilitators guideCurriculum timetableHandouts of slide units 1-5-you may need these if the electricity fails!

It is advisable to distribute the packs on arrival day so that participants can have alook at night before coming to class.Organization skills and team dynamics are very important at this stage.



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Formal Introduction Introduce yourself let participants briefly introduce themselves. Housekeeping-toilets, refreshment timetable, evening arrangements

Formal Opening If you decide to have a formal opening by the Principal or another, please

remember they are very busy peopleo Give written brief to them well in advanceo DO NOT WAIT FOR THEM as they may often be held up by other

commitments.o Proceed with curriculum timetable on time and simply break promptly for

ten minutes for formal opening when Principal arrives, so Principal is notkept waiting.

o The Principal may also wish to observe for a while.

Explain Purpose of Training:Increase mental health capacity in health centers and dispensaries by in-servicetraining.

At the start of days 2- 5Revision of the previous days topics. 10 minutes

a. Ask participants how they found the previous day b. Whether they have read the relevant parts of the WHOPHC guidelinesc. Any problems encounteredd. Any new learning experience

Setting the ground rules

Activity: Setting ground rules:An interesting thing about adult learning is the purpose of learning. Learners come to learning situationwith a number of expectations and carry with them issues/roles and responsibilities, status etc. It isimportant that ground rules are set together with participants so that they have sense of ownership. Thiswill minimize some domestic problems like going shopping and dogging classes.

Ask delegates what rules they are putting forward to facilitate smooth running of the course.List them on the flip chartAgree on the rules

Facilitator puts the rules on the wall to remain during the course as reminder to both delegates andfacilitators.

Identifying delegate expectations

Activity: Identifying delegates expectations, and setting strategies to meet these expectations.



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It is important to be aware of what expectations delegates come with to the workshop. Together thefacilitator and delegates work on the strategies that will ensure that expectations are met. This will act aschecks and balances throughout training workshop.

Objective : Explore from the delegates their expectations, issues/baggage they are bringing with them andstrategies to tackle them.

3-part activity20 minutes

1. Give each delegate paper and ask them to answer the following questions (5 minutes max) What do I want from this course? One thing I hope will happen is One thing I hope wont happen is I will know if the course has been successful if.

2. Pool ideas on to flip chart3. The facilitator then puts the sheets on the wall where they remain for the duration of the course. Andreferred to.As they go up, the facilitator addresses each of the issues, for instance:

Positive: Yes we will be covering this on day 3 so look out for it and be thinking about what questions youhave and what ideas you want to share (gets delegates involved and engaged).

Negatives, for instance: I hope we dont have to do role playsFacilitator question: What makes you dislike role-plays?Typical discussion: Feel silly, will be laughed at.Well you need to know that we will be doing some role plays- as for some topics they are the best way of helping you learn-as you cant practice on real people!! I am sure other people are just as apprehensive andwill not laugh at you but support you.Facilitator turns to group for confirmation.

Describe the Teaching and Learning Methods which will be usedThe methodology adapted is participatory whereby a mixture of activities are usedincluding; lecture-discussion using slides, videos, role-plays, small group discussionsand large group discussion.When choosing and adapting activities, facilitators need to bear in mind that theorder of units has been carefully thought through, so facilitators need to read thewhole document and teaching slides before hand, and follow the order set out andthe timetable.

Activity: Pre-training assessment:Objective : To explore delegates knowledge on mental health

Facilitators administer a prepared pre-test to delegates-see appendix.

General notes to facilitator Follow the timetable as closely as possible At each break, make note of which slide has been reached to make it easy to

resume afterwards



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If participants look sleepy , insert another role play immediately!!



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UNIT ONE: CORE CONCEPTSUNIT ONE: CORE CONCEPTS

Unit One introduces participants to the context and concepts of mental health and mentalillness.

Topics to be covered in this unit are:1. Meaning and scope2. Mental and physical health and illness3. Mental and neurological health, gender and the millennium development goals

Objectives:Upon completion of this unit learners shall be able to do the following :

Define mental health and mental illnessUnderstand the causes, symptoms and impact of mental illness to individual, familyand society.Identify linkages between physical and mental healthAppreciate the contribution of mental health to Millennium Development Goals

Facilitators role:

Introduce the subject to participants by:Write 3 questions on a flip chart and write

i. Mental Health?ii. Factors influencing Mental Health?

iii. Consequences of positive mental health to individual, family,community?

Ask participants to give answers to questionsWrite answers on a flip chartDiscuss the answers

Duration 10 minutes

Write 3 questions on a flip chart:iv. Mental illness?v. Causes?

vi. Consequences at individual, family and community?Ask participants to give answers to questionsWrite the answers on flip chartDiscuss answers given.

Duration 10 minutes

Present the prepared slides with running comments.



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Conduct general discussion on the subject. Participants should be givenopportunity to share their experiences.

Duration 15 minutes

Summarize the topic.

NB: Participants will know quite a bit about mental health and mental illness. Theytherefore need to be motivated to give out what they know and that can be shared.

Activity :

Review a.Ask delegates in 2s to imagine they were to give a 3-minute talk to their local volunteers on mental healthand mental illness.Give them 10 minutes to write a talk and then choose 2 groups to deliver (3 X 2=6minutes).

Lots of applause needed.Will check learning and internalize it.

Review bAsk delegates to return to their 3-minute presentations and add 2 minutes on symptoms of mental disordersand psychosis.Give them 10 minutes to review 1 and write 1aChoose 1 group to deliver (6 minutes)

Review cAsk delegates to return to their 5-minute presentations and add 1 minute on symptoms of mental and

physical health and MDGs.Give them 10 minutes to review a, b and c.Choose 1 group to deliver (6 minutes).

Summary:Mental health is a positive sense of well-being, belief in own worth and dignity, and dignity of others, andability to function adequately. Mental illness thus is a condition whereby there is disturbance in thinking,cognition, feeling and behaviour. It affects all aspects of human development including social andeconomic burden, psychological and physical burden to individuals, families and society as a whole. Wecan intervene in mental disorders by:* Enhancing healthy functioning through promotion of health promoting activities such as good nutrition,education, MCH services* Stabilizing the disturbed functioning through early detection and appropriate treatment* Restoring healthy functioning through rehabilitation activities



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UNIT TWO: CORE SKILLS ESSENTIAL FOR MENTAL HEALTH PRACTICEUNIT TWO: CORE SKILLS ESSENTIAL FOR MENTAL HEALTH PRACTICE

IntroductionIntroduction

Mental health care is a problem solving process, and one needs essential skills toMental health care is a problem solving process, and one needs essential skills to facilitate the process. Communication is the most essential skill in humanfacilitate the process. Communication is the most essential skill in human interactions that is crucial for all parts of the process. We have divided the processinteractions that is crucial for all parts of the process. We have divided the process into the 5 components of assessment, diagnosis, planning, implementation andinto the 5 components of assessment, diagnosis, planning, implementation and evaluation skills.evaluation skills.

assessment -the health worker has to collect, validate, organize and record informationusing interview, observation and examination. Topics on identifying a personwith mental health problems, and mental state examination fall under thiscomponent.

diagnosis -the health worker applies her or his thinking skills in interpreting informationin order to identify patients mental health status including strengths, problems,causes of problems etc. topics covering diagnosis, differential diagnosis, andcase formulation fall under this component.

planning -the health worker plans what goals need to be met and how. the goals andobjectives should aim to meet patients needs and problems. priorities should bespecified and negotiate with the patient on treatment plan. a topic on care

planning fall under this component.

implementation -carrying out interventions is the core role of a primary care worker.

evaluation -the health worker has an obligation to assess the effectiveness of care provided to the client. monitoring progress of the patient.

Topics to be covered in this unit:

Communication SkillsConducting interviews

Mental State Examination

DiagnosisDifferential Diagnosis, Investigations and Case Formulation

Care PlanningPsychosocial SupportBreaking Bad NewsCommunity Based RehabilitationMedication ManagementManaging Aggressive And Violent Patient Including Domestic Violence



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Case Scenarios

Scenario 1:Joseph is a 45-year-old man married with 3 children. He also has one child with his

mistress of whom his wife is ignorant. Joseph has been a regular attendee at the clinicwith several complaints including frequent fevers, loss of weight and skin rashes. After some investigations and management, the patient asks you if he could have HIV test withcondition that his wife should not be told. You discuss with Joseph who seem to beunderstanding and have him tested. Results come to be HIV positive. This time Josephchanges his mind that is not going to disclose to anybody.How would handle this? Justify your approach.

Scenario 2:Think of a patient that you have cared for, where they became emotional .

How did you handle the situationHow differently might you respond to an emotional outburst now?

COMMUNITY BASED REHABILITATION

MEDICATION MANAGEMENTMEDICATION MANAGEMENTSee role plays 5 and 6

MANAGING AGGRESSIVE AND VIOLENT PATIENT INCLUDINGMANAGING AGGRESSIVE AND VIOLENT PATIENT INCLUDING DOMESTIC VIOLENCEDOMESTIC VIOLENCE

Case scenario 3: The violence cycleSita married Mr. Opatha when she was 18 years old. Soon afterwards Mr. Opatha beganto shout at her. At first she was concerned because he had been so loving before theywere married. The reasons for his anger were often small: One day it would be becausethe dinner was not tasty: another day just because he had had too much to drink and wasunhappy at work. Sita spoke to her elder sister, who reassured her that a little anger wasnormal in every marriage. But for Opatha anger seemed to get worse with time.One day, Sita returned home later than usual from the market. Opatha was very angry. Heaccused her of not being a good wife, and that he thought she was having an affair with

another man. Sita apologized and said she was not having an affair. But this only madeOpatha angrier. He slapped her on the face. Sita was shocked. It was the first time he hadslapped her. She ran to her room and cried. Opatha said sorry. But it happened again andagain. The beatings became more regular. After a severe beating, Opatha would cry andsay sorry. He would threaten to kill himself if she left. The accusation and threats madeher stop meeting her friends and she became isolated. She could no more enjoy sex withhim, which made him angry.



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One day when Opatha wanted sex, she refused. He became furious, again accusing her of having affairs. Then he started beating her. Finally, he raped her. The next morning, Sitatried to kill herself by drinking poison. It was only when she went to the hospital that thehealth worker found out about the violence. In the meantime, 15 years had passed sinceSita had married Opatha.

ExerciseIn your groups discuss the situation in the following areas:* Identify the 3 components of violence cycle.* How will you handle the situation?

UNIT THREE: MANAGING COMMON NEUROLOGICAL DISORDERS INUNIT THREE: MANAGING COMMON NEUROLOGICAL DISORDERS IN PRIMARY CAREPRIMARY CARE

Topics to be covered in this unitEpilepsy

DementiaDeliriumParkinsonismHeadache

19.15. DELIRIUM19.15. DELIRIUMUNIT FOUR : MANAGING COMMON MENTAL HEALTH DISORDERS INUNIT FOUR : MANAGING COMMON MENTAL HEALTH DISORDERS IN

PRIMARY CAREPRIMARY CARE Topics to be covered in this unit:

Depression and mixed anxiety-depressionAnxiety

SomatisationDissociationSleep problemsPost-traumatic disorders

Eating disordersAdjustment disordersSexual disorders

Alcohol abuseDrug abuseAcute psychosisBipolar disorder

SchizophreniaLearning disabilityChildhood emotional disordersChildhood conduct disordersADHDASD



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ObjectivesUpon completion of this unit learners shall be able to do the following:Understand the presenting complaints and diagnostic criteria for the commonmental health problems in their working areaUnderstand different management approach to clients with mental health problems

Understand specific education to be given to clients and families of mentally illclients.Identify the needs and problems of children and adolescents with emotional andmental health problemsGive appropriate advice to parents of children with emotional and mental healthproblemsCare for clients with both physical and mental health problems.Understand the relationship between different aspects of health conditions andmental health.Appreciate the contribution of mental health promotion, prevention of diseases,treatment, reduction of disability and mortality.

.

Facilitators role

2. Make slide presentation for common mental health problems- psychoticconditions.

3. Give time for discussion after every condition

4. Give a copy of case formulation for Mr. Hassan in groups of four for discussion.a. Let participants identify patients diagnosis, differential diagnosis, cause,investigations to be carried, treatment and prognosis.

5. Ask participants to make a case formulation of any case already covered for presentation.

6. Facilitate discussion during presentations7. Let participants role play management of patients with different mental disorders

e.g. Schizophrenia, Bipolar, Alcohol abuse8. Discuss and summarize main points9. Give participants evaluation forms to fill during their spare time.

Evaluation forms contain Strengths, Weaknesses and suggestions for improvement inrelation to course objectives, content, teaching methodology and presentation.



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UNIT 5Topics to be covered in this unit:

Kenya health policyMental health policyRoles and responsibilities at each level

1. PHC2. District3. Provincial4. National

Mental health legislationHIV/AIDS and mental health problemsMalaria and mental healthReproductive health and mental Health

Childhood illnesses and mental HealthHealth Management Information SystemCommunity Mental Health Care

Traditional And Religious Health PractitionersMental Health Promotiona. General Population

b. School Health Educationc. World Mental Health Day

Objectives:Upon completion of this unit learners shall be able to do the following:Understand the main points of health policy and mental health policy.Understand the rights and expectations of people with mental health problems

Appreciate their key position in overall integrated system of delivery.Understand roles and responsibilities at different levels of mental health deliveryUnderstand the relationship between mental health problems and legal systemComprehend human rights issues, and their role in implementing legislation.

Activity: ImagineActivity: ImagineAsk delegates in group of 6 to imagine they are a patient with mental health problems and whathuman rights they would have the right to expect- 10 minutes feedback from each group.Then facilitator links to policy.Will make legislation more real.

Activity: Consequences of Legislation, Mental Health PolicyActivity: Consequences of Legislation, Mental Health PolicyIn groups of 2 :Tell a story or draw



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1: a person with mental health problems and the world in which they live now (lack of care, withtheir symptoms, with the causes and consequences, with risks and all the problems they face)

2: a person with mental health problems and the world in which they could live if policy,legislation and delivery of services all came together; incorporating all you have learnt during the day 1 andyour understanding of new legislation.

Objectives:Upon completion of this unit learners shall be able to do the following:Understand principles of engaging with clientsUnderstand principles and approach to community mental health careAppreciate the need to collaborate with traditional health practitioners in mentalhealth careUnderstand mental health promotion

Initiate mental health promotion activities in your area of work.



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Case Scenario 5: Engagement with clients.

Rama is 25 years old and lives with his parents in a 3-bedroom house. He left school at the age of 18 after completion of his ordinary level secondary education. His parents sent him to a private high school but hecould not perform. He has been using cannabis from the age of 14 without parents knowledge. At the ageof 19 Rama was arrested and charged with possession of cannabis.

While being held on remand his behaviour was agitated and he was also suicidal. He claimed to be possessed by an evil spirit, which told him to adopt leadership position in the final war between good andevil. He was instructed to cleanse the world of the opposite forces, but he was confused as to which side hewas on. He was assessed and diagnosed as Schizophrenia secondary to cannabis abuse.

Rama has been non-adherent to medication. He considers his medication and any contact with the mentalhealth services as harmful and is only sporadically compliant with treatment. He considers that his family,the mental health services, criminal justice and wider society are setting me up each time by making metake medication that harm, while society tries to stop me using the things that mellow and chill me out. Hedenies any need for mental health services.

Exercise

In your groups discuss on the following aspects:* Identify the needs and problems of Rama and his family* How would you go about ensuring that Jinasena and family are fully engaged with mental healthservices?

HEALTH MANAGEMENT INFORMATION SYSTEMHEALTH MANAGEMENT INFORMATION SYSTEM

A system of collecting, recording, keeping and reporting including dissemination of health related information (mental Health) with a clear flow of communication fromservice point to decision/policy level and vice versa .

COMMUNITY MENTAL HEALTH CARECOMMUNITY MENTAL HEALTH CARE

An approach of caring people within their social and geographical environment.Services and support be provided in peoples homes, giving the person as muchindependence as possible. The role of a community mental health worker is to;

Establishing population-based needs for treatment and care Providing a service system linking with a wide range of resources of adequate

capacity, operating in accessible locations Delivering evidence-based treatment to people with mental illness Home visits should be conducted to assess mental status and general health,

patients compliance with medication, and to appraise the patient and her or hisfamilys social economic position including interactions and how the client isdoing with the family environment.



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Summary:Community mental health care is a comprehensive approach of caring clients, familiesand community within their geographical and social environment.It is an empowering strategy to both clients and professionals.

TRADITIONAL AND RELIGIOUS HEALTH PRACTITIONERSTRADITIONAL AND RELIGIOUS HEALTH PRACTITIONERS

Traditional and Religious Health Practitioners are the major health care resource in mostAfrican societies. It is estimated almost 40% of clients will consult TH or RH at one timein sickness or related problems. People often simultaneously consult both traditionalhealers and western medicine. It is therefore important that efforts are made to enhancecollaboration and partnership with THs through dialogue, mutual trust, training and,research development.

MENTAL HEALTH PROMOTIONMENTAL HEALTH PROMOTION

Mental health promotion and disease prevention is the first level intervention in a healthcontinuum. It can be seen as a kind of immunization, working to increase the resilience of individuals, families and communities, as well as to reduce conditions, which are knownto damage mental well-being in everyone whether or not they currently have a mentalhealth problem. Strengthening the mental health of individuals, families, organizationslike schools and communities not only reduces vulnerability to mental health problems

but also improves physical health, increases productivity, reduces risk taking behaviours,..Mental health workers need to explore different avenues and opportunities for mentalhealth promotion within catchment area.Mental Health education to school children, teachers and the community

Facilitating self-help groupsSupporting parentsMobilizing communities for Mental Health day celebrations

SUMMARY/REVIEW, EVALUATION AND THE WAY FORWARD

Knowing where you come from helps to exactly strategize on where you want to go fromhere. During the training we have learned quite a number of different things professional,academic and social. All these are worth reflecting.

Topics to be covered :

Summary Of The Week Post Course EvaluationFuture Working

Objectives:Objectives:



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Upon completion of this unit learners and facilitators shall be able to do the following:Conduct a post training assessmentReflect main points covered during the courseIdentify main strengths and weaknesses related to course aims, objectives, content,teaching and learning methods including teaching and learning materials.

Give suggestions for improvement in relation to the course content and coursedelivery.Get into groups and plan the coming years activitiesAppreciate future roles and responsibilities in ensuring continuity and sustainabilityof training initiative.

Facilitators Role1. Administer the post test assessment (15 minutes)2. Give summary of what has been covered during the week using units as a guide.

a. Divide participants into 5 groups b. Give one unit to each group for summary presentation

c. Discussd. Allow some questions3. Evaluate the course with participants

a. Ask participants to give the overall evaluation of the coursei. What have they learnt from the course?

ii. What were the strengths of the course?iii. What were the weaknesses or pitfalls of the course?iv. How can we improve?

b. Summarize the points on flip chart and discuss4. Discuss with participants on future roles and responsibilities

END OF COURSEEND OF COURSE



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REFERENCESREFERENCES

Andrews, G. & Jenkins, R. (Eds) (1999). Management of Mental Disorders (UK Edition).Sydney: World Health Organisation Collaborating Centre for Mental Health andSubstance Abuse.

Paton, J. & Jenkins, R. (Eds) (2002). Mental Health Primary Care in Prison . London:Royal Society of Medicine.

Jenkins, R. (Ed) (2004). WHO Guide to Mental and Neurological Health in PrimaryCare . London: Royal Society of Medicine Press.

Menatl Health - Training the Trainer Programme Sri Lanka - Facilitators Guide - KAMHA.ORG

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