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Terms of reference
1. Working with
MOH, WR office and UNFPA develop and test an instrument for needs assessment
of psychosocial distress in the community.
2. Training of
physicians to enhance their capacity in delivering mental health needs of the
Tsunami affected community.
3. Identify future
country needs in developing their mental health system in short and
long-term.
4. Capacity
building within the country in community mental health through training of
community health workers in identification and management of epilepsy using
SEARO modules.
Magnitude
of the Tsunami disaster
The Tsunami resulted in massive damage
to Maldives.
Official government statistics report the following:
 Displaced
and homeless persons on 26 December:15,000
Islands
totally evacuated : 13
Injured:
1,313
Deaths:
82
Missing:
26
The Maldives
Government has said about 100,000 people i.e., more than one third of the
total population has been affected. 15,000 have been displaced. A high number
has been rendered unemployed or underemployed. There is substantial evidence
that loss of employment and livelihood, particularly sudden loss, very
frequently gives rise to anxiety and depressive disorders. Of the affected
population about 30 to 50% of the population will need some form of
psychosocial support ant 5 to 10% may need psychiatric care.
Psychosocial
support activities in the community
The government
of Maldives launched a well
organized community-based campaign to provide psychosocial support to the
disaster-affected persons. A Psychosocial Unit was formed in the National
Disaster Management Centre. Immediately after the disaster, this unit
mobilized volunteer groups consisting of some previously trained counselors
working with different agencies and other volunteers interested in providing
psychosocial support to the disaster affected community. All members of the
team were local Maldivians who spoke the local
language and were familiar with the local culture. Volunteers who were not
trained in counseling were trained in a two day programme
organized by Red Cross utilizing two experts from India, many such
courses have been conducted and more are planned for the future. The
volunteer teams immediately went to the islands and formed Emotional Support
Brigades consisting of youth, elderly and health care providers. Through this
out-reach programme, all affected islands have been
reached, and each and every affected person has been provided at least some
emotional and psychological support.
The above programme is being implemented by the Psychosocial Unit
of the National Disaster Management Centre facilitated by UNFPA and UNICEF in
terms of budget for travel and by Red Cross for training. WHO has also
provided the technical material for training.
UNFPA has been
officially designated as the coordinator of the psychosocial relief effort to
the Tsunami affected community.
Red Cross conducted
a qualitative rapid assessment of the affected islands in terms of overall
emotional status. However, a quantitative needs assessment of the magnitude
of the psychosocial distress has not been carried out. WHO has been requested
to assist the Government in developing the needed instruments to conduct this
assessment. Red Cross also has long term plans for
empowering communities for disaster preparedness for the future and
developing income generation schemes.
Activities
Undertaken
1.
Meetings held
a) Discussions with
Ms. Aminath Zeeniya, Programme
Manager Mental health, Ministry of Health (MOH).
b) Discussions with
Dr. Manuel Carballo, Executive Director,
International Centre for Migration and Health and consultant to UNFPA.
c) Discussion with
Dr. Satyabrata Das,
Acting Country Manager, American Red Cross.
d) Discussion with
Mr. Abdul Hameed Coordinator, Psychosocial unit,
Disaster Management Centre
e) Attended
consultation workshop for discussion of UNFPA Tsunami Emergency Projects on
Reproductive and Psychosocial Support.
f) Discussion with Dr. Abdul Azeez
Yoosuf, Director General Health Services and Dr.
Sheena Moosa, Deputy Director Health Services.
g) Discussions with
Dr. Sheena Moosa, Deputy Director Health Services and Dr. Shehenaz Fahmy, Deputy
Director, MOH.
h) Discussion with
staff at Faculty of Health Sciences, Ms.Aishath Ahment Didi, Assistant Lecturer
and Curriculum Coordinator, Ms. Aishath Rameela, Assistant Lecturer and Ms. Mariyam
Warujina, Assistant Lecturer.
2.
Development
and testing of a needs assessment instrument for psychosocial distress in the
community
The General
Health Questionnaire (GHQ-12) has been extensively used in many countries as
a measure of psychosocial distress. Starting with an original English
version, it was translated into Dhivehi and back translated into English. It
was then tested on a sample of 43 people affected by the Tsunami in one
island. Analysis of the data suggested that those with a GHQ-12 score of 7 or
more need additional psychosocial support. The five additional questions in
the needs assessment questionnaire were also helpful to identify some more
affected persons in need of psychosocial support. A detailed report of the development and
testing has been prepared (Annex 1)
3. Training of physicians to enhance their
capacity in delivering mental health needs of the Tsunami-affected community
Technical material prepared by SEARO for training of physicians, including
power point slides to be used during training were handed over to the
MOH. Unfortunately actual training of physicians could not be organized
because of problems in transporting large number of physicians to Male. MOH
is considering using a consultant in the future to conduct the training in
Regional and Atoll hospitals.
However, since
all physicians in the islands are expatriates (except
one Maldivian), MOH was not keen to devote too much effort into training
these physicians.
The same
training material developed for physicians could be used in training
community health workers and nurses who live in the islands and work there on
a long-term basis. When needed these para-medical
staff could be supported by doctors
4.
Identify
future country needs in developing their mental health system in the short
and long-term
The government
of Maldives has expressed
an interest in developing their mental health system which is suitable to its
culture and its unique geographical layout.
a) Strengthening
the Ministry of Health
Development of
National Mental Health Policy and Plan
1) Workshop
of stakeholders to be conducted to discuss the results of the mental health
survey and development of mental health policy, plan and programme.
WHO manual on assessment of mental health services and development of mental
health policy, plans and programmes has been provided to
MOH.
2) Recruitment
of a mental health professional (to be based in MOH) to assist MOH in framing
a mental health policy and plan. Attached draft TOR was discussed with MOH (Annex
2)
3) Recruitment
of a mental health consultant (to be based in WR office) for training of
physicians, nurses, community health workers in mental health. Attached draft
TOR was discussed with MOH (Annex 2)
b) Developing mental heath services inIGMH, Male
Recommendations
made by previous WHO consultants were discussed with MOH. MOH pointed out
that there are two psychiatrists at IGMH, one of whom is a Maldivian. No
other Maldivian psychiatrist is likely to be available in the near future.
None of the existing Maldivian doctors in Male have expressed any interest in
mental health. Thus the only possibility of enhancing mental health services
at IGMH is by training of some nurses in psychiatric nursing. At present the
cadre of psychiatric social worker and occupational therapist (recommended by
the previous consultants) do not exist in Maldives, but could be
considered in the long-term.
c) Community mental health training at the RegionalHospital, AtollHospital and all smaller islands
Physicians at
Regional and AtollHospitals, and island
health centres are expatriate physicians, so MOH is
not keen to devote too much resources on training
them. Perhaps a video-based training programme
could be considered. However, the practical solution is to train nurses and
community health workers in mental health at the Regional, Atoll and all
islands who will be available for service delivery on a long-term basis. This
is particularly important as they are familiar with the local culture, and
the only way for expatriate physicians to communicate with patients is
through these local workers.
d)
School
mental health programme
WHO technical material
for teachers and parents on identification and management of behavioral and
learning disorders is ready. The consultant who prepared this material can be
sent for one week to train master trainers.
Director General
Health Services said that this has to be discussed with the Ministry of
Education to finalize the dates (probably later in the year) for the training programme
considering that multiple training programmes have
already been undertaken and planned for Tsunami-related work.
e) Undergraduate training in clinical
psychology
MOH desires to
send one student for training in a bachelor’s course in clinical psychology.
This person will be placed in the Ministry of Health and will oversee
clinical services, be responsible for supervision, management and training of
paramedical workers. The person will be based in Male but will be required to
travel to the Regions. Training of the identified candidate will be overseas
at an appropriate Centre.
f) Mental Health activities in other
Ministries
Strengthening
the Faculty of Health Sciences (FHS)
The faculty of
health science is under the Ministry of Education. Discussions were held with
FHS regarding a course in psychiatric nursing and inclusion of mental health
training for community health workers. Based on these discussions the staff at the FHS need to observe similar courses being
conducted overseas. The consultant in mental health who will be recruited for
three months could also assist in developing a curriculum to be used for this
training. The technical material developed by WHO
for training of community health workers in the identification and management
of generalized tonic clonic seizures can be
included in the current curriculum.
Enhancing
the management and staff capacity for Guraidhoo
special care facility
The Home for
Special Needs is an excellent facility for long-term care for people with
special needs. The staff could benefit from updating their knowledge and
skills in mental health. The
consultant in mental health to be recruited could assist the Ministry of
Gender in this activity.
5.
Capacity
building within the country in community mental health through training of
community health workers in identification and management of epilepsy using SEARO modules
Training for
community health workers (as master trainers) in the identification and
management of generalized tonic clonic seizures was
conducted in the northern and southern region. In the northern region the
training was conducted at the Kulhudufushi Regional
Hosptila, Ha Dha Atoll.
The training was attended by 15 participants ( 7
nurses from KulhudufushiRegionalHospital and 3 from the Shaviani and Haa Alif Atoll and 5 community health workers from the Shaviani and Haa Alif Atolls). In the southern region training was
conducted at HithadhooRegionalHospital. The training
was attended by 20 participants (13 Nurses, 2 Regional Health Officers and 6
Community Health Supervisors) from HithadhooRegionalHospital, Hulhumedhoo Health Centre, Feydhoo Health Centre, Hulhudhoo
Health Centre, Maradhoo Feydhoo
Health Post, and Gn.FurahmulahAtollHospital. The training
was well received by the participants. Data collection, reporting and
monitoring forms were also provided. (Annex 3).
6.
Recommendations
a)
Recommendations for psychosocial
support to those identified by the needs assessment instrument
 The
capabilities of the Emotional Support Brigade could be enhanced with training
in simple counseling skills (e.g. with use of WHO manuals).
Training
of physicians in the islands to deliver mental health services for the
Tsunami- affected communities.
Community
health workers could be trained in the identification and management of
common psychiatric conditions using the same material as for physicians.
b)
Recommendations for implementation of
the needs assessment instrument
Needs assessment to assess the magnitude
of psychosocial distress should be conducted for all adults in the affected
islands. MOH may consider conducting the same needs assessment for families
indirectly affected due to large numbers of displaced persons moving into the
their households.
MOH may consider if data management
support for needs assessment instrument can be provided by the expert already
placed in the MOH for 3 months.
c) Recruitment
of a mental health consultant and a mental health professional
A consultant in mental health may be
immediately recruited. His/her main assignment will be training of physicians
and paramedical staff. A draft TOR which was discussed with MOH is attached. (Annex 2)
A mental health profession could be recruited
to work in the MOH to assist in development of mental health policy and
services. A draft TOR which was discussed with MOH is attached. (Annex 2)
d) Training
Inthe short-term the consultant in mental health to be recruited will do
the training of physicians and paramedical staff. In the long-term the
Faculty of Health Sciences (FHS) will train the paramedical staff.
A staff member of the FHS should be sent
to observe curricula for paramedical staff (nurses, community health workers)
being implemented in some other centre.
e) e) Recommendations for the programme on epilepsy
i. Training of all paramedical staff
(nurses, community health workers, family health workers) at the RegionalHospital, AtollHospital and health
posts
Master
trainers in the northern and southern region have been trained for the
identification and management of generalized tonic clonic
seizures. Master trainers in the central region need to be trained. These master trainers can train other
paramedical staff on identification and care of patients with generalized
tonic clonic seizures with the technical material provided
by WHO. Nurses and family health
workers and can be trained in the
identification and care of generalzed tonic clonic seizures, while community health workers if they are
allowed to prescribe anti-epileptic drugs can be trained in the management of
generalized tonic clonic seizures.
ii. All physicians
at the Regional Hospital/Atoll Hospital/Health posts should be
provided the technical material developed by WHO on
the identification and management of generalized tonic clonic
seizures.
iii. Community education through Information,
Education and Communication (IEC) campaigns. WHO has
developed a video on stigma removal which has a dual sound track and could be
dubbed in Dvivehi. Local experts could develop IEC material (posters,
pamphlets, messages on the radio etc) on epilepsy to inform the people about
epilepsy and encourage people to seek treatment.
iv. Ensuring
availability of phenobarbital. The
continuous availability of phenobarbital should
be ensured at the Regional Hosptial/Atoll
Hospital/Health Centre/Health Posts and an additional drug (eg. phenytoin sodium) for
patients who do not respond to phenobarbital,
should be made available at the Regional and AtollHospital.
v. Regular reporting
and monitoring of the programme at the Regional
level
The
quarterly reporting of identified cases, treatment started, and control of
seizures should be done and data should be sent regularly to the Regional
level. A draft of the forms that can be used are
attached in Annex 3.
vi. Establish a
referral system for hard to treat cases. Those patients that do not
respond to treatment at the Atoll Hosptial should
be referred to the Regional Hospital/IGMH Hospital in Male for care under
experts.
vii. Population-based interventions: Public health
policies that can modify risk factors for epilepsy will help reduce the
incidence and prevalence of epilepsy. Examples of such policies include
improving the quality of obstetric services through well trained birth
attendants. Strengthening of
Integrated Management of Childhood Illnesses especially for fever and
infections. Campaigns to educate communities about the medical nature of
epilepsy and remove myths and misconceptions about epilepsy could reduce
stigma against epilepsy and encourage patients to seek medical treatment.
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