Received Date: November 14, 2016; Accepted Date: November 18, 2016; Published Date: November 25, 2016
Citation: Dube-Marimbe B, Mangezi W, Kaul P, Kaseke F, Madhombiro M, et al. (2016) Needs Assessment for Development of a Mental Health Curriculum for Village/Lay Health Workers to Manage Caregiver Burden in Zimbabwe. J Ment Disord Treat 2:129. doi:10.4172/2471-271X.1000129
Copyright: © 2016 Dube-Marimbe B, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Visit for more related articles at Journal of Mental Disorders and Treatment
Introduction: Village health workers (VHW)/Lay workers have been used effectively in HIV programmes in Zimbabwe and may potentially be useful in supporting caregivers of people with mental illness, if they are adequately trained and supervised by health professionals. Objective: To explore the training needs of VHW in supporting caregivers of persons with mental illness. Methods: Fifty two VHWs were conveniently selected from 5 out of 9 provinces in Zimbabwe and participated in focus group discussions (FGD) using a standardized study guide. Forty six health professionals completed a self-administered open ended questionnaire. Interviews were audio recorded and transcribed verbatim in Shona and translated into English. Data were analyzed thematically using Atlas Ti. Statistical Package for Social Sciences version 16 was used for sociodemographic data analysis. Results: The overall perceived training needs for VHW included training on counseling skills, psycho- education for caregivers, stress management, education on mental health conditions in order for them to effectively support caregivers of patients with mental illness in their communities in Zimbabwe. Conclusion: The needs analysis demonstrates perceived gaps in the knowledge of VHW in training caregivers of patients with mental illness. Designing a curriculum and assessing its impact on patient care and caregiver perceptions may go a long way in reducing caregiver burden in Zimbabwe.
Caregiver burden; Mental health curriculum; Lay/village health workers; Zimbabwe
Village Health Workers or lay workers have the potential to provide psychosocial interventions as part of primary and secondary prevention of mental, neurological and substance use (MNS) disorders in low to middle-income countries (LMIC) . It has been suggested that interventions that rely on non-specialised workers could deliver equally effective and acceptable general health and mental health interventions as those delivered by specialist health workers [2-4]. Lay worker interventions are often cheaper and accessible compared with reliance on professional specialist health workers.
In LMIC mental health services are scarce, cover a small proportion of the population and face chronic shortages of financial and human resources . Zimbabwe, like other LMIC, faces major deficits in mental health services . This shortage of human and material resources limits the sustainability and coverage of mental health care programs. This lack of mental health programmes has resulted in the majority of people with mental disorders being taken care of in the community by their families .
Task shifting/sharing may potentially be an effective approach in alleviating this critical shortage of human resources in mental health . This refers to the delegation of tasks to cadres who are less trained or lay workers who can take up the responsibility of diagnosis and management of less severe cases whilst the specialists take care of more complex conditions . Village health workers (VHW)/lay workers have been utilized successfully in other programs in Zimbabwe such as the HIV/AIDS program. Nyati and Sebit  suggested that such a strategy may be effective for management of psychiatric illness.
Therefore task shifting is a progressively promoted method that can relieve shortages in specialist health human resources [9,10]. Adequate training and supervision of these non-specialized cadres by psychiatrists, psychologists and mental health nurses is essential. However, research on the content of this training and the effectiveness of task shifting is necessary .
Numerous studies in Western countries have shown that family care giving causes stress, depression and financial difficulties [12,13]. Caregivers require emotional support and psychoeducation for them to effectively provide care and support to their relatives with mental disorders. Providing information using a problem-solving approach helps caregivers cope more effectively. Offering emotional and practical support has been found to reduce burden among caregivers of patients with schizophrenia.
The results of a study conducted by Marimbe et al.  on caregiver burden and needs of caregivers in Zimbabwe showed that caregivers experienced psychological, emotional, social and financial burden as a result of the caregiving process. Caregivers required support from health professionals to help them cope with the caregiving process which they felt was lacking as due to a critical shortage of health professionals. They felt they were not being given adequate time to express their challenges to the health professionals. Sixty eight percent of the caregivers in that study were at risk of common mental disorders (CMD) as a result of caring for their relative with a mental illness . In the same study, health professionals expressed that there was a critical shortage of human resources and as a result they hardly got the opportunity to deal with caregiver issues. Therefore training of VHW may alleviate the critical shortage of mental health professionals and help in the training of caregivers thereby reducing caregiver burden.
This study sought to explore the training needs of VHW in order for them to effectively train and support caregivers of people with mental illness in their communities.
The study used qualitative methodology. Participants were drawn from health professionals (mental health nurses, general nurses, occupational therapist, psychiatrist and psychologists) and VHW who were conveniently selected from Harare, 2 district hospitals and 2 provincial Hospitals. These hospitals represented 4 of the 9 provinces in Zimbabwe. Health professionals completed a self-administered open ended questionnaire which explored their views on how VHW could be engaged in supporting caregivers in the community. Village health workers were involved in focus group discussions (FGD) to explore their training needs until information saturation.
Data gathering procedure
Health professionals completed a self-administered questionnaire. The questions were on whether the VHW were adequately trained to support caregivers of people with mental disorders, and their perceptions on VHW ability to support caregivers in reducing caregiver burden. Informal discussions were conducted with the Director of Nursing services in the Ministry of health and child care (MOHCC) in order to ascertain the presence of perceived gaps in the curriculum.
FGDs were conducted with VHW and each lasted 60 to 90 minutes. An interview guide comprised of questions to ascertain whether VHW were trained to support caregivers of people with mental illness, their confidence in supporting caregivers, and gaps in their curriculum and their training needs was used to obtain data.
Data management and analysis
Interviews were audio recorded and transcribed verbatim in the local language and then translated into English. Data were analysed using a thematic approach (familiarization, identifying a thematic framework, indexing, charting, mapping and interpretation)  using NVivo 8 qualitative data analysis software. A constant comparative method was used to identify the domains and themes emerging from the transcripts. Interviews were discontinued after information saturation.
Statistical Package for Social Sciences (SPSS version 16) was used for sociodemographic data analysis.
Ethical approval was obtained from the Joint Research Ethics Committee at the University of Zimbabwe, College of Health Sciences (ref: JREC/193/15) and The Medical Research Council of Zimbabwe (ref: MRCZ/B/932/15). Written permission was obtained from the Ministry of Health and Child Care and participating hospitals. Informed consent was obtained from all participants. Interview notes, consent forms and the audio recorder were kept in a locked cupboard for the entire study period to maintain confidentiality and data were stored on a password protected computer.
A total of 52 VHW participated in four focus group discussions. Their ages ranged from 20 to 65 years. Their work experience ranged from 5 and 20 years. Forty (74%) participants had formal education which ranged from seven years of primary education to four year of secondary education whilst 14 (25%) had no formal education. Forty three (80%) had received training as VHW whilst 11(20%) were nominated to be VHW in their communities but were awaiting the 21 week initial training which is conducted by the Ministry of Health and Child Care (MOHCC).
Forty six (92%) health professionals responded to a structured questionnaire on how VHW could be involved in the management of caregiver burden. Twenty three (50%) were Mental Health Nurses, 18(39%) Registered General Nurses, 2(4.3%) Psychiatrists, 2(4.3%) Occupational Therapists whilst 1(2.2%) was a Psychologist. Informal discussions were conducted with two key stakeholders from the MOHCC.
The overall training needs that emerged from both health professionals and VHW included training on counseling skills, psychoeducation for caregivers, stress management and relaxation techniques, education on mental health conditions and follow up of patients. The other theme that emerged was the potential barriers to training and potential strategies to enhance training of VHW as shown below:
VHWs expressed the need for them to be trained in counseling so that they could be better equipped to support caregivers in the community:
“I think most of the caregivers of people with mental disorders need to receive counseling. I was trained on counseling people living with HIV but I don’t know if the counseling is the same with caregivers of mental illness people. Please train us so that we can help them” (FGD 4, VHW).
Yet another participant said:
“Those relatives really need help because it is difficult to deal with a person with mental illness. I remember this woman in our village whose huts were burnt down by her mentally ill son, she remained with nothing and up to now she is still suffering from the effects but still has to continue staying with that son…it must be very difficult…I feel pity for her but I don’t know how to help that situation. I think if we are taught to do counseling we can help” (FGD 1, VHW).
The importance of the counseling training for VHW was further echoed by the health professionals like one participant said:
“They should counsel the patients and their relatives on dangers of abusing alcohol and other hard drugs. These days there is so much drug abuse in the community and us as health professionals usually see the patients when they are already ill but since VHW are there with the patients in the community they should try to educate them about the dangers of alcohol. This will reduce caregiver burden” (Survey, Mental Health Nurse).
Stress identification and management
The VHWs also expressed the need to be equipped with skills on identification of caregivers who were stressed and how to manage them:
“I want to know more about stress management. There are so many people that we meet who have a lot of stress which is caused by different things so if we are taught to manage stress we can help not only the caregivers of people with mental disorders but people with other issues too”(FGD 1, VHW).
Yet another participant said:
“I can say I want to know more about how you tell that a person has stress and depression because surely if I was the one with a child with mental illness I will have depression”. (FGD 2, VHW).
Stress identification and management was further echoed by health professionals like the following participants said:
“The patients really stress their families when they are sick. When the patients are followed up by VHW the caregivers will have less stress. They should be taught on counseling skills and how to teach caregivers to cope with different conditions thereby preventing stress”. (Survey, Psychologist).
“They should help those caregivers who are stressed by their ill relatives. There are some caregivers who have given up on their ill relative and end up not taking them to the hospital and the patient ends up roaming around the streets and some of them commit crimes in the process. So the VHW should support these caregivers” (Survey, Occupational Therapist).
“They should identify those caregivers who are stressed and help them on how they can cope with their relative who is unwell. They should teach the caregivers not to give up but how to deal with stress” (Survey, Registered General Nurse (RGN)).
Psychological first aid
Participants expressed the need for VHW to be equipped with adequate knowledge and skills on what to do when they encounter patients with mental illness before they take them to the health facility for treatment like the following participants said;
“VHW should be taught on the importance of psychological first aid to the caregivers so that they know how to take care of the patient before he is taken to the hospital. This will prevent burden of care” (Survey, Psychiatrist).
“Some patients are a problem to their parents, I once saw a mother crying and saying her son is breaking property and threatening to kill the mother if she took him to the hospital so I think the VHW should teach them what to do when the patients becomes violent” (Survey, Rehab technician).
“As for me at the moment I am not confident on what I should do when I meet someone who is mentally ill and they are violent. I think I can actually run away from them like any other person because they are so scary, they can injure you and no one will compensate you since it’s a mentally ill person but if you train us we can try to help them” (FGD 3, VHW).
Follow up of patients
Health professionals expressed a strong need for patients to be followed up in the community to monitor medication compliance and any signs of relapse as echoed by the following participant;
“If the patients are closely monitored at community level, the rate of relapses will be less and this will reduce the burden on the caregivers and improve their wellbeing. This will also reduce admissions to mental health institutions and also reduce the rate of crimes committed by patients when they are sick such as breaking property”(Survey, Mental Health Nurse).
For VHW to be able to monitor patients in the community there was need for them to be knowledgeable about the signs of mental illness, signs of medication side effects and course of action initially when they encounter such problems like one participant said;
“We also need to know about the medication that is given to people with mental disorders and the side effects so that we can help the caregivers on issues of compliance to medication for their relatives through follow up home visits” (FGD 2, VHW).
Psycho-education for caregivers
Health professionals also expressed the need for VHW to help educate the caregivers on different mental health conditions so that the caregivers understand the possible causes of their relatives’ conditions. This was important so that the caregivers may help in monitoring compliance, prevention of relapse and seeking medical attention in the formal health sector as echoed by the following participants;
“They should teach the caregivers about the causes of mental illness, what mental illness is and what it is not so that the caregivers know what they are dealing with and can do the right thing than take the patient to a traditional healer or prophets” (Survey, RGN).
“Basic psycho-education is very essential so that the caregivers understand the patient’s conditions and know what they are dealing with” (Survey, Mental Health Nurse).
“They should be trained on the basic side effects of medications used to treat mental disorders and should be given drugs that they can use when the patient is psychotic or depressed” (Survey, RGN).
Training on mental health conditions
Most VHW expressed the need for them to be trained in mental health so that it would be easy for them to educate the caregivers in the community.
“We were never taught about mental disorders but when there are such problems in the community we are expected to assist. This becomes very difficult because we do not know what to do and these patients at times become violent to people and we do not know what to do. We need to be trained so that we can help them effectively” (VHW).
“They should be trained so that they can teach the community about mental illness and thereby prevent stigma” (Survey, Mental Health Nurse).
Health professionals expressed the need for VHW to be trained on using screening tools such as the Shona Symptom questionnaire (SSQ) and other screening tools available to assess caregivers for burden and psychological morbidity which can help facilitate early interventions for caregivers.
“They should be trained on how to screen patients for symptoms of mental illness and relapse and also to screen the caregivers for burden psychologically, physically and financially” (RGN).
Potential barriers and alternative strategies
In as much as most of the VHW expressed the need to be educated on different mental health conditions so that they can easily identify what a person is suffering from; they identified certain cultural beliefs that could hinder their efforts in dealing with caregivers in their communities like one participant said:
“This belief that mental illness is caused by bad spirits could hinder us from trying to help these families. People in our African culture always want to start by going to consult traditional healers and spiritual healers. At the end of the day there are delays in taking the patient to the hospital as they always want to be cleared by the traditional healer first. This might hinder our progress in trying to convince the caregivers to take the patients to the hospital early” (FGD 1, VHW).
The health professionals however felt the VHW were the best people to educate informal health providers on the causes of mental illness in order to facilitate early referral of the patients to the health facilities for treatment thereby reducing caregiver burden.
“The VHW should also teach the traditional healers and prophets about the causes of mental illness, that it’s not always about witchcraft, this will help them to refer the patients to the hospital early” (Survey, RGN).
Some of the VHW however still believed that is was their duty to educate the community about mental health problems though they required support from like the following participants expressed:
“In my opinion I think we need to educate our community leaders first, especially the chiefs and the headman. Once these are aware of the causes of mental illness then it becomes very easy to disseminate the information to the grassroots through them as they are respectable people in the community. This can facilitate early identification of households with people with mental health problems” (FGD 4, VHW)
“The VHW should be given allowances for supporting caregivers and patients, t- shirts with messages on prevention of mental disorders, bicycles so that they can conduct home visits, stationary for records purposes if they are to effectively carry out their tasks in the community” (Survey, RGN).
“The police also need to work closely with us so that if we report that there is a violent person in the community they can quickly come and assist to handle the patient and take them to the hospital”(FGD 1, VHW).
The results of this needs assessment showed that there was a gap in the current curriculum for VHW. The common themes that emerged with regards the training needs for VHWs included the following: Counseling skills for caregivers, Stress management and relaxation techniques, Psychological first aid, Psycho-education for caregivers, how to assess caregiver burden using the Shona Symptom questionnaire (SSQ) and other screening tools available. These aspects are also included in the curricula for lay workers in India  and in other LMIC including Malawi.
The Lancet global mental health series has strongly encouraged task-shifting/sharing of mental health interventions to non-specialists as a key approach for closing the treatment gap [17-20]. Lay workers have been used in various services which include public, private and non-governmental organizations (NGOs). These include clinics, half-way homes and community outreach services. They have been involved in varied activities and roles which include detecting, diagnosing, treating and preventing common and severe mental disorders, intellectual disability and epilepsy. Their roles are dependent on their level of training. Lay health workers have also been involved in supporting caregivers through ensuring that patients adhere to medication as well as in detection of mental health problems. This can also be done in Zimbabwe in order to encourage early identification and management of mental health problems and prevention of relapse which might further increase the burden of care among caregivers. Lay workers may also take on follow-up roles of patients in the community and provide health education to communities in order to promote mental well-being .
Trained lay counsellors working within a collaborative-care model can reduce prevalence of common mental disorders, suicidal behaviour, and psychological morbidity and disability days among those attending public primary care facilities . A study conducted in Goa India by Buttorff et al.  revealed that within public primarycare facilities, the use of lay health workers in the care of subjects with common mental disorders was not only cost-effective but also cost-saving. Lay counselors have been found to have a positive effect on symptomatic relief, social functioning and satisfaction with care in patients with CMD attending primary care clinics although the impact, compared with usual care, is greater in the public sector . Psychosocial interventions with a clearly defined aim that includes giving information and having a discussion group have been found to have positive effects on burden and satisfaction for caregivers of people with dementia which may also be the same with caregivers of patients with other mental health disorders [23-25].
In many LMICs, training and supporting adequate numbers of specialists may not be achieved in the near future. It therefore becomes critical in these settings to consider possibilities for expanding firstlevel access to mental health services. The use of lay workers, who are far more numerous and low-cost than specialists, is one option that is highly relevant to LMICs including Zimbabwe. It is therefore critical to disseminate the results of this study to the relevant authorities in the Ministry of Health and child care who are responsible for training of VHWs in Zimbabwe so that measures are put in place to include the component of caregiver support in the training of VHWs .
The needs analysis demonstrates perceived gaps in the knowledge of VHW in training caregivers of patients with mental health illness. Designing a curriculum and assessing its impact on patient care and caregiver perceptions may go a long way in reducing caregiver burden in Zimbabwe.
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals