Impact of Training Health Extension Workers in Relation to Child Mental Health Care in Rural Ethiopia

Tilahun, Dejene (2017) Impact of Training Health Extension Workers in Relation to Child Mental Health Care in Rural Ethiopia. PhD thesis, Addis Ababa University.

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Abstract

Back ground: Child mental disorders, including autism, are major contributors to the global burden of disease leading to long lasting burden, disability and cost toward affected children and their families. These problems are aggravated by severe shortage of services. Access to services is further impeded by negative beliefs and stigmatising attitudes towards affected children and their families. Task-shifted care provided by community health extension workers (HEWs) has the potential of increasing access to services, and improving community perceptions. This study was conducted as an initial step for developing interventions to improve task-shifted care provision for children with autism and their families. Objective: This thesis is based on three sub-studies that aimed to evaluate: (i) experiences of stigma, explanatory models and unmet needs of caregivers of children with autism (sub-study 1); (ii) the training needs of HEWs to provide integrated child mental health care (sub-study 2); and (iii) the impact of training HEWs through the Health Education and Training (HEAT) programme in relation to child mental health disorder including autism, and appropriateness to the needs of HEWs and affected families in Ethiopia (sub-study 3). Methods: Study setting: The first sub-study was conducted in Addis Ababa, while the second and third sub-studies were conducted in the Southern region. Study design: The studies were primarily cross-sectional with a mixed-methods approach in sub-study 2. Participants and methods Sub-study 1: Participants were caregivers (n=102) of children with developmental disorders—two third of whom were caring for children with intellectual disability (n=68) and a third for children with autism (n=34). Caregivers‘ perceived experiences of stigma (Family Interview schedule) and explanatory models of illness and unmet needs were assessed. Data were subject to descriptive and multi variate analysis. Sub-study 2: In a mixed study approach, 104 HEWs who had received HEAT training were interviewed using a structured questionnaire designed to assess their experience and service practice, and 11 HEWs were involved in in-depth interviews. The quantitative data were subject to descriptive analysis while the qualitative (in-depth) interviews were subject to framework analysis. xiii Sub-study 3: participants comprised of three groups of HEWs: i) HEWs who completed a basic mental health training module (HEAT group, N=104); ii) HEWs who received enhanced training, comprising basic HEAT as well as video-based training on developmental disorders and a mental health pocket guide (HEAT+ group, N=97); iii) HEWs untrained in mental health (N=108). All participants completed a questionnaire assessing beliefs and social distance towards children with autism. Impact of training was assessed by comparing attitudes, experiences and service practices between the three groups. Results: Sub-study 1: Most caregivers reported experience of stigma: 43.1% worried about being treated differently, 45.1% felt ashamed about their child‘s condition and 26.7% made an effort to keep their child‘s condition secret. Reported stigma was significantly higher in caregivers who had sought traditional help (p<0.01), provided supernatural explanations for their child‘s condition (p=0.02) and in caregivers of Orthodox Christian faith (p=0.03). Caregivers gave a mixture of biomedical and supernatural explanations for their child‘s condition. The biggest reported unmet need was educational provision for their child (74.5%), followed by treatment by a health professional (47.1%). Most caregivers reported that talking to health professionals (86.3%) and family (85.3%) helped them to cope. Sub-study 2: Most HEWs (88.5%; n=93/104) reported that they were interested in the training provided and all respondents considered child mental health to be important. Participants in the qualitative interviews considered the problem of child mental disorders to be widespread and to cause a large burden to the family and the affected children. They reported that improving their competence was important to address the problem and to tackle stigma and discrimination. Participants also listed some barriers (e.g. lack of competence, stigma and institutional constraints), and opportunities (e.g. staff commitment, and positive attitude) toward service provision. Sub-study 3: Training intervention had significant positive impact on belief, attitude and social distancing. HEAT+ trained (Z=-6.24, p< 0.001, r=-0.44) and basic HEAT trained (Z=-6.14, p< 0.001, r=-0.42) HEWs were more likely to believe that children with autism can improve their language skills compared to untrained HEWs. Both the HEAT (p=0.004) and HEAT+ group (p<0.001) showed fewer negative-beliefs towards children with autism than the untrained-group. The HEAT+ group in turn displayed fewer negative-beliefs than the HEAT-group (p<0.001). xiv Both the HEAT (p<0.001) and the HEAT+ group (p<0.001) showed decreased social-distance towards children with autism compared to the untrained-group; the HEAT+ group displayed a lower preferred social-distance than the HEAT-group (p=0.017). Planned contrasts using Bonferroni correction for multiple comparisons revealed that the HEAT+ group had significantly lower positive-beliefs scores than the untrained-group (p=0.01). Conclusions: Caregivers of children with developmental disorders and autism have high levels of unmet needs and perceived stigma. HEWs have high levels of motivation to engage in integrated child mental health care and are important resources in scaling up care for child mental health. Brief training has the potential to equip HEWs for the task of supporting integrated child mental healthcare. These findings have relevance for task-sharing and scale-up of autism services in low-resource settings worldwide. Recommendation: It appears that caregivers and children with developmental disorders and autism are neglected. Appropriate policy response should include strategies to guide healthcare delivery to children with mental health problems including autism. The tools used in this study may support such a policy response.

Item Type:	Thesis (PhD)
Uncontrolled Keywords:	Stigma, Child community health care, Impact of training; Autism; child mental disorder, child developmental disorder, health extension workers; Ethiopia
Subjects:	R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine R Medicine > RJ Pediatrics > RJ101 Child Health. Child health services
Divisions:	Africana
Depositing User:	Vincent Mpoza
Date Deposited:	17 Oct 2018 14:09
Last Modified:	17 Oct 2018 14:09
URI:	http://thesisbank.jhia.ac.ke/id/eprint/6891

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