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Demographics
Of the twelve (12) health care workers enrolled in the study, ten (10) were females and two (2) males. The oldest participant was aged 55 years, while the youngest was 36 years. Half of the participants were nurses six (6), two (2) clinical officers, one (1) psychiatric clinical officer, two (2) community health assistants, and one (1) community-based mentor mother. Eight (8) of the participants were recruited by the Ministry of Health, while three (3) were recruited by external funding partners representing clinics such as Prevention of mother-to-child transmission, antenatal clinic, child welfare clinic, family planning, and psychiatric clinics.
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Staffing
A total of fifty-one (51) staff members worked at the Kangemi health center, while forty-one (41) staff members were at the Kariobangi health center. In both facilities, seven (7) staff members were supported by partners staff who assisted with additional service coverage. The two facilities had at least three psychiatric health care workers - one nurse at Kangemi health center and two Psychiatric Clinical Officers at the Kariobangi health center - trained to manage mental health-related challenges. Personnel at the health centers were either MOH or external partner organizations employees. Despite both health centers being externally funded, the Kangemi health center had forty (40) MOH staff and eleven (11) partner supported staff, while Kariobangi health center had twenty-seven (27) and sixteen (16) staff, respectively. The Kangemi health center had more staff than the Kariobangi health center, despite both facilities serving an almost similar population, 59,000 and 65,039, respectively.
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Services
In both facilities, clinics were running five days a week except for the hospital’s psychiatric clinic once a week. Services are limited, with maternity services being offered only in the Kangemi health center, and youth-friendly services are not emphasized in either clinic. Also, these community health facilities provide several services for nearby populations. These services include tuberculosis, antenatal and maternity, family planning, child welfare clinics, Comprehensive Care Clinic and HIV testing (HTS), laboratory, nutrition, and immunization. We found that three to four clinics ran lower frequency clinics than usual five days per week due to staffing issues. For instance, both facilities’ psychiatric clinic is held once a week and managed by outsourced staff from Kamili Organization. The non-communicable disease (NCD) clinic is held weekly at Kangemi and bi-weekly at Kariobangi Health Center and provides services on managing and preventing diabetes, hypertension, and cancer. While male health services in Kangemi are infrequent, the Kariobangi center offers a dedicated service where some male CHV help the male patients with their medical requirements. Health care workers reported that they made various efforts to engage with youth by tailoring services by providing them with unique slots for sexual and reproductive health and HIV services. Using the clinic entrance proved to be a source of shelter and a haven for many young women and adolescents who were homeless or exposed to violence and abuse. Despite several attempts at engaging youth, we did not see many well-developed youth-friendly services in either facility.
We found that many of the services were outpatient, running from 0800hours to 1700 hours except for the maternity services at Kangemi Health Center, which operated throughout (24 hours all days of the week). The services are run by clinical officers, nurses, laboratory technicians, while the community health assistants (CHAs) and community health volunteers (CHVs) actively escort patients to these services. These are high numbers of undiagnosed patients and unattended to mental health services from what we learned from our engagement. The numbers that are seen can quickly become a source of strain given that very few health care providers offer these services.
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Support
The Kangemi Health center has been receiving external funding from Afya Jijini (USAID), Aids Healthcare Foundation (Japan), Malteser, Jhpiego, Kamili Organization, and the national level support from the Nairobi City County and the Ministry of Health (MOH). The Kariobangi Health center similarly has been receiving external funding support from Afya Jijini (USAID), AIDS Healthcare Foundation (Japan), Concern Worldwide, MSF (France), and the national level support from Nairobi City County and the Ministry of Health. Community mental health expertise is offered from both the Mathari National Training and Referral Hospital and Kamili Organization, an NGO specializing in training nurses in mental health care for outpatients. Many of these services combined integrated sexual and reproductive health services, youth-focused and mental health services.
Systemic Barriers
I. Lack of Integrated Services
While discussing barriers on a systemic level, participants identified a lack of integrated services as a hindrance to improving mental health outcomes. Staff conveyed various resource and infrastructure challenges such as:
“- okay like the-the-the integration of family planning you know previously family planning-family planning-we have family planning room in outpatient so our clients we used to send them there so they integration is not a bad thing of family planning it is good since our clients will not queue again you know but the room is not-is not convenient to provide the service like you see we don’t have water, we don’t have sink yes, so hygiene is an issue and we don’t have a couch as you can see for you to give an implant you have to-the patient has to be on bed on a couch so it limits-it limits our capacity to-to provide the service so you see the management will take it as if we are rejecting or we are rejecting the change but it is- it is not-they have to act on those things before we go ahead because we are only giving injection and if you talk to a client and she decides that she wants implant you know you will not convince them that let me give an injection because that is what I can give I told them I will just be sending them until we do one two three things [some silence] but it is a good thing [some silence].”…… “The other policy is for the-the-the CCC and PMTCT to give drugs, pharmacy is incorporated in our [laugh].” Female Nurse, KG
Another provider described how implementing integrated medical services within healthcare would be vastly significant:
“Integration is when we incorporate mental health care into all service points like when someone comes to my clinic he/she is able to be screened for mental health and just the same way we are doing with TB as in every work station somewhere even from the gate the soldier can screen and know that this is a person with depression or stress or what and they may be able to assist them in a way or another. So that is the integration that-that mental health that someone-any client is able to be screened for mental health issues at every workstation facility”. Reason “Yes, because previously people used to feel like mental health is-they used to stigmatize the mental health and they used to attach it to people who are mad they are in Mathari but mental health issues start from- as in with us even us the health care workers could be struggling with mental health issues and we transfer them to our clients, so it is very important when from really primary health care everyone is so conscious about their own mental health so that even as they take care of clients, they are sober and they give quality care and just to protect them from those clients from having bigger issues of mental health like depressions.” Female Nurse, KG
II. Lack of Support
Another area of concern was the lack of support for mental health services. Below, participants mention the need for more significant support from partner and donor agencies:
“it’s my prayer that the partners they have on board may implement because most of these health partners who come on board they are either on a research or maybe they are just passing by for one or two issues then they end the support. It is my prayer that if we may get more of the support and also if they can impart more knowledge to the health providers given the different clinics I think this may be of help, because I may attest as a person that since you came on board I am able to serve my clients better than I was previously. So I would like also maybe the same knowledge to be imparted to the other health providers and we may see ways of sustaining the same just by the knowledge, if you give us a lot of knowledge we may look for ways of sustaining the same services in this clinic and for the benefit of our clients; as I know most of our clients as we interact with them we see that they have issues that really need to be sorted out and I think this is one of the areas where we meet like every other person in the community; here in the health center, yes. But thank you very much for the much that you have done “- -Female HCW, KG
III. Privacy Concerns
Many healthcare workers highlighted issues of privacy and feeling that their facility lacks appropriate visual and auditory privacy:
“Yes. We lack- I think in terms of rooms and because sometimes you just find that the counselor is outside with a client talking so you know even for the-for you to capture the concentration of that client is a challenge, because the client may see somebody whom he/she knows at stares at him/her so and you need a quiet room and also privacy and confidentiality of a client is very important” Male Nurse, KR
“We need a room, a permanent room for psychiatric clinic, with all the drugs stored there with a permanent staff there specifically to deal with psychotic patients and psychotic issues” Male Nurse, KR
a) Social Barriers
I. Culture and Stigma
Participants also talked about social barriers in terms of cultural beliefs and stigma surrounding mental health that need to be urgently addressed. One nurse expressed difficulty addressing mental disorders to a patient with a different cultural belief:
“Because there are some cultures where people don’t even go to hospital when they are sick; they believe in prayer. So such like when you meet such a patient it will be hard to convince this client to come to the facility because he has a belief that if a t all he can be prayed for he will be healed. In attitude you know there are those staffs who normally take that in psychiatry we are dealing with mental issues, it can just be a minor medical issue or a major or something you can handle even not using drugs, something you can come maybe talk with the patient not a must he or she ends up taking drugs …These beliefs you know most of the youths they have that mentality that when you are stressed you end up using drugs that it reduces stress; something like that. When you have family issues maybe with your wife and you have an issue you end up taking drugs or alcohol so that you feel like you are relieved” Male Nurse, KR
b) Individual Barriers
I. Attitudes and Behavioral Issues in HCWs
The first barrier that health facility workers identified has to do with their jobs. HCWs described that a change in provider attitude and behavior is essential to improving health services. One provider commented on the necessity for change:
“- - we need to change because for example like an adolescent who is having HIV there is still stigma even within the staff members, after the client has come they are like “that girl and the way she is young, where did get HIV from…” Female, HCW, KG
Another provider described how she is already changing her approach towards clients to improve trust levels:
“I must say that to some extent your team has also helped us to realize that some of our attitudes will make the client either to open up or not to open up. So very true and I must say for the last three or so months I am experiencing some changes; now that we have interacted with your team we are able to approach these clients in a better way that will enable them come very close to us as compared to the previous times whereby they could share just a little bit then maybe reserve the major - -.” Female HCW, KG
Other providers shared how good attitudes held by health care workers could positively impact their patients’ outcomes:
“Yes; there has been a good rapport of late and one of the areas, maybe I can point out one area; we have group sessions and during the group sessions we start ourselves by giving our experiences and given the experiences we also allow them the space to come in and share what they think we can do better to help them and this one has enabled clients to open up especially in the groups and for those who seem to be a little bit reserved we have also given them the space on a one on one interaction and things are working better. So it is a plus, for the last three months yes we are seeing different results from the clients and also from the health providers” Female HCW, KG
II. Lack of Training
Only three participants among the two facilities had psychiatric training, with one participant who had a psychiatric diploma. The remaining HCWs reported being exposed to mental health topics back in-school training, yet; all participants equivocally shared that their previous exposure was limited. Below, a nurse describes her work set up and desire to receive further mental health exposure:
‘We would love to learn more about mental health. Basically, most of the people have gone through; like for the nurses and clinical officers they have gone through the basic training on psychiatry. The normal; the basics but there is more into the diagnosis - - so when it comes to knowledge people just; people are not very well acquainted with how to identify early. Mostly we only think the psychiatric people are people who have reached a point where already they are maybe talking to themselves; you can see the psychiatry condition physically. But we are not yet at that level of identifying the psychiatric condition just by interviewing” Female Nurse, KR
A common theme regarding the necessity for more exposure and better education surrounding mental health was stressed throughout various interviews. One nurse describes the importance of integration of services and proper mental health training:
“To integrate the mental health [Silence] I think it is training of staff so that when for example it’s on a Friday and a mental health client comes; I am able to do the counseling, I am able to cater for his problems and in the process if I find that he has another problem I take care of it” Female nurse, KR
Other participants discussed learning new skills that could help them engage with their clients better. Providers echoed a shared struggle to get their clients to open up due to communication barriers that impacted help-seeking behaviors. Below, providers talk about the benefits of having an orientation or classes concerning their role:
“I may say to some extent yes I’ve been given some information though I may not say I am fully baked for the position I believe given a chance probably some orientation or maybe a class or two I may be more empowered to handle the clients, but tentatively basically the knowledge I’ve acquired from your team I believe at this juncture I may be able to look at a client and tell that this client is not in the same mood probably like I saw them in the previous session. I may be able to detect one or two things that may be an indicator that this client needs some mental health care session.” Female HCW, KG
Another participant emphasized adequate training would be able to provide staff with the confidence of providing hands-on support and timely care:
“Okay, maybe just basically I would say refresh a bit and also some little empowerment on the same because there are those who get a little bit reserved so you may not be able to take it out from them. There are those who are a bit adamant; maybe the skill of how to go about it I believe I may need to be orientated on that to be able to get through to this client to open up” Female HCW, KG