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Training lay counsellors to provide psychosocial support to ART users: Lessons learned

Training lay counsellors to provide psychosocial support to ART users: Lessons learned. Ashraf Kagee. The context. In many resource-constrained environments, psychosocial services for users of antiretroviral therapy are often inadequate.

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Training lay counsellors to provide psychosocial support to ART users: Lessons learned

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  1. Training lay counsellors to provide psychosocial support to ART users: Lessons learned Ashraf Kagee

  2. The context • In many resource-constrained environments, psychosocial services for users of antiretroviral therapy are often inadequate. • NGO’s provide many of psychosocial and support services.

  3. A health-enabling community • Campbell (2003): A health-enabling community -- people feel empowered to act upon and take charge of their own health. • Baum (1999): Social capital refers to the level of participation that community members have in local networks and organisations. • It includes interpersonal trust, reciprocal help and support, and a positive local community identity.

  4. ART adherence • Encouraging optimal adherence is an important dimension of HIV care. • ART users have limited access to mental health and psychosocial services. • There are high costs associated with employing professional psychologists, counsellors, and social workers to provide a support system for ART users. • Lay counsellors and patient advocates are a cost-effective alternative in helping to create a health-enabling community for ART users.

  5. Research on lay counselling • Nagel et al (1988): nursing home residents who received services from a lay counsellor had fewer symptoms of depression compared to those who had not. • Neuner et al (2008): trained lay persons to provide narrative exposure therapy to survivors of war trauma in a refugee settlement in Uganda. • Igumbor et al (2011): ART users who received patient advocacy services had a higher proportion of viral load suppression than ART users who did not receive such services.

  6. Research context • Peri-urban area in South Africa • PA’s working under the auspices of an NGO provided psychosocial support to patients receiving ART services at a community hospital. • Main functions of PAs were to: • encourage adherence • accompany patients to ART clinic if necessary • discuss problems with medication taking • help resolve psychosocial problems

  7. Typical problems experienced by patients • Stigma, resulting in having to hide ART medication • Poor access to mental health services • Family problems • Difficult relationships with clinic staff • Lack of privacy for counseling at clinics • Substance abuse • Transport difficulties • Long patient waiting times • Food insecurity • Social discouragers, e.g. some religious leaders discouraging adherence.

  8. Patient advocates • Have minimal training prior to their work as PA’s • Meant to provide an interface between the patient and the health care system • Some are ART users themselves • Receive a small stipend for their activities

  9. Objective • To report on the results of a counselling training programme for lay counsellors. Research questions • Can community members be trained in basic counselling skills? • Is it feasible to conduct training in 8-10 workshop sessions?

  10. Method Participants: • PA’s enrolled in the pilot programme were 8 women who worked under the auspices of an NGO. • Participants ages ranged from 28 to 43; HIV status not disclosed. • Prior to starting their work as PA’s they had received basic HIV counselling training, which by all accounts was limited.

  11. Training • Training involved 9 two-hour didactic workshops focusing on relationship skills, e.g. reflecting, paraphrasing, and summarising, as well as problem-solving, exploring logical consequences, and generating alternatives. • Workshops were presented by a registered psychologist. • Emphasis was placed on practicing individual skills, role-playing, and discussing the ways in which these skills could be applied in the PA’s work with patients.

  12. Assessment • At the end of the training each PA was asked to conduct a mock counselling session lasting 10 minutes with one of the raters, while the others observed the session and rated the PA’s counselling skills. • Four raters were involved in the assessment (3 masters students in clinical/ counselling psychology and 1 doctoral level psychologist).

  13. Assessment • The “client” presented with one of the typical problems experienced by patients. • Counselling task was for the PA to process how the client might negotiate the problem using counselling skills. • Following the role play, all 4 raters were asked to rate the PA’s skills.

  14. Rater Evaluation Form • eye contact • attending posture • reflection of content and feeling • encouraging • paraphrasing • summarising • appropriate questioning • gathering data • setting goals • exploring alternatives • identifying positive assets, etc.

  15. Rater Evaluation Form • 20 item Likert-type scale • Rating was done by the observers • Using a 5 response option: 1 = requires continued training 3 = acceptable level 5 = high level of competence • Total score = 100

  16. Counsellor Rating Form • Sincere Honest • Likeable Warm • Experienced Reliable • Friendly Expert • Empathic Trustworthy • Skilful Prepared • Sociable Easy to talk to • Helpful

  17. Counsellor Rating Form • 3point response option • 15 item instrument • Rating by client • Total score = 75 • Internal consistency: 0.89 (Epperson & Pecnik, 1995)

  18. Table 2: Results of Counselor Evaluation Form analysis

  19. Skills in which PA’s displayed proficiency • Eye contact • Attending posture • Reflection of content • Encouraging • Summarising • Gathering data • Exploring alternatives • Giving directives • Allowing the patient to tell her story • Terminating the session

  20. Skills for which further training was needed • Reflection of feeling • Paraphrasing • Appropriate questioning • Interpretation • Exploring logical consequences • Setting goals • Confronting the patient’s incongruities • Identifying positive assets • Challenging in a supportive manner

  21. Conclusions • PA’s were rated higher on skills that were of a more technical nature than those that required deeper conceptual understandings. • PA’s were able to learn, retain, and demonstrate technical skills with some degree of success. • These are “easier” to repeat after seeing a trainer demonstrate them.

  22. Conclusions • Conceptually complex skills involve greater cognitive processing of what the patient says, generating a higher order of meaning, and providing feedback that is comprehensible, yet reflects the conceptual analysis developed. • For these skills to be mastered, a more sophisticated conceptual apparatus is necessary. • 18 hours of training appeared to be insufficient.

  23. Conclusions • Careful selection of PA’s may be necessary rather than accepting all comers. • On-going monitoring, training, supervision, and mentoring is also necessary.

  24. Conclusions • Can community members be trained in basic counselling skills in 8-10 workshop sessions? • Answer: Yes, but with limited results.

  25. Implications for further research • Need to develop a programme of optimal length and intensity to maximise skill development. • There is a need to identify optimal methods of supervision, monitoring and evaluation of PA skills. • Success of counsellor training should ultimately be measured in terms of its effect on patients, e.g. psychosocial well-being, level of adherence, and QOL.

  26. Acknowledgements • Oliver Fuchs • Trish Blake • Mareli Fischer • Lena Andersen • Phillippi Trust • Medical Research Council

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