The courses aimed to promote the skills and knowledge of participants on identification, support of children and families with mental health problems and to develop their self-confidence and leadership skills.
Successive Evaluation
A comparison of data across different points in time within the same setting provides feedback about whether or not a practice is being sustained in the long term (31). Successive evaluations were directed at the performance of participants and of trainers and on content and the quality of the course program. A set of tools such as tests, structured and semi-structured questionnaires, group discussions and video feedback were used. After each course, objectives and evaluations were compared and resulted in modifications of the next cycle. A precondition for the OSCE approach are local clinical examples. The rhythm how to proceed has to be adapted to the level of expertise of participants. The process appeared slow and was finally successful due to a long-term commitment of partners from both sides. The audit process underlying the course development resulted in a stable concept.
The mental state descriptions of the trainees gradually became more intervention oriented as patient care opportunities to relate specialized and basic care were encountered repeatedly (32, 33). Almost in all of the trainings, implementation of occupational activities needed the biggest effort.
At the conclusion of the first phase of our collaboration, we have published our model of teaching developed for this course (13). The main focus and findings of the paper was mainly on successful implementation of collaborative work to develop and cascade the new model of teaching for child and adolescent psychiatry in Jimma Ethiopia. The current paper however emphasizes about successful continuity and transition from collaborative phase into independent phase to implement teaching and clinical service by the local staff. While the master-program and child psychiatry course in Jimma was running, other experiences on training child mental health were published.
Comparison with other trainings
To compare trainings one has to consider target populations, training methods, hours of training, evaluation and follow up/ outcome.
The Health Education and Training (HEAT) program (integrative program of Open University, UK, with Federal Ministry of Health FMoH, Ethiopia) is used by the Ethiopian government to upgrade rural health extension workers to the level of diploma in Ethiopia. The training component on mental health comprises 10 sessions, equivalent to 2 weeks of fulltime training. One session focuses on child development and child mental health, including a discussion on developmental problems (34). As of 2018, 25,000 health workers have been trained or were in training using the HEAT curriculum. A group of 104 health extension workers were interviewed after a brief training session on child mental health. At follow up four months after the training, 52 out of the participants reported that their knowledge had improved. Fourteen felt that they are able to identify mental health problems in children and 22 felt to be able to provide service. The authors conclude that the training appeared to have some impact on improving knowledge and skills of health care providers (34).
Rural health extension workers in the Southern Nations were trained more extensively by HEAT + for children with developmental disorders. The enhanced HEAT + includes five short video scenarios in English and in Amharic modelling a health extension worker interviewing mothers of children with autism or intellectual disability. In a Randomised Controlled Trial (RCT), the participants of two groups with training and with enhanced training showed fewer negative beliefs and decreased social distancing towards children with autism compared to a group of untrained health extension workers (35).
The International Association of Child and Adolescent Psychiatry and Allied Professions IACAPAP has set up a “Massive Open Online Course essentials of child and adolescent psychiatry across the world” (MOOC). The aim is to enable whoever is interested worldwide to learn most basic notions of common child & adolescent mental health problems (36). Courses are given through online platform for self-study and 4 to 5 themes are treated per week for 5 weeks. The estimated effort is 4 hours per week, with an overall time of 20 hours. Evaluation is done by quiz questions and by open questions and feedback by trainers at weeks four and five. The last step is a week of local personal training. It was not possible to identify any reports on the results of the online training.
Primary school teachers in Nigeria were trained to recognise and handle ADHD symptoms in the classroom. The WHOmhGAP module on behavioural disorders was used in a three-hour session and a booster session in two weeks later. Compared to the control group in the waiting list, the intervention group had higher post-intervention scores on knowledge of ADHD, less negative attitudes towards ADHD and higher scores on knowledge of behavioural interventions (15).
In another setting, family volunteers in Pakistan were trained for support of children with intellectual disability and pervasive developmental disorders from the WHOmhGAP module. The duration of the training through a tablet-based training was 8 days, and the intervention as a whole was for 6 months. Pre and post intervention data from 68 families indicated an improvement in disability and socio-emotional difficulties in the child, reduction in stigmatising experiences and greater family empowerment to seek services and community resources for the child (14).
The concept of the WHOmhGAP training manual is a cascade of training trainers, who train health care providers (37). Trainers will be trained during five days by an interactive teaching approach. Supporting material consists of personal stories, role plays, multiple-choice questions, video links and follow-up. The content of the training is accompanied by a timetable. The section child psychiatry is scheduled for 5.8 hours. Taken together the ten modules of the training last about 46 hours and can be achieved during 5 or 6 consecutive days.
Across all trainings mentioned above, time allocated to child mental health is momentary to have a lasting effect. The evaluation and outcome of the trainings demonstrated that knowledge is accumulated and that there is better understanding of mental health problems in children. However, there is a gap between knowledge and practice. In a teaching pyramid, acquiring knowledge is the first step. The next steps are to have seen, to see and treat patients with guidance and finally to practice. It seems that the strategy to train primary care professionals necessarily needs support and backup from specialists. The National mental health strategy Ethiopia (2012) (5) recommends an intervention pyramid based on primary mental health care with specialist support. The mhGAP-training manual published in 2017 recommends a cascade of training by training trainers. Our approach, which had started in 2010, is quite similar to this approach. Therefore, a comparison of policy and practice is needed. An audit in districts around the City of Johannesburg, South Africa, using a regional health information system, revealed that Community mental health services did not meet any of the norms cited by the Mental Health Policy (38).
For child mental health, cooperation between different systems other than the health system is needed: schools, in broader sense professionals from the educational system, social work and psychology and families and communities. An example of cooperation exists for children with autism. Four types of service providers were identified: clinics, autism centers, schools with inclusive programs and community-based rehabilitation organisations. Most providers are located in Addis Ababa. They cooperate well, however they are inaccessible for the majority of the population in rural areas (39).
Limitations
Several studies in low and middle income countries have indicated similar challenges and barriers in achieving the intended outcome for mental health related trainings. Examples are stigma, lack of competence, institutional constraints and practical problems such as shortages of rooms and child friendly environment in a clinical setting (34, 39–41). The child psychiatry course is one out of 16 courses within the master program. It can be expected that only a few of the participants are motivated to pursue a career in child and adolescent mental health. At a University it is a continuous challenge to find a balance between clinical work, teaching and research. To upgrade their training, some graduates started a PhD program.
However there is a lack of clear and well defined clinical career opportunities in child and adolescent mental health program in the country and in most low and middle income countries, which makes it difficult to continue practical clinical work for the graduates.
Thus the high turnover of staff has to be taken into account. Since the beginning of the master program, three psychiatrists had followed in succession in the role of head of the department. Although distant learning via the internet was offered, restricted access to the internet and constraints of time and motivation due to an overwhelming high burden of workload were limiting factors (42, 43).
In the present project, favourable influences by far predominated. There was continuous support and backup from trainers and students and from Universities on both sides. Mutual understanding and a trusting relationship had developed between trainers. Patient care for children and families was done throughout all courses and is being practiced in the department. The development and implementation of culturally appropriate psychosocial interventions took a long time. We were able to “address the specific kinds of problems, modes of clinical presentations and social predicaments seen in the local population” as suggested by Faregh et al. (2019) (44).