Training in the management of post-traumatic stress disorder in Uganda.

The aims of this study were to establish the feasibility and effectiveness of training Ugandan mental health workers in the management of post-traumatic stress disorder (PTSD) based on guidelines from the UK National Institute of Health and Clinical Excellence (NICE). The Butabika Link is a mental health partnership between the East London Foundation NHS Trust (ELFT) and Butabika National Psychiatric Referral Hospital, Kampala, Uganda, supported by the Tropical Health Education Trust (THET), and based on the recommendations of the Crisp report (Crisp, 2007). The Link has worked on the principle that the most effective partnership between high-income and low- or middle-income countries is through organisations already delivering healthcare, that is, through the support of existing services. Butabika Hospital is a centre of excel-. Butabika Hospital is a centre of excellence, serving an entire nation of 30 million people, many of them recovering from 20 years of armed conflict that took place mainly in the north of Uganda. In addition, Uganda has received refugees from conflicts in neighbouring states, including Congo, Rwanda, Kenya, Sudan and Burundi. The Ugandan Ministry of Health's Strategic Plan (2000) has prioritised post-conflict mental disorders and domestic violence, which is reflected in the vision of the Link's work.

Epidemiological data on PTSD in Uganda are scarce, though specific studies in war zones suggest a prevalence rate of 39–44% (Boardman & Ovuga, 1997; Ovuga et al, 1999, 2008; Liebling-Kalifani et al, 2008).

This paper describes how the East London and Ugandan trauma teams planned, delivered and evaluated a staff training programme in Butabika.

Method

The London team emailed training slides to Butabika staff. These included an introduction to a neurological model of traumatic memory (Brewin, 2001), trauma-focused cognitive– behavioural therapy (CBT) (Ehlers & Clark, 2000) and our own work with interpreters (d’Ardenne et al, 2007). THET provided training in the evaluation of partnership projects in June 2007 and also provided a third of the team’s travel costs.

The London team arrived in September 2007 and spent 2 days with the Butabika staff for a briefing and to meet staff working with traumatised patients. The hospital has access to selective serotonin reuptake inhibitors (SSRIs) and CBT-trained psychology trainees from Makerere University. Training priorities were agreed with the executive director of the hospital, the consultant psychiatrist, the lead nurse in trauma and other clinical staff. Managers agreed to release clinicians for 4 days’ training and ongoing time for further reading, supervision and trauma-related practice.

There were two key aims of the training:

to establish its feasibility – whether it would be possible to arrange workshops for the numbers and range of staff at Butabika

to establish its effectiveness – whether it would increase professionals’ ability to recognise and diagnose PTSD, and whether local clinical practice for PTSD patients would change.

Workshops were devised to cover:

first principles of PTSD

evaluation of trauma work

child abuse

psychological treatments of PTSD in adults

psychological treatments of PTSD in children

grounding exercises with PTSD patients – theory and practice

dual representation model of traumatic memory

identification of ‘hot-spots’ and revisiting traumatic memory

case discussion of child soldiers and the management of aggression

psychological effects of war on children

group therapy with traumatised adults

working with interpreters and PTSD.

Four morning workshop sessions were advertised. The format was interactive, with slides, group exercises, role-plays, plenary feedback, discussion and written exercises. Three 90-minute workshops were held per morning, with breaks. Afternoons were spent on feedback, case-note audits and preparation. Forty-one mental health staff attended two or more workshops, including psychiatric nurses, occupational therapists, psychologists, counsellors, psychiatrists, trainee paediatricians and psychiatric clinical officers.

A written quiz was given at each workshop to clarify trauma experience and understanding. Participants were given evaluation sheets including a five-point Likert scale with these questions:

How understandable was this workshop to you?

How helpful was this workshop to you personally?

How relevant was the workshop to your clinical practice with traumatised patients?

What else would you have liked to learn?

The evaluations were scored and discussed, and training was adjusted accordingly. Clinical log-books were distributed to record ongoing changes in clinical practice with PTSD patients. General psychiatric staff identified group projects for their PTSD patients.

Results

A large majority of the participants (80%) reported increased confidence in recognising trauma. Outcome scores improved as the training progressed (Table 1). For example, on day 1, 25% of participants could name all PTSD symptoms by DSM–IV criteria and by day 4 this increased to 100%.

Table 1

Trainee outcome: mean item ratings on a 5-point Likert scale (n = 18–40 for attendance at individual workshops)

	Day 1	Day 2	Day 3	Day 4
How helpful was this workshop?	3.2	3.2	4.0	4.2
How relevant was this workshop?	4.6	4.3	4.9	4.8
How understandable was this workshop?	2.0	2.5	3.0	3.9

0 = not at all; 5 = completely.

Ward groups for PTSD patients were identified to help rape victims, survivors of floods, war-affected children and survivors of childhood sexual abuse. Examples of written feedback, taken from clinical logs and from workshop forms, were published in a THET report in October 2007. Before the training, interventions for these patients were either non-existent or they were given supportive counselling. An education programme for carers was established to inform them of the meaning of intrusions, avoidance and hyper-arousal.

Training was followed by further requests for training, reading materials, online supervision and exchange visits. Staff undertook evaluation of their trauma interventions and recorded this in case notes or clinical logs, as reported by the trauma manager.

A strategy has been developed to use the unit as a centre that trains trainers, who will be able to reach rural communities unable to access a national centre. The unit will use psychiatric clinical officers already working across the 16 districts of Uganda to complete and evaluate its training as the next stage of work.

Discussion

The aims of this study had been to establish the feasibility and effectiveness of training Ugandan mental health workers in the management of PTSD. The Ugandan team requested a Western training and clinical model for severely traumatised patients already in their care.

A PTSD training programme was devised rapidly that could engage significant numbers of clinicians working across mental health settings. Role-play and demonstrations were valued, as were presentations of local cases. Comprehension, utility and relevance improved with time, although data on reliability were affected by extreme ratings at the ends of the scales. London pronunciation, speed of speech and reliance on psychological jargon were quickly altered on feedback from participants.

Training involved cross-cultural and mutual learning. The London team learned how to phase work, about how limited resources can be built up, and about community approaches involving village elders in the rehabilitation of traumatised boy soldiers.

The study had many limits. It was very brief and small, and the training needs of a national referral centre considerably exceeded resources. But it provided hope as a first step and this was acknowledged, with a plan for sustainable training over future years and further exchanges, which continue today.

It is feasible to train mental health staff in Uganda to diagnose and refer PTSD patients. The effectiveness of the training was demonstrated but it will require ongoing evaluation for real and sustained development.

Dedication

This study is dedicated to the memory of Dr James Walugembe, who died shortly after completing this paper and whose work inspired this training.