“Like a doctor, like a brother”: achieving competence amongst lay health workers delivering community-based rehabilitation for people with schizophrenia in Ethiopia

Asher, Laura; Birhane, Rahel; Teferra, Solomon; Milkias, Barkot; Worku, Benyam; Habtamu, Alehegn; Kohrt, Brandon A.; Hanlon, Charlotte

Abstract

Background
There are gaps in our understanding of how non-specialists, such as lay health workers, can achieve core competencies to deliver psychosocial interventions in low- and middle-income countries.

Methods
We conducted a 12-month mixed-methods study alongside the Rehabilitation Intervention for people with Schizophrenia in Ethiopia (RISE) pilot study. We rated a total of 30 role-plays and 55 clinical encounters of ten community-based rehabilitation (CBR) lay workers using an Ethiopian adaptation of the ENhancing Assessment of Common Therapeutic factors (ENACT) structured observational rating scale. To explore factors influencing competence, six focus group discussions and four in-depth interviews were conducted with 11 CBR workers and two supervisors at three time-points. We conducted a thematic analysis and triangulated the qualitative and quantitative data.

Results
There were improvements in CBR worker competence throughout the training and 12-month pilot study. Therapeutic alliance competencies (e.g., empathy) saw the earliest improvements. Competencies in personal factors (e.g., substance use) and external factors (e.g., assessing social networks) were initially rated lower, but scores improved during the pilot. Problem-solving and giving advice competencies saw the least improvements overall. Multimodal training, including role-plays, field work and group discussions, contributed to early development of competence. Initial stigma towards CBR participants was reduced through contact. Over time CBR workers occupied dual roles of expert and close friend for the people with schizophrenia in the programme. Competence was sustained through peer supervision, which also supported wellbeing. More intensive specialist supervision was needed.

Conclusion
It is possible to equip lay health workers with the core competencies to deliver a psychosocial intervention for people with schizophrenia in a low-income setting. A prolonged period of work experience is needed to develop advanced skills such as problem-solving. A structured intervention with clear protocols, combined with peer supervision to support wellbeing, is recommended for good quality intervention delivery. Repeated ENACT assessments can feasibly and successfully be used to identify areas needing improvement and to guide on-going training and supervision.

Citation

Asher, L., Birhane, R., Teferra, S., Milkias, B., Worku, B., Habtamu, A., …Hanlon, C. (2021). “Like a doctor, like a brother”: achieving competence amongst lay health workers delivering community-based rehabilitation for people with schizophrenia in Ethiopia. PLoS ONE, 16(2), Article e0246158. https://doi.org/10.1371/journal.pone.0246158

• Journal Article Type: Article
• Acceptance Date: Feb 12, 2021
• Online Publication Date: Feb 25, 2021
• Publication Date: Feb 25, 2021
• Deposit Date: Feb 22, 2021
• Publicly Available Date: Feb 25, 2021
• Journal: PLoS ONE
• Electronic ISSN: 1932-6203
• Publisher: Public Library of Science
• Peer Reviewed: Peer Reviewed
• Volume: 16
• Issue: 2
• Article Number: e0246158
• DOI: https://doi.org/10.1371/journal.pone.0246158
• Keywords: General Biochemistry, Genetics and Molecular Biology; General Agricultural and Biological Sciences; General Medicine
• Public URL: https://nottingham-repository.worktribe.com/output/5344767
• Publisher URL: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246158