Somalia has a population of 11 265 116 (in 2017), with a total life expectancy of 55 years (WHO, 2015; Worldometers.info, 2017). There are few mental health services in Somalia, which is incongruous to the country's need. Since the outbreak of civil war in 1991, the country has been plagued by conflict and unrest. A huge number of Somali citizens have been subjected to torture, beatings, rape and have suffered life-changing injuries; others will have witnessed such atrocities being committed to loved ones and friends. Many mental health diagnoses can be traced back to substance misuse involving khat, the leaves traditionally consumed in Somalia that are laden with the amphetamine-like chemical cathinone (WHO, 2010). Unsurprisingly, the World Health Organization (WHO) reports that one in three Somalis have been affected by some form of mental illness (this figure exceeds that seen in other comparable low-income countries) (WHO, 2011). Furthermore, a culturally derived lack of understanding of mental illness compounds the issue. Through misconceptions and sometimes antiquated cultural beliefs, people with mental illness are often ostracised, stigmatised and even imprisoned or chained against their will (Hooper, Reference Hooper2013). In fact, between 2000 and 2010, 90% of mental health patients had been subjected to at least one episode of chaining, a practice both ubiquitous and indeed endorsed in many mental health facilities within Somalia (WHO, 2010).
The initial scoping report, conducted in October 2013 (and updated in June 2015), was carried out by Praxis.
Outcomes underlined that an ‘on the ground’ programme would not be feasible in light of the endemic political and security situations precluding the travel of staff to Somalia. Nevertheless, the scoping report felt that teaching and assistance via distance learning remained extremely viable, especially with the improvements in technology and internet access in Somalia.
Praxis identified the work of the King's Tropical Health and Education Partnership (KTSP) as a potential blueprint that Mersey Care National Health Service Foundation Trust (MCFT) could reproduce. KTSP has developed basic psychiatry courses for final year medical students at two partner universities and peer-to-peer learning sessions for both medical students and nursing students (THET, 2002; WHO, 2013).
The programme itself was devised with the help of a three-pronged collaboration between volunteers from MCFT, the Habeb Mental Health Foundation (HMHF) and the UK charity Human Development for Concern for Horn of Africa (HDCHA). The course content was accredited by a core of volunteer tutors. The programme consisted of 12 3-hour sessions delivered fortnightly, with the closing 30 minutes allowing for questions and discussion. The volunteer tutors varied from healthcare assistants to consultant psychiatrists. We developed a short ‘meet-your-tutors’ video which played at the first session (https://youtu.be/2MwRHFKM4g4).
The first session was delivered on 1 October 2015 with sequential sessions provided every 2–3 weeks until its culmination on 17 March 2016. There were initially 48 participants, many of which were from HMHF but also from WARDI Relief and Development Initiatives, Horseed International University, Shifo Hospital, Salaam University, Dr Hawa Abdi Foundation and Shifa Health Science University. The cohort included both Mogadishu residents and those travelling from afar (the furthest being several hundred miles). Three of the male participants were forced to drop out due to their long travel distances and the resulting cost. Similarly, several female participants left the course early because of safety issues, with the late finish times coinciding with night-time journeys home.
Breakdown of course participants
Following the initial loss in participant numbers, 35 individuals remained enrolled in the programme. Four people of this cohort had completed WHO mental health training in 2004, revalidating this in 2009. A number of others had received training through HMHF. Of the 35 participants, there were 19 nurses, 5 nursing assistants, 7 doctors and the remaining participants had other roles.
A baseline survey was conducted at the outset of the programme and results showed that almost half (n = 16) of the participants rated their knowledge of the treatment of mental health problems as poor, 11 participants rated it as OK and merely 8 were confident enough to mark it as good (note that three participants provided no response).
Participants were then asked about the extent to which they felt they were armed with the requisite skills in treating and attending to those with mental health problems. Just 1 of the 35 felt ‘fully’ equipped, with another participant saying ‘mostly’. The majority (n = 17) believed they were ‘partially’ equipped, 13 reporting ‘to a small extent’ and 3 ‘not at all’.
Considering the previous data, it is unsurprising that when participants were asked to rate their confidence in adequately meeting the needs of patients with mental health problems, they broadly fell towards the lower end of the scale: 6 reported being ‘not confident at all’, 9 had ‘not much confidence’, 12 were ‘partially confident’, 6 were ‘mostly confident and just 2 were ‘fully confident’.
Overall, the project garnered extremely positive feedback from the participants and those providing the training. Several interviews were conducted to obtain subjective data on the programme. Interviewees from Somalia included the coordinator, the Director of HMHF and, as participants, one of the nurses and a social worker. Interviewees from Liverpool included the MCFT Clinical Director, Director for Commissioning and the Project Manager.
Dr Mustafa Abdirnaham Ali (coordinator in HMHFH) praised the programme, specifically in relation to the gap it was able to fill within the healthcare system in Somalia, and the very evident value it brought to participants. However, he did feel that securing accreditation in the future would be advantageous in expanding the project. He is quoted as saying:
‘We really appreciate all the efforts Mersey Care staff gone through to put this programme together and make it flexible to support and optimise our learning. I want to commend Mersey Care for their wonderful work and knowledge given to us. I want to also say a big thanks for this opportunity given to us to learn and participate in this pioneering initiative.’
The Director of HMHF was in agreement with the Dr Abdirnaham Ali's comments and he went on to further stress the importance of continuing to improve knowledge and skills of the staff within the Foundation as well as extending the programme to other health workers in the surrounding area.
An unqualified nurse who took part in the programme said:
‘The courses have re-energized me and my approach to diagnosing patients. I am now much more confident and eager to put this knowledge into practice. I feel I now have the understanding to tackle the most difficult patients I'm responsible for.’
A social worker from Shifo Mental Hospital commented:
‘I truly appreciated Mersey Care training staff professionalism, knowledge and patience with the class. I enjoyed the course and found the material very useful in my work. I also liked the presentation style.’
Dr Yasir Abbasi, Clinical Director and Consultant Psychiatrist in Addiction Services at MCFT and the Project Director re-iterated these observations. He was also keen to draw attention to the positive experience the programme provided for the trainers. It demanded that they consider and explore the dilemma of managing mental health patients with minimal resources and funding, a scenario with which they are not faced in their own practices within the UK. He was quoted as saying:
‘As a trainer, it gave me great insight in to trans-cultural practices and their implication on mental health- This has improved my confidence in dealing with and discussing mental health issues with local Somali diaspora whilst being culturally sensitive at the same time.’
Options moving forwards
The principal, and most natural, next step would likely be in furthering the MCFT partnership with HMHF, and facilitating continued distance learning. This would be directly linked to exploring the capacity for establishing a secure, neutral site within southern Somalia in which face-to-face training could be instigated. Furthermore, as suggested by the programme coordinator in Somalia, procuring accreditation would potentially incentivise reluctant participants and act to further raise the public profile of mental health in the country. Finally, such programmes can help give insight into the cultural understanding of mental health problems and possibly help us to evaluate the extent of the psychiatric morbidity within the Liverpool-based Somali diaspora. Research into this area could possibly identify any unmet healthcare needs. If this was the case, plans could then be drawn up to meet these needs.