History and Background
Woodley clinic is a health facility in Kibera Constituency, Nairobi City County. The clinic is one of the oldest clinics in the city and was started in 1948 by the colonial government as a child welfare clinic for their families. After Kenya got its independence, it became a public facility to serve Woodley Estate community (an estate for elite city administrators).
In 1983 it was upgraded to a health centre to offer extended services. With the development of better estates for the elite in the city, it was handed over to the council to offer services to the general public. The clinic serves a bigger part of Kibera slum. Kibera is the largest urban slum in Sub-Saharan Africa. It is congested with shanty houses and houses a big population of people. Kibera houses almost 1 million people. The slum is inhabited by people of low social economic status, has poor sanitation, and a high criminal rate due to unemployment, commercial sex work and illiteracy. The community living in this slum is cosmopolitan and composed of many tribes with diverse political affiliation, one of the reasons that fueled the post election violence in Kenya. The clinic serves a wide catchment of the slum.
Services offered in this facility are family planning, cervical cancer screening, antenatal and postnatal services, HIV testing and counseling and child welfare clinic services that include immunization, growth monitoring and nutrition counseling. The clinic has six nurses who are government employees.
The post election violence in Kenya after the disputed presidential election in 2007/8 was characterized by rape, forced evictions, assault, malicious destruction of property, theft and retaliatory attacks. According to police reports more than 1500 persons lost their lives and over 200,000 persons were internally displaced. These persons were subjected to homelessness, squalid living conditions, poor health, unemployment and poverty, and had to deal with the brutality of rape and murder. The post election violence saw the burning of wares and merchandise in stores in the biggest market in the slum that was offering employment to many slum dwellers.
Surveys carried in the area thereafter showed an increased number of persons presenting in the health facilities in the area with signs of mental illness and worsening conditions to those who had previous mental illness diagnoses. It is on this premise that Africa Mental Health Foundation (AMHF), the Peter C. Alderman Foundation (PCAF) and the Ministry of Health-MOH (Kenya) formed a collaboration to create a mechanism to offer psychotrauma care to these persons. This was done through establishing a Pyschotrauma clinic at the Woodley clinic to integrate mental health services into its routine services. The goal of the clinic is to meet Peter C. Alderman Foundation’s mission which is to heal the emotional wounds of victims of terrorism and mass violence. It therefore offers care and help to the victims of post election violence in Kibera slum which was one of the areas worst hit by the violence. The clinic is strategically located to ensure easy accessibility by the community members in the area. The Peter. C. Alderman Foundation officially opened the clinic in July 2012 as the first such clinic in Kenya.
The psychotrauma clinic was started to operate on a task shifting model; an innovative model that entails the use of primary health care workers in offering mental health services shifting this role from mental health specialists who are rare in the country. This was aimed at increasing the accessibility, affordability, acceptance and delivery of mental health services in an area where there is a shortage of specialists and without involving costs to these persons. This model integrates mental health services in primary health care services in public health centres and dispensaries.
Dispensaries and health centres are run by enrolled community nurses or registered clinical officers, an equivalent to a physician assistant. This model employs the use of the community strategy. The community strategy was developed five years ago by the Ministry of Health and was aimed at using community health workers (CHWs) in reducing the burden of cholera, malaria and improve the uptake of maternal and child welfare services by the community. Community health workers are high school graduates who have basic training on health matters and operate under a trained enrolled nurse attached to the units called a community health extension worker (CHEW). The community is divided into devolved units called community units each with a number of CHWs. They offer health education, are informed at identification of persons with symptoms and signs of disease and offer appropriate referrals to the health facilities. They thus link the community with the health care workers.
Our psychotrauma clinic is served by a number of CHWs whose main tasks include offering psychoeducation to the community, identify social support for our clients, ensure that our clients have good support from the families and the community at large and ensure that they are accepted by the community and are thus engaged in community activities. They also ensure compliance to the management, do home visits for the clients and appropriately refer clients to the health facilities.
The clinic is being run by a PCAF clinical officer (physician assistant) and social worker assisted by a clinical psychologist and a visiting psychiatrist from AMHF. They screen, diagnose and treat persons with mental illness. They also offer psychotherapy, monitor treatment outcomes, conduct follow-ups and supervise the community health workers.
Other than the referrals from the CHWs, other clients seen at the clinic are either self-referrals, referred by community health extension workers, by nurses working in other departments in sister health facilities or privately owned healthcare facilities in the area.
The clinic receives supplies of psychotropic drugs from Mbagathi District Hospital pharmacy (a district pharmacy that supplies drugs to the health centres) operating on a fixed quota to the health centres.
On arrival to the clinic, clients are registered in the clinic’s general permanent register and then sorting is done. Clients are then sent to various departments in the clinic depending on need of the client. From these departments, clients in need of mental health services are also referred to the psycho trauma clinic. At the clinic the PCAF model is employed and involves taking socio demographic history, psychiatric history, performing mental status examination, filling Traumatic Event Checklist, filling the Self Reporting Questionnaire, filling Harvard Trauma Questionnaire, screening for alcohol dependency and substance use using the CAGE Tool and assessment of functioning. After administering these to the patient a provisional diagnosis is made and management planned according to the diagnosis. A follow up date is then given to the client and drugs dispensed by the clinical officer. A CHW is then assigned to the client for follow up on compliance and with the aim of doing a home visit. Where any difficult arises a psychologist or psychiatrist is engaged.
From January to December 2012 the Woodley clinic registered a total number of 52,380 patients, of those screened 93 were treated in the psycho trauma clinic.
In the first quarter of 2013 (January, February and March) a total number of 196 patients were seen in the psycho trauma clinic with 86 being new clients and 40 ongoing patients.
The psycho trauma clinic is facing inadequate supply of psychotropic drugs. This is because the increasing number of patients comes with a bigger need for these drugs and the fixed quota of drugs supplied from the district pharmacy is inadequate.
Unchanging poverty and unemployment means inability to address basic needs in families resulting in underweight infants. The parents and the infants are psychologically traumatized. This is a stressor that may affect the treatment outcomes. Some of the clients referred may not have bus fare to attend to the clinic as scheduled since they come from a distant location from the clinic.
The political atmosphere that prevailed before the just concluded elections was tense and marred with uncertainty. This affected them psychologically and tension in the election months affected the clients turn out to the clinic.
Due to poor drainage and sanitation in the slum it is difficult to conduct home visits especially in the rainy months of March and April and November and December.
A large number of the relatives are on casual employment and prefer going to work than taking care of the patients or bringing them to the clinic.
A good number of community units in the slum have not yet been covered since CHWs in these units have not been trained.
The PCAF nurse is unable to pay home visits to all the mental health patients attending the psychotrauma clinic due to the distance from where they come from and the clinic due to the poor infrastructure in the slum. There is also a challenge of narrow paths that a vehicle cannot navigate through.
Some of the notable local partners to our clinic are;
• Africa Medical Research Foundation (AMREF) which hosts a rehabilitative centre for the rescued street children, Joseph Kang`ethe Social Home for the street children.
• Medicine San Frontiers (MSF) – Belgium who have two rescue centers in the larger Kibera slum for the victims of sexual assault and domestic violence.
• Maryland University who are involved in cancer screening by providing the required equipments and reagents and have employed a case manager for HIV/AIDS mothers and children. She is also in-charge of support groups who normally meets on a monthly basis.
• There is positive and increasing trend on the number of clients seen in the client since its inception
• Community health workers and community health extension workers are increasingly playing a vital role in community mental health since their training and inception of the model.
• There is increasing willingness of other nurses and community health workers to get similar training as those already trained, a number that can be instrumental in covering the entire region.
• There is improved reporting and data collection.
• Recruitment and re-training of community health workers has eased follow up and integration of persons with mental illness into the community which is vital in improving treatment outcomes of persons with mental illness
• There has been a reduction in stigma and discrimination due to community outreach services and health talks which has also increased the number of persons seeking services at the clinic.
• A regular dialogue meeting between community health workers and the provincial administration represented by the area chief has helped in addressing issues of mental health and drug abuse through public gatherings (barazas).
• In our current setting the psychotrauma clinic sees a good number of patients with HIV cormobidity. Some of them acquired HIV through sexual assault during the post election violence after the disputed elections of 2007/8 or through commercial sexual work due to widespread unemployment. HIV services are also offered at the clinic.
• Increase the number of patients attending the clinic to 500 per quarter since the region is very expansive and highly populated and not fully covered.
• To have at least one of our neighboring health centres in full operation as per PCAF guidelines.
• Engage the neighboring health district so that they can fully incorporate provision of mental health services in their routine primary health care activities as part of trying to cover the entire slum.
• To engage a wider area served by community health workers other than that covered by our District to ensure a bigger coverage.
• Engage more partners dealing with health issues in the slum so that they can smoothly refer more clients to our clinics
• Engage partners dealing with socioeconomic empowerment in this area so that they can assist our clients in formation of self help support groups so that our clients can engage in income generating activities like garbage collection, car wash services, embroidery e.t.c to reduce the burden of poverty in our clients- seen as one of the factors that could be affecting our treatment outcomes
• We have four other large slums in the city in addition to the Kibera slum, Korogocho, Mathare, Kangemi and Mukuru kwa Njenga. It is also worth noting that similar circumstances that occurred in Kibera occurred in these slums and that many psychotrauma patients may be living in these slums. Mukuru kwa njenga is special in that it is also situated next to a oil pipeline which had fuel spill in 2011 and more than 100 people died and more than 120 people survived with severe burns. A significant number lost their livelihoods and homes. These persons may benefit from this model and its expansion to cover them may thus be very helpful.