Community interventions done by community health workers

People reach their full potential for good health and well-being with good nutrition, shelter, access to health services and a clean environment.

The ability to make decisions , take responsibility, cope, socialise and have caring relationships, have an impact on health and well-being, as well.

Individuals, families or communities in a crisis, without the latter support, find it difficult to cope.

Therefore, when crisis are not dealt with soon they evolve into situations where families and communities feel overwhelmed.

Very often institutionalisation is a harsh and cruel solution but often resorted to simply because early help was not sought or given.

If the skills and the ability to access services and resources are strengthened among individuals, families and communities, it is possible to provide far more effective and humane responses to crises.

What is COPING?

It’s trust in oneself and others.

This is imperative in countries such as Sri Lanka where the provision of services and infrastructure, as well as access to them, are limited.

How and what is done

Community health workers work in residential places and far afield. This type of reaching out is compulsory. 

The reason why is for the community health workers to learn how to build relationships with people in the community.

They do 6 months initial training and are paid during this period and given accommodation, food and transport.

This period gives the trainee and the employer time to assess each other - like a probation period.

Senior Community Health Workers, those who have worked for more than 3 years,  are also responsible for management and administration.

While some staff may have more administrative and managerial responsibilities, they also have to attend the on-going training periods.

Good examples are Sanjaya Paul who joined Nest in 1991, Sisira and Priyanganie Malkanthi, 12 years ago, Priyanthe Gunasinghe, 12 years ago, Maria Lambert, 3 years ago, Wasanthie Gunewardena, 4 years ago, and Kumari Jayasekere, 14 years ago. They all joined as trainees.

Today Sanjaya is Director Devclopment; Priyantha, Maria, Kumari, Madushi, Manel, Sepalika and Sisira are Managers.

The Occupational Therapy centre doesn’t have a Manager but works as a Team and each day a member of the team is leader.

Training is conducted by different resource persons representing different professions such as Law, Social service, Psychiatry, Psychologists, Speech Therapists, Artists, Accounts, etc. spending time with the staff at Kare House once a month.

The range of issues that community health workers identify and work with differ from location to location. Each district in Sri lanka has its own set of customs, traditions and beliefs.

However, the fundamental questions that they try to address are to prevent cruelty, sadism, marginalisation and institutionalisation.

They are also trained to identify situations where potential psychosocial difficulties may arise. Therefore, their role is not only to provide support but to promote psychosocial wellbeing.

Programmes are carried out with people in the psychosocial field and related areas such as Public Health Midwives, teachers, health care workers, religious leaders, and service providers. At a programme they are taught to understand the psychosocial dimension within their own work and to intervene as necessary.

The kind of interventions

They range from providing care to a terminally ill person, helping a family gain the skills that are necessary to cope with a crisis, working in an institution to ensure better care for residents and to support their reintegration into the community, provide alternatives to institutionalisation, and formal and informal educational activities.

Community Health Workers are able to decide on the type of intervention or the range of interventions needed for a particular situation. While the nature of the situation may mean that they have to make decisions individually they also work as a team.

Interventions in Institutions

Long-term institutionalisation seriously affects an individual’s growth, development and happiness. It atrophies their natural skills. Institutions are baording schools, Children’s Homes., Homes for the elderly, Certified School (which are residntial), detention Homes, and mental hospital (for long term psychiatric care).

Unfortunately, the social and health services in Sri Lanka have a bias towards institutionalisation or institutionalised ways of providing services which may be quite harmful.

This is especially evident in psychiatric services and child protection services. This results in the long term institutionalisation of people in hospitals and homes, sometimes even for life.

Nest works to minimise the effect of institutionalisation within these institutions. It helps children and adults to leave the institutions and to prevent people wherever possible from entering the institutions.

Methodology & how to interact with people

Nest visits institutions, hospitals, institutions for children, schools in the districts it works in.

It works with the relevant authorities such as health workers, Probation and Child Care workers, Child Rights Promotion Officers, social service workers to create an environment within the institution that would not hinder the growth and development of people.

Also, to maintain their links and relationships with the communities and families they come from.

Whenever possible, people are supported to return to their communities.

In order to facilitate the return to community, especially for people who have been in long-term psychiatric care, Nest has halfway homes where residential facilities are provided for people to help them to regain life skills they have lost or forgotten while institutionalised.

These life skills include those necessary to participate in daily life, ability to care for oneself and interpersonal skills.

Community Development

The community workers will continue to strengthen service provision and the quality of care in the social services sector.

Special emphasis is given to psychosocial services. They will also work on challenging discrimination, ostracisation, prejudices, institutionalisation, stigma, and negative attitudes, which prevent women, families and communities from receiving a stable and healthy lifestyle.

a. Nest is promoting the advantages of providing community mental health care that involves families and is linked to a range of support systems in the community, so that individual dignity is maintained and community links strengthened.

b. Nest is promoting the advantages of community mental health care and treatment, which will reduce the disrupting of family life and individuals freedom, when communities are encouraged to empower themselves with information on treatment, and caring facilities in their own locality/community/family.

c. National, environmental resources are used positively and not in a way which can promote negative habits and an unhealthy lifestyle.

d. Women with HIV are sometimes sent to hospital and it is then a huge job for Nest to empower the women, and to sustain their economic, social and psychological state.

Where Nest meets the Community

• Families and communities in selected Divisional Director of Health Service areas in 6 districts, with special focus on women and children
• Individuals and their families receiving care in institutions such as hospitals with attention to long term psychiatric hospitals for women (Unit 2 of Mulleriyawa Mental Hospital), children’s homes, detention homes for children and rehabilitation centres for children
• Service providers, students and decision makers in the field of psychosocial service provision such as Public Health Midwives, doctors, nurses, medical students, trainee nurses, teachers, social protection workers, Probation Officers, Child Rights Promotion Officers.

Social protection

Sri Lanka ’s social protection mechanisms have a welfare, charity and top down approach.

Within this environment, support services for crisis situations are limited. The services that are available tend to be bureaucratic. Very often, women and children are the main victims of this approach as they are often overlooked.

Some non-state interventions too tend to undermine local resilience and cultural systems, creating dependency and imposing, non sustainable activities. This approach has increased after the tsunami.

There is a deep need for local, community based networks that have experience and understanding of local situations and culture that can work with communities.  It is also important to ensure that local resilience and coping mechanisms are not undermined and weakened.

It is becoming increasingly difficult for such networks to survive, given the volume of resources and outside expertise that is currently being poured into the country.

Nest’s programme has the advantage of having established relationships with communities and state institutions with over 21 years of experience and history in the field.

It is vital that Nest continues to be present in communities and that it keeps pushing its approach that stresses local understanding of experiences, local solutions and focussing on resilience and strength rather than vulnerability and hopelessness.

Training

Nest’s training of community health workers is conducted in the areas of development, environment appreciation, communication, hospital care, community care, reproductive rights and family interactions.

The training draws equal attention to women working alongside men.

They will live and work in a residential district centre away from home. This is to prevent families interferring with their offspring and also when working in one’s own family area favouritism cant begin. This concept was unheard of culturally when Nest began in 1987 .

Women usually bear the major burden of care-giving in families and communities . As a result, Nest emphasises working with women in order to strengthen their coping skills.

At the same time, Nest works changing the behaviour of men, so that the responsibilities are shared equitably between women and men.

It is important that the attitudes, practices and behaviour of men are challenged in order to make the situation of women better.

Every centre has a Manager who has amongst his many reponsibilities the cash impress. His/her function is as a role model. He/she takes initiative and makes decisions with responsibility, and in turn this is conveyed to the families in the community.

Many women are managers and where there are young girls in the community we have found that they are not shy to visit the centre and discuss their issues.

Empowerment of women is not only for people affected by mental health and psychosocial issues, but also considered to be important for the organisation.

An idea of approximate numbers in some institutions

1. There are 740 women at Unit 2’s long term care section of Mulleriyawa Mental Hospital (Colombo District),
2. 250 men in Hendela Mental Hospital long term care (Gampaha District),
3. 150 children in the SOS village in Moneragela District
4. 60 men and women in Hendela Leprosy Hospital (Gampaha District).
5. Boys and girls in a Detention Home in Hikkaduwa ( Galle district) 165.
6. Number of families Nest works with directly in most districts is 150 and indirectly 2000. Taking indirect and direct numbers together, Nest is in touch with 95,000 people per year, of which 64% approximately are female, and 10,000 of them are in regular contact.

Geographical Areas where Nest works

Anuradhapura District; Colombo District; Galle District; Gampaha District; Krunegela district; Moneragala District; Kandy District.