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Department of Psychology Faculty of Arts and Social Sciences Training lay counsellors to provide psychosocial support to ART users: Lessons learned Ashraf Kagee

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The context In many resource-constrained environments, psychosocial services for users of antiretroviral therapy are often inadequate. NGOs provide many of psychosocial and support services. 2

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A health-enabling community Campbell (2003): A health-enabling community -- people feel empowered to act upon and take charge of their own health. Baum (1999): Social capital refers to the level of participation that community members have in local networks and organisations. It includes interpersonal trust, reciprocal help and support, and a positive local community identity. 3

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ART adherence Encouraging optimal adherence is an important dimension of HIV care. ART users have limited access to mental health and psychosocial services. There are high costs associated with employing professional psychologists, counsellors, and social workers to provide a support system for ART users. Lay counsellors and patient advocates are a cost- effective alternative in helping to create a health- enabling community for ART users. 4

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Research on lay counselling Nagel et al (1988): nursing home residents who received services from a lay counsellor had fewer symptoms of depression compared to those who had not. Neuner et al (2008): trained lay persons to provide narrative exposure therapy to survivors of war trauma in a refugee settlement in Uganda. Igumbor et al (2011): ART users who received patient advocacy services had a higher proportion of viral load suppression than ART users who did not receive such services. 5

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Research context Peri-urban area in South Africa PAs working under the auspices of an NGO provided psychosocial support to patients receiving ART services at a community hospital. Main functions of PAs were to: -encourage adherence -accompany patients to ART clinic if necessary -discuss problems with medication taking -help resolve psychosocial problems 6

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Typical problems experienced by patients Stigma, resulting in having to hide ART medication Poor access to mental health services Family problems Difficult relationships with clinic staff Lack of privacy for counseling at clinics Substance abuse Transport difficulties Long patient waiting times Food insecurity Social discouragers, e.g. some religious leaders discouraging adherence. 7

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Patient advocates Have minimal training prior to their work as PAs Meant to provide an interface between the patient and the health care system Some are ART users themselves Receive a small stipend for their activities 8

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Objective To report on the results of a counselling training programme for lay counsellors. Research questions Can community members be trained in basic counselling skills? Is it feasible to conduct training in 8-10 workshop sessions? 9

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Method Participants: PAs enrolled in the pilot programme were 8 women who worked under the auspices of an NGO. Participants ages ranged from 28 to 43; HIV status not disclosed. Prior to starting their work as PAs they had received basic HIV counselling training, which by all accounts was limited. 10

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Training Training involved 9 two-hour didactic workshops focusing on relationship skills, e.g. reflecting, paraphrasing, and summarising, as well as problem- solving, exploring logical consequences, and generating alternatives. Workshops were presented by a registered psychologist. Emphasis was placed on practicing individual skills, role- playing, and discussing the ways in which these skills could be applied in the PAs work with patients. 11

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Assessment At the end of the training each PA was asked to conduct a mock counselling session lasting 10 minutes with one of the raters, while the others observed the session and rated the PAs counselling skills. Four raters were involved in the assessment (3 masters students in clinical/ counselling psychology and 1 doctoral level psychologist). 12

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Assessment The client presented with one of the typical problems experienced by patients. Counselling task was for the PA to process how the client might negotiate the problem using counselling skills. Following the role play, all 4 raters were asked to rate the PAs skills. 13

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Rater Evaluation Form eye contact attending posture reflection of content and feeling encouraging paraphrasing summarising appropriate questioning gathering data setting goals exploring alternatives identifying positive assets, etc. 14

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Rater Evaluation Form 20 item Likert-type scale Rating was done by the observers Using a 5 response option: 1 = requires continued training 3 = acceptable level 5 = high level of competence Total score = 100 15

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Counsellor Rating Form SincereHonest LikeableWarm ExperiencedReliable FriendlyExpert EmpathicTrustworthy SkilfulPrepared SociableEasy to talk to Helpful 16

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Counsellor Rating Form 3 point response option 15 item instrument Rating by client Total score = 75 Internal consistency: 0.89 (Epperson & Pecnik, 1995) 17

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Counselor Evaluation Forms Total Scores (out of 100) CRF Total Scores Rater 1Rater 2Rater 3Rater 4Total Ave % Client rating Counselor 1 71686920869.3 51 Counselor 2 36484913344.3 60 Counselor 3 50534815150.3 47 Counselor 4 55657319364.3 63 Counselor 5 58716119063.3 56 Counselor 6 54645116956.3 64 Counselor 7 64415015551.6 35 Counselor 8 52605716956.3 29 Mean % 57 50.6

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Table 2: Results of Counselor Evaluation Form analysis 19

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Skills in which PAs displayed proficiency Eye contact Attending posture Reflection of content Encouraging Summarising Gathering data Exploring alternatives Giving directives Allowing the patient to tell her story Terminating the session 20

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Skills for which further training was needed Reflection of feeling Paraphrasing Appropriate questioning Interpretation Exploring logical consequences Setting goals Confronting the patients incongruities Identifying positive assets Challenging in a supportive manner 21

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Conclusions PAs were rated higher on skills that were of a more technical nature than those that required deeper conceptual understandings. PAs were able to learn, retain, and demonstrate technical skills with some degree of success. These are easier to repeat after seeing a trainer demonstrate them. 22

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Conclusions Conceptually complex skills involve greater cognitive processing of what the patient says, generating a higher order of meaning, and providing feedback that is comprehensible, yet reflects the conceptual analysis developed. For these skills to be mastered, a more sophisticated conceptual apparatus is necessary. 18 hours of training appeared to be insufficient. 23

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Conclusions Careful selection of PAs may be necessary rather than accepting all comers. On-going monitoring, training, supervision, and mentoring is also necessary. 24

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Conclusions Can community members be trained in basic counselling skills in 8-10 workshop sessions? Answer: Yes, but with limited results. 25

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Implications for further research Need to develop a programme of optimal length and intensity to maximise skill development. There is a need to identify optimal methods of supervision, monitoring and evaluation of PA skills. Success of counsellor training should ultimately be measured in terms of its effect on patients, e.g. psychosocial well-being, level of adherence, and QOL. 26

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Acknowledgements Oliver Fuchs Trish Blake Mareli Fischer Lena Andersen Phillippi Trust Medical Research Council 27