HIV counselling, mental health and psychosocial care in Thailand

Transcription

1 University of Wollongong Research Online University of Wollongong Thesis Collection University of Wollongong Thesis Collections 2007 HIV counselling, mental health and psychosocial care in Thailand Kathleen Barbara Casey University of Wollongong Recommended Citation Casey, Kathleen B, HIV counselling, mental health and psychosocial care in Thailand, PhD thesis, School of Psychology, University of Wollongong, Research Online is the open access institutional repository for the University of Wollongong. For further information contact the UOW Library:

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3 HIV Counselling, Mental Health and Psychosocial Care in Thailand Volume One A four-study investigation that examines the relationships between recruitment, training, work organisation practices and the psychological health of HIV counsellors and other mental health care providers; and the efficacy of the national response to HIV mental health and psychosocial care. A thesis submitted in the partial fulfilment of the requirements for the award of the degree Doctor of Philosophy from University of Wollongong by Kathleen Barbara Casey, BA, Dip Ed. (Special Education), Dip.Ed. Studies, MA (Psychology) School of Psychology Faculty of Health and Behavioural Sciences 2007

4 Thesis certification I, Kathleen Barbara Casey, declare that this thesis, submitted in partial fulfilment of the requirements for the award of Doctor of Philosophy, in the School of Psychology, Faculty of Health and Behavioural Sciences, University of Wollongong, is wholly my own work unless otherwise referenced or acknowledged. The document has not been submitted for qualification at any other academic institution. Kathleen Barbara Casey 10 November 2007

5 Table of Contents List Of Tables, Figures, Illustrations... iv List Of Special Names Or Abbreviations... vii List Of Foreign Language Terms... ix Abstract... xiii Acknowledgements... xv Chapter 1 Orientation To HIV Infection And Psychosocial Sequelae... 1 Definitions...1 The Natural Course Of HIV Infection- Physical And Psychological Sequelae...1 Conclusion...9 Chapter 2 The Realm Of HIV Counselling The Aims And Objectives Of HIV Counselling...10 The Counselling Context...11 The Activities Of HIV Counselling...12 Conclusion...15 Chapter 3 HIV Counsellor Training In Resource Constrained Settings Key Issues Related To Training Health Workers In The Provision Of HIV Mental Health And Counselling Services...18 Training For HIV Mental Health Service Delivery...20 HIV Psychiatry And Counsellor Training In Thailand...21 Summary...22 Chapter 4 The Impact Of HIV/AIDS Related Work On Counsellors And Other Health Workers Mitigation Of Occupational Stress...43 Conclusion...44 Chapter 5 The Relationship Between Personal Control, Work, Mental And Physical Health Definitions And Concepts...46 Locus Of Control, Mood And Occupational Stress...48 i

6 Locus Of Control, Occupational Stress And Physical Health...49 Locus Of Control, Occupational Satisfaction, Achievement And Burnout...50 Locus Of Control: Socioeconomic And Socio-Cultural Perspectives Chapter 6 Monitoring HIV Mental And Psychosocial Care Programs National Program Evaluation...55 Approaches To HIV National Program Evaluation...56 Monitoring And Evaluation Of HIV Mental Health And Psychosocial Care...59 Development Of Program Indicators For Psychosocial Prevention And Care Programs...62 Conclusion...64 Chapter 7 Introduction To The Research Studies Chapter 8 Study 1: Rapid Appraisal And Response: VCT And Psycho-Social Care Study Background...69 Aims And Objectives...70 Methodology...71 Results...79 Discussion Limitations Of This Study Conclusions Chapter 9 Study 2: An Exploratory Study On The Subjective Experiences Of HIV Counsellors In A Major HIV Testing, Treatment And Care Facility In Thailand Chapter 10 Study 3: The Relationships Between Training, Work Environment, Individual Locus Of Control, And Psychological Well Being Study Background Aims And Objectives Methods The Locus Of Control Of Behaviour Scale (LOC-B) The Thai HIV Counsellors Survey (THCS) Results Discussion Conclusions ii

7 Chapter 11 Study 4: Development And Evaluation Of A Pilot HIV Nurse Counsellor Training Program In Thailand Study Background Methodology Results Limitations Of The Study And Suggestions For Further Research Conclusions Chapter 12 Discussion And Conclusions References iii

8 List of Tables, Figures, Illustrations Table 1.1: HIV and AIDS Estimates... 8 Figure 2.1: HIV counselling within a comprehensive treatment and care model Table 2.1: Common psychosocial and psychiatric problems needing intervention in HIV infected and affected individuals Figure 3.1: Model illustrating the interaction between work environment and individual components leading to mental health effects Table 6.1: Comprehensive evaluation framework Table 8.1: Results of desk audit on policy framework Table 8 2: VCT - Practices acknowledged by hospitals (% of hospitals indicating yes) Table 8.3: Results of HAPS VCT - Practices acknowledged by private hospitals, NGOs and PHA community groups.(% of indicating practices implemented) Table 8.4: Desk audit results of written VCT policy, legislation Table 8.5: Policy implementation acknowledged by government facilities providing care to infected individuals Table 8.6: Practices related to key policy areas related to HIV psychosocial care in Private hospitals Table 8.7: Results from the HAPS Government Survey Counselling service provision by types of patient Table:8.8: Results of HAPS survey-coverage of HIV AIDS services by private hospitals, NGO and PHA groups Table 8.9: Percentage of hospital/health centres replies about room for counselling service.. 95 Table 8.10: Average days taken to inform blood test result by type of hospital Table 8.11: Reported average HIV counselling caseload per day (% Facilities reporting average daily caseload) Table 8.12: VCT services provided by Private hospitals, NGO s and PHA support services Table 8.13: Percentage of hospital/health centre reply about counselling services Table 8.14: Average number of counsellors actively engaged in hospital/health centre by type of presenting problem Table 8.15: Average counsellor client load per day iv

9 Table 8.16: Percentage of government hospital/health centre responding to questions about type of counselling performed in the government hospital/health centres Table 8.17: Type of counselling performed in Private hospitals, NGO ad PHA sector Table 8.18: Percentage of government hospital/health Centres reporting on perceived adequacy of the number of counsellors available to provide HIV counselling services Table 8.19: Percentage of government hospital/health centres reporting about equipment to support work of mental health service Table 8.20: Percentage of government hospitals/health centres reporting counselling staff had received basic course counselling training Table 8.21: Percentage of private hospitals, NGOs and PHA group reporting on courses counsellors had undertaken Table 8.22: Percentage of government hospitals/health centres reporting the following content as included in counsellor training Table 8.23: Percentage of private hospitals, NGOs and PHA group reporting on courses counsellors had undertaken Table 8.24: Percentage of government hospitals/health centres reporting staff had attended continuing education courses in counselling Table 8.25: Continuing education courses undertaken by counsellors in the private hospitals, NGO and PHA organisations Table 8.26: Percentage of government hospitals/health centres reporting on topics staff had undertaken Table 8.27: Percentage of staff government hospitals/health centres reporting received specialist training to manage HIV related psychiatric disorders Table 8.28: Specialist HIV mental health care training in the private and community sector Table 8.29: Advanced counsellor training undertaken by counsellors in the private hospitals, NGO and PHA organisations Table 8.30: Research training in government health services Monitoring, Evaluation and Quality Assurance for HIV Counselling Table 8.31: Program indicators used to monitor VCT and HIV counselling programs Table 8.32: Summary of language capacity of potential trainers Table 9.1: Response categories Issues identified to be significant work related stressors. 150 Table 10.1: Validity data for Thai GHQ v

10 Table 10.2: HIV counsellors by age, gender, marital status and profession and years of counselling experience Table 10.3: Total individual scores on the GHQ Table 10.4: Reasons for failing to take up HIV counselling after having received training Table 10.5: Sample statistics Table 10.6: Sample statistics Table10.7: Sample Statistics for LOTOT and GHQ sub-scales Table 10.8: Correlation results for LOTOT and GHQ-sub-scales Table 10.9: Relationship of LOTOT and sub-scale of QUIT Table 11.1: Quantitative analysis of change in knowledge Table11 2: Participants average perceived level of change in knowledge for key areas of training Table 11.3: Participants average perceived level of change in skill ability for key areas of training Table 11.4: Results for Pre and Post Training Knowledge Assessments Table 11.5: Participants average response scores for key areas of training Table 11.6: Participants average response scores for evaluation of the trainers vi

11 List of Special Names or Abbreviations ACRONYMS ADC ART ARV AusAID CBT CDC CSW DMH EIA ELISA GHQ HAART HAPS HBC HCW HO HIV IEC LOC LOC-B MPH MTCT NGO NNRT NRTI OPTA OI AIDS Dementia Complex Antiretroviral therapy Antiretroviral Australian International Development AID Agency Cognitive Behaviour Therapy Centers for Disease Control and Prevention Commercial sex worker Department of Mental Health,Thailand Enzyme immune assay Enzyme-linked immunosorbent assay General Health Questionnaire Highly active antiretroviral therapy HIV AIDS Psychosocial Care Survey Home-based care Health Care Worker Hypothesis Human immunodeficiency virus Information, education, and communication Locus of Control Locus of Control of Behaviour Ministry of Public Health Mother-to-child transmission Nongovernmental organisation Non-nucleoside reverse transcriptase inhibitor Nucleoside reverse transcriptase inhibitor Office of the Population and Technical Assistance Opportunistic infection vii

12 OVC PCR PCP PHA PLHA PMTCT PPTCT PWA RAR RAR-VCT P&S SE STI TB THCS UN UNAIDS UNICEF VCT WB WHO ZDV Orphans and vulnerable children Polymerase chain reaction Pneumocystis carinii pneumonia People with HIV and AIDS People living with HIV/AIDS Prevention of mother-to-child transmission Prevention of parent-to-child transmission People with AIDS Rapid Appraisal and Response Research Rapid Appraisal Research Standard Error of Measurement Sexually transmitted infection Tuberculosis Thai HIV Counsellors survey United Nations Joint United Nations Programme on HIV/AIDS United Nations International Children's Emergency Fund Voluntary counselling and testing World Bank World Health Organization Zidovudine viii

13 List of foreign language terms khun-ngam khwamdi kilsea maha karunathikkhun decha chaiyen mai pen rai arom dii kreng jai man sai karma samsara moral goodness passion and prejudice highest compassion power calm,easy going contented, nothing really matters ever smiling to be considerate, to feel reluctant to impose upon another, to take another person s feelings ( and ego ) into account, or to take a measure not to cause discomfort or inconvenience for another person mixture of jealousy and disgust ethical causation cycles of rebirth ix

14 Abstract Rationale: International research has demonstrated that in order to retain a skilled and healthy cadre of willing health-workers there is a need to monitor and develop strategies to mitigate adverse impact of this work and improve the quality and effectiveness of client and patient mental health care. Aims: (i) Monitor and evaluate Thailand s national HIV mental health and psychosocial care program. (ii) Measure the impact of HIV mental and psychological care on health care providers. (iii) Examine the relationship between occupation-related psychological morbidity and the recruitment, training, clinical supervision and work-practices of HIV mental health service providers. (iv) Develop, implement and evaluate a training curriculum that addresses the demands of the HIV client population in Thailand. Method: In Study 1, 826 government hospitals, 1000 government health centres, and 1135 non-government organisations and private providers participated in: semi-structured, key informant interviews; focussed group discussions; and criterion-referenced appraisals of health policy and service delivery. Study 2, a small exploratory, qualitative study, utilised a schema of five key stressors commonly associated with HIV care to analyse responses gained from HIV counsellors and employed semi-structured interviews and focussed discussion groups. Study 3, a cross-sectional study, explored the relationship between training, work practices, Locus of Control of Behaviour and the self-reporting of signs and symptoms of psychological distress. 803 HIV counsellors completed a series of questionnaires including the Thai version of the General Health Questionnaire (GHQ-28), the Locus of Control of Behaviour Questionnaire and the Thai HIV Counsellors Survey (THCS). Study 4 involved the development, delivery and evaluation of a series of short courses designed to train 79 health workers to provide HIV counselling. The training was evaluated by pre and post knowledge examinations and anonymous evaluations. Results: Study 1 found that policy and legislation failed to adequately guide the practitioner in a number of key areas including: testing and counselling of minors; testing without informed consent; confidentiality of medical records and disclosure of HIV status; and duty of care in terms of threatened suicide or harm to others. Furthermore, it was found that epidemiological data had not been adequately considered in terms of providing specific psychological support services, and developing counselling curriculum, and that xiii

15 the conduct of Thai based psychological and operations research had been limited. Whilst there was good national coverage of HIV testing counselling services, psychological services to address HIV issues across the disease continuum were limited and frequently provided by individuals without adequate training. There does not appear to be any systematic mechanism for monitoring and evaluating HIV mental health and psychosocial care. This study also revealed that Thailand is limited in its ability to provide adequate HIV field-experienced, trained mental health care personnel who can teach in the necessary languages that would enable sharing of the Thai health sector experience within the region. Study 2: The respondents identified a number of workplace stressors including: fear of contagion; client-professional boundary issues; difficulties with being identified as working in the sphere of a highly stigmatised disease; the experience of multiple losses, in a context of perceived inadequate training; role expansion; and perceived lack of recognition and reward. Participants also identified a number of work and socio-cultural influences which were perceived to mitigate the impact of the work. Study 3: Failure to take up counselling duties after training was primarily associated with counsellors having too many competing non-counselling duties (31.2%; n=108), and being deployed to other workplaces in a non-counselling capacity (22.8%,n=79). Over 81% (n=441) of respondents who indicated that they were continuing to work as counsellors reported signs and symptoms of psychological disturbance on the GHQ-28 screening at a level that warranted further mental health assessment. There was a significant positive correlation between GHQ-28 caseness and Locus of Control of Behaviour scores (r =.118; p<.001). Decisions to leave counselling were positively associated with self reported psychological disturbance (r =.324; p<.001) and the perception that their work was not helpful to clients (r =.108; p<.001). Study 4: The results clearly showed that the curriculum, and method of training resulted in both perceived and measured change in knowledge and skills and were reported to have resulted in improvements in the trainees perceived self confidence to meet the demands of their clients. Conclusion: The studies identified the many challenges inherent in providing effective HIV counselling, mental health and psychosocial services in Thailand. This research suggests that delivering HIV psychosocial care services in Thailand has potentially an adverse impact on: the health and well being of care providers; the quality of care received by clients and patients; and ultimately on the ability of the health system to retain its skilled personnel. xiv

16 Acknowledgements This thesis could not have eventuated without the support and dedication of a number of people. First and foremost, I would like to extend my appreciation to the Royal Thai Government for providing this opportunity and the resources to conduct this research. I thank the staff members from the former AIDS Centre for Counselling, Training and Research Centre (ACCTAR) who participated in the research. I would like to specifically thank Dr Prawate Tantipiwatanaskul and Ms Suchada Sakornsatian who provided invaluable assistance in the early stages of this research. In addition I would like to remember the late Danai Sandhagul for his guidance, support and management of the large volume of data collected and translated for study 1. I would like to thank Ms Charmaine Turton (Albion Street Centre), and Graham Frize (formerly Albion Street Centre) who assisted me in the delivery of many of the training courses reported in Study 4. I would like to acknowledge Ms Yueming Li for her statistics advice and data analysis review in Study 3. I would especially like to thank the clients/patients and counsellors who provided the information, which formed the data for this thesis. Study participants willingness to give their time to attend interview focus groups or fill in the questionnaires for the studies is appreciated greatly. There are many others in Thailand who have contributed to the research especially to Study 1. Where possible these individuals have been acknowledged in the Additional Acknowledgements list in the appendix 21(volume 2, page 201). I would sincerely thank my supervisor Associate Professor Nigel Mackay for his professional commitment, support, guidance, and encouragement. Nigel added to this research through his comments, insights and suggestions. He also served as the inspiration for my interest in socio-cultural research. Nigel has remained a patient and constant source of support when I have had to face the many challenges of conducting research in an alternate cultural setting. He has guided me in managing the often tenuous a balance between working in resource poor settings and continuing with my research and studies. I would also like to express my sincere gratitude to the department s statistical consultant and lecturer, Dr Peter Caputi for his generosity of time and patience in assisting me with his guidance and review of this large volume of data and statistics. I would also xv

17 like to acknowledge Dr Charles Skinner for his review of this thesis and his advice. My thanks are also extended to Professor Linda Viney for her guidance, support and encouragement when I initially proposed this research. I would also like to note that this work was conducted whilst I was fully employed and travelling extensively in developing countries. I acknowledge that this work could not have been possible without the support of past and current employers with their practical support, encouragement over the years. Specifically in this regard I would like to thank Professor Julian Gold of the Albion Street Centre, Australia; and my clinical supervisor Dr Kim Begley. I would also like to thank the staff of the HIV Department at the World Health Organization, and my current employers and colleagues at Family Health International. My gratitude is also extended to the staff of the Department of Non-Communicable Diseases and Mental Health, World Health Organization Geneva who inspired me to consider this research and offered support, information and encouragement in the early stages of the research. Thanks also go to Gary Wright, Albion Street Centre for his assistance with the diagrams, tables and the formatting of the thesis and Katherine Coote, Albion Street Centre, Sydney for her review and comments on the final version of the thesis. I extend my deep sense of gratitude to my parents Shirley and Patrick Casey who encouraged me to travel, enjoy the opportunity to work in other cultures and to take advantage of the educational opportunities that they were unable to experience. Final words of gratitude go to my life partner Dr. Montree Phongphojkasem who provided valuable cultural insights, as well as his encouragement and the necessary thesis policing service that kept me from giving up. xvi