An Upgrade

I didn’t really know what to expect when I designed this research project at home in Kansas City.  How many participants is it realistic for me to survey?  How will I travel to each site?  How will I convince each clinic to work with me?  Who will help me do the surveys???

I had the basic research design mapped out, but all of these details spun around inside my head for a year as I prepared to leave, knowing that they would only be solved once I was actually in Swaziland.  Since my prior experience in Swaziland was as a Peace Corps Volunteer , I was resigned to do this the hard way- using my contacts in 3 of the regions I had experience with, taking the bus to the research site, staying overnight with host families and sleeping on the floor,  and figured I would spend a considerable amount of time trying to find local Swazi’s to partner with.

As a Peace Corps Volunteer, I walked for more than 2 hours a day to meet with active community members and worked extremely hard to “prove” myself to the leadership and community members.  It took a long time to integrate into my community and for projects to start gaining momentum.  So, I didn’t know what to expect this time around.  I hoped that my previous experience would speed up the process some, but I had no idea what was in store for me.

Two weeks ago I sat across from the National Coordinator for RHMs at the Ministry of Health and had a meeting on how we would work together.  We drafted a letter to each of the four regional clinic directors calling a meeting to discuss the research and ways they can support the project.  We also discussed my ideas for helping mitigate stress for RHMs, which the coordinator liked and stated she would incorporate in the national plan, which rolls out in January.  As I sat there, I started to pinch myself to make sure this was really happening!

During a previous meeting with my University of Swaziland supervisor, she encouraged me to increase my target number of participants from 200 to 1,000.  She is also helping to recruit my research assistants, and the Dean of the Health Science department at the University has agreed to organize transportation so we can all ride to the research sites together.  Every time we finish a meeting, my supervisor says, “this research will be very interesting!” 

I’ve finally scraped my jaw off the floor and am on cloud nine.  I certainly have gotten a research “upgrade.”  Yebo!

FAQ

I have been asked often what I’m doing in Swaziland and have found it difficult to formulate a quick answer.  Here is a better idea of what I’m doing here and why. 

Q:  What are you doing in Swaziland?

A:  I am working on a research project titled, “Emotional Effects of Caregiving: Depression and Quality of Life in Rural Health Motivators and Care Facilitators in Swaziland.  I am also taking siSwati classes and speaking at Rotary clubs in district 9400 and participating in Rotary events.

Q: What are Rural Health Motivators (RHMs) and Care Facilitators (CFs) and why are you researching them?

A:  RHMs are community members who are chosen by their community to receive training in first aid and caregiving.  They provide care, support, and health education to community members.  CFs have a similar role but are affiliated with the Red Cross, whereas RHMs are affiliated with government. 

I am researching the emotional toll their work has on their life because:

-There is a need to care for caregivers in Swaziland as it has the highest rate of HIV in the world, and caring for someone with a chronic illness is extremely taxing.

-I worked with RHMs when I was in Swaziland as a Peace Corps Volunteer and saw how draining their work was.

-There is a low level of mental health understanding in the general public in Swaziland, so many of the RHMs may not know the symptoms for depression, burnout, and compassion fatigue, making it difficult for them to seek treatment.

-There was a similar study done on depression rates and community health workers in South Africa (done by the South African Depression and Anxiety Group) which found that 89% of their sample had depression, and I believe there is also a high rate of depression existing among community workers in Swaziland.

-I believe that a lot can be done within the current system and for little or no cost.  Therefore, shedding light on the issue will go a long way towards developing interventions to lessen the emotional burden of caring, and subsequently making a real difference in the lives of caregivers.

Q:  Who are you partnering with?

A: I have two supervisors at the University of Swaziland as well as help from the psychology department at William Jewell College.  Also, I am partnered with the Baphalali Red Cross, the National Coordinator for RHMs at the Ministry of Health, and the Mbabane Mental Health Support Group. 

Q: What is this for?

A:  This project is not for a masters or PhD program.  It is simply because I saw a need and personally wanted to be back in Swaziland. 

While serving at Mother Teresa’s Home for the Dying and Destitute in Calcutta, India in 2004, I became very aware of the need to support helping professionals and anyone in a caregiving role.  In high school I chose to enter the mental health profession after deciding that I wanted to be a physician in order to help people heal.  After experiencing clinical depression as a teenager, I decided I wanted to focus on mental health because the stigma creates an additional barrier to care.  Since then, I have had a particular interest in underserved populations.  This has lead me back to Swaziland to work on access to care for caregivers, with the hope that this research will highlight the need to pay attention to caregivers’ needs and provide supportive structures for them.  Through this, I also hope to draw attention for the need for more comprehensive mental health support for all Swazis.  Currently there is one psychiatric facility that employs two psychiatrists for the entire country.  This is equivalent to a ratio of one psychiatrist to half a million people. 

Q: Tell me more about the research design.

A:  Research participants will include 800 RHMs, 200 from each of the 4 regions, and 200 CFs, totaling 1,000 participants.  They will be surveyed during their monthly meeting.  Data will be collected at 10 sites, with 100 participants surveyed in each site.  I have hired 10 research assistants to assist with data collection.  Participants will answer 3 questionnaires: a demographic questionnaire, Zung Depression Scale, and WHO Quality of Life survey. 

Q:  What are you looking for in the data analysis?

A:  The first thing that I am looking for is the overall rate of depression.  I am also interested to see where caregiving is beneficial to the caregiver and enhances quality of life, and also where it is stressful and diminishes quality of life.  Finally, I will be looking at differences in the data, for example, what makes one person prone to depression and another person not?  What is different about those who do have depression?  Is it because they have a higher burden of care, less resources and are more socially isolated?  Is it because they also have an illness, or are caring for a family member in addition to their work in the community?  Is it because of age, education, or length of time working as community health worker?  If we can answer some of these questions, then we can better know how to mitigate the negative aspects of caregiving while enhancing the positives.   

Q:  How do you possibly make a difference in a country with a human resource crisis and the highest HIV rate in the world?  Isn’t it inevitable that caregivers will be stressed, no matter what you do?

A:  A big complex problem does not require one giant complicated answer.  It requires lots of small, simple changes.  It requires attention.  It requires lots of hands in the pot.  I have decided to put my hands in this pot because I feel I have a lot to offer and because I think there are some small, simple changes I can help with; the biggest being that I can draw attention to them.  The literature suggests that even while it is typical for nurses working with HIV+ patients to have a high depression rate, their rates of burnout and job dissatisfaction remain low in those who expressed having adequate support and a high feeling of personal satisfaction from caregiving.  Therefore, by increasing levels of support, a lot can be done to mitigate the stress of caring. 

My two main ideas are to increase social support and technical knowledge and to provide mental health education to help community health workers identify the symptoms of depression in themselves, and to identify positive coping mechanisms.  The best way I can think of to increase social support is to structure the monthly meetings, which currently serve the purpose of handing out the monthly stipend, into a support group.  Here, RHMs and CFs would discuss challenges and triumphs of their work and be able to draw from the experiences of other RHMs in their area.  This time can also be used for continuing education, so the workers can gain more knowledge on health issues and feel more prepared when visiting the sick in their community.  A training manual can be created and given to the nurse or lead RHM in each community, so they can facilitate the lesson easily.  When I return to each research site, I will conduct a health talk on depression and mitigating stress.  I will also develop a mental health referral list which will be distributed along with information on depression and other mental health disorders.