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.

Where in the world, is Swaziland?

I hope that for some of you, this title reminded you of the awesome show on PBS about 15 years ago called, “Where in the World is Carmen Sandiego.”  That, not surprising now, was my favorite show- I was even in my grade school geography-bee because of it.  And here I am traipsing around the world just like Carmen.  Unfortunately, my geography knowledge failed me when I got my assignment four years ago as a Peace Corps Volunteer.  I ripped open my assignment packet, “Yes, I’m going to Swaziland!”

“Where is Swaziland again…?”

According to my globe, Swaziland is a small country in Southern Africa almost completely surrounded by South Africa, except for the eastern side that borders Mozambique.  It is about the size of New Jersey and has a population of about 1.1 million.  Its economy is mostly agriculture based, with corn and sugar cane as it’s biggest exports. 

It is actually called the Kingdom of Swaziland and is one of the last absolute monarchies.  King Mswati III is the current king.  Swaziland gained independence in 1948 from England.  Back in colonial days it was considered a protectorate and made a rather peaceful transition out of colonial rule.  Today the King has almost complete power.  Political parties are banned, but there is an elected parliament.  I think it’s a pretty American impulse to automatically think any non-democratic government is wrong, but some people strongly believe that the kingship and the preservation of the Swazi cultural structure is what kept Swaziland from civil unrest during independence, unlike so many of it’s African neighbors.   If you are interested in learning more about this political tension, “Without the King” is a documentary that focuses on these issues.

While the kingship may have spared civil war, Swaziland continues to face many challenges.  66% of the population lives below the poverty line, and Swaziland has the highest rate of HIV in the world with a TB/HIV coinfection rate of 80%.   HIV has wiped out a significant portion of the working population, as people of reproductive age (those most susceptible to HIV infection because they are sexually active) are also the most productive members of society.  This affects the economy, but also contributes to a growing OVC population.  OVCs are orphan and vulnerable children.  Nercha, the national emergency response council on HIV/AIDS, estimates that 23% of all children in Swaziland have lost one or both parents and 31% are considered orphaned or vulnerable. 

Swaziland is a beautiful country known for its incredibly friendly people.  There are four regions in Swaziland: Hhohho, Manzini, Lobombo, and Shiselweni.  I currently live in the Hhohho region.  The capital city is Mbabane and the national language is Swati.  SiSwati has 3 clicks and a series of other tricky sounds like hl, tf, and ts.  And don’t forget about wildlife!  Swaziland is home to 498 species of birds (so, Mom, I guess there are a few birds here after all!), the “Big 5” and many diverse indigenous trees and flora. 

But I guess you could have gotten most of that information from a guide book…  What do I like about the Kingdom of Swaziland?  I like hopping onto a crowded khombi (like a small bus) that’s blasting music, drinking emahewu (a sour corn drink) at the end of a long, hot day, being called by my siSwati name: Jabulile Buthelezi, the stunning scenery, the amazing people, goofing around with Swazi kids, and the incredible sense of community I feel here.

I suppose it was worth the 23 hour flight… for the THIRD TIME!  

Horoscope

According to the Swazi Times newspaper last week, this was my horoscope:

There could be some worry about not being useful or being left out of the scheme of things today.  This can be eased by jumping in with both feet and putting your thoughts into action.  This is a time to take risks and dare to be a little eccentric.  You will prosper through new insights and an independent point of view.  Your career could open up now- keep your ears and eyes open so that you do not miss some important opportunity.

Hmmm...  Couldn't have said it better myself!

The Sum of 6 Weeks

 The blog is up, at last!  Most of you know that mass communication is not my “thing,” so please still humor me with some personal emails. 

It is a beautiful Monday in Swaziland.  Spring has come and has brought a string of very unpredictable weather, but today it is sunny and feels like it is 70 degrees F.  So far my study has generated a lot of interest, which has afforded me the opportunity to network and be involved in a number of diverse activities.  This morning I sat in on a meeting at the WHO office on palliative care.  Since roughly 50% of Swazi’s are living with HIV, there is a lot of emphasis on the need for care giving with this chronic illness.  So we really need to be looking at those care givers and how they are coping… which is where I come in!

But let me jump back and give you an idea of what I’ve been up to.  Here’s my list:

In August I spent 2 and a half days in Johannesburg on the way to Swaziland at the South African Anxiety and Depression Group’s office.  They did the study on Home Based Care Givers in South Africa that gave me the idea for my study in Swaziland.  I was able to travel to a township and visit a counseling center they recently set up in a trailer to support the needs of the township.  We also went to a nearby school and met with the principal to organize a training on mental health among teachers and to set up a support group at the school.  I also spent time in the office gathering materials including Speaking Books on various topics.  Speaking Books were designed to help people with low literacy “read” the book, and are such a wonderful tool!  While at the office I also listened in on the mental health support counseling line, and had dinner with the executive director.

The first couple of weeks in Swaziland were spent meeting with Simon Khumalo (my Red Cross contact), Denise Mortlock (Mental Health Support Group Leader), attending my host Rotary club meetings, and setting up meetings with the Red Cross Director and my supervisors and the University of Swaziland.  I also ran around getting my immigration documents in order, getting my student ID, and visiting Mambane (my Peace Corps community). 

August 10^th I attended an in-service training at the Manzini Psychiatric Hospital on Bipolar Disorder and met one of the two psychiatrists in all of Swaziland.  August 26-28^th I attended the Rudasa Rural Health in Southern Africa Conference.  This conference was held in Swaziland for the first time this year.  I really enjoyed this conference because it gave me a good indicator of what’s been done in Swaziland since I was last here in 2007 and also what has been successful in other countries.  Task-shifting was one of the major issues that was discussed to help with the human resources issue.  This year the first Physician’s Assistant program was established in South Africa, and there is talk of developing a medical school in Swaziland.

In August I also started my service work.  I have chosen to volunteer at the Baylor clinic in their teen club.  Teen Club is a support group for HIV+ children aged 10-18.  The Teen Club in Mbabane has over 150 children participating.   Check out their website at: http://bayloraids.org/programs/swaziland/adolescent.php.  The Baylor Clinic specializes in pediatric HIV and is the only center of it’s kind in Swaziland.  They have several satellite clinics and also provide training for nurses and doctors in the care and treatment of HIV in children.  The Baylor doctors facilitated my Peace Corps technical training in HIV and I have a lot of respect for their work in Swaziland.

In September I attended Umhlanga, which is the largest festival in Swaziland.  Also called the Reed Dance, young girls (they are supposed to be virgins) participate in this week-long ceremony which culminates on the last day with a dance for the King (where the King has the option of choosing a wife).  Do not worry- I did not participate in the ceremony- I only watched, so I was NOT chosen J

I have also met with my supervisors at uniswa (the University of Swaziland), the Red Cross, and the national coordinator for the RHM program to go over my surveys.  I’ve been over my demographic questionnaire so many times that I don’t ever want to look at it again!  However, a lot of great recommendations have come from these meetings and I am really pleased with the changes that were made.  I have also made arrangements to get the surveys translated, which should be done by this weekend.  The next steps are to present the research project to the ethics committee at the Ministry of Health and Social Welfare on September 24^th.  We have also decided to expand the research and survey 1,000 participants!  I am going to hire 10 research assistants who will collect the data at 10 research sites (one site per day and each re

SiSwati classes should start up either this week or next.  I have arranged to join in a class at the international high school that will go until December.  Then in January I will get a private tutor, as I will be too advanced for the existing classes.  My comprehension has improved, but I’ve been slacking on speaking siSwati since most people automatically speak to me in English in the capital. 

Rotary:

I’ve attended 5 meetings and been to two clubs (will attend a third tonight) and joined (as an honorary member) the Rotaract club.  The Mbabane-Mbuluzi Rotaract organized a retreat for their club plus the Manzini and Uniswa clubs to foster more fellowship in the clubs and help retain members.  I attended this 3 day retreat at Mlawula, a nature reserve in the northeast of Swaziland.  There were about 26 Swazis and me!  It was a great way to meet Swazis my age, build friendships, practice siSwati, and learn more about the Rotaract clubs.  Rotaract is for young adults under 30, so it is a perfect way for me to connect with like-minded Swazis.  Besides that, I really needed to let my hair down and have some fun, after weeks of meetings and first impressions. 

            Last week I spoke at my host club and it went very well.  I really enjoy the club because it is pretty casual, small, and I have gotten to know some of the members well already.  Most of them are appalled that I don’t have a car and am using public transportation, and so have been very generous with rides.  They have also taken me to the Mbabane Club, which has been fun!  My host counselor is a professor at the university and teaches literature.  We’ve bonded over discussions of African Literature, and if I have enough time, I plan to audit her African Literature course next semester.  She was also instrumental in the acquisition of my student ID, which took 2 days of running around. 

            So, things are going quite well.  I feel so overwhelmed with how cool this opportunity is, and how connected I’ve gotten since my arrival.  Know that I think of you often and hope you are well. 

            Sahle Kahle (Stay Well)

            -Carrie/Jabulile