Chronic crises

Psychosocial projects in chronic crises combine emergency and development objectives, activities and strategies. In principle, psychosocial projects in chronic crises need to develop cultural-specific and locally defined outcome, or output indicators. Often, a standardised and locally validated symptom or functioning checklist is not available. To create one, the local people need to be consulted and further research is required. This increases proximity and allows for fine-tuning of the project to meet clients’ needs. A promising methodology is described by Bolton.¹⁸¹

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Output indicators

Validated quantitative output indicators should be defined during project assessments, and modified during implementation of a programme as knowledge about the local community and context increases.

Interventions focusing on functionality improvement are often difficult to evaluate with symptoms only. Therefore, locally developed outcome or output indicators should be developed with the assistance of the local people. Through focus group discussions and key-informant interviews, the client perspective of the psychosocial problems can be researched. It is helpful to describe the locally defined outcome, or output indicators for both the ‘psycho-’

and the ‘socio-’ component in terms of functionality and coping. The Mental Health monitoring guideline accompanying the data tool describes how to use both client- and counsellor-rated scoring.

Output indicators are described in qualitative and quantitative terms using local individual and group perspectives. The following information can be included:

• Complaint and functional rating by client at first visit compared to final visit.

• Local signs and symptoms of trauma-related dysfunction and pathology (can be done in local terms of physical, mental, social, spiritual and moral health),

• Local terms used to describe the improvement of psychosocial functioning or the reduction of disability for instance in terms of improvement of social contacts, ancestors are resting in peace, decreased worrying, improved physical activities, improved ability for self-care and care for others, improved self-control over daily activities (eg self-sufficiency in resources), reduced number of conflicts, improved family relationships, and increased number of daily activities or social contacts.

• Knowledge improvement, for instance on stress-related behaviour and familiarity of psychosocial services as a result of social and educational activities.

The appreciation of services as qualitative output indicator is measured by means of structured interviews focusing on the client perspective. The validity of the questionnaire depends on the baseline knowledge that the team has of what is expected from the services.

Process indicators

It may not always be possible to develop locally defined outcome, or output indicators for instance due to security constraints, lack of human resources, insufficient educational level of the staff or an inexperienced expatriate or project team.

In these circumstances only process indicators are used to describe the effectiveness of the programme. Process indicators cover only the activity level of the project. In other words the decision to use process indicators limits future programme evaluation to the activities level.

Moreover, unlike in emergencies, the assumptions between the indicators and the effect on the psychosocial condition of the client are less evident. For example, it is not certain whether cognitive behavioural techniques that function in Western cultures have similar positive effects in non-Western societies.

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Process indicators are described both in qualitative and quantitative terms. To monitor quantitative indicators MSF uses the Mental Health Standard Data Tool. Qualitative indicators can further describe the extent to which activities affect the condition of the client or community, and include: quality of services operationalised as sufficient client-contact time, file-keeping, confidentiality, training and knowledge of counsellors, level of case discussion etc; improved restoration of human dignity, client satisfaction (‘psycho-’

component), proximity to target population, for instance presence in the community;

connectedness, quality of the community network such as contacts with other NGOs, chiefs, leaders and traditional healers (‘socio-’ component), and a specific indicator for advocacy action.

Methods of obtaining data can include:

• Exit interview, where clients leaving the counselling session are interviewed on certain topics (eg satisfaction with services, reduction of complaints, increased functioning etc)

• Drop-out analysis, in which a randomly selected number of people of the group who did not follow up on their appointments are interviewed about their reasons for dropping out, and their current level of symptoms, complaints, etc is recorded.

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M HUMAN RESOURCES MANAGEMENT

The project management is responsible for recruiting national staff (counsellors and community health workers). Selection criteria such as age, gender distribution and professional background should be developed locally. Staff selection should not be limited to those with a professional background. Other criteria are equally important, such as: attitude (eg the applicant should be compassionate), interpersonal skills (eg good communication), interest in and motivation for the work, previous counselling experience, training, and the ability to analyse, plan and intervene when faced with difficult or complex cases.

Tbl. 21: Criteria for staff recruitment

Criteria

Expatriate • Professional background (Eg psychiatrist, psychotherapist, clinical and counselling psychologist, social worker, social psychiatric nurse)

• Work experience (preferably clinical, community-based)

• Attitudes/expectations of humanitarian work National • Professional background

• Attitudes and compassion

• Interpersonal skills

• Level of interest and motivation for the work

• Previous counselling experience and training

• Ability to analyse, plan and intervene when faced with difficult or complex cases (tested through the use of three short case studies) (explain)