Chain-free initiative

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Chain-free initiative pilot project in Afghanistan
Final progress report of phase I, January 2008

Overview
Design and status implementation
Achieved expected results

Overview

The chain-free initiative is a new project being implemented by the World Health Organization. The project is aimed at developing, implementing and evaluating a model for quality mental health services focused on improvement of the quality of life of patients with mental disorders. The initiative aims to combat the stigma associated with mental health and provide people suffering from mental illness with equal opportunities to access basic humanitarian treatment in hospitals, homes and the environment in which they live.

The project is planned to be implemented in three phases: phase 1 (chain-free hospitals), phase 2 (chain-free homes) and phase 3 (chain-free environments). These three phases of the project are specifically designed to support service users in almost every aspect of life.

Design and status of implementation

The project is being supported by the World Health Organization and the plan of action was designed by the National Mental Health Directorate in the Ministry of Public Health, with technical support from WHO.

The plan of action and needs assessment for the implementation of the first phase of the project (chain-free hospitals) in Kabul Mental Hospital was prepared in early 2007. As a result of hard work and mutual cooperation between WHO, the national Mental Health Directorate of the Ministry of Public Health and Kabul Mental Hospital the first phase of the project was successfully implemented.

In order to reach to the overall goal of the project, a total of seven main expected results were identified for the planning phase of the project. Each result was subdivided into products and ultimately into relevant activities.

One of the main objectives of this phase was to establish a model for the chain-free initiative which could be copied to other parts of the country. A model is now ready and training and IEC materials, terms of reference for the chain-free committee, progress reports for each quarter and other necessary tools have been developed.

Achieved expected results

1. The hospital is clean, renovated and maintained in good shape

• A thorough needs assessment was conducted in the hospital. The needs assessment included one-on-one discussions with managers and administrative and support staff of the hospital. A detailed draft plan of action was prepared accordingly and was presented to all hospital staff. The staff were asked to comment on the draft plan and suggest proposed modifications.

• Based on the needs assessment, hospital wards were renovated. Renovation included painting and repairing the wards, repairing toilets, making a partition to prepare a waiting room for outpatients and an emergency unit.

• The hospital was also provided with some necessary items such as blankets, bed sheets, clothes, shoes, etc.

• In order to keep the hospital ward clean and in good shape, the hospital support staff were provided with a monthly cleaning kit. In the meantime, service users and their relatives showed an interest in taking part in regular maintenance activities of the hospital. The hospital ward is now cleaned regularly.

2. Chains are removed from the hospital and no patients are chained

• Since the beginning of the project, the hospital has been completely free of chains. Patients are not allowed to enter the hospital with chains. A standard guideline has been developed by the chain-free committee that describes which restraining strategy to use in order to handle a disturbed patient when s/he first enters the hospital. In light of this guideline, hospital staff are using alternative methods such as soft restraints, medication and temporary seclusion to control disturbed patients. Different restraining strategies advised by the physicians are registered in the patients’ files.

• The hospital was provided with some essential medications. A list of required medication was prepared by the chain-free committee at the beginning of the project.

• In order to make sure that the project is going smoothly, a focal person for the project within the hospital was selected. The focal person is provided with a monthly incentive.

3. The hospital staff are aware of the users’ rights and are trained to handle disturbed patients professionally and humanely

In order to enhance the capacity of hospital personnel all staff have received training on how to handle psychiatric emergency cases in both the emergency room and the psychiatric ward. Training was conducted in two different batches. One batch was undertaken for technical staff and the other for technical, administrative and supportive staff. The training covered:

• Characteristics of an emergency room

• Psychiatric emergencies

• Physical restraint and seclusion

• Rapid tranquilization

• Suicide

• How to diagnose G.M.C in the emergency room

• Violent behaviour

• General principles of forensic psychiatry

• Communication skills

4. Users are aware of their rights and their rights are protected

Two main strategies were used to raise awareness among service users of their rights and certain mental conditions.

• A schedule for daily mental health education was prepared and all patients and families who were waiting for a consultation were given education on a certain topic on a daily basis.

• Families of admitted patients were gathered once a week for short-term training where a psychologist gave them information on how to deal with their patients inside the hospital and how to take care of them when discharged. They were also given information on the side-effects of psychotropics and the importance of long-term therapy.

• Moreover, to raise awareness about human rights among the staff, families and patients some materials were developed by the chain-free committee. IEC materials consist of small brochures on different mental disorders, different kinds of posters, and some flip charts for mental health education.

5. A chain-free committee consisting of authorities from the central MoPH, psychiatric hospital, human rights commission, security post and possibly some ex-users and families is in place

• A multi-specialty committee called a chain-free committee was developed at the beginning of the project. This committee was formed of both technical and non-technical members to be responsible for providing technical support to the project.

• The committee met regularly twice a week. The terms of reference for the committee were drawn describing its responsibilities, scope of the work, duration and frequency of meetings, etc.

6. A users’ association consist of users and family members is available

• It was planned to establish an association of service users and providers. This association was supposed to meet on a regular basis and work for the users’ rights. Some members of this association have been identified but the official establishment of this association is yet to come in the next phase of the project— chain-free homes.

7. The project is regularly supervised and monitored:

Regular external monitoring is conducted by a member of the National Mental Health Directorate. Regular internal monitoring is done by the chain-free focal point in the hospital, and other members of the committee.

(WHO Regional Office for the Eastern Mediterranean wishes to acknowledge the Ministry of Public Health of Afghanistan especially Dr Ruhullah Nassery, for their contribution to the implementation of this project.)