Looking back at our time in Zambia

Joanna and Simon have been back in Scotland for nearly 5 weeks and there has been time to reflect on what happened during our work in Zambia and to get started on the next stage of planning for the completion of our Feasibility Study (which is funded by a Scottish Government International Development Small grant). In particular we are applying for further funding to strengthen ZTA for the future and have starting planning for the next phase of work in Zambia in early 2018.

First, our time in Zambia resulted in several successful outcomes; including people trained, models of training tried out, contacts made and contacts renewed. Three training courses were delivered during September and October 2017 and 30 people successfully completed the course: ten staff at Livingstone General Hospital, Southern Province, nine staff at Chainama Hills Hospital, Lusaka and eleven student nurses from the Chainama Hills College of Health Sciences. One of the local trainers completed her training and is now certified as a Therapeutic Art Trainer in Lusaka. She is the first of the Zambian trainers on whom the future sustainability of the ZTA training in Zambia depends. Four new trainee  trainers began their first stage training, and will hopefully complete their work over the next 12-18 months. This will mean we are well on the way to having a pool of Zambian trainers who can deliver the course. 

We evaluated three different models of training delivery during thus visit, in response to local conditions. At Chainama Hills Hospital the training was delivered in six 3-hour sessions over a period of 5 weeks; at Livingstone General Hospital the training was delivered over 4 ½ days and for the students of Chainama Hills College the training comprised 10 sessions of 2 hours each. Whilst each of the 3 courses worked well and participants were able to complete them successfully, we felt that delivering a shorter, more intense training was a way to make better use of trainers and participants’ time and we will focus on this in future courses.

During our visit we were also able to make progress with the monitoring and evaluation of the training, to fit with the plan for our Feasibility Study. We met with Margarate Munakampe from SCHEME, Department of Public Health, University of Zambia. Margarate is the M & E expert working with us to evaluate the ZTA training model and she has quickly grasped our approach and begun work on an evaluation model. We are enormously grateful for her help and advice and that of Professor Charles Michelo, the head of  SCHEME.

We were also able to meet with mental health and nursing personnel from the  Zambian Ministry of Health, to keep them informed of our work and to build our links with the wider health system in Zambia; with Dr Ravi Paul, Head of the Department of Psychiatry, University of Zambia Medical School at UTH Hospital in Lusaka and with senior staff at Chainama Hills Hospital.

We met with Sylvestor Katontoka, the Chief Executive of Mental Health Users Network Zambia and with his help and support, delivered a “taster” session to his members in Kanyama, a compound in southeast Lusaka. We had planned to deliver a second session but this had to be cancelled due to circumstances beyond our control in Kanyama. The response to the first session was very positive so it was disappointing not to be able to follow this up but we met with the MHUNZA Chief Executive again to discuss whether they might offer therapeutic art sessions in future.

All in all it was a very busy but successful seven weeks and the thirty successful participants in the three training courses gave us very positive feedback on the experience. During the evaluation sessions we conducted, participants commented on how their views of patients had changed for the better, how their skills and confidence had increased and how working with patients was a positive experience for them. A frequent comment concerned the importance of a mutually empathic and understanding relationship between patients and staff and how art making facilitated this.

Since our return to Scotland we have been taking a critical look at our capacity as an organization both at home and in Zambia and can now focus on developing this to ensure the sustainability of the training and practice within Zambian health systems. We have submitted our new grant application, have begin to plan for future training courses, and to look at how to develop ZTA and the Therapeutic Art training model in Zambia!

LAST FEW DAYS

Partly it feels as though we have been here for ever and partly that we have just arrived! As always the last week or so builds up to a rush of final meetings and reports. It is intensified at this time of year for us by the deadline for Scottish Government Small Grants application coming at the beginning of November. So a lot of international communication has gone on while we firm up our ideas for the best way forward with our partners here, building on what we have learnt from this Feasibility year so far. Consolidation and capacity building seem to be where we are at - both at home and in Zambia.
With the help of our trainee trainers we have finished the training courses at Chainama Hospital and College. As always for us the most interesting part is the reflective evaluation where trainees record what has changed for them. A great emphasis this year on the power of simple art making to open up communication  and the shared process to improve relationships. Assessment marks have been very positive too - so between us we seem to be getting the message across! We had productive meeting with Sergio Mainetti, who is the CBM/Basic Needs lead in the area to see where our approach might fit with what they are doing.
Just a couple of busy days to go and then seeing if all the things I wasn't going to buy but which have somehow appeared in my cupboard, are going to fit in my modest bag. Then it will be goodbye to Gossner which provides such a peaceful base and back to the cold.

In Livingstone and Lusaka

Joanna has spent the last 
week in Livingstone, 200 miles south of Lusaka at the Livingstone General Hospital following an invitation from Dr Sheikh supported by the SMS Dr 
Kachimba, delivering training to 10 hospital staff in the mental health unit there. Participants included medical staff, occupational therapists, clinical officers, a nurse and a physiotherapist. The Occupational Therapy department welcomed us with training space and enthusiasm and it was a privilege to work with such a close knit team. They even managed to come up with some clay which was well used! This was the first time the training has been delivered over a concentrated 5 days and worked very successfully. At the end of the course all ten participants passed and their feedback and evaluation of the course was very positive. " Did not know clients can open up that quick. Art has made it possible."- "How I feel and think about patients has definitely changed. After developing significant rapport with the patients as am able to look at them as human being with potential to develop themselves and achieve their aspirations."
We hope that this model of the training will be useful in similar hospital settings elsewhere in Zambia as it could be an efficient use of both trainers and participants time and resources.

Meantime, Simon has been coordinating the training at Chainama Hills College Hospital in Lusaka for both hospital staff and student nurses and student clinical officers.

These courses are now nearly finished and will end in the next week when participants have completed their final evaluation and assessment. The course for hospital staff has been led by Wala Nalungwe, one of our new Zambia trainee trainers, as part of our plan to establish the sustainability of the training within the resources of the Zambian healthcare system.

We are now in the final two weeks of our time in Zambia and are trying to hold meetings with key players within the health system here to embed the ZTA training within the wider system of training for health professionals in Zambia and to carry forward the monitoring and evaluation programme for the work. It is going to be a very intense few days as we try to round off the trainings and meetings. We still hope we may be able to do a second workshop with MHUNZA members before we leave on 27^th October. The second planned workshop had to be cancelled because the hospital where it was to be held had no water or power.

All this to do and the temperature is climbing again to the mid 30s this coming week. The sun is almost directly overhead at this season, so the only thing to do is not to go out in the midday sun!
All very well for him here in comparatively cool Lusaka but I had to walk to and fro to the Hospital in Livingstone in a seriously high midday sun!

HALF WAY IN

This week has gone really quickly. The training at Chainama, both Hospital staff and College students are warming up, as is the weather! Actually we had some heavy rain, briefly yesterday evening which felt really good.
On Monday we held a Taster session for the Kaynama MHUNZA group and staff from the Hospital there. Though not as many people turned up as we had hoped it was really interesting and got positive responses. sadly the follow up session planned for Friday - where more people were coming was cancelled at the last minute because there was no power or water at the hospital. The plan is to reschedule for when I am back from Livingstone.
We are having half way catch ups with the trainee trainers, both stages 1 and 2. As we are trialling this training model their feedback is really important and has been helpful in developing the monitoring structures.
In the training the use of clay always sparks things off and we have seen it used in many different ways by trainees and patients. The nonverbal communication exercise always causes a lot of laughter as well as reflection.






On Thursday we got a lift with Heidrun and Felistus to the First Night concert of the Lusaka Proms Festival, "Night on Broadway". Some amazing voices and jazz musicians - a wonderful evening.

In the house next to us here at the moment is a group from Western Province, Liangati Mubula Project, who are
trying out making products, jams etc from fruits from their region. Their plan is to try them out around town at the end of the week. I was allowed to taste one of the jams - it was delicious. Watch this space - good things to come!
All in all a mixed but busy week

Training sessions are underway

We are now at the end of week two of our visit and all the planned training is happening, after a bit of reorganization and re-structuring of the course. There are sessions for Chainama Hospital staff two mornings a week that are well attended by a mixed group of nurses, physiotherapists, clinical officers, doctors and two of the hospital security staff. The afternoon group for students from Chainama College of Health began this week when students returned after the water shortage ended (see last week’s blog). Both groups are led by a Zambian trainer with support from Joanna and Simon.

Three of the trainees

This is the first part of our project to bring on board local trainers with a view to making the project sustainable in the Zambian health system. Both trainees completed the initial ZTA training course in 2015 and began their  training as trainers in January this year. They are now leading a course themselves with our support. We hope to have a third trainee beginning this phase of the training at the end of the year if we are able to deliver a course in Ndola. In addition 4 more trainees have begun the first part of their training, shadowing the courses led by Zambian trainers. 

the student group at work

Both trainings are going well at this stage. We have had to make a lot of changes to the course for the college students to make it fit their programme. We have re-designed the course to fit into fourteen afternoon blocks of 2 hours each - and fitted around four public holidays. We will be able to finish the course within the time available, ending just in time for Zambian Independence Day on 24^th October.

our meeting with MHUNZA

We have also got back in contact with the Mental Health Users Network of Zambia (MHUNZA). We are going to deliver two taster workshops for their members next week. Our aim is to find out if Therapeutic Art is useful to them and something they would want MHUNZA to consider taking forward as a project . MHUNZA would be able to do this on if it could attract funding and ZTA would be able to support them in getting it set up. There is now a body of people in Zambia who have completed one of our training courses and would be able to run sessions for MHUNZA members.

We have met with Mr Mayeya from the Ministry of Health who is responsible for mental health services in Zambia to keep up our contact with the ministry. At his behest, we may be able to meet with the ministry official responsible for professional training, to find out how ZTA training fits into the wider plans for training health staff in Zambia.

It has been a very busy but productive week: planning, redesigning the course, writing notes, designing forms and delivering the training sessions. The next week will be very full with five days of training sessions and preparing for Joanna to go to Livingstone to deliver the course there over 5 days.

Thankfully we have a calm place to return to each night at Gossner Mission, where we can work and re-charge ourselves! If you are ever in Lusaka, it’s highly recommended - by ZTA and Mosi the Gossner cat!

Back again.
We are  following on from Lesley's visit in June. It was a really productive time and we are now here to build on what she established and set in place.
Back  in Scotland as well as working on the training materials, we have been extending our skill base. Colin, a very experienced trainer and programme manager has joined us as a Trustee and added a lot in a short space of time. We have also been doing some fundraising. A Pop Up restaurant proved a great success and a very enjoyable evening as well as profitable.

A lot of hard work. We really are grateful to our many supporters who
contribute in so many ways.

lot of hard work but also fun and good results.
Here in Lusaka we have found things pretty well set up, great support in Chainama. One problem being owing to necessary repairs the mains water in Lusaka has been turned off all week. Consequently the College students we were planning to start with have had to go home. We do hope to complete the training none the less. The Training of Trainers is moving on to Stage 2 with 2 trainees taking the lead in delivering the training.                                                                                                                                                                       We also have 4 starting the Trainer Training and already we are seeing the training develop fresh energy with new ideas and approaches.


 Also great support with Monitoring and Evaluation from Margarate Munkampe - a wonderful asset!

The trainees from Chainama Hospital have started with the first sessions and already shown real enthusiasm and understanding.
So watch this space.

Reaching out to the provinces – and a trip to Malawi

June 2017

Echoing the WHO proclamation ‘ leave no-one behind’  we feel it’s important not to  miss out  the training needs of mental health workers who work at some distance from the capital Lusaka. Of course it is important to work out the logistics of such an initiative before rolling up with our trainers – so I am visiting the mental health units in Livingstone in Southern province and Ndola in the Copperbelt on a short 3 week planning visit to Zambia. 

The trip to Livingstone by bus, even on a mini bus  - as I was -   which avoids the compulsory weighbridge stops for larger vehicles takes 7 hours…   passing through Kafue, Mazabuka, Choma and Pemba on the way.  It’s always interesting to observe the changes in Zambia at different times of the year. In January – it was the rainy season but now it is dry and the maize crop has long been harvested.   Farming can only continue now where there is irrigation and it was interesting to pass the big irrigated circles – bright green beside the neighbouring dried up grass. Buses are good places to chat with your neighbour and on this occasion I was sat beside someone who worked for an HIV charity, delivering training to counsellors and especially targeting vulnerable groups like men in prisons.   So a good conversation passes the time, and a stop at Choma and an egg roll from the bus station café kept me going till I arrived in Livingstone.

Livingstone was noticeably hotter than Lusaka – where at this time of year, it is cool enough to put on a fleece. I’d booked into Jollyboys Lodge which is mainly for  the many   backpacking travellers, who visit the area for the falls,  rafting and kayaking – but serves as a comfortable and reasonably priced place to stop for a couple of days.    I was made very welcome at the hospital, and met the mental health team as well as the Occupational therapy and Physiotherapy heads.  Mental health services here have been much neglected over the last years, but now with new leadership – efforts to improve the service are underway, and increased referrals from the local area show that more people are seeking and receiving help and care. We hope that ZTA can deliver its course here in October – as a contribution to increasing the quality of mental healthcare in the area.

 Next Ndola – another 7 hour bus journey!  Boarding this bus which had seen better days, took me back to very a dodgy bus journey in Ghana on a different project last year with several break downs on the way. However this bus – though old , and with the door held closed with a rope, and with narrow seats prompting squeezing  and shunting about a bit when stiffness in back or limbs begins to bite, made good  and safe progress .  Sharing the seat this time was a man travelling from Malawi to Congo ….  a much longer journey than mine and he estimated he would not be in Congo by tonight  as the border will close at nightfall. He explained he was a Congolese refugee and was just going back for a week to see how things were.

Arriving in Ndola bus station, taxi drivers come to tout their business for disembarking passengers. My taxi driver tells me there are 2 lodges of the name of Fatmols – where I am booked.  Fortunately I had saved the number on my phone following my booking. I passed him my phone to call the lodge - for ease of communication – in Nyanja and  confirmed where we were meant to be going … which was actually beside  the football stadium on the edge of town. This prompted a brief commiseration, that Zambia had lost in the under 20s world cup against Italy last week - and I heard that England had won!

 Ndola General Hospital is the biggest big hospital in the northern part of Zambia. I located the mental health unit, which as is common is located in the oldest part of the hospital. It is good to hear that a new building for mental health is in progress. I am sure that patients and staff alike will be very pleased once they are able to move into better facilities. The staff team here are enthusiastic to add Therapeutic Art as a skill for their staff. The large murals in the OT room created by a mental health patient  were evidence to  how patients could use art to express themselves.

 Following  ongoing linking up  with  the Ministry of Health  and our  new Zambian trainers – who will complete their training this year , I was  able to visit Malawi for a few days  and while there  made a couple of visits to the mental health service in Blantyre and  Zomba Hospital.  These visits were enabled through the Scottish Malawi Mental Health Education Partnership (SMMHEP) and helped me understand the similarities and differences between Zambian and Malawian mental health services – and existing movement of professionals between the two neighbouring countries.

 This trip has proved very productive in taking our plans for training trainers forward and the warmth and enthusiasm of the mental health leaders and staff make it a joy to do this work.

 I am now back in Scotland and meet up with the ZTA team next week to plan for the next training delivery trip later this year - provinces included!  We will be discussing our shortfall of funds for this trip …. Please donate  so we can train trainers.. and  improve the care in Zambia  through using art  to improve communication and mental health.

                  

SPRING AND AGM

Here in Scotland Spring has arrived and with it for us very good news to set us up for the year. We have been awarded a grant by the Scottish Government Small Grant scheme to consolidate the work in Zambia this year. We couldn't be more pleased and at our AGM yesterday confirmed the plans for the next 12 months.
We have heard from the three trainee trainers in Lusaka and they have been working on the training materials to ensure they are contextually relevant. This work will be continued with Lesley when she goes out at the end of May to do the groundwork for our cooperation with SCHEME and for the ZTA Course delivery in other Provinces which is due to take place in September and October.
Here we are continuing to spread the word about the training and share what we have learnt from the responses of trainees and patients that we think is really important learning for the use of art in health contexts and the practice of Art Therapy.
Anyway we are all very optimistic about the work though a bit overwhelmed about all there is to do- very exciting!

FINISHING UP AND MOVING ON

Last Chainama group

So these are the last days of this trip. As always the last sessions are fascinating with the evaluations of the training by the trainees and the assessments. We used a simpler evaluation process this year with a view to its being more replicable. The trainees used post its to make responses to a series of questions about what changes there might have been for them over the training. Interesting responses and discussion - the main outcomes being positive changes in communication, observation and interpersonal skills as well as powerful reflections on the value of art making for them and their patients.


With the assessments safely out of the way we shared the marking with the ToT trainees for their learning of the process. Then came the really stressful bit that I had been left with - writing everyone's names neatly and accurately on the Certificates! This done they have all been safely delivered for presentation, a very satisfactory set of outcomes.

ToT trainees

The outcomes of the trainings have been reported to the Institutions and plans confirmed for the next steps. It has been great to get such positive feed back and enthusiasm for maintaining the practice.
I met with the three ToT trainees to check out their feelings about what they have learned in stage 1 of the training and to consolidate the next stages and what we have to do together to refine and adapt the contents of the manual.

Clay work made by a trainee after discussion of the value of group work

For me this clay piece says so much about the process and what we have all learned from each other

Looking back at my first time in Zambia

It's always sunny in Zambia!

I have been looking at some of the photos I took in Zambia and realising what a partial view they offer. As I was going through them, I kept thinking “if only I had a shot of that view” or “it didn’t look like that at all” or ‘why didn’t I get that”. That’s the nature of a short visit; you think you’re seeing a lot but there are so many gaps in the view and you have to beware of making judgements based on such a limited experience. Zambia presented me with equal measures of stimuli and confusion so it could be easy to leap to mistaken conclusions.

Where are we going today?

 Much of my time at the beginning was spent in trying to sort out what was happening, attempting to understand what people were saying and not knowing where I was or where I was going. Like any new place, it took a while to orient myself. This was my first experience of working in a developing country and had I not been able to work alongside two experienced trainers, Lesley and Joanna, I would have been completely lost. The people I met were unfailingly courteous and helpful but I struggled to follow conversations and to pick up the keys to what was being said. Although the official language is English, Zambians also use many other languages and often used Nyanga, Bemba or another local language as well. The subtleties of gesture and non-verbal communication in Zambia meant I must often have missed something or, worse, just appeared plain rude.

Maybe Google knows where I am....

The teaching sessions were accordingly difficult at first but gradually began to make a comprehensible pattern and it became apparent that the course we delivered really did offer a useful toolkit for the Zambian mental health workers who took part. Now that Zambian ethical approval has been obtained to conduct an evaluation of the work, it will be possible to gather data and information about the impact we are having and to test out the outcomes of the training more rigorously. Health systems in Zambia are very different to those I am used to in Scotland and evaluating what we do is correspondingly more challenging but equally important.

It has been good to find out that the skills and knowledge I had acquired over my years of practice in Scotland were valid and useful in Zambia and could be shared with workers there. I still feel that I have only just begun to understand the differences and similarities in Zambia and in the Zambian health system compared to Scotland, and I have a lot more to learn. It was good to come back to Scotland and find that the Scottish Government is focusing on Zambia as one of its partners for international development work and will announce a new funding initiative in early March 2017. ZTA will hopefully be able to get involved in this new strand of work and to continue its contribution to mental health systems in Zambia.

 Simon

TIME RUSHING BY

The last couple of weeks always seem to come upon us in a rush. To start with there seems to be plenty of time to get everything done and where does it go!
Both training programmes are virtually ended now - so making sure all the course content has been covered has been a major concern. In both training sites the quality of the discussion has been great with people really trying to work out how within the very real constraints of resources and structures they can carry on using this approach.
Lesley has finally got Ethical approval for the use of trainee data for analysis, quite a marathon - it is a very rigorous process.
We had an encouraging meeting at the Ministry of Health and it does seem as though the roll out of Training of Trainers will be supported as far as possible by the Institutions, the Districts and the Ministry. We have made good progress with the ToT trainees at reviewing what we have offered them and clarifying the requirements for the future and for the next stage. Also good progress in structuring the course contents.
Sylvester and Pierre from MHUNZA organised a meeting of their members to reflect on the possible use of a Well Being measure. To check its relevance and language and the feedback has been very useful, Two of the ToT trainees attended that meeting and we will hear from them on Monday. This is something that might be useful in the future as part of getting service user responses to therapeutic art  practice and we are grateful for their help with this.
Tomorrow we start the evaluations and assessments and introduce the ToT trainees to this part of the process. Lesley leaves on Thursday and I will be finishing the assessments and holding feedback meetings to keep people updated.
We have just had three days without rain but earlier in the week there continued to be really heavy downpours every day, driving is a real skill in these conditions and the patience and courtesy shown by Zambian drivers is a lesson to many of us!

TAKING STOCK

The week has rushed past and Lesley and Simon are back  from Chipata-they got a 5.0 am bus  (7 hour journey) and actually managed to arrive  by in time to join us at the Dutch Reform Church monthly Market yesterday and enjoy the array of wonderful things to buy. I have to say I have set myself a few packing issues for the return journey! They were even up for an evening at Modzi Arts listening to 70s Zambian music - some stamina.





The training has again been full of surprises and the trainees  have used their wide experience to enrich the learning for us all. We have been using role play a bit more in some of the experiential art work and this has proved very fruitful for all.

 As we are working with the ToT ( Training of Trainers) trainees we have had to apply more detailed attention to structuring the content of the training and this has proved to be a very valuable exercise but it has also been reassuring in that it seems as though it will be possible to produce a model that can be replicated without becoming too rigidly manualised.
We are getting to the stage  in this trip when we have to start arranging all the meetings and feedback sessions to report to the Institutions and the Ministry so that planning for the next developments can start. The endings always seem to come in a rush.
Lesley has changed her return flight so she will be here to help with most of the evaluation and assessments. These again we have adapted in light of experience and in planning how it can be most effective in different settings.
We sadly say goodbye to Simon this week as he is off back to the Scottish winter. I am sure he will be posting about his impressions but another head and pair of hands has been a great asset.

WELL INTO TRAINING

So another week over. It goes so fast! We have had two weeks full training at both UTH and Chainama and continue to be completely absorbed by the directness of the responses to the training both from trainees and the patients who attend in Chainama. Simon as a newcomer has shown great resilience and taken over bits of training,spent a long time reconstituting the raw clay provided for us by one of the trainees and generally keeping Lesley and I focused.  

The three people who have joined us in the Training of Trainers piloting have already contributed ideas and responses. This included a wonderful energiser exercise which had the whole UTH group and trainers moving round in a circle rhythmically chanting and having to incorporate spelling our name when picked on. There have been days when the rain has been heavy and prolonged in a way completely different from at home, Simon - who despite advice - did not bring an umbrella very nearly didn't get any breakfast as it was too heavy to get from his room to our house! One training group at Chainama managed to get to the OT building but it would have been impossible to get patients across so the morning was spent very productively in art exercises, reflection and case sharing. Lesley has been gallantly working on the revisions required by the Ethics body and got them submitted - hopefully we will hear on Monday - this for using the feedback data from trainees for analysis and publication. Apart from work we have had an evening in a bar listening to music from a friend's band - great sounds! - a meal with another friend at the wonderful Lebanese restaurant nearby and last Sunday we went out of town a way and saw the orphaned baby elephants at the David Shepherd rescue park. They are entrancing and the long process of re-wilding them once they are fit is impressive. so we are managing our work life balance. Next week Lesley has some work in Chipata and it seemed a good opportunity for Simon to see something of the country - so they are off on the bus on tuesday and Simon is going to spend a night at South Luanga Park. Meanwhile I am left running the training! with the help of the 3 ToT trainees, actually midway through as we are the routine and course content is quite well established. But time will tell. A postscript - I started posting this blog on Friday, only now has the internet connection allowed it!