Project Launch Field Update from Region 1: Liberia, West Africa

         PROJECT LAUNCH FIELD UPDATE FROM REGION 1: LIBERIA, WEST AFRICA

 
        Since 2003, Liberians have been coping with the aftermath of a 14-year civil war, of which, Post-Traumatic Stress Disorder (PTSD) is still a concerning outcome. A representative national survey indicated that 44% of the total Liberian population presented PTSD symptoms 5 years after the end of the war [1]. Moreover, another study noted that those particularly in specific geographical locations where violent conflicts took place, presented PTSD even twenty years after the conflict [2]. The recent Ebola outbreak in the region exposed this population to a new perceived life threat. Witnessing the severely ill, exposure to deceased bodies, and quarantine procedures were strong triggers for a population with already high incidence of PTSD, propagating new fear behaviors [3], and expected to contribute to a rise in mental disorders [4]. The World Health Organization (WHO) declared Liberia Ebola free on January 3, 2016. Since then, most relief programs gradually left the country. Based on the chronic and debilitating characteristics of PTSD, it was expected that levels of trauma would rise further among communities affected by both emergencies.

The First Target Region

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On June 3rd, 2017, we launched our new trauma relief program, the Sankofa Project, in the Banjor region, one of the most impacted by the Ebola Virus Disease (EVD) outbreak. With the invitation of Mr. Wolabah Yekeku, the community chief, we were guided to the Pinyonkosa village with a list of EVD survivors to commence the outreach.

Recruitment, Assessments, and Preliminary Diagnoses

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     Utilizing the DSM-5 diagnostic criteria for PTSD and Major Depressive Disorder (MDD), the first round of interviews to enroll participants yielded concerning results. In total, 88% of our interviewees qualified for a preliminary diagnosis of PTSD (PCL-5 Criteria including severity of symptoms averaging at 43.3), while 68% also qualified for MDD (PHQ-9 scores > 10). Moreover, 42% presented suicidal ideation. Only 5% diagnosed for MDD without PTSD.

      We also noted that every person interviewed, including the few who did not meet either diagnostic criteria, were highly symptomatic under the DSM-5 PTSD Cluster D, which recognizes negative mood and cognition as a new group of symptoms not previously included in the DSM-IV. Symptoms in cluster D have been widely observed in traumatized individuals with histories of repeated exposure to traumatic experiences, whom are also often diagnosed under “Disorder of Stress Not Otherwise Specified” (DESNOS), and commonly referred to as cases of “complex” trauma, rather than acute PTSD.

      Due to limited resources, we were unable to collect information on further conditions such as anaemia, alcohol, drug use and psychosis for MDD-related symptoms, as recommended by the WHO's Interim Guidance Clinical Care for Survivors of EVD by the WHO (2016). The high incidence of PTSD symptomatology presented among this community may be residual and accentuated from the war period. Among all participants that met that diagnostic criteria for PTSD, 39% also reported surviving severe physical violence during the war, and yet, all of them listed EVD as the "worst stressful event" in their lives (in which the provisional diagnosis is based on).
      Without pre-Ebola mental health assessments, it is difficult to understand how war-related trauma was triggered or worsened due to EVD. It is also premature to suggest that such percentages are representative of all communities impacted by EVD. These initial numbers are a very small but concerning indication of the severe long-term impact of consecutive humanitarian emergencies in mental health.

Group Allocation and Participant Response to Clinical Tasks

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      Participants were allocated to groups based on severity of symptoms. During the first session, the biggest challenge was to motivate participation. We presented the program as as opportunity for individuals to learn techniques which they could utilize to alleviate stress and increase well-being to the body and mind whenever needed. We refrained from speaking about trauma, war, or Ebola to avoid re-traumatization. The stressful event was only briefly noted during the screening process. To learn more about our clinical curriculum, click here. We focus on ANS stabilization, cognitive and interpersonal domains without addressing the traumatic narrative.
     Many felt shy or laughed when asked to try new tasks, such as vocalization, guided imagery and breath work. We empowered them with the choice not to do any task they did not feel comfortable with. Two out of ten group members who completed all exercises shared with the rest of the group a deep sense of wellbeing, further triggering curiosity among others. Despite low participation, everyone returned the following day for session 2 and completed all tasks. By the end of day, 5 out of 10 shared significant relief of somatic symptoms (head, neck, chest, and stomach pain reduced). We will be monitoring symptom improvement at intervention completion, 1, 6 and 12 months. The first set of data will be available in the first week of July here on our website.

The "Vu sound" is a simple Somatic Experiencing (SE) technique in which participants are asked to sustain the sound "VU" while exhaling. The sound creates a pleasant vibration in the stomach, sending cues of safety to the brainstem (a part of the brain that controls vital autonomic body functions) and assists in the stabilisation of the autonomic nervous system (ANS) disregulated by traumatic experiences.

Resonant Breathing is another simple technique that regulates Heart Rate Variability (HRV), further promoting stabilization of the Autonomic Nervous System and alleviating somatic reactions of trauma.
 
Community Health Worker (CHW) Training and Response to Curriculum
Our Liberian staff, experienced in working with traumatized communities, required two hours of training to adapt to the new curriculum format and a meeting for feedback after leading the first group session. We estimate that CHWs without former experience will require two full days of training - one theory, and one practical. Our upcoming implementation in region 2 (Uganda), commencing in July 2017, will provide us a more accurate estimate of training times for non-experienced community workers.

Intervention Application (App) Platform
During the first two weeks, we focused only on clinical challenges, accuracy, and safety of our participants. In the upcoming weeks, we are also beginning to field test all core features of our App prototype v1.0. Our Innovation Director is in Liberia to closely supervise and improve the functionality of the tool according to the needs of our Liberian staff, and limitations of the regions we are targeting. 

Community Response (Non-Participants)
After learning about the Sankofa Project, a group of young adults in the community requested Second Chance to provide training so they can volunteer to help lead groups instead of joining one. As they accurately stated, our staff was too small to meet the demand for services in the community. We are taking note of CHW training interest and look forward to running training sessions when funding permits.

Sankofa Blue Group #11.                                                                        

Sankofa Blue Group #11.                                                                        

We would like to thank and acknowledge all of our supporters and partners for making this project possible. We will continue to share monthly updates from the field so that you can follow how your donation is making a difference. If you haven't donated yet, please consider supporting us today. We stretch every donation to create sustainable impact. 

Footnotes
[1] Johnson et al., 2008
[2] Galea et al, 2010
[3] Chan, 2014
[4] Shultz, Baingana and Neria, 2015

We respect our participant's confidentiality. All images are posted with consent.