Doctor of Philosophy
School of Psychology - Faculty of Health and Behavioural Sciences
Casey, Kathleen B, HIV counselling, mental health and psychosocial care in Thailand, PhD thesis, School of Psychology, University of Wollongong, 2007. http://ro.uow.edu.au/theses/73
Rationale: International research has demonstrated that in order to retain a skilled and healthy cadre of willing health-workers there is a need to monitor and develop strategies to mitigate adverse impact of this work and improve the quality and effectiveness of client and patient mental health care.
Aims: (i) Monitor and evaluate Thailand’s national HIV mental health and psychosocial care program. (ii) Measure the impact of HIV mental and psychological care on health care providers. (iii) Examine the relationship between occupation-related psychological morbidity and the recruitment, training, clinical supervision and work-practices of HIV mental health service providers. (iv) Develop, implement and evaluate a training curriculum that addresses the demands of the HIV client population in Thailand.
Method: In Study 1, 826 government hospitals, 1000 government health centres, and 1135 non-government organisations and private providers participated in: semi-structured, key informant interviews; focussed group discussions; and criterion-referenced appraisals of health policy and service delivery. Study 2, a small exploratory, qualitative study, utilised a schema of five key stressors commonly associated with HIV care to analyse responses gained from HIV counsellors and employed semi-structured interviews and focussed discussion groups. Study 3, a cross-sectional study, explored the relationship between training, work practices, Locus of Control of Behaviour and the self-reporting of signs and symptoms of psychological distress. 803 HIV counsellors completed a series of questionnaires including the Thai version of the General Health Questionnaire (GHQ-28), the Locus of Control of Behaviour Questionnaire and the Thai HIV Counsellors Survey (THCS). Study 4 involved the development, delivery and evaluation of a series of short courses designed to train 79 health workers to provide HIV counselling. The training was evaluated by pre and post knowledge examinations and anonymous evaluations.
Results: Study 1 found that policy and legislation failed to adequately guide the practitioner in a number of key areas including: testing and counselling of minors; testing without informed consent; confidentiality of medical records and disclosure of HIV status; and “duty of care” in terms of threatened suicide or harm to others. Furthermore, it was found that epidemiological data had not been adequately considered in terms of providing specific psychological support services, and developing counselling curriculum, and that the conduct of Thai based psychological and operations research had been limited. Whilst there was good national coverage of HIV testing counselling services, psychological services to address HIV issues across the disease continuum were limited and frequently provided by individuals without adequate training. There does not appear to be any systematic mechanism for monitoring and evaluating HIV mental health and psychosocial care. This study also revealed that Thailand is limited in its ability to provide adequate HIV field-experienced, trained mental health care personnel who can teach in the necessary languages that would enable sharing of the Thai health sector experience within the region. Study 2: The respondents identified a number of workplace stressors including: fear of contagion; client-professional boundary issues; difficulties with being identified as working in the sphere of a highly stigmatised disease; the experience of multiple losses, in a context of perceived inadequate training; role expansion; and perceived lack of recognition and reward. Participants also identified a number of work and socio-cultural influences which were perceived to mitigate the impact of the work. Study 3: Failure to take up counselling duties after training was primarily associated with counsellors having too many competing non-counselling duties (31.2%; n=108), and being deployed to other workplaces in a non-counselling capacity (22.8%,n=79). Over 81% (n=441) of respondents who indicated that they were continuing to work as counsellors reported signs and symptoms of psychological disturbance on the GHQ-28 screening at a level that warranted further mental health assessment. There was a significant positive correlation between GHQ-28 “caseness” and Locus of Control of Behaviour scores (r =.118; p<.001). Decisions to leave counselling were positively associated with self reported psychological disturbance (r =.324; p<.001) and the perception that their work was not helpful to clients (r =.108; p<.001). Study 4: The results clearly showed that the curriculum, and method of training resulted in both perceived and measured change in knowledge and skills and were reported to have resulted in improvements in the trainees’ perceived self confidence to meet the demands of their clients.
Conclusion: The studies identified the many challenges inherent in providing effective HIV counselling, mental health and psychosocial services in Thailand. This research suggests that delivering HIV psychosocial care services in Thailand has potentially an adverse impact on: the health and well being of care providers; the quality of care received by clients and patients; and ultimately on the ability of the health system to retain its skilled personnel.
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