Village Health Teams (VHTs) are the primary point of contact for health services in Uganda (Ministry of Health, 2017). VHTs are responsible for basic health interventions, such as recording basic health and demographic data, referring patients to higher-level health services and following-up after appointments, and providing education on health issues to community members (Ministry of Health, 2012). While VHTs have high levels of interaction with the community, there is no evidence of their training in Trauma-Informed Approaches (TIAs). The Village of Lukodi is in Gulu District, Uganda. Gulu was the site of a 20-year civil war, ending in 2006. During the war, over 95% of the population was relocated to Internal Displaced People’s camps (Nampindo et al., 2005). The war left a significant burden of Post-Traumatic Stress Disorder (PTSD) due to a disruption of life, deaths of friends and families, abductions of children to become child soldiers, and sexual assault of women (Ovuga & Larroque, 2012). As a result of coping with war and poverty (Dowhaniuk & Oketa, Unpublished), residents believe the greatest health-related challenge facing the village is Alcohol-Use Disorders (Dowhaniuk et al., In Review). 21.73% of the <18 year old population of Lukodi have probable Alcohol Dependence (AD), with the rate of probable AD in men reaching 36.99% (Dowhaniuk et al., Unpublished). A lack of detailed, local-level data on mental health and non-communicable diseases makes monitoring and evaluation (M&E) difficult for VHTs, researchers, and practitioners.
For this grant, VHTs in Lukodi will be trained on TIAs to better understand the impact of trauma on individual and community level health, help influence individuals towards healthy coping mechanisms, and passively collect community-level data on ACEs using the World Health Organization Adverse Childhood Experience International Questionnaire (WHO ACE-IQ). At the primary prevention level, VHTs will be able to spread knowledge on the impact of ACEs and trauma to community members in order to help community members understand how health-related issues, such as alcohol, can be a coping mechanism for trauma, and not solely an individual-level issue. At the secondary prevention level, VHTs will be able to recognize symptoms and causes of ACEs, passively collect data using the ACE survey for a local ACEs baseline for M&E, and refer individuals to higher level health facilities where mental health services can be offered.
This program will mainly target the community-level of the CDC's Social-Ecological Model (CDC, 2002). By focusing on the community-level, practitioners can focus their efforts on strategies that operate where social relationships occur and the settings and interactions of daily community life. The main justification for focusing on the community level is its potential interactions with the individual, relationship, and societal levels of the Social-Ecological Model. Communities remain an important point of contact for health in Uganda and Sub-Saharan Africa (CDI Study Group, 2010). Through daily interactions with VHTs who utilize a trauma-informed approach and discuss trauma-related illness and ACEs, community members will likely begin to understand the connection between trauma, stress, ACEs, and health. Therefore, the impact of the VHTs are likely to not only influence the community level, but also provide sensitization at the individual level, and potentially impact interpersonal relationships at the relationship level. If the program is well-received by Lukodi community members, there is a high likelihood that local governments will notice and begin to understand Trauma-Informed Approaches, potentially implementing them at higher levels of government or in other communities. In this respect, operating at the community level could result in a transfer of knowledge and skills at other levels, due to the high rate of contact between VHTs, community members, and local government.
Finally, this project utilizes many of the SAMHSA (2014) Trauma-Informed Principles, including trustworthiness and transparency, peer support and mutual self-help, collaboration and mutuality, and empowerment, voice and choice. The continuation of this grant from a long-term CBPR project helps to influence all these principles in mutually supportive ways. The trustworthiness and transparency of the project has been influenced by collaboration and mutuality and empowerment, voice, and choice within the topic selection process and various stages of the research process. Relevant to this project, the CBPR topic of AUDs was selected by community members (highlighting empowerment, voice, and collaboration), and community members and VHTs expressed significant interest in this program through focus groups on community member evidence-based programming. During the focus groups, community members identified VHTs as trustworthy and well-respected individuals in the community. When conducting a focus group with the VHTs, they expressed a desire for this training in order to better serve the community of Lukodi. Collaboration and mutuality are also achieved by ensuring the VHTs are included in the data collection process for monitoring long-term ACEs prevalence in Lukodi and to help ensure future trainings are directed towards areas of need. Finally, by using the community strength of the VHTs, this project is helping to integrate TIAs into the current health system.
References:
CDC. (2002). The Social-Ecological Model: A Framework for Violence Prevention [Data set]. Centers for Disease Control and Prevention Division of Violence Prevention. https://doi.org/10.1037/e585452012-001
CDI Study Group. (2010). Community-directed interventions for priority health problems in Africa: Results of a multicountry study. Bulletin of the World Health Organization, 88(7), 509–518. https://doi.org/10.2471/BLT.09.069203
Dowhaniuk, N., & Oketa, S. (Unpublished). Alcohol-Use Disorders in Gulu District, Uganda: A Grounded Theory Analysis.
Dowhaniuk, N., Oketa, S., & McKune, S. L. (Unpublished). Cross-Sectional Survey of Alcohol-Use Disorders in a Post-Conflict Northern Uganda Community using the World Health Organization Alcohol Use Disorder Identification Test (WHO AUDIT).
Dowhaniuk, N., Oketa, S., & McKune, S. L. (In Review). Perceptions of Community Health Needs and Solutions in Post-Conflict Gulu District, Northern Uganda Using Photovoice.
Ministry of Health. (2017). Annual Health Sector Performance Report FY 2016/17 (Annual Health Sector Performance Report FY 2016/17). Republic of Uganda Ministry of Health.
Ministry of Health Republic of Uganda. (2012). Village Health Team: A handbook to improve health in communities. Ministry of Health. http://article.sciencepublishi...jph.20160402.16.html
Nampindo, S., Phillipps, G. P., & Plumptre, A. (2005). The impact of conflict in northern Uganda on the environment and natural resource management. Wildlife Conservation Society and USAID.
Ovuga, E., & Larroque, C. (2012). Post Traumatic Stress Disorder – A Northern Uganda Clinical Perspective. Post Traumatic Stress Disorders in a Global Context. https://doi.org/10.5772/27605
SAMHSA. (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. Substance Abuse and Mental Health Services Administration.
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