International Review of Psychiatry, August 2014; 26(4): 453–459
Building mental health workforce capacity through training and retention of psychiatrists in Zimbabwe
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MELANIE A. ABAS1,2*, SEKAI M. NHIWATIWA2*, WALTER MANGEZI2, HELEN JACK1,3, ANGHARAD PIETTE1,2, FRANCES M. COWAN5,6**, ELIZABETH BARLEY1,4, ALFRED CHINGONO2, AMY IVERSEN1** & DIXON CHIBANDA2** 1IoPPN, King’s College London, UK, 2Department of Psychiatry, Faculty of Medicine, University of Zimbabwe College of Health Sciences, Mount Pleasant, Harare, Zimbabwe, 3Department of Psychiatry, Oxford University, Oxford, UK, 4Florence Nightingale School of Nursing and Midwifery, King’s College London, UK, 5Department of Infection and Population Health, University College London, UK, and 6Centre for Sexual Health and HIV AIDS Research (CESHHAR), Avondale, Harare, Zimbabwe
Abstract Despite the need to improve the quantity and quality of psychiatry training in sub-Saharan Africa (SSA), very little is known about the experiences of psychiatric trainees in the region. This is the first study examining psychiatric trainees in a low-income country in SSA. It was carried out as part of the needs assessment for a unique Medical Education Partnership Initiative (MEPI) programme to find African solutions for medical shortages in Africa. We approached all doctors who had trained in post-graduate psychiatry in Zimbabwe in 2010 and conducted in-depth qualitative interviews with all except one (n ⫽ 6). We analysed the data using constant comparison and thematic analysis. Trainees described the apprenticeship model as the programme’s primary strength, through providing clinical exposure and role models. Programme weaknesses included shortages in information sources, trainee salaries, trainers, public health education, and in the mental health service. Most respondents were, however, eager to continue practising psychiatry in Zimbabwe, motivated by family ties, national commitment and helping vulnerable, stigmatized individuals. Respondents called for sub-speciality training and for infrastructure and training to do research. Resources need to be made available for psychiatric trainees in more SSA settings to develop public health competencies. However, investment in psychiatry training programmes must balance service provision with trainees’ educational needs. Directing investment towards needs identified by trainees may be a cost-effective, context-sensitive way to increase retention and learning outcomes.
Background Recent reactions to the low number of psychiatrists in low-income countries have been a call for task shifting of mental healthcare to community or lay health workers (Patel, 2009). However, attention is now on education and retention of medical doctors in Africa (Mullan et al., 2011). This is in the face of the recognition that developing health systems still need trained medical specialists for clinical work and education and to take part in management, public mental health and advocacy (Frank, 2005; Horton, 2010; Patel, 2009). Improving recruitment and retention of trained psychiatrists should therefore be a priority in sub-Saharan Africa (SSA), but very little research has been done to gather views of trainee
psychiatrists in SSA about what would encourage them to remain in their home country and what they want from training programmes. High quality training can improve recruitment and retention (Frenk et al., 2011). Recent expert consensus on medical education stresses the importance of developing educational programmes around contextspecific competencies and of engaging students in the design of health education programmes (Aguilera-Guzman et al., 2004; Frenk et al., 2011; Stigler et al., 2010). We aimed to interview all post-graduate psychiatric trainees in Zimbabwe, to understand their experiences of psychiatric education and how this training has influenced their intentions to continue or stop working as psychiatrists in the country.
*Joint first authors. * *These authors contributed equally. Correspondence: Melanie A. Abas, MD, Institute of Psychiatry, King ’s College London, 16 De Crespigny Park, London SE5 8AF, UK. Tel: ⫹ 44 20 7848 0341. E-mail: [email protected] (Received 9 May 2014 ; accepted 12 May 2014 ) ISSN 0954–0261 print/ISSN 1369–1627 online © 2014 Institute of Psychiatry DOI: 10.3109/09540261.2014.924487
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Our findings will help identify innovative training solutions for psychiatry in low-resource settings.
Methods
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Setting: psychiatric training, mental healthcare, and capacity building in Zimbabwe The University of Zimbabwe College of Health Sciences (UZ-CHS) Department of Psychiatry is the only institution in Zimbabwe providing postgraduate psychiatric training. Once one of the most vibrant and research-active departments in the UZ-CHS, the Department of Psychiatry has been severely affected by the economic challenges facing Zimbabwe. Despite this, it continues to teach a 1-year diploma in mental health and a 3-year master’s degree in psychiatry (MMed). The diploma covers clinical care; the MMed additionally covers neuroscience, psychology and sub-specialities. In 2010 there were only seven qualified psychiatrists working in the country, three in government or at UZ-CHS also doing part-time private sector work to supplement their salaries, and the rest full-time in the private sector. Government-funded mental healthcare in Zimbabwe receives less than 1% of the overall health budget (Mangezi & Chibanda, 2010). It is provided through six psychiatric hospitals comprising inpatient wards and outpatient clinics, with little psychosocial or community mental healthcare other than limited follow-up prescribing by primary healthcare workers.
of postgraduate medical and psychiatric curricula (Beresin & Mellman, 2002; Bienenfeld, 2000; Leung & Leung, 2002) and informed by preliminary discussions. Respondents were also asked about their training and confidence in the competencies required to effectively fulfil the seven key roles of a physician: a medical expert, communicator, collaborator, manager, health advocate, scholar and professional (Frank & Danoff, 2007). Data analysis We used principles of constant comparison (Glaser, 1978) and thematic analysis (Braun & Clarke, 2006) to guide data analysis and evaluation. Three researchers (M.A., E.B. and A.P.) independently coded four interviews and agreed on a set of descriptive codes that captured the main ideas expressed in the transcripts. MA and AP then coded the remaining interviews using these codes, adding new codes if they came across an idea not already captured. A code list and a copy of all anonymized transcripts were then given to the Zimbabwean researchers to review. Their comments were incorporated into the coding. We used NVIVO 8 software for code organization and to facilitate code comparison. The whole multidisciplinary research team reviewed the codes and, through discussion, came to consensus about the key themes expressed. Parirenyatwa Hospital Joint Ethics Committee, the Medical Research Council of Zimbabwe and King’s College London Ethics committee granted ethical approval (PNM/12/13-28) for this study.
Sample All doctors who had studied either the diploma or MMed psychiatry training programmes in Zimbabwe during 2010 were invited to participate. There were no exclusion criteria. Data collection One of the authors (M.A.), who has experience working in psychiatry in Zimbabwe but had not taught or supervised any of the respondents, carried out recruitment and conducted all the interviews. All interviews were in-depth, face-to-face, semi-structured, audio-recorded and conducted in English over a 2-week period in 2011. They lasted approximately 50 minutes (range: 35–90 min). Informed written consent was obtained. Interviews were transcribed verbatim and identifying information – such as life stage, gender and whether diploma or MMed – was removed. The interview guide consisted of open-ended questions based on a literature review of components
Results Six of the seven postgraduate trainees were interviewed: two male and four female, four diploma and two MMEed. One diploma graduate was moving to specialize in general medicine, three diploma graduates planned to enter the MMed, and the seventh doctor wanted to take part but was unavailable due to travel difficulties. Themes A list of emerging themes is shown in Fig. 1.
Strengths of training There appeared to be consensus among the respondents that clinical exposure to large numbers of patients with severe mental disorders gave them good experience in assessment, diagnosis, treatment and communication.
Training and retention of psychiatrists in Zimbabwe Strengths of training: Direct supervision and apprenticeship Role models in team work and communication: Volume of exposure to severe mental illness
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Weaknesses of training: Lack of learning resources Lack of exposure to up-to-date evidence Small number of trainers Lack of specialist training opportunities Perceived lack of competencies as manager, advocate and scholar Demoralising service gaps Poor integration with other medical specialties Stigma of psychiatry among health professionals Low salaries Lack of research training Motivating factors for retention: Making a difference in their country through improving mental health Interest in psychiatry Commitments to family and to country Reducing stigma about mental illness
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information sources, no instruction in speciality areas, psychology, or integrated care, no training in advocacy, management, or ethics, little training in research, and low salaries. Many trainees were disheartened by the lack of resources for patient care. ‘A lot of children come with serious problems. Most of the times we end up sending them home because there is no space for them on the wards and a lot of them are lost to follow up, it’s really difficult.’ One respondent recounted paying for medication for a patient with drug-resistant depression. Interviewer: Are you saying the junior doctors paid for her treatment? Respondent: Yes. Because it’s hard to let them suffer.
Fig. 1. Emerging themes in training and retention.
‘The best part I think is the clinical exposure, as we really see a lot of patients and a lot of it I can call psychiatric pathology.’ Trainees appreciated the apprenticeship model, which allowed them to work closely alongside the consultant for many hours, both observing and being observed. Participants reported that they enjoyed the hands-on teaching they received during clinical work on the wards and in outpatient clinics. ‘I think the teaching aspect has been more on the practical side, which is something I appreciate the most.’ Many felt that they particularly benefited from direct feedback from the consultant on their interview style and communication skills. ‘You can actually be instructed and perform something in front of the consultant, which I found to be very challenging and you learn really, much more.’ Respondents also appreciated seminars and small group teaching. ‘I feel quite confident really because of the small number of us, you can’t really run away, they will tell you “it’s better to express it this way”.’
Weaknesses of training The weaknesses that respondents noted in their training were primarily related to resource shortages: poor patient care resources, lack of adequate
All interviewed felt that better Internet access and library resources would significantly improve their training experience. At the time, there was poor Internet access at the hospital and university. Students were paying $2 per minute (2% of their 2010 monthly salary) to use an Internet cafe to access journals. This contributed to respondents’ sense of isolation from the rest of the world and their anxiety about not having up-to-date evidence. ‘I think that’s the biggest problem, that we’ve got very few books in the library.’ ‘People will tell you, “no, this is the baseline, or this is the approach to things”, but it might be an old approach … what is the latest?’ Trainees also noted that an absence of training opportunities in key sub-specialities – such as child psychiatry, forensic psychiatry, liaison psychiatry and community psychiatry – was a barrier to becoming a comprehensively trained psychiatrist. There were no trained child psychiatrists or child neurologists working in the government sector and no training offered in these areas. ‘We have got very limited exposure here. We are not seeing many child psychiatric patients, very few forensic patients.’ Respondents also noted that they felt underprepared to integrate mental and physical healthcare and to perform psychological therapy. ‘I think we need to have rotations which can involve the liaison aspect, on the general medical wards, I think it would be important, especially when you look at chronic diseases.’ ‘We do have
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lectures, but no clinical exposure to doing psychotherapy sessions.’
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When asked about training in management, public health and advocacy, all respondents indicated that they had not received any. Most understood advocacy only at the individual patient level, so gave examples of referring individuals for social welfare or to Alcoholics Anonymous.
‘We have a little business actually, that’s how we manage to send our children to school, you have to divide your time between, which is not good.’ Retention following training Factors that encourage psychiatric practice in Zimbabwe
‘It hasn’t been formalized. I’m going to be a manager, how will I manage this?’
Strong interest in mental health, belief in the importance of psychiatry, and commitment to family and country motivated participants to continue working in psychiatry in Zimbabwe.
They also voiced a desire for training in ethics and in professionalism; e.g. ethical concerns about patients having side effects.
‘It’s [psychiatry] quite beautiful ... There’s no right or wrong answer but you know, you need to read a lot … So it’s quite challenging.’
‘There is only one professional organization … I’m not sure what they do there.’
All trainees stated that they intended to remain in Zimbabwe. The one respondent who planned to leave psychiatry said he would have continued if subspeciality training opportunities were available. A key motivating factor for all respondents to remain in Zimbabwe was family.
Respondents’ frustration was particularly apparent when discussing how competent they felt as a ‘scholar’. Most were worried about being ill-prepared in research methods. ‘You are just doing it blindly; you are not sure what you are doing. That’s one of the weaknesses that I find in this course, if they could expose people to more research.’ More than half of respondents believed that if they had better training in research, they could bring in research grants to subsidize their government salaries. They saw doctors working in other specialities successfully earning research salaries. Even now, whilst training, most have problems. You have to balance your training and looking for money in other places, doing locums, running a practice, all sorts of other things, which sometimes distract you away from your studies… Yeah, if you get a fellowship, then at least, you can rest your mind. All respondents stated that they could not afford to live off the salary they received as psychiatry trainees, pushing them to consider working outside the country. ‘What’s forcing people sometimes to leave when they don’t want to leave are basically the salaries that they are giving people.’ Some trainees worked shifts as locum doctors, relied on relatives for support, or had income from business ventures outside medicine, including running a taxi service, working in a restaurant, or doing paid upholstery.
‘Well, truly speaking I’m in Zimbabwe because of my family, and my family is not moving from here and I’m going to stay here.’ They also expressed a love of and commitment to their nation and valued the appreciation they got from their patients. ‘I like Zimbabwe a lot, no matter how much hardship we went through in the last 7 years, still there is something about this country that I like. Something about the patients which I like. They give you a special respect.’ Many respondents expressed a strong motivation to ‘make a difference’ by improving mental health in their country and reducing the stigma and misunderstanding surrounding mental illness. ‘I would like to be known for changing the plight of children afflicted with mental illness.’ As part of their aspiration to improve mental health, three trainees described plans to move to rural areas of Zimbabwe to practise psychiatry. ‘I would love to maybe just, in a way, go around the country, training people, improving mental health ... training the clients themselves.’ Respondents also described stigma against mental healthcare in the wider community, which was demoralizing but also motivated some trainees to want to bring about change.
Training and retention of psychiatrists in Zimbabwe ‘Here in Africa, people don’t believe in mental health, because they will tell you, “there are evil spirits and everything and there’s a lot of witchcraft” … We need to demystify the whole profession itself.’
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Factors that discourage government psychiatric practice in Zimbabwe Low salaries, stigma of mental health, and lack of willingness from other health professionals to engage in mental healthcare made it difficult for the trainees to continue practising in Zimbabwe following training. Many of the trainees mentioned that they would need to enter private practice to supplement government sector salaries. In part due to the low salaries of psychiatrists, many respondents felt that other medical professionals stigmatized mental healthcare. ‘If I tell anyone I’m going to do say psychiatry they say, “Ay! Do you want to be poor?”.’ The trainees observed that colleagues in other specialities knew little about psychiatry, were resistant to integrating mental healthcare into their own clinical practice, and were generally disrespectful of psychiatry, which impacted trainee morale and patient care. ‘There’s basically no coordination between the psychiatric department and the department who look after HIV positive patients which I find very, very disturbing actually.’
Discussion Our study is the first to gather the views of trainee psychiatrists in a low-income SSA country. We found that most trainees are committed to continuing psychiatry in their home country, but shortages in learning resources such as books and Internet access and little opportunity for sub-speciality experience limited the effectiveness of the training programme and dampened enthusiasm. These findings fit with two previous systematic reviews about retention factors across the general health workforce in low-income settings and with a study in Ghana across a range of mental health workers showing that professional training, appreciation, career development and infrastructure are important factors in attracting and retaining health staff in low-income countries, as well as financial rewards (Jack et al., 2013; Lehmann et al., 2008; Willis-Shattuck et al., 2008). Although our respondents wanted to help society none asked for training in being educators or in how to develop
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health systems (Horton, 2010). Factors encouraging the respondents to ‘stick’ in Zimbabwe were commitments to family and country (Padarath et al., 2003). One of the strongest elements of the existing training programme was the traditional apprenticeship model, involving many hours of clinical exposure and mentorship (Dornan, 2005). A training programme, however, cannot rely only on this model. Future interventions could build on the successful apprenticeship model, adding elements to make it more of an active learning experience and incorporating sub-speciality training. One striking finding in our study not emphasized in previous literature on psychiatry education in Africa was the strategies being used to cope with low trainee salaries. Trainees were coping financially only by having a second job or being subsidized through savings or relatives, and all envisaged having to take on private work once qualified. The importance of private practice in subsidizing government salaries for African psychiatrists has not been adequately discussed previously and should be addressed in training programmes. Another key finding was that respondents thought that the ability to do psychiatry research would motivate them to stay in the field and would raise the status of psychiatry among other medical professionals through adding to scientific knowledge as well as being a source of income (Chu et al., 2014). Although we were able to interview 86% (6/7) of all psychiatric trainees nationally, study limitations include the small sample size that was limited by the number of trainees in the country. As the number of trainees and trainers is small, participants may not have been candid. This study was conducted in Zimbabwe and the findings may not be generalizable to other settings. However, through discussions through the African-wide Medical Education Partnership Initiative (MEPI) network (MEPI, 2014; Mullan et al., 2012) there seem to be relevant messages for other regions. Our experience since these and other data were collected on medical training in Zimbabwe shows how investment can follow from training programme evaluation. The University of Zimbabwe College of Health Sciences has been leading a major capacity building programme funded through the MEPI (Jombo et al., 2011; MEPI, 2014). Investments have since been made in Internet and intranet capability, the library, faculty staff development and an education leadership programme (Connors et al., 2013). A research support centre is being built. Twelve psychiatry master classes have been held supported through external partnerships with universities in the UK, South Africa and the USA, co-taught with local faculty staff. Ten mental health scholars have been appointed, mentored by external and local faculty. A
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child psychiatry clinic and an HIV mental health clinic have been established and a research platform is emerging (IoP, 2012), both providing training opportunities. Psychiatry faculty staffing at UZ-CHS has increased from two to four, and three faculty staff members have registered for PhDs. These changes demonstrate the revival that can occur in a short time frame. Policy makers, researchers, hospital managers and others implementing psychiatric training programmes in a low- or middle-income country may draw a number of lessons from our findings. There can be great value in consulting with trainees when designing or monitoring programmes, as part of a broader evaluation effort of programmes aiming to both educate and retain. Particularly in situations with limited resources, consulting with trainees allows for targeted resource investments that satisfy trainee needs and interests, which are likely to include adequate salaries, IT resources, basic patient care resources, and journal subscriptions. Additionally, future interventions could strengthen existing apprenticeship models by adding more active learning approaches and incorporating sub-speciality training and public health training. To facilitate a stronger apprenticeship model, consultant trainers in SSA medical schools need to be updated on public health aspects of psychiatry and to devote regular time to working outside hospitals, enabling them to provide a learning environment and expertise that will build trainees’ skills and interest in working in a rural or primary care setting. A further lesson is to ensure opportunities for psychiatrists to engage in research projects, potentially in collaboration with institutions from high-income countries, in which they are given leadership roles and are able to help drive the research agenda (Chu et al., 2014). Research may help with retention of psychiatrists while contributing data that could be valuable within a developing health system, but will necessitate that psychiatrists get some training in research methods and the challenges of conducting research in low-income settings (Chu et al., 2014). Building capacity in research and sub-specialities could be achieved by widening the pool of local training opportunities, for example through linkage with non-governmental organizations or private practitioners, regional placements, research training fellowships and in-country capacity-building by visiting collaborators. Long-standing, mutually beneficial educational partnerships between higher and lower income settings have been described (Alem & Kebede, 2003; Sapag et al., 2013; TAAP, 2011).
disabling mental disorders in lower income countries. It will also potentially increase availability of psychiatrists equipped to take on public health and supervisory roles, which will be critical as task-shifting of mental healthcare to non-specialist health workers is scaled up in many countries (Breuer et al., 2014). However, resources need to be made available for psychiatric trainees in more SSA settings to develop public health competencies, for example in leadership, teaching and advocacy (TAAP, 2011). Increasing the prestige of and training quality in psychiatric specialization programmes could reduce the stigma of mental healthcare and increase interest in psychiatry among medical students, which could lead to further increases in the number of psychiatrists and improved attitudes toward psychiatry among physicians in other specialities and in primary care. While training programmes must address interests of trainees, they must also meet the needs of the health system and the population. The current model of psychiatry training in many African medical schools is based on individual patient care within specialist psychiatric services, although some medical schools in SSA are moving to innovative community-based education models (Mullan et al., 2011). Conclusions Training the specialist mental health workforce is crucial for improving health outcomes in Africa and for reducing the mental health treatment gap (Willis-Shattuck, et al., 2008). Many international organizations, including the World Health Organization and the US President’s Emergency Plan for AIDS Relief are investing in medical education. This study demonstrates that future psychiatrists want strong clinical skills, information sources, integration of physical and mental healthcare, and research training. Directing resource investment towards locally identified training needs and key resource shortages that trainees find demotivating may be a cost-effective, context-sensitive way to increase retention and learning outcomes. Investment should also be made available for trainees to develop competencies which might lead to more interest in a public health approach. However, training programmes must not neglect the interests of trainees, including sub-speciality training and opportunities for research. Lack of such opportunities could prompt students to leave psychiatry or to practise outside of their home country.
Implications for population mental health Given the massive shortage of psychiatrists, improving recruitment, retention, and training of psychiatrists will increase access to vital specialized care, which is necessary and may reduce the burden of untreated
Acknowledgements A.I., D.C. and M.A. conceptualized the study. M.A. wrote the first draft, and undertook data collection
Training and retention of psychiatrists in Zimbabwe
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and analysis. A.P. wrote the second draft and undertook analysis. E.B. supervised data analysis, S.N., W.M., D.C, A.C. and F.C. undertook data analysis. H.J. and F.C. and S.N. interpreted and wrote the third draft. All authors edited and contributed to final draft. Declaration of interest: The Fogarty International Centre, the Office of the Director, National Institute of Health (IR24TW008893-01REVISED) contributed to costs of transcribing, data analysis and write-up through a grant to the University of Zimbabwe, but took no role in study design or interpretation. The authors alone are responsible for the content and writing of the paper. References Aguilera-Guzman, R.M., de Snyder, V., Romero, M., & MedinaMora, M.E. (2004). Paternal absence and international migration: Stressors and compensators associated with the mental health of Mexican teenagers of rural origin. Adolescence, 39, 711–723. Alem, A., & Kebede, D. (2003). Conducting psychiatric research in the developing world: Challenges and rewards. British Journal of Psychiatry, 182, 185–187. Beresin, E.M.D., & Mellman, L.M.D. (2002). Competencies in psychiatry: The new outcomes-based approach to medical training and education. Harvard Review of Psychiatry, 10, 185–191. Bienenfeld, D. & Klykylo, W. (2000). Process and product: Development of competency-based measures for psychiatry residency. Academic Psychiatry, 24, 68–76. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology Qualitative Research in Psychology, 3, 77–101. Breuer, E., De Silva, M., Fekadu, A., Luitel, N. P., Murhar, V., Nakku, J., ... Lund, C. (2014). Using workshops to develop theories of change in five low and middle income countries: Lessons from the Programme for Improving Mental Health Care (PRIME). International Journal of Mental Health Systems, 8, 15. Chu, K.M., Jayaraman, S., Kyamanywa, P., & Ntakiyiruta, G. (2014). Building research capacity in Africa: Equity and global health collaborations. PLOS Medicine, 11(3), e1001612. Connors, S.C., Challender, A., Gandari, J., Nyaude, S., Proctor, J., & Walters, B. (2013). The way forward: Year two of the MEPI grant programs in Zimbabwe.: University of Colorado Denver: The Evaluation Center. Dornan, T. (2005). Osler, Flexner, apprenticeship and ‘the new medical education’. Journal of the Royal Society of Medicine, 98, 91–95. Frank, J. (2005). The CanMEDS 2005 Physician Competency Framework. Better Standards, Better Physicians, Better Care. Ottawa, ON: Royal College of Physicians and Surgeons of Canada. Frank, J. R., & Danoff , D. (2007). The CanMEDS initiative: Implementing an outcomes-based framework of physician competencies. Medical Teacher, 29, 642–647.
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Building mental health workforce capacity through training and retention of psychiatrists in Zimbabwe
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MELANIE A. ABAS1,2*, SEKAI M. NHIWATIWA2*, WALTER MANGEZI2, HELEN JACK1,3, ANGHARAD PIETTE1,2, FRANCES M. COWAN5,6**, ELIZABETH BARLEY1,4, ALFRED CHINGONO2, AMY IVERSEN1** & DIXON CHIBANDA2** 1IoPPN, King’s College London, UK, 2Department of Psychiatry, Faculty of Medicine, University of Zimbabwe College of Health Sciences, Mount Pleasant, Harare, Zimbabwe, 3Department of Psychiatry, Oxford University, Oxford, UK, 4Florence Nightingale School of Nursing and Midwifery, King’s College London, UK, 5Department of Infection and Population Health, University College London, UK, and 6Centre for Sexual Health and HIV AIDS Research (CESHHAR), Avondale, Harare, Zimbabwe
Abstract Despite the need to improve the quantity and quality of psychiatry training in sub-Saharan Africa (SSA), very little is known about the experiences of psychiatric trainees in the region. This is the first study examining psychiatric trainees in a low-income country in SSA. It was carried out as part of the needs assessment for a unique Medical Education Partnership Initiative (MEPI) programme to find African solutions for medical shortages in Africa. We approached all doctors who had trained in post-graduate psychiatry in Zimbabwe in 2010 and conducted in-depth qualitative interviews with all except one (n ⫽ 6). We analysed the data using constant comparison and thematic analysis. Trainees described the apprenticeship model as the programme’s primary strength, through providing clinical exposure and role models. Programme weaknesses included shortages in information sources, trainee salaries, trainers, public health education, and in the mental health service. Most respondents were, however, eager to continue practising psychiatry in Zimbabwe, motivated by family ties, national commitment and helping vulnerable, stigmatized individuals. Respondents called for sub-speciality training and for infrastructure and training to do research. Resources need to be made available for psychiatric trainees in more SSA settings to develop public health competencies. However, investment in psychiatry training programmes must balance service provision with trainees’ educational needs. Directing investment towards needs identified by trainees may be a cost-effective, context-sensitive way to increase retention and learning outcomes.
Background Recent reactions to the low number of psychiatrists in low-income countries have been a call for task shifting of mental healthcare to community or lay health workers (Patel, 2009). However, attention is now on education and retention of medical doctors in Africa (Mullan et al., 2011). This is in the face of the recognition that developing health systems still need trained medical specialists for clinical work and education and to take part in management, public mental health and advocacy (Frank, 2005; Horton, 2010; Patel, 2009). Improving recruitment and retention of trained psychiatrists should therefore be a priority in sub-Saharan Africa (SSA), but very little research has been done to gather views of trainee
psychiatrists in SSA about what would encourage them to remain in their home country and what they want from training programmes. High quality training can improve recruitment and retention (Frenk et al., 2011). Recent expert consensus on medical education stresses the importance of developing educational programmes around contextspecific competencies and of engaging students in the design of health education programmes (Aguilera-Guzman et al., 2004; Frenk et al., 2011; Stigler et al., 2010). We aimed to interview all post-graduate psychiatric trainees in Zimbabwe, to understand their experiences of psychiatric education and how this training has influenced their intentions to continue or stop working as psychiatrists in the country.
*Joint first authors. * *These authors contributed equally. Correspondence: Melanie A. Abas, MD, Institute of Psychiatry, King ’s College London, 16 De Crespigny Park, London SE5 8AF, UK. Tel: ⫹ 44 20 7848 0341. E-mail: [email protected] (Received 9 May 2014 ; accepted 12 May 2014 ) ISSN 0954–0261 print/ISSN 1369–1627 online © 2014 Institute of Psychiatry DOI: 10.3109/09540261.2014.924487
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Our findings will help identify innovative training solutions for psychiatry in low-resource settings.
Methods
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Setting: psychiatric training, mental healthcare, and capacity building in Zimbabwe The University of Zimbabwe College of Health Sciences (UZ-CHS) Department of Psychiatry is the only institution in Zimbabwe providing postgraduate psychiatric training. Once one of the most vibrant and research-active departments in the UZ-CHS, the Department of Psychiatry has been severely affected by the economic challenges facing Zimbabwe. Despite this, it continues to teach a 1-year diploma in mental health and a 3-year master’s degree in psychiatry (MMed). The diploma covers clinical care; the MMed additionally covers neuroscience, psychology and sub-specialities. In 2010 there were only seven qualified psychiatrists working in the country, three in government or at UZ-CHS also doing part-time private sector work to supplement their salaries, and the rest full-time in the private sector. Government-funded mental healthcare in Zimbabwe receives less than 1% of the overall health budget (Mangezi & Chibanda, 2010). It is provided through six psychiatric hospitals comprising inpatient wards and outpatient clinics, with little psychosocial or community mental healthcare other than limited follow-up prescribing by primary healthcare workers.
of postgraduate medical and psychiatric curricula (Beresin & Mellman, 2002; Bienenfeld, 2000; Leung & Leung, 2002) and informed by preliminary discussions. Respondents were also asked about their training and confidence in the competencies required to effectively fulfil the seven key roles of a physician: a medical expert, communicator, collaborator, manager, health advocate, scholar and professional (Frank & Danoff, 2007). Data analysis We used principles of constant comparison (Glaser, 1978) and thematic analysis (Braun & Clarke, 2006) to guide data analysis and evaluation. Three researchers (M.A., E.B. and A.P.) independently coded four interviews and agreed on a set of descriptive codes that captured the main ideas expressed in the transcripts. MA and AP then coded the remaining interviews using these codes, adding new codes if they came across an idea not already captured. A code list and a copy of all anonymized transcripts were then given to the Zimbabwean researchers to review. Their comments were incorporated into the coding. We used NVIVO 8 software for code organization and to facilitate code comparison. The whole multidisciplinary research team reviewed the codes and, through discussion, came to consensus about the key themes expressed. Parirenyatwa Hospital Joint Ethics Committee, the Medical Research Council of Zimbabwe and King’s College London Ethics committee granted ethical approval (PNM/12/13-28) for this study.
Sample All doctors who had studied either the diploma or MMed psychiatry training programmes in Zimbabwe during 2010 were invited to participate. There were no exclusion criteria. Data collection One of the authors (M.A.), who has experience working in psychiatry in Zimbabwe but had not taught or supervised any of the respondents, carried out recruitment and conducted all the interviews. All interviews were in-depth, face-to-face, semi-structured, audio-recorded and conducted in English over a 2-week period in 2011. They lasted approximately 50 minutes (range: 35–90 min). Informed written consent was obtained. Interviews were transcribed verbatim and identifying information – such as life stage, gender and whether diploma or MMed – was removed. The interview guide consisted of open-ended questions based on a literature review of components
Results Six of the seven postgraduate trainees were interviewed: two male and four female, four diploma and two MMEed. One diploma graduate was moving to specialize in general medicine, three diploma graduates planned to enter the MMed, and the seventh doctor wanted to take part but was unavailable due to travel difficulties. Themes A list of emerging themes is shown in Fig. 1.
Strengths of training There appeared to be consensus among the respondents that clinical exposure to large numbers of patients with severe mental disorders gave them good experience in assessment, diagnosis, treatment and communication.
Training and retention of psychiatrists in Zimbabwe Strengths of training: Direct supervision and apprenticeship Role models in team work and communication: Volume of exposure to severe mental illness
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Weaknesses of training: Lack of learning resources Lack of exposure to up-to-date evidence Small number of trainers Lack of specialist training opportunities Perceived lack of competencies as manager, advocate and scholar Demoralising service gaps Poor integration with other medical specialties Stigma of psychiatry among health professionals Low salaries Lack of research training Motivating factors for retention: Making a difference in their country through improving mental health Interest in psychiatry Commitments to family and to country Reducing stigma about mental illness
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information sources, no instruction in speciality areas, psychology, or integrated care, no training in advocacy, management, or ethics, little training in research, and low salaries. Many trainees were disheartened by the lack of resources for patient care. ‘A lot of children come with serious problems. Most of the times we end up sending them home because there is no space for them on the wards and a lot of them are lost to follow up, it’s really difficult.’ One respondent recounted paying for medication for a patient with drug-resistant depression. Interviewer: Are you saying the junior doctors paid for her treatment? Respondent: Yes. Because it’s hard to let them suffer.
Fig. 1. Emerging themes in training and retention.
‘The best part I think is the clinical exposure, as we really see a lot of patients and a lot of it I can call psychiatric pathology.’ Trainees appreciated the apprenticeship model, which allowed them to work closely alongside the consultant for many hours, both observing and being observed. Participants reported that they enjoyed the hands-on teaching they received during clinical work on the wards and in outpatient clinics. ‘I think the teaching aspect has been more on the practical side, which is something I appreciate the most.’ Many felt that they particularly benefited from direct feedback from the consultant on their interview style and communication skills. ‘You can actually be instructed and perform something in front of the consultant, which I found to be very challenging and you learn really, much more.’ Respondents also appreciated seminars and small group teaching. ‘I feel quite confident really because of the small number of us, you can’t really run away, they will tell you “it’s better to express it this way”.’
Weaknesses of training The weaknesses that respondents noted in their training were primarily related to resource shortages: poor patient care resources, lack of adequate
All interviewed felt that better Internet access and library resources would significantly improve their training experience. At the time, there was poor Internet access at the hospital and university. Students were paying $2 per minute (2% of their 2010 monthly salary) to use an Internet cafe to access journals. This contributed to respondents’ sense of isolation from the rest of the world and their anxiety about not having up-to-date evidence. ‘I think that’s the biggest problem, that we’ve got very few books in the library.’ ‘People will tell you, “no, this is the baseline, or this is the approach to things”, but it might be an old approach … what is the latest?’ Trainees also noted that an absence of training opportunities in key sub-specialities – such as child psychiatry, forensic psychiatry, liaison psychiatry and community psychiatry – was a barrier to becoming a comprehensively trained psychiatrist. There were no trained child psychiatrists or child neurologists working in the government sector and no training offered in these areas. ‘We have got very limited exposure here. We are not seeing many child psychiatric patients, very few forensic patients.’ Respondents also noted that they felt underprepared to integrate mental and physical healthcare and to perform psychological therapy. ‘I think we need to have rotations which can involve the liaison aspect, on the general medical wards, I think it would be important, especially when you look at chronic diseases.’ ‘We do have
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lectures, but no clinical exposure to doing psychotherapy sessions.’
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When asked about training in management, public health and advocacy, all respondents indicated that they had not received any. Most understood advocacy only at the individual patient level, so gave examples of referring individuals for social welfare or to Alcoholics Anonymous.
‘We have a little business actually, that’s how we manage to send our children to school, you have to divide your time between, which is not good.’ Retention following training Factors that encourage psychiatric practice in Zimbabwe
‘It hasn’t been formalized. I’m going to be a manager, how will I manage this?’
Strong interest in mental health, belief in the importance of psychiatry, and commitment to family and country motivated participants to continue working in psychiatry in Zimbabwe.
They also voiced a desire for training in ethics and in professionalism; e.g. ethical concerns about patients having side effects.
‘It’s [psychiatry] quite beautiful ... There’s no right or wrong answer but you know, you need to read a lot … So it’s quite challenging.’
‘There is only one professional organization … I’m not sure what they do there.’
All trainees stated that they intended to remain in Zimbabwe. The one respondent who planned to leave psychiatry said he would have continued if subspeciality training opportunities were available. A key motivating factor for all respondents to remain in Zimbabwe was family.
Respondents’ frustration was particularly apparent when discussing how competent they felt as a ‘scholar’. Most were worried about being ill-prepared in research methods. ‘You are just doing it blindly; you are not sure what you are doing. That’s one of the weaknesses that I find in this course, if they could expose people to more research.’ More than half of respondents believed that if they had better training in research, they could bring in research grants to subsidize their government salaries. They saw doctors working in other specialities successfully earning research salaries. Even now, whilst training, most have problems. You have to balance your training and looking for money in other places, doing locums, running a practice, all sorts of other things, which sometimes distract you away from your studies… Yeah, if you get a fellowship, then at least, you can rest your mind. All respondents stated that they could not afford to live off the salary they received as psychiatry trainees, pushing them to consider working outside the country. ‘What’s forcing people sometimes to leave when they don’t want to leave are basically the salaries that they are giving people.’ Some trainees worked shifts as locum doctors, relied on relatives for support, or had income from business ventures outside medicine, including running a taxi service, working in a restaurant, or doing paid upholstery.
‘Well, truly speaking I’m in Zimbabwe because of my family, and my family is not moving from here and I’m going to stay here.’ They also expressed a love of and commitment to their nation and valued the appreciation they got from their patients. ‘I like Zimbabwe a lot, no matter how much hardship we went through in the last 7 years, still there is something about this country that I like. Something about the patients which I like. They give you a special respect.’ Many respondents expressed a strong motivation to ‘make a difference’ by improving mental health in their country and reducing the stigma and misunderstanding surrounding mental illness. ‘I would like to be known for changing the plight of children afflicted with mental illness.’ As part of their aspiration to improve mental health, three trainees described plans to move to rural areas of Zimbabwe to practise psychiatry. ‘I would love to maybe just, in a way, go around the country, training people, improving mental health ... training the clients themselves.’ Respondents also described stigma against mental healthcare in the wider community, which was demoralizing but also motivated some trainees to want to bring about change.
Training and retention of psychiatrists in Zimbabwe ‘Here in Africa, people don’t believe in mental health, because they will tell you, “there are evil spirits and everything and there’s a lot of witchcraft” … We need to demystify the whole profession itself.’
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Factors that discourage government psychiatric practice in Zimbabwe Low salaries, stigma of mental health, and lack of willingness from other health professionals to engage in mental healthcare made it difficult for the trainees to continue practising in Zimbabwe following training. Many of the trainees mentioned that they would need to enter private practice to supplement government sector salaries. In part due to the low salaries of psychiatrists, many respondents felt that other medical professionals stigmatized mental healthcare. ‘If I tell anyone I’m going to do say psychiatry they say, “Ay! Do you want to be poor?”.’ The trainees observed that colleagues in other specialities knew little about psychiatry, were resistant to integrating mental healthcare into their own clinical practice, and were generally disrespectful of psychiatry, which impacted trainee morale and patient care. ‘There’s basically no coordination between the psychiatric department and the department who look after HIV positive patients which I find very, very disturbing actually.’
Discussion Our study is the first to gather the views of trainee psychiatrists in a low-income SSA country. We found that most trainees are committed to continuing psychiatry in their home country, but shortages in learning resources such as books and Internet access and little opportunity for sub-speciality experience limited the effectiveness of the training programme and dampened enthusiasm. These findings fit with two previous systematic reviews about retention factors across the general health workforce in low-income settings and with a study in Ghana across a range of mental health workers showing that professional training, appreciation, career development and infrastructure are important factors in attracting and retaining health staff in low-income countries, as well as financial rewards (Jack et al., 2013; Lehmann et al., 2008; Willis-Shattuck et al., 2008). Although our respondents wanted to help society none asked for training in being educators or in how to develop
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health systems (Horton, 2010). Factors encouraging the respondents to ‘stick’ in Zimbabwe were commitments to family and country (Padarath et al., 2003). One of the strongest elements of the existing training programme was the traditional apprenticeship model, involving many hours of clinical exposure and mentorship (Dornan, 2005). A training programme, however, cannot rely only on this model. Future interventions could build on the successful apprenticeship model, adding elements to make it more of an active learning experience and incorporating sub-speciality training. One striking finding in our study not emphasized in previous literature on psychiatry education in Africa was the strategies being used to cope with low trainee salaries. Trainees were coping financially only by having a second job or being subsidized through savings or relatives, and all envisaged having to take on private work once qualified. The importance of private practice in subsidizing government salaries for African psychiatrists has not been adequately discussed previously and should be addressed in training programmes. Another key finding was that respondents thought that the ability to do psychiatry research would motivate them to stay in the field and would raise the status of psychiatry among other medical professionals through adding to scientific knowledge as well as being a source of income (Chu et al., 2014). Although we were able to interview 86% (6/7) of all psychiatric trainees nationally, study limitations include the small sample size that was limited by the number of trainees in the country. As the number of trainees and trainers is small, participants may not have been candid. This study was conducted in Zimbabwe and the findings may not be generalizable to other settings. However, through discussions through the African-wide Medical Education Partnership Initiative (MEPI) network (MEPI, 2014; Mullan et al., 2012) there seem to be relevant messages for other regions. Our experience since these and other data were collected on medical training in Zimbabwe shows how investment can follow from training programme evaluation. The University of Zimbabwe College of Health Sciences has been leading a major capacity building programme funded through the MEPI (Jombo et al., 2011; MEPI, 2014). Investments have since been made in Internet and intranet capability, the library, faculty staff development and an education leadership programme (Connors et al., 2013). A research support centre is being built. Twelve psychiatry master classes have been held supported through external partnerships with universities in the UK, South Africa and the USA, co-taught with local faculty staff. Ten mental health scholars have been appointed, mentored by external and local faculty. A
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child psychiatry clinic and an HIV mental health clinic have been established and a research platform is emerging (IoP, 2012), both providing training opportunities. Psychiatry faculty staffing at UZ-CHS has increased from two to four, and three faculty staff members have registered for PhDs. These changes demonstrate the revival that can occur in a short time frame. Policy makers, researchers, hospital managers and others implementing psychiatric training programmes in a low- or middle-income country may draw a number of lessons from our findings. There can be great value in consulting with trainees when designing or monitoring programmes, as part of a broader evaluation effort of programmes aiming to both educate and retain. Particularly in situations with limited resources, consulting with trainees allows for targeted resource investments that satisfy trainee needs and interests, which are likely to include adequate salaries, IT resources, basic patient care resources, and journal subscriptions. Additionally, future interventions could strengthen existing apprenticeship models by adding more active learning approaches and incorporating sub-speciality training and public health training. To facilitate a stronger apprenticeship model, consultant trainers in SSA medical schools need to be updated on public health aspects of psychiatry and to devote regular time to working outside hospitals, enabling them to provide a learning environment and expertise that will build trainees’ skills and interest in working in a rural or primary care setting. A further lesson is to ensure opportunities for psychiatrists to engage in research projects, potentially in collaboration with institutions from high-income countries, in which they are given leadership roles and are able to help drive the research agenda (Chu et al., 2014). Research may help with retention of psychiatrists while contributing data that could be valuable within a developing health system, but will necessitate that psychiatrists get some training in research methods and the challenges of conducting research in low-income settings (Chu et al., 2014). Building capacity in research and sub-specialities could be achieved by widening the pool of local training opportunities, for example through linkage with non-governmental organizations or private practitioners, regional placements, research training fellowships and in-country capacity-building by visiting collaborators. Long-standing, mutually beneficial educational partnerships between higher and lower income settings have been described (Alem & Kebede, 2003; Sapag et al., 2013; TAAP, 2011).
disabling mental disorders in lower income countries. It will also potentially increase availability of psychiatrists equipped to take on public health and supervisory roles, which will be critical as task-shifting of mental healthcare to non-specialist health workers is scaled up in many countries (Breuer et al., 2014). However, resources need to be made available for psychiatric trainees in more SSA settings to develop public health competencies, for example in leadership, teaching and advocacy (TAAP, 2011). Increasing the prestige of and training quality in psychiatric specialization programmes could reduce the stigma of mental healthcare and increase interest in psychiatry among medical students, which could lead to further increases in the number of psychiatrists and improved attitudes toward psychiatry among physicians in other specialities and in primary care. While training programmes must address interests of trainees, they must also meet the needs of the health system and the population. The current model of psychiatry training in many African medical schools is based on individual patient care within specialist psychiatric services, although some medical schools in SSA are moving to innovative community-based education models (Mullan et al., 2011). Conclusions Training the specialist mental health workforce is crucial for improving health outcomes in Africa and for reducing the mental health treatment gap (Willis-Shattuck, et al., 2008). Many international organizations, including the World Health Organization and the US President’s Emergency Plan for AIDS Relief are investing in medical education. This study demonstrates that future psychiatrists want strong clinical skills, information sources, integration of physical and mental healthcare, and research training. Directing resource investment towards locally identified training needs and key resource shortages that trainees find demotivating may be a cost-effective, context-sensitive way to increase retention and learning outcomes. Investment should also be made available for trainees to develop competencies which might lead to more interest in a public health approach. However, training programmes must not neglect the interests of trainees, including sub-speciality training and opportunities for research. Lack of such opportunities could prompt students to leave psychiatry or to practise outside of their home country.
Implications for population mental health Given the massive shortage of psychiatrists, improving recruitment, retention, and training of psychiatrists will increase access to vital specialized care, which is necessary and may reduce the burden of untreated
Acknowledgements A.I., D.C. and M.A. conceptualized the study. M.A. wrote the first draft, and undertook data collection
Training and retention of psychiatrists in Zimbabwe
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and analysis. A.P. wrote the second draft and undertook analysis. E.B. supervised data analysis, S.N., W.M., D.C, A.C. and F.C. undertook data analysis. H.J. and F.C. and S.N. interpreted and wrote the third draft. All authors edited and contributed to final draft. Declaration of interest: The Fogarty International Centre, the Office of the Director, National Institute of Health (IR24TW008893-01REVISED) contributed to costs of transcribing, data analysis and write-up through a grant to the University of Zimbabwe, but took no role in study design or interpretation. The authors alone are responsible for the content and writing of the paper. References Aguilera-Guzman, R.M., de Snyder, V., Romero, M., & MedinaMora, M.E. (2004). Paternal absence and international migration: Stressors and compensators associated with the mental health of Mexican teenagers of rural origin. Adolescence, 39, 711–723. Alem, A., & Kebede, D. (2003). Conducting psychiatric research in the developing world: Challenges and rewards. British Journal of Psychiatry, 182, 185–187. Beresin, E.M.D., & Mellman, L.M.D. (2002). Competencies in psychiatry: The new outcomes-based approach to medical training and education. Harvard Review of Psychiatry, 10, 185–191. Bienenfeld, D. & Klykylo, W. (2000). Process and product: Development of competency-based measures for psychiatry residency. Academic Psychiatry, 24, 68–76. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology Qualitative Research in Psychology, 3, 77–101. Breuer, E., De Silva, M., Fekadu, A., Luitel, N. P., Murhar, V., Nakku, J., ... Lund, C. (2014). Using workshops to develop theories of change in five low and middle income countries: Lessons from the Programme for Improving Mental Health Care (PRIME). International Journal of Mental Health Systems, 8, 15. Chu, K.M., Jayaraman, S., Kyamanywa, P., & Ntakiyiruta, G. (2014). Building research capacity in Africa: Equity and global health collaborations. PLOS Medicine, 11(3), e1001612. Connors, S.C., Challender, A., Gandari, J., Nyaude, S., Proctor, J., & Walters, B. (2013). The way forward: Year two of the MEPI grant programs in Zimbabwe.: University of Colorado Denver: The Evaluation Center. Dornan, T. (2005). Osler, Flexner, apprenticeship and ‘the new medical education’. Journal of the Royal Society of Medicine, 98, 91–95. Frank, J. (2005). The CanMEDS 2005 Physician Competency Framework. Better Standards, Better Physicians, Better Care. Ottawa, ON: Royal College of Physicians and Surgeons of Canada. Frank, J. R., & Danoff , D. (2007). The CanMEDS initiative: Implementing an outcomes-based framework of physician competencies. Medical Teacher, 29, 642–647.
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