Reflections on a Guyana visit

Dr Tania Hart, from De Montfort University reflects on her visit to Guyana in May 2019

The World Health Organisation have identified 10 key threats to world health in 2019, one of which is weak primary health care systems (WHO, 2019).  WHO clearly sums up the benefits of good primary health care by stating it is the most efficient method of improving health outcomes, advancing universal health and achieving the United Nations sustainable development goal 3: of ensuring healthy lives and promoting well-being and better health for all ages. A good primary health care system, as seen in many high income countries, does not only prevent disease by managing vaccination programs, supporting the chronically ill and promoting better  palliative care, but most importantly, it  can also successfully empower people and communities by placing a greater emphasis on promoting and preventing better health and detecting early health care problems. This focus on empowering individuals to promote their own well-being and resilience is ARCLIGHT’s key emphasis.

In 2008, Guyana’s laid out its mental health sector strategy in a World Health Organisation commissioned document. This document stated that Guyana’s number one priority at the time should be, promoting better mental health and the need for movement of mental health care into the primary health care system. It also stated improvements in mental health can only come about through prevention (WHO Aims Report, 2008 Pp7). I would agree that this is where the focus should be. Having visited Guyana, however, I have seen firsthand, the complexity, of introducing a primary care system that places some of its focus on mental health. This is because despite Guyana’s small population of approx. 773,000, its primary mental health services are literally non-existent.  Non-Government organizations (NGO’s) are presently filling the gap as much as they can when it comes to mental health care. Plus stretched hospital services and a handful of qualified mental health practitioners, including psychiatrists, psychologists, psychotherapists, counsellors and general nurses, are trying their best to promote the mental health of the population, however services remain fragmented and not all inclusive.

This blog therefore outlines some of my key reflections, after visiting and talking to people who play a central role in operationalising and strengthening the primary care provision in Guyana’s capital of George Town and beyond.  These people, being university lecturers developing  training programmes in nursing and psychology and nursing officers overseeing nursing services throughout the 10 regions in Guyana. (The photo is taken outside the Nursing School in George Town, and standing between ARCLIGHTS project team members, at the very centre of our picture, is the Deputy Nursing Matron who spoke to us).

I feel the University of Guyana will undoubtedly be one of the most important players in strengthening Guyana’s primary health care provision. This is because at present there are only a small number of professionally qualified mental health workers. Presently their School of Health train general nurses and medics, but it does not run a pre-registration mental health nursing programmes, nor does it run post registration programmes which focus on mental health and wellbeing.  There are however plans, with the Building of  UG’s impressive School of Behaviour Sciences, to begin promoting more proactively a new psychology programme, which aims to ensure Guyana has a larger pool of psychology and counselling graduates who can be utilised to help develop Guyana’s mental health service provision from primary, secondary and tertiary care delivery. Thus psychology graduates will have an important role in promoting better mental health in Guyana, breaking down the taboos and stigma associated with mental health and detecting and treating mental illness.

My concern, however, as a nurse, is it is nurses and midwives that make a substantial contribution to health-delivery systems in primary care, acute care and community care settings and that new workforce development is good, however, it is nurses who are best placed to lead strategic and operational health development. Once suitably qualified in mental health they will have the expertise to offer holistic care and because they are at the front line of health care delivery are arguably best placed to help promote, protect and manage health care problems across populations. I come to this conclusion from speaking to Guyana’s nurse academics and nurse matrons who at the forefront of health care management and learnt the following from them:

  1. Post graduate modules related to mental health and primary care are much needed in Guyana. Presently there are no nurses qualified in mental health nursing. Neither are their school nurse training programmes or health visiting programmes that focus on the promotion of wellbeing, child and family mental health.
  2. The Guyanese trained nurses are well appraised because they are taught to a high level clinically. This is because they cannot rely on other allied professionals to do things, like take blood, pass nasal gastric tubes etc. so they are trained to an advanced clinical level. Mental health, however, is an aspect presently overlooked in their repertoire of skills and it is the mental health skills and health promotion skills that have the potential to advance their practice yet further. Possibly making them some of the best qualified nurses in the world.
  3. Concerning, however, is a present shortage of nursing staff in Guyana. Low pay often means nurses are going abroad to work in better paid jobs. Plus private hospitals in Guyana often pay higher wages than public institutions. This brain drain therefore means there are very few well qualified and experienced nurses available to lead strategic workforce changes or operationalise new ways of working and policy around mental health.

The Deputy Nursing Office travels to many of the remote areas of Guyana, ensuring the quality of nursing is assured. The key challenge she faces is finding staff to work in the remoter areas of the country. This she said was mainly due to young newly qualified nurses not wanting to relocate to places where life is quieter. I could not help reflect on the fact it is perhaps the vast, sometimes impassable, geographical terrain that will be Guyana’s real challenge, when it comes to strengthening their primary health care mental health care provision. This is why, Dr Andrea Berardi’s work exploring the resiliency of people living in the very remote areas of region 9 of the Rupununi will be invaluable. Arguably Digital technology (an aspect of our own ARCLIGHT project), will have to play a key part in the promotion of mental health, (as it is beginning to do so in the UK for different reasons associated with the growing aging population and health care capacity). It is technology, which has the potential to enable geographical divides to be crossed and nurse consultation to happen more easily. For example ensuring the availability of digitally available self-help materials as well as ensuring the accessibility of telehealth consultations, all of which will be invaluable. Teleconferencing however is still the technology of tomorrow in extremely remote areas of the world like in some parts of Guyana.

WHO do, however, place an emphasis on the urgency of digital technology development in order to tackle today’s health care challenges, stating:

 “The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies, for the exchange of valid information for diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, in all the interests of advancing the health of individuals and their communities”.

(World Health Organization, 2010)

The ARCLIGHT project is using innovative digital technology in the form of a Raspberry Pi computer. This very small computer creates its own Wi-Fi zone, termed a MAZIzone. This means people in remote areas, who do not have access to conventional Wi-Fi, can up load materials, from any SMART device, to the Raspberry Pi and also download any materials stored on the device. For instance we will upload self- help materials and our research participants will upload materials they wish to share. Notably the Open University are presently using this type of technology to distribute training guides in the form of PDF’s via a MAZIzone document sharing NextCloud tool (the equivalent of a Dropbox).

In summary I am of the firm opinion it is the nursing workforce who can be utilized to help develop Guyana’s mental health primary care system, both strategically and operationally, as they already have developed a nursing infrastructure which ensures even those in the most remote communities have some way of accessing nursing support for physical problems. Therefore the next step is to ensure they have access to training so they can offer accessible mental health provision and this training should not only place an emphasis on managing mental illness but also equip nurses to promote resiliency, wellbeing and positive mental health or ‘brain health’ more widely via for example school wellbeing programmes or community well-being projects..

It is ARCLIGHT’s goal, through action research methods and participatory approaches, that are encouraging co-produced knowledge, to explore more about how Guyanese people cope with adversity, how they bounce back from hardship, what they draw upon when faced with difficulties and how they understand mental health, both positive mental health and negative mental health and what they need in their communities to promote better brain health. By exploring this in more detail we hope to utilise such information in the development of a mental health educational programme which places an emphasis on primary care provision that better promotes, prevents, detects and treats Guyanese people.

References:

WHO AIMS Report on Mental Health in Guyana (2008) Available at: https://www.who.int/mental_health/guyana_who_aims_report.pdf

WHO information related to primary health care available at:

https://www.who.int/primary-health/en/

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