PURPOSE OF THE STUDY
The study of the facility was in line with objectives of the WHO QualityRights project which include the following:
- Improve quality of care and human rights in inpatient and outpatient mental health services
- Create community-based and recovery-oriented services that respect and promote human rights
- Promote human rights, recovery and independent living in the community
- Develop a movement of people with mental disabilities to provide mutual support, conduct advocacy and influence policy-making processes
- Reform national policies and legislation.
The half-day workshop was organized primarily to disseminate key findings of the study of the Pantang Hospital using the QualityRights Assessment Tool kit as the basis. The study sought to assess the basic service delivery standards and legal protection provided by Pantang Hospital to persons with mental disability (users) in line with the United Nations Convention on Rights of Persons with Disability (UNCRPD).
Thus the purpose of the study was to:
- Plan strategies to build capacity of hospital authorities;
- Strengthen systems to reduce treatment gap for mental illness;
- Promote service delivery that respects the fundamental human rights of users at the facility and their autonomy;
Methodology of the study
For the purpose of undertaken the study, the research team followed the guideline as detailed out in the QualityRights Tool kits and relied on the following three methods as prescribed in the tool kit.
Data Collection. Data collection was in three parts namely:
- Interviews: The interview schedule covered users of the Pantang hospital, relatives and carers, as well as hospital staff;
- Observation: The observation was made at the facility
- Document review: Documentary review was done for purposes of triangulation of the study findings
Sample Size: The following constituted the respondents for the study and sample size: Hospital staff- 10; Users in the Facility-20; Relatives or carers of users in the facility- 10. Thus in all, there were 50 respondents.
It is important to point out that the study hinged on six articles, namely Article 12, 14, 16, 19, 25 and 28 of the United Nations Convention on the Rights of Persons with Disability. The study was to look at some five (5) themes, involving twenty-five (25) standards and each of the standards has a set of criteria that were all looked at, totaling 116 criteria which were evaluated during the period that the study took place at Pantang.
After the collection of data, a team of Assessors was constituted and tasked to thoroughly review the data collected, analyze the findings and proceed to rate the facility in line with the rating criteria contained in the WHO Quality Right Toolkit.
The Five rating criteria are as follows:
|LEVEL OF ACHIEVEMENT||DESCRIPTION|
|Achieved In Full(A/F)||There is evidence that the criterion, standard of theme has been fully realized|
|Achieved Partially(A/P)||There is evidence that the criterion, standard or theme has been realized but some improvement is necessary.|
|Achievement Initiated(A/I)||There is evidence that steps have been taken to fulfill the criterion, standard or theme, but significant improvement is necessary|
|Not Initiated||There is no evidence of attempts or steps towards fulfilling the criterion, standard or theme|
|Not Applicable(N/A)||The criterion, standard or theme does not apply to the facility in question( e.g. rating sleeping quarters for outpatient or day treatment facilities)|
The overall rating of the Pantang Facility was made in the light of the following Five Themes:
- Theme 1: The right to an adequate standard of living (Article 28 of the Convention on the Rights of Persons with Disabilities (CRPD)
Theme 2: The right to enjoyment of the highest attainable standard of physical and mental health (Article 25 of the CRPD)
Theme 3: The right to exercise legal capacity and the right to personal liberty and security of person (Articles 12 and 14 of the CRPD)
- Theme 4: Freedom from torture or cruel, inhuman or degrading treatment or punishment and from exploitation, violence and abuse (Articles 15 and 16 of the CRPD)
- Theme 5: The right to live independently and be included in the community (Article 19 of the CRPD)
General Study Findings
The study showed that the facility at Pantang has made some modest gains which, to all intents and purposes, is significant progress in relation to themes 1 to 3, which focuses on adequate standard of living for users, the right to enjoyment of the highest attainable standard of physical and mental health as well as the right to legal capacity and personal liberty.
The study findings, however, suggest that some interventions need to be taken if the facility (that is Pantang) is to fully realize the intent of themes 1-3. For instance, the researchers observed that some of the wards had been renovated and brought to highly acceptable standards, yet other structures such as the Administration Block leaked in several areas of the building.
Similarly, the study found that the cooking area was open and the conditions of the surroundings, was, in the opinion of the research team, inappropriate. Also, the study sought to find out whether users had the opportunity or liberty to communicate with relatives while on admission. The researcher said in his presentation of findings that it did not appear to the Team, during the period the team collected data at the facility that users had the opportunity or freedom to communicate with family and /or with any other person outside the walls of the facility.
The Researcher made some comments on the accessibility of the facility to persons with physical disability and observed that at the main entrance at the Administration block, there was a ramp to facilitate access, but that there was no such provision in the wards and in bathing areas, and that there was no hand bars in the bathrooms to support people with physical disability.
On Theme 2, the presentation observed that the facility is available for everyone to access- as no one is turned away from accessing services at the facility on the basis of sex, age, ethnicity, etc. However, the study looked at access in terms of the number of staff available to provide quality mental health services. The researcher said the team gathered at Pantang that as at the time of the study, there were Four (4) Psychiatrists; Fifteen (15) General Medical Doctors and Three hundred (300) Nurses and argued that the number of service providers at the facility was woefully inadequate. The study also looked at psychosocial support, networks, availability of psychotropic medications and adequate services for general and reproductive health in the facility.
Theme 3: The team made comments on their assessment relating to Theme 3, and made the point that staff of the facility gave users some attention and engaged them. On the issues of whether users were given information of their rights as users, the survey finding maintained that, users only said they had been at the facility long enough and that they actually wanted to leave, as they felt they had recovered well enough to go home.
Also, users said they were unaware of their right to have access to their personal records and what it contained.
The issue of legal capacity was discussed during the presentation. The study showed that at the time of admission, the consent of Users was not taken; and that relatives made the decisions on admission of the users. Also, the study showed that confidentiality was regarded highly in the facility and that Nurses were extremely particular about it, even though access of users to their records was limited.
For themes 4 and 5, the study identified some significant gaps that still exist at the facility. According to the presentation, the team of researchers witnessed cases of verbal abuse; but not sexual abuse. On seclusion, the standard of the theme (4) requires that the facility must have alternative ways of de-escalating incidents, apart from seclusion. The Team mentioned that this was not the situation as they saw in the facility, and that rather, the facility used seclusion mainly as a form of threat to them so that they could comply with whatever directives they were asked to follow. Users felt that was not appropriate and in the secluded area, they complained of mosquitos and all the ills associated with seclusion- such as darkness.
The study looked at whether the facility used electroconvulsive therapy; and said this was not the case with Pantang. The relevant standard requires that the practice must not be abused and that if that was to be used, the user ought to be informed, even in a case of referrals. However, the Research or study showed that this was not being done at the facility.
The standard also focuses on safeguards to prevent torture, the need to educate staff on need to avoid abuse of users and of available channels for reporting complaints in the event where a user is abused. More importantly, users ought to feel free and be willing to report such complaints without any fear that such action will be used against them.
According to the presentation which was based on the study, some users confirmed that they had in the past reported cases to the hospital staff. However, they claimed that these reports are not acted upon. For instance, a service user referred to an occasion when a misunderstanding occurred between two users of the facility, resulting in hot food pouring on one of the users involved. However, when this was reported to the Nurse on duty, no action was taken, and that instead, the Nurse made extremely degrading comments, which the User considered inappropriate.
The study found that there was a customer desk in each of the wards occupied by a Senior Staff (usually the in-charge) who is also expected to receive complaints from users, most of which do not receive any attention.
On the issue of whether or not there were interventions to facilitate networks for reintegration into their communities, the study finding made reference to the presence of social welfare officers who are to work with users to facilitate their reintegration into the communities. On the related issues of linkages to communities, the study observed that some work has been done by the facility for users, especially those who are unable to pay for services as the facility puts in place some payment plans are agreed with users at the point of discharge from the facility. The study showed that when it comes to facilitating accommodation, employment placements for users, that is a huge challenge for the facility and therefore a challenge for any reintegration initiative.
Study Key Findings
The following were the key findings from the study as presented by the Research Team:
- There were separate wards for males and females users in the facility, thus ensuring privacy to users
- All the wards had water reservoirs providing for constant flow of water to users in the bathrooms, toilets and dining areas
- The sleeping area was not overcrowded, as there was enough space to accommodate a maximum of five users
- The rooms were well ventilated with natural air and ceiling fans
- Fire extinguishers were visibly displayed
- The food menu made provision for dietary needs of users
- The facility does not experience shortage of psychotropic medicines due to internal arrangement with private providers of medicine.
- Bathrooms and toilet facilities in the renovated wards were generally clean.
- Entrance to the wards had ramps to provide access for persons with physical disabilities
- Maintenance works for some wards and buildings in the facility were not done in a long while, making the walls look too dirty and paints peel off.
- There were water leakages in some bathrooms and toilet areas, causing flooding.
- Bathrooms were not disability friendly, because there were no ramps and hand-bars.
- Window nets were too dusty and this could hinder the circulation of fresh air in the bedding areas.
- Safety rules were not fully followed because there were no emergency exit points or info-graphs to show escape points.
- Food was prepared in an open yard because the main kitchen was under renovation.
- The surrounding was unhygienic with uncollected waste and smelly gutters
- Cases of verbal abuse were reported and witnessed
- Quantity of food served was reported to be inadequate.
- There was no evidence of general health promotion and education, as this was reported to be work in progress.
- The surroundings of the wards were too bushy which could serve as breeding place for mosquitoes and reptiles, thus posing risk to users and staff.
- Family members and/or relatives do not seek consent of users on the preferences for treatment during admission, especially those that are poor.
- Participation of users in social activities within the facility and community is hindered by staff fears that users may abscond and secondly due to financial and logistical constraints.
The study showed that the facility at Pantang has made some modest gains which, to all intents and purposes, is significant progress in relation to themes 1 to 3. It is relevant to note that the first three themes focus on adequate standard of living for users, the right to enjoyment of the highest attainable standard of physical and mental health as well as the right to legal capacity and personal liberty. The study findings however, suggest that some interventions need to be taken if the Facility (that is Pantang) is to fully realize the intent of themes 1-3. For instance, the researchers observed that even though some of the wards had been renovated, other structures such as the Administration Block leaked in several areas of the building.
For themes 4 and 5, the study identified some significant gaps that still exist at the facility. According to the presentation, the team of researchers witnessed cases of verbal abuse; but not sexual abuse. On seclusion, the standard of the theme (4) requires that the facility must have alternative ways of de-escalating incidents, apart from seclusion. The Team mentioned that this was not the situation as they saw in the facility, and that rather, the facility used seclusion mainly as a form of threat to users so that they could comply with whatever directives they were asked to follow. Users felt that both the process as well as the seclusion proper was not appropriate; and that in the secluded area, they have contended with mosquitos and all the ills associated with seclusion-darkness.
The study report made some recommendations for improving on service delivery. They include the following:
- There is need for maintenance to be carried out within the wards on regular basis to ensure users have good standards of living.
- Bathroom and toilets should be fitted with disability friendly facilities such as ramps and hand-bars to promote access to those facilities by persons with disability.
- There is need for frequent dusting of the window nets to ensure oscillation of fresh air into sleeping area.
- Staff and users should be trained on safety rules and procedures while info-graphics and signage for emergency escapes should be visibly displayed showing exit points within the wards.
- The surroundings should be regularly cleared of weeds to avoid exposing users to other forms of diseases and risks.
- The human resource capacity of the cooking staff should be improved to ensure that all food is cooked within the premises of the facility. This will allow for close monitoring of the hygiene conditions.
There is the need to have a structured complaint reporting mechanism and staff should be trained to properly manage that process without interfering in the reports filed by users. This will provide an avenue for useful feedback on the standard of services delivered in the facility.