Psycho Social support for Ebola victims

In spring 2014, the Ebola Virus Disease Epidemic (EVD) spread across West Africa into Sierra Leone. It killed over 3,500 individuals in Sierra Leone alone, and left about 3,500 survivors in its wake. Early emergent health consequences for survivors include joint pain, depression, anxiety, neurological symptoms, chronic pain, and ophthalmological issues. Throughout the epidemic and in its aftermath, survivors have been exposed to a multitude of risk factors that are known to trigger common mental health disorders such as trauma, post traumatic stress disorder (PTSD), anxiety and depression. These include exposure to life-threatening disease, bereavement, financial loss, lack of services, stigmatization, and isolation from support systems. In addition to the impact on survivors, children were left orphans, families lost breadwinners, and countless others were traumatized by their experiences, treating, collecting, and disposing of individuals and bodies. Survivors and frontline workers including medical professionals, burial teams, cemetery workers, and many others continue to face high levels of stigmatization within their communities.

Amidst the Ebola Virus Disease (EVD) outbreak, IsraAID’s mission in Sierra Leone launched in September 2014, when a preliminary needs assessment highlighted the gaps in mental health response being provided. Given their expertise in trauma and psychosocial support, IsraAID has subsequently offered a range of programming striving to mitigate the implications of EVD on stress, trauma, and social stigmatization and marginalization on survivors, frontline workers, and other communities impacted by the EVD epidemic. 

IsraAID has subsequently undertaken a range of projects working with international NGOs, local NGOs, and International Organizations. Since it’s launch IsraAID Sierra Leone has undertaken over a dozen projects. IsraAID’s efforts in Sierra Leone have and continue to respond to the emerging mental health and psychosocial needs of the Sierra Leonean people. To this end, during the third quarter of 2016, IsraAID implemented the ‘Ebola Heroes’ project recognize and share inspiring stories of different frontline workers and community members that were infected or affected by the EVD epidemic.

 Program Summary

The ‘Ebola Heroes’ project was undertaken over a four-month period.  In Kambia implementation was ten weeks while in Kailahun it was compressed into six weeks.

The Ebola Heroes project aimed to 1) support those impacted by EVD, 2) recognize and collect inspiring stories of survivors, frontline workers and community members 3) facilitate community dialogues on stigmatization and community rebuilding.  Through this multipronged approach the project strove to promote the resilience of participants, mitigate communal stigmatization and help memorialize stories of those who were crucial to curbing the spread of EVD. This goal was tackled through a multifaceted approach i) peer support sessions were provided in both the Kailahun and Kambia districts, trained social workers offered selected groups emotional support ii) over 245 interviews were collected from across the Kambia and Kailahun districts iii) community sensitizing events were held in each district capital bringing over 300 people a piece to discuss and reflect on EVD and stigma.

In its needs assessment, IsraAID identified four target groups for providing the peer narrative therapy support across Kambia and Kailahun town. These groups were identified based on the advice of a range of community stakeholders. These groups were as follows:

• 40 high school students between the ages of 15 and 22 years;
• 20 petty traders between the ages of 35 and 45 years;
• 28 Ebola survivors and vulnerable youth engaged in farming, masonry, welding, etc. between the ages of 15 and 40 years; and
• 25 caregivers between the ages of 31 and 43 years who are currently responsible for supporting orphans.

The Ebola Heroes project had three main components – 1) the collection of testimonies from over 245 EVD survivors and frontline workers to honour and memorialize their work; 2) the implementation of peer support groups in Kambia and Kailahun districts of Sierra Leone, 3) two community events held in each which featured the FreeTong Player theater troop.

The organization of the peer support groups was based on ‘narrative therapy practice’, which allows individuals to build resilience through sharing their stories and learning from the experiences of others. This model focused on the possibility of conversation and collaboration. To this end, the weekly modules included:

1. Sharing traumatic experiences and practicing externalization: sharing stories to build trust and practice distancing one’s self from one’s pain.
2. Building trust: establish ground rules for a safe space and undertake community trust building efforts.
3. Tree of life: what roots us and how do we grow? reflection on past, present and future.
4. Ebola and the community: reflection on stigma and methods to respond and re-integrate into communities.
5. Anger management: how are we responding to our pain and what might be best practices and tools for responding better to it?
6. Dream affirmation: developing goals and action plans to achieve them. Focusing on believing in a future that is better.
7. Inner strength and resilience: boost confidence through promoting self recognition of resilience and inner strength. Reflection on personal capacity to overcome adversity.
8. My purpose and toolbox: reflection on personal growth, tools developed and ways for integrating lessons to promote personal health.
9. Sustainability measures were incorporated in the design of the project from its commencement to ensure that the project could have longevity. Beneficiaries were selected and grouped by common characteristics / attributes that would provide a reason for them to continue meeting even after the project had ended. For instance, the caregivers group in Kailahun district comprised of members of the Child Welfare Committee (CWC), that meet regularly at the Ministry of Social Welfare office in Kailahun town. Similarly, other target groups in Kambia were convened under the auspices of an umbrella organization – Community Association for the Welfare of Children (CAWEC) in Kambia. The Ebola Heroes project identified beneficiaries with the assistance of the CWC and CAWEC, so that the members of these organizations are now equipped with better skills and tools to continue supporting each other through peer groups.

Sustainability measures were incorporated in the design of the project from its commencement to ensure that the project could have longevity. Beneficiaries were selected and grouped by common characteristics / attributes that would provide a reason for them to continue meeting even after the project had ended. For instance, the caregivers group in Kailahun district comprised of members of the Child Welfare Committee (CWC), that meet regularly at the Ministry of Social Welfare office in Kailahun town. Similarly, other target groups in Kambia were convened under the auspices of an umbrella organization – Community Association for the Welfare of Children (CAWEC) in Kambia. The Ebola Heroes project identified beneficiaries with the assistance of the CWC and CAWEC, so that the members of these organizations are now equipped with better skills and tools to continue supporting each other through peer groups. 

A new survey instrument tool was piloted to begin to examine, and eventually quantify, the relationship between the participant's experience with group narrative therapy and an increased sense of empowerment.

This is a One Group Pre-Post Test Design. The instrument adopted used Linkert-based scales to measure changes in:

1. Personal Agency: Optimistic self-belief to cope with difficult demands in life; i.e. the belief that one's actions are responsible for successful outcomes (perceived); and
2. Mastery of Environment: One’s personal ability to choose or create contexts suitable to one’s personal needs and values.

The scales correspond to the main objectives of group narrative therapy – inner strength and resiliency, the recovery of personal agency, and are based on the individual’s perception of self.

The three main positive outcomes of the Ebola heroes project were:

1. Reduction of Stigmatization:Engaging in peer group sessions helped the participants build their inner strength and resilience to overcome the stigma they faced in their communities. The community event, which was the culmination of the project served as an eye opener for community members to end stigmatization against survivors and frontline workers.

1. Awareness and Education: Most participants learned a lot through the messages delivered during the various activities. For example, the ‘red and black’ game taught them to practice cooperation within the community and how it could help build efficiency.

The Freetong Players’ act during the community event highlighted some of the humiliation that frontline workers and survivors were faced with during the Ebola crisis. This sent a message to community members that survivors and frontline workers should not be condemned, but recognized for their roles and reintegrated into their community.

1. Restore Hope and Confidence: As a result of the EVD epidemic, and the consequent stigmatization, many participants were suffering from low self-esteem and feelings of inferiority. The facilitators were able to restore hope and raise confidence levels amongst the participants, especially through the sharing of stories and personal accounts.

Quotes From M&E Tools

Question: Could Ebola Heroes have provided you with additional support during session what do you think would have been the most helpful?

• “The peer group helped us to understand ourselves even better.’’
• “Teenage pregnancy is one of topics that I had learnt more about on how to sensitize my peer group in school and in my community.’’

Question: What did you like best about the peer group? What about the peer group would you change?

• “I like the tree of life exercise.”
• “In the peer group session we had a lot of interaction and the tree of life taught us about our family background.”

Question: Is there anything else you would like to share with us about your experience participating in this peer group?

• “My experience participating in this peer group session is concerning the tree of life. It helped me to know more about my root which talks of where I originated from, ground, fruit, leaves, trunk etc.’’
• “I would also like for this group to continue because it serves as a way of helping me to forget about my problems whenever I am among my colleagues.’’
• “At first, I thought this program was a waste of time but now I realize that I can now quickly think of ways to solve difficult situations that I undergo daily because we are not the cause of the problem but rather we are the solutions.”
• “I have learnt a lot of strategies on how to handle conflict during the sessions, for example I now know that it is better to work together rather than fighting each other to succeed.”   

Thank you to all the donors who helped make 'Ebola Heroes' such a success. 

IsraAID’s mission in Sierra Leone started in September 2014 amidst the Ebola Virus Disease (EVD) outbreak, where a preliminary needs assessment highlighted the gaps in the mental health and psychosocial support response being provided. Given our expertise in trauma and psychosocial support, IsraAID has subsequently offered a range of programming striving to mitigate the implications of EVD on stress, trauma, social stigmatization and marginalization on survivors, frontline workers, and other communities impacted by the EVD epidemic. 

Through the provision of these projects, IsraAID SL recognized the need to support and empower frontline workers including medical personnel, burial teams, survivors, and a myriad of other individuals who were integral in curbing the spread of Ebola.  One therapeutic program launched was Ebola Heroes, which had a multilayered approach, striving to 1) collect narratives of those involved in the EVD response, 2) offer support to individuals who continue to face stigmatization, isolation, and other impacts from the response 3) provide community events to combat stigmatization and celebrate the strength of Sierra Leones communities.

The ultimate goal of the Ebola Heroes project is to mitigate the psychosocial impact of Ebola Virus Disease on affected populations, emphasizing survivors and service providers.

In this phase of the project, IsraAID SL is focusing on strengthening the local existing mental health and psychosocial support (MHPSS) structures through capacity-building at the community level, by developing peer-based support networks. IsraAID SL is working to rebuild and strengthen the capacity of the communities themselves rather than creating dependency on support from the outside. The main outcomes achieved thus far are: 

• Development of eight peer support groups that have met for a total of 16 sessions and were structured to promote sustainability and continuation after the cessation of involvement by the facilitating field officers.

• To date we have an archive of over 400 oral testimonies and portrait photography of survivors, burial team members, hotline operators, nurses, doctors, and citizens who volunteered to share their experiences. These testimonies are the foundation of the Ebola Museum and Education Center being constructed on the campus of Njala University in Moyamba district.

• Organization of a community events including dramatization of experiences, music and contributions from participants of the peer support groups have been held in each community, Kailahun and Kambia.

After completing the first phase of the program in Sierra Leone's Western Area, IsraAID has expanded the project into the eastern and northern provinces respectively. On April 24^th, 2016, Ebola Heroes initiated this phase in Kailahun and Kambia Districts. IsraAID’s field officers have been meeting with four peer support groups in Kambia Town and three in the Kailahun Town.

These groups are composed of high school students, caregivers for orphans, Ebola survivors, and community volunteers. Each group is composed of 20 participants meeting for two hours each gathering. During each session the field officer’s facilitated the group, guiding them through psychosocial activities and discussions using narrative practice technique.

 In mid-May we hosted our first community event in Kailahun in partnership with the Ministry of Social Welfare and the theater troupe Freetong Players International. The event included a dramatization of people's stories of heroism in the face of the epidemic, distribution of educational material regarding the effect of stigmatization on the community and had over 500 people in attendance. Through this event, the community had the opportunity to share their experiences during the epidemic and reflect on lingering stigmatization and fears.

Margaret's Story

In our Ebola survivors group in Kailahun, we heard Margaret’s story. Margaret, a 32-year-old woman, is originally from the village of Koindu in the east of Kailahun District. She lost six members of her family to EVD including her mother, elder sister, her two children and two nieces and nephews. It was her sister who first contracted the virus and later infected their mother, then the children of the house and finally Margaret herself. After surviving the disease and enduring the loss of her family, Margaret moved to Kailahun township because the memories of her family in Koindu we too much for her to bear. She now lives in Kailahun and works as a trader in the market. After recounting her story, the group thanked her for the show of fortitude and courage. They further complimented her for her resilience in sharing such loss with the group. Since the beginning of the sessions, Margaret has begun to open up to the group and express more positive emotions and opinions about her situation.

Aminata's Story

In our high school girls group in Kambia, we heard the story of Aminata, a 19-year-old student. Aminata had attended the Kollenten Secondary School in Kambia before Ebola came to Sierra Leone. With the Ebola outbreak in 2014, her life was changed forever. Her father volunteered to work as a hygienist in one of the treatment centers as a source of income for the family. He contracted Ebola at the center. One day he felt ill and was taken to the treatment center where he tested positive. The family was quarantined for 21 days, and within the quarantined period, her mother, elder brother and sister showed signs of the virus and eventually died along with her father. Aminata's mother and father left behind four children, and her elder brother and sister who died also left behind four children.  Aminata is now the primary caregiver for all eight children and struggles to maintain them while also attending high school. She is enrolled in a tailoring training program hoping that this skill will enable her to generate income. In the evenings, her siblings ask many questions about those that have died. It is difficult for her to cope with the responsibility, and thus she often tells them that their parents are only away on a trip. She is very overwhelmed with her new role and finds no time to take care of herself. She has expressed thanks for the support group. It has helped her cope emotionally with the stress and sadness she constantly feels in her current circumstances.

These two stories are just a couple of the dozens of harrowing stories that we have collected from Kambia and Kailahun. The discipline of narrative practice teaches that through the sharing of stories, one begins the process of healing and building resilience from trauma.  Through undertaking these interviews and recording the stories, IsraAID SL strives to simultaneously provide therapeutic support to individuals and communities through narrative practice and memorialize their experiences for perpetuity.

All testimonies and portraits, in addition to the Ebola Museum, are uploaded to a website for the wider world community to engage and learn from Sierra Leone's experience.

http://ebolaheroes.com/