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The need to support staff and look after their well-being was recognised by the Director of the Centre for Development of Family Medicine, Head of Primary Care. This case-study describes how staff well-being was integrated into the PHC system in Kosovo.

This was accomplished through raising awareness on staff well-being and stress management as well as strengthening knowledge of and skills in stress management. Eighteen national PHC staff were trained and more than a thousand family doctors and nurses attended stress management workshops. A steering committee consisting of key stakeholders was responsible for overseeing the execution of the programme. This steering committee successfully advocated for integration of staff well-being and stress management in the revised mental health strategy — The curriculum developed for the training was integrated in the professional staff development programme for family doctors and nurses.

The effectiveness of the programme was assessed through an evaluation including a survey among PHC professionals trained under the programme. Evaluation findings showed that offering structured support, entailing the opportunity to discuss work related problems and providing tools to deal with stress related to work or personal life, helps staff to continue their professional tasks under challenging conditions. Evaluation findings suggest that results can be sustained through an integrated approach and involvement of key stakeholders.

The case study may be of interest to policy makers involved in health reform processes and for managers implementing changes in complicated post conflict contexts. For both groups, acknowledgment of staff well-being could be a key ingredient in the motivation of staff and the quality of services.

The Republic of Kosovo is a self-declared independent country in the Balkans region of Europe. However, Russia, Serbia and a significant number of other countries including a few EU members did not. Serbia rejected that decision and negotiations between Serbia and Kosovo are on-going. Political relationships with Serbia remain tense. The Kosovar population, still suffering from the mental health consequences of the — war, is now facing new challenges, such as human trafficking, drugs, criminality, economic crises combined with high rates of unemployment and corruption.

After having gone through a long process of war and its aftermath, Kosovo is in the process of transforming itself towards western democratic systems in all sectors within government, non-government and private organizations and institutes. This process is a great challenge for all involved, but combined with residual injuries and trauma from the recent war and a lack of financial resources the challenge is even greater for the health sector. The armed conflict in Kosovo from — had a direct impact on well-being and health status of virtually the entire population and the health system at large.

The health system, struggling to cope with the demands due to the war, had to deal simultaneously with an increase in the number of patients and a lack of professionals in certain fields. Kosovar Serbian doctors had left Kosovo, exacerbating the already existing shortage of doctors, in particular in rural areas [ 1 ]. Essentially, the entire health system had to be rebuilt and restructured. European systems were introduced on an ad hoc basis during and immediately after the war.

A health reform plan was designed; however, financial resources were and continue to be very limited. A major change has been the introduction of family health centres and family health doctors in the health system. Family health centres have increased access of the less fortunate to health care.

Development of human resources is one of the key goals in PHC. Special training programmes have contributed to the development of the new PHC system. These include:. Before the war, Kosovo only had psychiatric clinics; psycho-social services were not available. After the war, eight one in each region mental health community centres were established, providing not only psychiatric care but also psycho-social services and community interventions. Also, mental health assistance was introduced within the PHC system; the family health centre providers are now identifying mental health problems amongst their patients.

Not all cases can be treated at the family centre level; many need to be referred to the above mentioned mental health community centres, which have limited capacity. Within the health reform process, new strategy papers for basic mental health care were developed and since mental health community centres are part of the secondary public health system.

Health professionals in Kosovo face many challenges. First, most staff have been affected themselves by the war. Second, many health staff, in particular staff working in the primary health system are directly and daily dealing with clients affected by war and its consequences: poor health, war related injuries, poverty, disrupted families, violence, unemployment, etc. Third, the status of the health professionals has been challenged during the last few years.

Medical staff was always treated with respect and appreciation, but currently staff in health centres is less able to assist clients in the way they were used to: only basic services can be delivered and in spite of some improvement in recent years, continued lack of equipment, drugs and treatment is being seen as a failure by the medical staff. For advanced treatment, only affluent patients can afford to visit private clinics or go abroad. As a result, the level of stress amongst the health professionals is high.

With this case—study in Kosovo as well as with several surveys among national staff in other countries affected by war and conflict [ 2 — 6 ], we have started to address an important gap in knowledge about the mental health and psychosocial consequences of working in these stressful conditions.

Staff well-being and mental health issues among national staff are also important in that national staff far outnumber international staff, and make up the majority of the workforce in most humanitarian organizations. The need to support staff and look after their well-being was also recognised by the Director of the Centre for Development of Family Medicine.

The intervention started with a needs assessment. The needs assessment consisted of a quantitative and a qualitative assessment. The protocol for this assessment was determined to be non-research by the United States Department of Health and Human Services Centers for Disease Control and Prevention CDC senior scientific staff who reviewed the proposal according to standard procedures.

We obtained written informed consent from each participant. The qualitative assessment was performed by conducting interviews with key individuals in the primary health care service in each of eight administrative districts: Ferizaj, Gjilan, Lipjan, Prishtina, Peja, Gjakove, Prizren, and Mitrovica. In each district, the directors and coordinators of family health centres were interviewed. In addition to district directors and medical training coordinators, a number of municipal directors and several nursing coordinators were interviewed.

In total, more than 25 key people were interviewed. The face-to-face interviews collected information on stressors affecting the individual director or coordinator, as well as the stressors known to affect his or her staff. In addition, the interviewees were asked about individual strategies for coping with stress, and institutional mechanisms in place for helping staff coping with stress.

Directors and coordinators were also asked to describe any previous training and knowledge in the field of stress management. Finally, the interviewees were asked for their recommendations and suggestions for improving stress levels. The results of the qualitative assessment provided in-depth information about the stressors that the PHC workers faced and provided invaluable information in addition to the results of the quantitative assessment we conducted. Most, though not all, interviewees reported relatively high levels of stress for themselves and their staff.

Many of the main stressors such as level of workload and low salaries were uniformly reported across the districts, but some sources of stress related specifically to current or historical conditions unique to a particular area. Doctors and nurses, in particular, felt disillusioned with their loss of status and their difficult economic conditions. The methodology for the quantitative assessment is summarized in Table 1. Main results included the following:.

The results from the quantitative assessment corroborated findings from earlier studies amongst national humanitarian aid workers and health staff in post conflict regions. Similar studies have been completed in a range of settings, including Uganda, Sri Lanka and Jordan. All have indicated the vulnerability of national staff to high levels of stress and the potential value of organizational support [ 2 — 6 ].

The main purpose of the needs assessment was to assess the level of stress amongst staff. The outcome justified the overall objective of the programme to strengthen the capacity of staff and health care professionals providing PHC services by enabling them to recognize, deal and cope with the stress and the psycho-social consequences derived from war and war related injuries amongst themselves and their clients.

How the overall objective of the programme was achieved is described in the case study below. The main activities of the programme consisted of: i development of curricula for courses; ii training of trainers for KRCT staff as well as mental health and health staff of PHC institutions in specific psycho-social and stress management skills; iii training of PHC doctors and nurses on stress awareness; iv integration of course curriculum in human resource development policies of the PHC clinics; and v contributing to the integration of staff support and stress management in the PHC system.

In March in the 5 th year of the programme, an evaluation was conducted to allow adjustments in the last half year of the programme. In June , the results were shared with stakeholders in Pristina. Possibilities for follow up and rolling out the programme in the region or within other sectors were explored during this conference as well. An important programme activity consisted of training. First, 18 trainers were trained over a period of three years.

The trainers were selected in such a way that all of Kosovo could be covered within a few hours of travelling. A group of 18 trainers were selected by KRCT based on the following criteria:. Despite reduced funding, training of trainers could be implemented as planned because of extra efforts of the facilitators. Through this cascade approach, a relatively large number of health staff could be trained in a short time; altogether over staff family doctors and nurses and 25 managers and training coordinators were trained.

Training output is summarized in Table 2. Trainers and health staff targeted under the programme originated from geographical locations throughout Kosovo. The number trained per region was proportional to the number of health staff in each region.

However, political developments between Kosovo and Serbia during the implementation phase of the programme limited the scope of the programme in Serbian enclaves. For instance, although Serbian speaking trainers and Serbian health staff were identified, circumstances did not allow their participation in the programme.

The training methodology focused on an interactive approach: Trainees were invited to share their methods and experiences, prepare case studies, try out energizers, and various relaxation techniques with many exercises were introduced. For most trainees this approach was a new concept perceived as a welcome change from the traditional lecturing workshops. The initial plan was to include all family doctors and nurses working in the PHC system in the training at the time. Actual coverage was much lower, because the number of staff was more than twice as high as originally estimated based on the statistics available at the start of the programme.

The trend in coverage is provided in Table 3. Reasons for the relatively high costs included the following: i training was carried out by international trainers, because the necessary expertise was unavailable in Kosovo; ii training venues were not within PHC facilities, but external; and iii trainees were compensated for time investments and travel.

Antares and KRCT ensured ownership of the programme by involving the Ministry of Health in general and the PHC system in particular in the programme design and implementation. A steering committee composed of seven senior policy makers was established in The steering committee monitored progress, supervised the quality of the programme, and oversaw the execution of the programme.

In , MOH endorsed this policy paper. The main objective of the policy paper is to prevent or mitigate the effects of staff stress and promote overall well-being. The policy paper describes indicators of success such as training on stress awareness and mainstreaming of staff well-being in all policies and practices. The policy will be monitored, evaluated and updated by the MOH.

Please refer to Table 4 for a summary. The steering committee also advocated for integration of staff well-being and stress management in the revised mental health strategy of — A task force consisting of five members from various primary health care institutions was established as the coordinating body at the operational level. Members of the task force, in cooperation with KRCT, have been engaged in supporting and facilitating programme implementation including identifying participants for trainings and meetings and arranging logistical support.

The specific task of the task force was to safeguard the quality of the training component of the programme, while the steering committee made sure that all activities were in line with the standard operating procedures and policies within Kosovo. Through the task force and steering committee, the programme also availed of a permanent quality monitoring system. A particular unintended result of the involvement of the steering committee and the task force in the training was accreditation of the training as stress management module in the training for family health staff.

The position of the members of the Steering Committee within the MOH was of great importance in facilitating the whole process of accreditation. The adoption of the policy paper, the integration of staff well-being and stress management in the new mental health strategy, and the accreditation of the stress management module facilitated the integration of staff well-being and stress management into the primary health system.

The relevance, effectiveness, efficiency and sustainability of the programme were evaluated during the last year of implementation. Findings suggest that the programme had been effective in terms of promoting team building and mutual respect amongst colleagues. In-depth interviews with trainers nine trainers, that is half of the staff trained as trainers and beneficiary health staff 15 doctors and nurses corroborated survey findings that the programme had contributed to raising awareness on stress management, not only on personal level, but also within teams and even, for some, amongst family members and within the community.

All interviewed trainers were satisfied about the skills they learned for training, including practical exercises and techniques. Five of the interviewed trainers mentioned that the training stimulated them to read more about stress management and use the e-learning website. Both trainers and health staff were satisfied with the training methodology; the interactive approach was a new concept perceived as a welcome change from the traditional lecturing workshops.

As a trainer, but also as person, it gave me more confidence, more positive feedback and energy. Health staff provided examples in meetings of managers who had changed their leadership style, and how the training had contributed to increasing mutual respect both between nurses and doctors as well as between managers and other staff following the training, positively impacting on team work.

Asked whether trainees actually do this, the answer was that some do indeed. Others however remarked that the training had made it easier to discuss stress and stressors. The evaluation came too early to assess whether there were any lasting changes — attributable to programming —in the lives of beneficiaries, health staff and managers of family health clinics or to measure a possible impact on their well- being.

The evaluation therefore did not include an end line assessment of staff well-being. The questions in the qualitative part of the initial needs assessment were primarily aimed at provide context of the findings of the quantitative part of the needs assessment. As such, they were less useful in providing programmatic baseline indicators.

The questionnaire developed for the evaluation contained partly the same questions as the needs assessment questionnaire, but findings could not very well be compared. In addition, although the initial plan was to include all family doctors and nurses in the training, actual coverage turned out to be much lower. The evaluation results are thus only representative for the staff trained under the programme. Lastly, integration of staff support and stress management in policy and practice was only at its infancy at the time of the evaluation.

Table 5 provides details on the evaluation methodology. Lessons learned and recommendations were combined to guide the identification of building blocks which factors to take into account for a model for integration of staff well-being, the necessary pre-conditions and feasible approach. These issues were discussed, validated and amended during a conference attended by stakeholders in June and during workshops in October Results can be summarized as follows:.

A conceptual framework model , summarizing the building blocks and their mutual interdependency, is outlined in Fig. The model emphasises the importance of raising awareness on the need to support health staff working in complex situations, under high work pressure, with limited resources and for a traumatised population. The needs assessment is always the starting point for a staff support programme; requests for support are fed through awareness of the need for support.

The implementation of a needs assessment leads to raised awareness. One of the most critical success factors was the establishment of a steering committee and task force up front. This has ensured ownership and integration in the health system. The involvement of these committees had a positive impact on the quality of the trainings leading to official accreditation and policy development.

This resulted in a policy paper on staff well-being in PHC as well as the integration of staff well-being and stress management into the revised mental health strategy — Key informants interviewed during the evaluation were unanimous in their praise for the way the programme was integrated into the existing health system. Other success factors included:. In our needs assessment we found serious mental health consequences of traumatic experiences among health care workers in Kosovo.

With the stress management program we have attempted to address some of the stress and PTSD-related symptoms among the health care workers. It is likely that not addressing these mental health issues would result in chronic problems, since we know from the literature that trauma and stress-related mental health problems can persist for many years if they are not being addressed [ 15 ].

The anecdotal information from the beneficiaries also suggests that the stress management program in Kosovo helped participants understanding their own trauma and decreasing stress levels. However, only longitudinal studies would be able to determine if stress management programs would prevent or ameliorate mental health issues among health care workers in post-conflict countries such as in Kosovo. There were also weaknesses. Challenges in capacity development included the unequal level of knowledge and skills on psycho-social issues amongst trainees, the fact that no follow-up was foreseen, according to some trainers insufficient time was given to master meditation and relaxation techniques, and the lack of consistency of participation both in terms of who participated pre-selected participants being replaced at the last minute by others , and their completeness of attendance participants attending only part of the training.

Integration of staff support and stress management into policy and practice at the municipality level also turned out to be a challenging task. Managers and directors at municipality level are elected and politically assigned. Policies and strategies at MOH level are not always accepted or fully embraced at municipality level. In the end, only two trainings were implemented, attendance was irregular, limiting the impact of the programme on some of the family health centres.

Staff turnover due to the political systems, overloaded agendas and political pressures, further negatively impacted on the effectiveness of the trainings for managers. The initial needs assessment confirmed that the overall objective of the programme to strengthen capacity of health staff to recognize and cope with stress was highly appropriate.

Findings confirmed that health professionals in Kosovo were, and still are, suffering from the mental health consequences of the war, resulting in high levels of stress and stress-related mental health conditions. Targeting family doctors and nurses was a good choice, because they make up the first line of health care and are as such the ones most affected by secondary traumatisation. Combining capacity building training of trainers and training of health staff and curriculum development in stress awareness and management proved to be a highly effective way of achieving programme objectives and addressing sustainability up front.

Training helped staff to manage stress and in doing so strengthened their coping mechanisms. This positively impacted on team-work and ability to deal with their clients. The training methodology with a focus on an interactive approach, relaxation techniques and exercises were a new concept perceived as a welcome change from the traditional way of lecturing. Participants felt energized and relaxed at the same time. A strong point of the programme was that mechanisms for sustainability were built in from the very beginning of the programme.

As a result, the programme was a true multi-stakeholder partnership in which Antares and KRCT, with the support of CDC, worked closely together with a steering committee and task force, both consisting of key actors from the health sector.

These committees were instrumental in policy and strategy development. Achievements included the adoption of the policy paper on staff well-being in PHC by the Minister of Health, integration of staff well-being and stress management in the new mental health strategy and accreditation of the stress management module, all together laying the foundation for the integration of staff well-being and stress management into the primary health care system.

The success of the integration of staff well-being within the PHC system in Kosovo resulted in interest in similar interventions within the region Albania and Macedonia as well as within other sectors within Kosovo. A concept note for replication of this model in a different context is under development and will serve as a basis for introducing staff support and staff well-being systems into the regions once funding is secured.

The financial and technical assistance for the project was provided by the Centres of Disease Control and Prevention in Atlanta. Thanks to commitment at all levels in the health sector including the Minister the model is being further developed and rolled out. AvdV led the evaluation of the programme in Kosovo, analysed and interpreted the evaluation survey data and was the main author of the evaluation report and this article.

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