Training in transcultural psychiatry and delivery of education in a low-income country

A recently established initiative, the Scotland Malawi Psychiatry Project (SMPP), has provided a unique opportunity for specialist registrars to combine a number of training objectives of the Royal College of Psychiatrists. Experience in teaching and assessment of students or junior colleagues is an


Background
Malawi has a population of 12.7 million and is one of the world's poorest countries.Half of the population live below the poverty line and the country performs poorly in all health outcome measures.The prevalence of HIV/ AIDS is high, with 25% of women of child-bearing age being HIV positive.Life expectancy has been seriously affected by the HIV epidemic and has fallen to 41 years.
There are limited epidemiological data concerning the prevalence of different mental illnesses in Malawi.Evidence suggests that in sub-Saharan Africa the prevalence of schizophrenia, bipolar disorder and postnatal depression is similar to that in high-income countries (Odejide et al, 1989;Stewart, 2007).Suicide is illegal in Malawi thus a true estimate is difficult to establish, but one study (Dzamalala et al, 2006) estimated 10-20 suicides per 100 000 population per year.Dementia related to HIV infection is an increasing problem that often goes unrecognised.Substance misuse is largely confined to the use of alcohol and cannabis.
The only state-funded tertiary psychiatric facility in Malawi is Zomba Mental Hospital which is run by a single psychiatrist, 5 clinical medical officers and 20 trained psychiatric nurses.The hospital has 330 beds and serves a population of 8 million.Of the 1675 admissions in 2006, over half were for psychosis or mania, with organic disorders accounting for a further 17%.The routinely available psychotropic drugs are chlorpromazine, trifluoperazine, fluphenazine depot, carbamazepine, amitriptyline and fluoxetine.At the time of the recent project visit, haloperidol, procylclidine and diazepam had been out of stock for 3 months.There are few community services to support the hospital and many patients receive little effective follow-up.Other local initiatives are currently addressing these difficulties.

The project
The project involved the delivery and examination of an undergraduate curriculum in psychiatry to 57 4th year students over a 5-week period in February and March 2007.The teaching was shared between Dr Kauye, five psychiatrists from Scotland and one Norwegian psychiatrist.Two weeks of theory teaching, consisting of lectures, seminars and group discussions of case vignettes, was delivered at the College of Medicine in Blantyre.The course material was based on UK and South African undergraduate standards and was modified for the cultural setting.The theoretical teaching was followed by an examination comprising multiple-choice, single best-answer and short-answer papers.The questions were adapted from University of Edinburgh undergraduate psychiatry examination and MRCPsych part 1 multiple-choice questions.
The second component of the curriculum was clinical training based at Zomba Mental Hospital.The students were divided into groups of ten and allocated a clinical supervisor.At first, the students were encouraged to interview patients in pairs and later presented their assessments in the small supervision groups.There was approximately 4 hours of direct clinical supervision per day.During this time, emphasis was placed on establishing rapport, taking a thorough history, formulating differential diagnosis and identifying remedial organic conditions.The tutorials provided an opportunity to discuss issues such as the role of traditional healers in mental healthcare and the effect of cultural context upon the content and interpretation of psychotic experiences.
The assessment of student performance during the clinical block comprised three elements: performance on the ward (including knowledge, participation and attendance); a written long case; and a final oral examination in which each student was interviewed by two examiners and core clinical knowledge was tested.

Outcome
The value of the project was measured by several indicators.The written and clinical examinations were deemed to be a measure of the effectiveness of the delivery of the teaching.The mean examination mark was 67.5% (range 52.5-84.5%).Nine students did not achieve the pass mark in the written component; they were notified of this and were able to improve their standard during the clinical block.
A second measure of evaluation involved the circulation of a questionnaire on attitudes to psychiatry.This was given to the students prior to the course and then again after the final examination.This questionnaire has been used in the UK as a standardised means of measuring attitudes to psychiatry (Burra et al, 1982).Early results show that the students' experience lessened the stigma they associated with mental illness and improved their attitude toward psychiatry as a medical specialty.
Students were also asked for personal feedback about their experience.Although a few voiced persistent scepticism about the Western concept of mental illness, the majority of feedback about the delivery of the teaching and the approach taken by the visiting teachers was positive.

Value as training experience for specialist registrars
This initiative provided a unique opportunity to contribute to a developing health system while offering an important training experience for those involved.Lessons were learnt about the development of a curriculum to match need, the preparation of lectures that were captivating and informative, and the importance of conveying succinct messages during clinical teaching.The teaching needed to be flexible to take account of the impact of differing cultural understandings of illness and the limitations of local resources.The exposure to a range of illnesses rarely seen in Britain, such as HIV-associated psychosis and cerebral malaria, was educational.The environment at Zomba Mental Hospital highlighted the challenges of working in an undeveloped health system and gave insights into how important psychosocial components of care can be provided despite these limitations.
It is planned that interested trainees and consultants will repeat the teaching visits over coming years.This project hopes to be the beginning of a long-standing collaboration with the aim of raising the awareness of mental ill health and, through education, improving standards of mental healthcare.

Declaration of interest
None.Funding detailed in Acknowledgements.