Introduction: the first of this series of articles about the Imam Sadr Foundation addresses steps the ISF is taking to help improve mental as well as physical health in Lebanon.

An observer of developments across Arab countries can note growing preoccupations at multiple levels:

• How will these communities overcome the period of violence and shift to situations that preserve the right of the people to life, dignity and freedom?

• Rising concerns about the conditions of vulnerable groups, such as women and religious/ethnic minorities.

• Communities and peoples caught in the tide of international interests which tug them in competing directions.

• Urban populations suffer from increased socio-economic and security concerns, with the political impacts of the current turmoil in the region still to be fully realized, along with inter-faith and intra-faith conflicts adding to the fears of minority groups. 

Progressively, the voices of wisdom have grown faint and the mechanisms of dialogue all but non-existent. These issues preoccupied the Imam Sadr Foundation to a great extent. We believe Lebanon possesses most of the grounds, conditions and opportunities that keep such risks at bay or at least allow their repudiation. In fact, Lebanon, in its history, composition and experience, is at odds with the bitter events sweeping through the region. It must be the antidote. 

In particular, Lebanon is seen as the scene of conflict, tension and potential confrontation. Over the years, Lebanon has suffered from civil war, occupation and regional conflicts. Although the education system covers the entire territories, the access is limited for the underprivileged population in the south. There is also a brain drain from peripheries to central Lebanon in the same way as from Lebanon to other countries. As for health, the governmental system is weak, thus private sector is essential to cover the need of the population. In the field of mental health the situation is even worse, due to stigma, lack of governance, lack of treatment facilities and lack of money.

The Mental Health Program is a substantial dimension of the partnership between ISF and NORWAC, which is gaining increasing recognition because it invests in a crucial field of vulnerable individuals. It consists of three folds:

Mental health within schools for the vulnerable

It consists of integrating the mental health dimension in the educational process in order to provide both the children and their parent(s) or caretaking family members with the necessary awareness and skills to deal with mental health issues. In parallel, several pedagogic, administrative and physical interventions are taking place to improve the well-being of the constituency, as well as its educational results.

The orphanage program sustains its services despite the emerging facts and challenges; the majority of the beneficiaries are now social and economic hardship cases. Thus, caring for them within their families is a priority.

Kindergarten and elementary education are adjacent to the orphanage and an important tool to facilitate social integration through the policy of accepting students from a wealthy milieu. This policy also has its financial effect and becomes a factor of sustainability, since the share of school fees in covering the operational cost is growing constantly.

In parallel, the inception of the Mental Health Program and specialized services for handicapped children proved very substantial in meeting the needs of an increasing ratio of those people, partly due to the relative uniqueness of this type of services in the area. This synergetic system is benefitting from the full support of the board, which results in establishing a comprehensive umbrella of partners and funders. Experience taught us that even if shortcomings occur from one party or more, the resulting deficit is always compensable via the mechanism of co-funding. It becomes a simple exercise of prioritization.

The specialized services insured to the handicapped children constitute several components: 

a) The psycho assistance;

b) The occupational therapy;

c) The physiotherapy exercises; 

d) The speech therapy;

e) The music and the fine arts (with an expansion in the scope to include pupils and teachers of the elementary school and the kindergarten);

f) The customized academic
curriculum;

g) The social counseling and support extended to the pupils’ families.

Mental health practitioner curriculum

The goal is availing qualified workers in the field by creating pools of trained professionals to identify onset mental disorders and to provide basic interventions, including a referral system, to meet the psychiatric and psychological needs of the constituency, mainly at primary health care settings.

It has now been running for five years and three groups of students have graduated. Most of the graduates are now integrating a mental health dimension within their daily work at the primary health settings and elsewhere. The gained experience necessitates the redesign of the program into a two-year, part-time module-based program, which launched in fall 2011.

In designing the program, we have been inspired by the Mental Health Nursing Curriculum, in construction, syllabus, learning outcomes, teaching/learning strategies and assessment methods (WHO Regional Office for Europe 2003).

Since this is a pioneering work, as mental health facilities hardly exist and we have to establish infrastructure and simultaneously train professionals in the field of mental health, we have chosen to focus somewhat less on evaluation and managerial skills and more on psychiatric core subjects according to the present needs. This approach will, however, regularly be reviewed and developed. Candidates need to be holder of, at least, a baccalaureate technique in nursing or university degree in social work or in other relevant fields.

The Mental Health Practitioner Program is a part-time module-based program running more than two years. It consists of eight modules and is managed by the Imam Sadr Foundation and its School of Nursing. As part-time modules, the students are expected to work in health/mental health organizations. The ISF will urge its health premises to cooperate with other relevant institutions in order to give the students practice and field experiences.

Apart from traditional lectures, the program includes other pedagogical methods such as problem-based learning, presentation and feedback techniques, discussions in groups, observation and interview and field visits, followed by presentations of what is learned. The students are responsible for certain topics under the supervision of a teacher. The students are hence expected to participate actively and their activities will be part of the final evaluation. 

During the two years of training, the student is expected to establish a professional identity and a profound understanding in how to use oneself as a tool in her/his work and to base her/his work on sound clinical practice. The student must also have respect for the patients and those affected by the illness and for other professionals. The graduated students should be rooted in professional ethics in their work and work in accordance with the law. The student suitable for work will also be part of the final evaluation.

The Imam Sadr Foundation feels a great responsibility in organizing this program and is well aware that a two-year program as such is only a first step, although an important one, towards a society that acknowledges mental health problems, that fights stigmas and gives treatments for those in need. The Foundation has hence included mental health in its Specialized Spinal Unit in Derdegiea.

The Specialized Spinal Unit

Derdegaya Center is to be rehabilitated in such a way that it serves as a specialized spinal unit for the patients with urinary tract problems. The following activities have taken place: Equipping the center, staff training, community awareness, consultation and database, as well as provision of services.

Until the mid-1970s when intermittent catheters were introduced, renal failure, septicemia and other urinary tract complications were the most frequent causes of death. The last 50 years has shown a dramatic improvement in survival, addressing morbidity and quality of life, with appropriate treatments and follow-ups. It is recommended a follow-up take place in a specialized spinal unit.

In this initiative in Lebanon, we focus on the consequences of urinary dysfunction, as these represent the most severe challenges related to morbidity, mortality and quality of life. This need is mostly found in the southern parts of Lebanon. Fortunately, the two organizations (NORWAC and ISF) had previously developed a socio-medical center in Derdegiea, including physiotherapeutic facilities. This center is not only a crossroad in the south at about a 20 minutes drive to Bint Jebail, Tyr, Merjouen, Sayda and Nabatye, but also is on well-built premises that are almost ready to accommodate the personnel and the equipment of the aforementioned project.

Implementation plan:

To establish the treatment program, a realistic plan for sustainable funding was put in place with a time frame of five years: 2014-2019.

The education program for workers includes both female and male personnel. Ten to 12 nurses and physiotherapists, as well as three doctors, are included in the training program.

The training program is principally taking place in Lebanon. Participation in abroad activities and conferences is also envisaged, as is a yearly exchange program of two to three weeks’ duration. The training consists of lectures and discussions, as well as clinical practices, in an interdisciplinary setting. Other components include possible use of telemedicine; the opportunity for academic grounding in Lebanon and the potential for a research project related to the work.

Medical assessment 

The medical assessment includes:

• A standardized questionnaire and data sets (ISCOS). 

• Examination with pressure recording of the bladder during filling (cystometry), as per (ICS). 

• Ultrasound examination, with the main objective to assess renal morphology and complications like hydronephrosis and nephrolithiasis. 

• The bladder will be examined for cystolithiasis. 

• Basic blood chemistry (hemoglobin, leukocytes, SR, creatinine, electrolytes) and urine culture for bacterial growth and resistance pattern.

• In patients with known or suspected complications, analysis of creatinine clearance in 24 hours of a urine sample will be done. This will require an overnight stay at the center. 

After the initial assessment, all patients receive an individual plan and recommendation for follow-up. There will probably be several cases where a catheter a demeure will need to be changed to intermittent catheterization. In these cases, patients will be admitted for two to three days’ stay with systematic training and motivation. Supply of catheters and medication will be done according to existing possibilities for support and reimbursement

Next Time: part two of this series focuses on how the ISF works for the empowerment of women.