IsiPAN (Isinusulong ang Psychiatry At Neurology): Kalusugan ng Diwa, Utak at Kaisipan tungo sa malusog na Pamayanan at Kinabukasan. A Community-Based Mental Health Program

Currently, mental health issues are of greatest importance to society as it is considered to be a growing invisible pandemic. It is strongly suggested to address concerns in the field of neurology and psychiatry, especially at the community level. One of the most popular interventions that the World Health Organization (WHO) recommends is to bring health promotion to the periphery. With this in mind, a public health campaign in one of the University of Santo Tomas Simbahayan partner communities, Kasiglahan Village Rodriguez, Rizal was born. This project aims to bring health awareness to the community, especially at the grassroots levels involving the municipal rural health unit, barangay health care workers and allied specialist stakeholders. They were taught symptom recognition, proper referral to specialists and prevention measures that the community may benefit from, which is much needed at this day and age. Further, this program can serve as a precursor to more public health initiatives regarding mental health in the community to spread awareness and aid in the prevention of mental health illnesses.


INTRODUCTION
Health as defined by the World Health Organization (WHO) is "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." [1] Thus, mental health is essential to a human's collective and individual ability to think, emote and interact. Although mental health is a significant component of health, recognition of mental disorders and awareness about its importance is limited. It has become a silent pandemic as more than 100 million people suffer from mental health disorders in the Western Pacific Region alone. [1] Stigma and lack of understanding about mental disorders are major barriers to seeking help and promoting better mental health. Increasing understanding and overcoming stigma through strategic communications, mental health promotion and social mobilization are crucial steps towards strengthening mental health programs. [1] Mental health promotion involves actions that improve psychological well-being. There are several ways to promote mental health, including early childhood interventions; socioeconomic empowerment of women; social support for elderly populations; programs targeted at vulnerable people; promotional activities in schools, communities, and at work; violence prevention programs; and anti-discrimination campaigns. [1] Mental health promotion should ideally be incorporated into community health programs. In addition to the health sector, it is essential to involve the education, labor, justice, transport, environment, housing and welfare sectors to name a few stakeholders. The WHO's goal is to see that mental health is integrated into primary healthcare systems across the world. There is knowledge but the major challenge now is to translate this into action and so that it reaches those most in need. [1] There is an urgent need to develop comprehensive, integrated and responsive mental health services in the community setting. The lack of human resources for mental health is a commonly reported problem globally, it is essential to train human resources, build capacity and engage in social mobilization for mental health in communities. While the numbers of specialists need to be increased, the immediate solution is to develop strategic plans for training, supervising and support for non-specialists to deliver essential mental health care. [1][2][3]

Objectives of the "IsiPAN" Project
To establish an effective mental health program, especially in addressing the stigma that comes with it, and mental health awareness campaigns should be a priority. [1,2] It includes creating relationship with the stakeholders for mental health such as local government units to bring together services from the health and non-health sectors; creating focused groups to facilitate plans for action; harnessing community resilience incorporating the social and cultural practices in the community; effectively utilizing social mobilization with the use of human and physical resources; and establishing leadership that responds to community needs, especially during disaster or crisis. [4] Given these particular guidelines, these are the objectives of the "IsiPAN" project: to develop comprehensive and responsive mental health services in community-based settings by integration of accessible interventions within nonspecialized healthcare services; to identify a focal unit or functional division responsible for mental health issues in the community; to harness capacities of local government units (LGU) and organized groups such as barangay, the smallest administrative division in the Philippines; health care workers to implement promotive and preventive interventions on mental health; to strengthen capacity building and social mobilization by training community nurses, Barangay Health Workers (BHW) and allied health specialists; to promote participatory governance and leadership in mental health projects; to implement strategies for health promotion and prevention about mental health issues in the community; to strengthen information systems, evidence and surveillance for mental health in the community; to create a good referral pathway for identified cases to specialists in a primary, secondary or tertiary hospital; to strengthen coverage of mental health services through multi-sectoral partnership in providing high quality service aiming at the best patient experience in a responsive service delivery network; to strengthen coordination amongst different stakeholders regarding different mental health issues, especially during emergencies/crisis. [1,2]

Community setting
Rodriguez, Rizal is a first class municipality belonging to the second congressional district of Rizal province located in the eastern part of Luzon. It is composed of 11 barangays, seven of which are classified as urban with a total land area of 36,307.31 hectares, mainly forestland and watershed area. It often serves as an area that continuously receives relocation projects from Metro Manila. Rodriguez is also prone to several natural hazards and disaster risks that affect all levels of development. The population of Rodriguez has steadily grown throughout the years. The population growth rates of Rodriguez over the years can be attributed to the large influx of migrants. The sharp increases or leaps in population size of the municipality were recorded mainly in Barangay San Jose and San Isidro, respectively. Thus, it helped change the character of Rodriguez from being rural to urban. The national census 2007 has revealed that Rodriguez has a relatively young population. Young dependents comprise 36% of the total population while economically productive individuals comprise 61.42% of the total population. [5] Literacy, defined as nominal literacy or the simple ability to read and write (vs functional literacy and numeracy), is generally high in Rodriguez at 97.94% of the working-age population 15 years and above. In urban barangays, the literacy rate is 98% while in rural barangays the literacy rate is 3% lower at 95%. [5,6] Social welfare services have been devolved to LGUs by RA 7160. The Municipal Social Welfare and Development Office carries out several health programs including welfare programs using locally generated resources. For the provision of social welfare and healthcare services, it has rural health units and day care centers throughout municipal barangays which make it more accessible for the target beneficiaries to avail of their services. The Casimiro Ynares Memorial Medical Center is a tertiary hospital that is operated by the Provincial Government of Rizal. This would benefit the local residents because it is a public health institution that charges lower fees than private hospitals and medical clinics. [5,6] To date, this is the breakdown of health facilities and health work force in Rodriguez (Montalban) Rizal: there are two major hospitals: Casimiro Ynares Memorial Medical Center (public) and H Vill Hospital (private) which offers a wide array of services, however, both do not offer services related to neurology and psychiatry; an infirmary located in Kasiglahan Village, San Jose, Rodriguez, Rizal; there are 33 doctors in total mostly general practitioners, internists, surgeons: three permanent doctors in the government including municipal health officer (pediatrician), assistant municipal health officer, 16 part-time assigned in the RHU (Rural Health Unit) while 14 are in the Ynares hospital; there are three dentists assigned in the RHU; 9 nurses in the RHU (5 permanent, and 4 contractual via job order), additional three nurses in San Jose Munting Ilaw Clinic; there are a total of 423 Barangay health workers in the whole of Rodriguez, Rizal; 83 of which are assigned in Barangay San Jose. [6] Amongst all the barangays in Rodriguez, San Jose is one of the largest and most populous. Its population as determined by the 2015 census was 124,868. This represented 33.82% of the total population of Rodriguez. [6] It is divided into six areas (Areas 1-6) for easier monitoring. It is also the place where Barangay 1K Kasiglahan is located, which is the partner community of the University of Santo Tomas Simbahayan and is the index community of this project. [5] IMPLEMENTATION OF THE PLAN OF ACTION

Courtesy Calls and Coordination for Implementing the IsiPAN Project
On Aug 9, 2019, an initial ocular was done in the community. The Simbahayan representatives endorsed the group to leaders of the partner community in 1K Kasiglahan. It was set on an informal meeting mainly aimed to familiarize with community leaders and the vicinity. This was followed by processing of the memorandum of understanding among stakeholders initially including the community leaders, University of Santo Tomas Simbahayan representatives and students/program leader of UST Master in Public Health International. On October 11, 2019, an informal meeting with Barangay San Jose Chairman Glenn Evangelista together with some community leaders took place at the Barangay Hall in San Jose Rodriguez, Rizal to discuss about the ways on how the local government unit can help the project, especially with logistics. On October 18, 2019, a more formal meeting was done at the same venue and different projects were specifically discussed one by one including the IsiPAN project. The group was introduced to more community leaders who would help with the logistics (venue, security, invitation of participants). Initially, the plan of the IsiPAN workshop was to conduct the one day mental workshop only with 1K Kasiglahan (Area 4-5) BHWs but with the help and wisdom of the honorable chair, the birth of a bigger project pushed through involving representatives from all areas (1-6) of San Jose because during the meeting, it was emphasized that there is really a dying need for mental health programs in the community. In summary, after the said meeting, a two-day workshop will push through with more BHWs to participate (November 30 and December 7, 2019). The venue for the lay forum Health Promotion for Mental Health activity was also finalized as well as the dates and it was set on Dec 14, 2019, at 1K Kasiglahan Covered Court. The barangay chair also advocated that we meet with the mayor and municipal health officer of Rodriguez, Rizal for more information about existing health programs in the locality.
On November 6, 2019, we had a courtesy call with the Mayor, Honorable Dennis Hernandez, who formally endorsed us to coordinate with the Municipal Health Officer Dr. Maria Carmela Javier. On November 11, 2019, a formal meeting with the Municipal Health Unit headed by Dr. Javier was done where it provided the venue for the IsipAN project to be presented.

Community Needs Assessment and Diagnosis
In order to identify issues from the roots in the community as part of planning, the first activity for the program is needs assessment and community diagnosis. In order to have a good picture of current mental health issues present in the community, this part was divided into several areas. Since the bulk of the project is about education of nonmental health allied providers, one of the activities done was the focus group discussion with them. It was done on November 15, 2019 at McDonald's Primark Kasiglahan meeting room. The goal of this activity was to have at least 15 attendees. There were a total of 20 attendees mostly BHWs and 2 community leaders which comprises more than 100% of the target as a measure of success. There were several guide questions for the discussion that they needed to answer and share something about. All discussions were done in Filipino as many of them preferred it that way. Most of them had been serving as BHWs for at least an average of 5-8 years and in unison said that they had not been exposed to any mental health training of any kind and thus were more eager to learn since they all felt that there was an urgent need for that since the cases they only knew were increasing. They also were eager to learn about what mental health symptoms, whether neurologic or psychiatric, they needed to know so that they could advise patients to seek help. To name a few some of the questions, it included: "Ano para sa iyo ang kalusugang pang-kaisipan?", "Ano pang mga pamamaraan kung paano mapapanatili ang maganda kalusugan ng utak at isipan?, "Ano po ang pang-karaniwang sakit ng utak at isip na iyong alam o nabalitaan?" (Please see attached questionnaire used in the discussion in the Appendix). At the end of the meeting, it was established that there was still little information known to BHWs about mental health in general. They were also confused as to what was considered as mental health concerns and where to bring patients identified with these conditions and symptoms because they observed that there were no available services in the community. All of them felt that people with mental health issues in the community do not seek for help urgently because of the fear of stigmatization. The outcome of this meeting was one of the bases for module development.
The second part of getting to know the needs and issues that had to be addressed was the meeting and brainstorming with the Municipal Health Officer, Dr. Maria Carmela Javier, and her staff last November 20, 2019, at the Rural Health Unit office. It was attended by her assistant Municipal Health Officer (MHO), Dr. Emily Ann Orocay, municipal health nurse Mrs. Josephine Dayao and the non-communicable nurse coordinator, Ms. Ma. Evan Laine Santos. They reported that to date, there is still no existing active mental health program in the municipality and they are still in the process of attending seminars about this provided by the Department of Health (DOH). The most recent that they attended to was the English Mental Health Gap Action Program (mhGAP) module of World Health Organization -Department of Health (WHO-DOH) almost a year prior to this engagement. The team believed that the mhGAP module was too technical and medical for BHWs since it was discussed in English. There was no formal data recording of any mental health diagnosis till date, whether it be a neurologic or psychiatric problem because it was still not part of the routine data collection that they do. However, based on the files of those applying for the Person with Disability card, mental health cases in 2018 were 20 while in 2019 it rose to 82. Likewise, during the meeting we had discussed how a referral pathway works in the community given that there are identified cases already with mental health issues. They disclosed that there was no neurologist or psychiatrist in the area currently, so they are really having a hard time dealing with issues concerning the two specialties. There were no formal referral pathways established and no first aid medications could be given in the RHU or infirmary due to unavailability of medications and expertise and knowledge of health care providers. Thus, people are having a hard time when there is an emergency or even with ordinary cases involving mental health. Problems identified include lack of infrastructure, lack of trained capable health providers in the community, lack of available medications, lack of training about mental health, poor surveillance of mental health disorders, poor health seeking behavior, lack of a referral pathway that would serve as a guide and lack of sustainable services for mental health concerns.
The last part of the evaluation was getting to know the sentiments of the community dwellers by having a one-on-one interview with those who volunteered and gave consent for the survey. The interview was conducted in a secured private area where ethical considerations were highly observed including utmost confidentiality since some topics regarding mental health issues, both neurologic and psychiatric, might be sensitive. There were a total of 42 volunteer respondents, mostly females with only 3 males in the group. Most of them have more or less 10 years of formal education, are plain housewives and migrants that had been living in the community for at least 5 years. An interviewer-assisted questionnaire (please see the attached questionnaire used in the discussion in the Appendix) about basics of mental health was used specifically asking about what they knew about mental health, whether they knew someone experiencing issues on mental health, the symptoms that they felt should there be any (whether it be neurologic or psychiatric), their way of life on how they maintained and strived to be healthy (mind and body) to name a few. Almost 90% of the respondents had low back pains and numbness of both hands, more than 50% of the respondents reported difficulty sleeping which may be reflective of insomnia, a quarter of the population revealed that they had symptoms of possible anxiety, 10% of the respondents volunteered had symptoms of sadness that affected their lives. Those identified to have symptoms were given a postinterview debriefing and subsequently referred to appropriate health providers. They signified understanding and agreed to seek professional help at the earliest. Most of them volunteered that they knew a lot in the community that manifested neurologic and psychiatric symptoms but did not go to the doctor because of financial constraints, lack of available services in the community, lack of knowledge about the symptoms and learned poor health seeking behavior. They also volunteered that substance abuse (alcohol, smoking, illicit drugs) was a problem in the community. They all expressed their desire to learn more about mental health and more importantly how to avoid problems related to it. The result of several discussions became the basis for the planned lay forum mental health awareness activity that was scheduled on December 14, 2019. They all expressed their attendance to that activity and narrated that they would bring family members as well to learn.

BHW Workshop Proper
The main aim of the workshop was to educate the BHWs about mental health, its common symptoms and issues, and more importantly on how to avoid and prevent it. There were two workshop schedules done on November 30, 2019, and December 7, 2019, respectively at the Municipal Livelihood Technical Education and Skills Development Authority (TESDA) Center 1K Kasiglahan, Barangay San Jose, Rodriguez, Rizal. The workshop was divided into two modules: morning session was about neeurological issues (mga karamdaman ng utak which included stroke, epilepsy, dementia, headache, low back pain and hand numbness; the afternoon session was about psychiatry (mga karamdaman ng isip which included depression, anxiety, substance abuse and cyberaddiction, psychosis). The modules were all in Tagalog, as preferred by the BHWs during the initial focus group discussion and as advised by the MHO. It included a basic definition of the different conditions, symptom identification, when to bring them to a doctor and more importantly in public health, the module was really strong on prevention. The modules were designed by a group of neuropsychiatrists who got involved in community neurology and psychiatry and were also consulted by three public health specialists. There was a consultation with three public health specialists about the module to make sure it followed the public health principles: Dr. Sandra Hernandez, Dr. Miguel Dorotan and Dr. Joel Buenaventura. The workshop was a combination of lectures, games, video presentations and role playing. The concept of psychological first aid by the WHO was also included in the discussion because at their level as BHWs, they could practice the three basic principles such as: Look (check for safety, check for people with urgent need, check for people with serious distress) Listen (approach people who may need support, ask about people's need and concerns, listen to people and help them to feel calm) and Link (help people address basic needs and access services, help people cope up with problems, give information, connect people to loved ones and social support). The workshop started with a basic pre-test in both neurology and psychiatry modules. The perfect score was 10 and the average score for neurology pre-test was 5.79, while for psychiatry it was 4.32. After each module, a post-test was given. There was an increase in score in neurology with an average of 9.25 while in psychiatry the average was 8.49. Those who scored <8 were given a one-on-one discussion about the items they had missed. All those who completed the workshop were given health promotion materials such as flyers and T-shirts. Certificates were given during a formal awarding ceremony with Barangay Chairman Glenn Evangelista on December 14, 2019, during the community lay forum event. Those who underwent training would be the core group of the health sub-committee on mental health. The target attendees set during the meeting was 20 for the two workshops. The first group of attendees were all from Kasiglahan village, a total of 27 BHWs (which is more than 100% of the target audience), while in the second workshop were 5 representatives each area from all six areas of Barangay San Jose and the total number of participants were 38 (which was almost 200% of the target). Those representatives will echo what they have learned to fellow BHWs from their respective area in February 2020 since the module was formally turned over to them via soft copy and hard copy in front of the health committee head, Honorable James Philip Marcelo and Barangay chair, Honorable Glenn Evangelista last January 15, 2020. The workshop program proper included topics relevant to mental health issues, neurologic and psychiatric signs and symptoms recognition, and introduction of must-know topics including stroke, dementia, epilepsy, headache, low back pain, depression, anxiety, psychosis to name a few. The whole program details are located in the appendix for reference. The workshop proper was done together with volunteer doctors/residents from the Department of Neurology and Psychiatry, University of Santo Tomas Hospital and Department of Neurology, Jose Reyes Memorial Medical Center.

Lay Forum Activity About Mental Health Awareness
On December 14, 2019, from 8 am to 11 am at the 1K Kasiglahan Covered Court, a lay forum mental health awareness campaign was done which targeted people in the community to participate actively. The goal was for them to be aware that mental health was equally important as physical health and to emphasize the prevention of diseases that concerns the mind and brain. It was well attended with almost 100 adult participants (the initial target was around 60-70 participants). Physical exercises were done that used the official zumba video of the DOH and the official FIT HEART MINUTE exercise video of the Philippine Heart Association. We also did mental calisthenics to promote brain exercises to keep the mind and brain healthy. Question and answer game pattern activity was done to entice the audience to participate and learn well about basic neurology and psychiatry issues and how to prevent them. Health promotion materials were distributed about how to keep the mind and brain healthy.

Municipal Health and Allied Offices Workshop
After the success of the workshop of the BHWs in the community, they now know how to identify the common symptoms and are very much aware on when to bring the patients to the health care provider, whether it be in an emergency setting or non-emergency setting. Therefore, it was but appropriate that the other stakeholders be trained as well when they are called for help or when patients are brought to them for care. Thus, in partnership with the Municipal Health Office, an order was done to encourage doctors, nurses, and other allied health providers to attend a workshop on mental health, specifically designed for them that would include not only symptom recognition but also proper coordination, diagnosis and management, at least first aid and observing a proper referral pathway. The one-day workshop was done at Coco Mountain Resort, Barangay San Jose Rodriguez, Rizal. The initial target was 50 participants. It was a well-attended activity, a total of 68 participants from varied specialties including doctors, nurses, policemen, community rehabilitation specialists, representatives from Disaster Risk Reduction Council, representatives from the Department of Social Welfare (DSWD), Tourism, community leaders and BHWs from other barangays, social workers, and the Department of Interior and Local Government (DILG). The workshop was divided into two modules: Psychiatry in the morning session and neurology in

Turnover and Future Activities Scheduled
The need for mental health advocates is a lot in this community, thus we have partnered with a non-governmental organization, Lingap Diwa Foundation, whose specialty is mental health (neurology and psychiatry) programs in the community. Since the start of the IsiPAN project, meetings were held for them to consider adopting the community for a more sustainable project. With much gusto, team leader Ms. Jojo Olayres and team specialist Mariel Rodriguez agreed on Dec 18, 2019, to partner with Montalban, Rizal as one of the communities they serve. On January 6, 2020, an agreement between students of UST and the MHO, Dr. Javier was inked. We have met and brainstormed for the proposed activities all year round in Montalban including of course Brgy San Jose. The Lingap Diwa Foundation was introduced during the turnover ceremony on the latter part of the Isipan workshop on January 10, 2020. Lingap Diwa aims to educate and empower communities about neurologic and psychiatric issues. They help individuals in communities gain access to medical professionals and experts for mental health screening and assessment of common neurologic and psychiatric diseases. They primarily promote awareness about neurologic and psychiatric diseases. They partner with both LGUs and NGOs, respectively, to hold activities geared towards educating communities and providing health services for free.

Future Activities
These are the possible activities in line for 2020 as agreed by MHO and Lingap Diwa: Feb 2020 -Training of all community health doctors (target is 20 participants) March 2020 -First medical mission wherein the MHO/RHU will cater to solely neurologic and psychiatric illnesses in the OPD; specialists will be brought by Lingap Diwa. During this time the community doctors are trained on-site by the specialists (this will be done every 3 months for a year -June 2020 and October 2020); medicines will also be provided for patients. Those patients screened will be invited to be part of a club/support group where they will have monthly activities. On the community side, last January 15, 2020, at San Jose Brgy hall in the presence of Chairman the afternoon session. Basic screening, diagnosis and management, especially first aid, and prevention again were discussed. Case-based discussions were also done together with video presentations and sharing of experiences. Pre-test and post-test were administered during the respective modules. The average of neurology pre-test was 6.78 while posttest was 9.22; while for the Psychiatry module pre-test average was 5.96 and post-test was 8.82. They were also given a lecture/workshop of brief neurology and psychiatry rating scales for easier identification of problems. The program ended with distribution of health promotion materials like bags and pamphlets. The referral pathway was also established during this time. The module in psychiatry was in collaboration with a community psychiatry specialist, Dr. Liecel Fulgencio whose practice was within the Marikina Area. Based on her meeting with Dr. Javier, the MHO, she agreed to see the most identified cases and if needed, they could contact her for advice, especially for emergency purposes. Since there was an identified need for a good mental health program, Dr. Javier, the MHO, will discuss with the municipal mayor and the rest of the Sangguniang Bayan about a possible municipal policy like other more advance cities and communities like Quezon City. The workshop program proper had topics related to neurologic and psychiatric signs and symptoms recognition as well as some insights about must know topics including stroke, dementia, epilepsy, headache, low back pain, depression, anxiety and psychosis to name a few. Throughout the whole program, prevention strategies were emphasized to help attendees plan their activities in their respective specialties and units for their future activities. The whole program details are located in the appendix for reference.

Multisectoral Referral Pathway Creation and Distribution
Since most of the stakeholders were present during the municipal health office mental health workshop, a time was allotted to create, approve and ratify the mental health referral pathway for emergency and non-emergency situations which would be distributed to all agencies and LGUs involved. The Municipal Health Office/Rural Health Unit (MHO/ RHU) office and the program leader coordinated as well with different hospitals that were included in the pathway for ease of patient transfer and referral.

Outcome
Project

CONCLUSION
Mental health programs in the community are really necessary in Rodriguez, Rizal to address the growing needs of the community. Health promotion is one effective intervention for mental health programs in the community.

DISENGAGEMENT
The disengagement activity from the community formally commenced on February 24, 2020, 2-4 pm at the Barangay Hall of San Jose, Rodriguez, Rizal where the different stakeholders took part.

RECOMMENDATIONS
1. Since the establishment of the health sub-committee on mental health, it was recommended that twice a year mental health promotion activity be done to increase awareness and decrease stigmatization.
2. Since there was an identified need for a good mental health program in the community, it was strongly recommended that there should be a more participative legislation and more dynam-ic leadership by passing municipal or barangay ordinances like other communities for an established and sustainable mental health program.
3. With the increasing demand for mental health services and lack of facilities as well and human resources, it was recommended that there should be provisions for the improvement of facilities, availability of medications in the community as well as increasing capable human resources.
4. Strengthened coordination amongst stakeholders was highly advised for more efficient mental health service delivery in the community.
5. Better information systems and surveillance systems would help the community monitor conditions related to mental health and in that way, it is more justifiable to make it a part of priority programs.
6. Constant training of health care providers, at least once or twice a year, for better service delivery.
7. Creating more specific programs for the youth and family since bulk of the population are also adolescents and mothers.
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