COMFORT FOR KIDS IN THE TIME OF EBOLA 1 TABLE OF CONTENTS 2 MENTAL HEALTH LIBERIA MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA CHC Community Health Committees C4K Comfort for Kids DHC District Health Committee DSM-5 Diagnostic and Statistical Manual of Mental Disorders 5th ed. EERTF Ebola Recovery and Restoration Trust Fund ACRO EVD Ebola Virus Disease GOL Government of Liberia HQ Headquarters NYMS MC Mercy Corps MCHT Montserrado County Health Team MGCSP Ministry of Gender, Children and Social Protection MIA Ministry of Internal Affairs MOE Ministry of Education MOH Ministry of Health and Social Welfare MOU Memorandum of Understanding M&E Monitoring and Evaluation PDO Project Development Objective PTSS Post-Traumatic Stress Syndrome PTSD Post-Traumatic Stress Disorder SDQ Strengths and Difficulties Questionnaire UASC Unaccompanied and Separated Children USAID United States Agency for International Development WB World Bank WHO World Health Organization YTF Youth Transformation Framework TAB 6 MENTAL HEALTH LIBERIA 7 LE OF Acknowledgements CON Executive Summary TENTS I. Introduction A Project Context B Project Rationale C Project Objectives D General Project Beneficiaries E Project Design 6 Background 7 Implementing Agencies 8 Revisions and Modifications II. Key Factors Affecting Implementation and Outcomes TABLE OF CONTENTS 8 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 9 III. Outcomes Annex 1. Project Costs and Financing A Outcome 1: Improvement in psychosocial wellbeing of Annex 2. Outputs by Component participating children B Outcome 2: Improvement in adult behavior and attitudes toward EVD affected children C Outcome 3: Decrease in post-traumatic stress disorder Annex 3. Supporting Documents and (PTSD) among project beneficiaries. Evaluation Tools D Outcome 4: Level of community willingness to support affected children. E Outcome 5: Direct Project Beneficiaries Annex 4. C4K Target School Districts F Conclusions (Montserrado County) IV. Lessons Learned and Recommendations Annex 5. Participating Schools V. Annexes Annex 6. Report of Supplemental Activities TABLE TABLE OF OF CONTENTS CONTENTS 10 11 This report is the product of a partnership between the World Bank Group and Mercy Corps teams that coordinated the implementation of the Liberian – Comfort for Kids (C4K) program over June 2015­ December 2016. The WBG team was led by Rianna L. Mohammed, Senior Health Specialist, and included Munirat Ogunlayi (Health Specialist), and Sarah McCune (WB mental health consultant). The Government of Liberia’s Ministries of Education and Health were instrumental partners in the program, along with the many teachers, supervisors and caregivers of Liberia’s children with whom the teams worked during the program. The teams also acknowledge the many community leaders and health worker who led effort to control the spread of Ebola in their neighborhoods, ACK towns and villages. In addition, the teams would like to thank the World Bank Group- administered Ebola Recovery and Restoration Trust Fund for financing the C4K program. NOWL The editing and publication of this report was done under the support of the World Bank Group Global Mental Health Initiative under the coordination of Patricio V. Marquez, Lead Public Health Specialist, and Sheila Dutta, Senior Health Specialist, Health, Nutrition and Population Global Practice, World Bank Group. The EDG final report was edited by Aaron Shakow, Director, Initiative on Healing and Humanity, Center for Global Health Delivery--Dubai, Harvard Medical School. Washington, D.C. 2018 MENTS ACKNOWLEDGEMENTS ACKNOWLEDGMENTS EXEC 12 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 13 UTIVE The 2014-15 outbreak of Ebola Virus Disease (EVD) in Liberia resulted in over 10,000 cases and 5,000 deaths. Recognizing the importance SUM of addressing children’s trauma, the Ebola Recovery and Restoration Trust Fund (EERTF) funded the implementation of a Comfort for Kids (C4K) program. Developed by Mercy Corps, an MARY international non-governmental organization, the C4K program encourages psychological healing, and promotes resilience in children who have experienced a crisis or disaster. The C4K program in Liberia was implemented between January 2015 and December 2016 in 15 townships in Montserrado County through a collaboration between Mercy Corps Liberia, the World Bank’s Liberian Health Task Team, and the Government of Liberia. Approximately 10,000 children between the ages of six and 13 in 94 schools received “My Ebola Story” workbooks and participated in associated classroom activities, which were facilitated by 753 C4K- trained teachers. The workbooks were adapted to the Liberian context by local illustrators, who worked with C4K staff to ensure that they were age- and content-appropriate. Following the introduction of the C4K program, teachers reported positive changes in their students’ behavior and mood. Students, they said, were more engaged and less despondent in class. Several teachers mentioned that the C4K program had prompted them to learn more about how to help children process their trauma. Also, to strengthen family bonds, and thereby increase children’s sense of security, teachers encouraged their students to share the workbooks with their parents. Program staff trained 612 parents on how to detect and respond to their children’s trauma reactions, and built the capacity of 280 health providers and 150 local leaders to further support the children’s recovery at the community level. Finally, in the course of program implementation, EXECUTIVE SUMMARY C4K staff developed a psychoeducation intervention targeted to 1,086 high-risk children and their families, and established a referral pathway to a Médecins Sans Frontières (MSF) clinic for children in need of more intensive mental health services. 14 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 15 Time constraints did not allow for a randomized evaluation of the C4K program. However, pre- and post-test evaluation results show that the C4K program was successful in improving the psychosocial health and well-being of Ebola-affected children and in increasing community support for them. Prior to receiving the C4K workbook and participating in the associated activities, only 37 percent of children showed acceptable levels of psychosocial wellbeing; after participation, nearly 92 percent did. Stigma and fear caused many adults to distance themselves from Ebola-affected children. Following their participation in C4K trainings, however, approximately 64 percent of adults were willing to support the children, up from 42 percent at baseline. Their behavior towards Ebola-affected children similarly improved. At baseline, 32 percent of adult participants reported that they treated Ebola-affected children with patience and understanding; after participation, 86 percent did. Representatives from the Ministries of Health and Education (MOH and MOE), health providers, school principals, community and religious leaders, and members of parent-teacher associations have expressed overwhelming support for the program and a desire for its countrywide scale-up. While direct program expansion is severely constrained by a lack of resources, C4K staff and other development partners are now working with the MOH’s mental health division and the MOE’s teacher training, early childhood education, and psychosocial divisions to develop school- based mental health programs. EXECUTIVE SUMMARY 16 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 17 A Project Context Ebola Virus Disease (EVD) reached Liberia in March 2014, after its emergence in Guinea in late December 2013. By August 2015, there had been 10,672 suspected, probable or confirmed cases of EVD in Liberia and 4,808 deaths.1 1 U.S. Centers for Disease Control & Prevention, “Ebola The Ebola epidemic of 2014-15 had a devastating impact on (Ebola Virus Disease), Previous Case Counts,” available at children in Liberia. According to government statistics, 4,345 http://www.cdc.gov/vhf/ebola/ children (2,271 girls and 2,074 boys) were affected directly by EVD, outbreaks/2014-west-africa/ either because they were personally quarantined and/or treated previous-case-counts.html for infection or because a member of their immediate family had been caught up in the epidemic or the public health response. By April 2015 the Liberian Ministry of Health and Social Welfare (MOHSW) had registered a total of 3,091 children as having lost one or both parents/primary caregivers to EVD (847 lost both parents and 2,244 lost one parent).2 This does not include the 2 UNICEF, “Liberia Ebola children who lost neighbors, teachers, or friends to EVD, or whose Outbreak Weekly Situation neighborhoods were placed under quarantine. Report #81,” 15 April 2015, available at http://reliefweb. int/report/liberia/liberia- For many Liberian children, the crisis of Ebola continues to this ebola-situatio+n-report-no-81- day, in the form of intrusive memories about illness, isolation, and 15-april-2015 death. This post-traumatic impact is particularly acute for children who were quarantined, separated from family during treatment, INTRO orphaned or otherwise directly affected by the epidemic. But even for those children who did not have these experiences, the very public scenes of suffering and death had a profound impact on their mental health and well-being. DUC Protective factors, such as a nurturing family life, dependable relationships, school attendance, and a stable political environment, can mitigate the negative psychological effects of a crisis, like Ebola. During the crisis, many of these protective factors were destroyed, leaving children vulnerable to experiencing further trauma. Left unaddressed, trauma can hinder children’s academic TION achievement, and can increase their risk of compromised mental health later in life. Both of these consequences are known risk factors for poverty. INTRODUCTION 18 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 19 B Project Rationale B The increased understanding in participating communities of how children and adults are affected by EVD and other crises through dissemination of key messages and educational The Comfort for Kids (C4K) program in Liberia was established materials to improve overall community support of EVD with a small grant to the World Bank’s Liberian Health Task Team affected children. from the Ebola Recovery and Restoration Trust Fund (EERTF). The C4K program encourages psychological healing, and promotes resilience in children who have experienced a crisis or disaster. 2 Key Performance Indicators (KPIs) It was developed in the wake of September 11, 2001 by Mercy Progress towards the achievement of the PDO was measured Corps (MC), an international non-governmental organization, through the following outcome (PDO-level) indicators: and has since been implemented following natural disasters in Haiti, China, and Japan; and in post-conflict and refugee settings A Improvement in the psychosocial wellbeing of in Gaza, Jordan, and Lebanon. Over 10,000 professionals, participating children. This indicator represents the paraprofessionals and parents in these locations have received percentage of children showing confidence and expressing C4K training. secure feelings and adaptation to their environment before and after participating in C4K activities. The data were C4K primarily centers on the “My Story” workbook and associated measured from the children’s checklist tool that focused on classroom activities, which provide children with the opportunity two main questions: (a) what kinds of problems do children to express their emotions about their experiences through have because of Ebola and (b) why do you think some drawing, writing, and facilitated discussion. C4K also provides children have problems while others don’t? The children were capacity building for parents, teachers, and other caretakers on encouraged to be as clear and specific as possible. how to identify and more effectively respond to children’s trauma responses and to support their recovery. B Improvement in adult behavior and attitudes towards EVD-affected children. We measured the percentage of C4K is a low-risk intervention which is implemented in conjunction adults in the communities showing improved behaviors and with referral pathways to more intensive mental health support in attitudes in acceptance of EVD affected children. Data were the event of severe mental or emotional distress. The successful collected using an evaluation tool/questionnaire before implementation of this program has been a contributing factor trainings with teachers, parents, community leaders and in increasing the resilience, psychosocial health and well-being of after the trainings to gauge whether there was attitude EVD-affected children aged 6-13, in project target areas. change because of the trainings. C Project Objectives C Post-traumatic stress disorder (PTSD) among project beneficiaries. This outcome level indicator measured the The Project Development Objective (PDO) for the C4K program percentage of parents, children and community members in Liberia was to “increase resiliency, psychosocial health and showing signs and symptoms of PTSD before and after the well-being in children aged 6-13 affected by EVD in Montserrado training. Since our staff members are not licensed mental County, Liberia by building local capacity to support children.” health professionals, we did not intend to identify or confirm cases of PTSD, which is a specific clinical diagnosis. The The PDO was to be achieved through: program intended to identify possible cases for referral to our mental health partners for evaluation and care. For this A The increased knowledge and ability of over 750 teachers, indicator, the program used the Hopkins Symptom Checklist INTRODUCTION more than 250 health care professionals and para- – 25(HSCL) and the Harvard trauma questionnaire. professionals, and over 750 parents, caregivers and key community stakeholders to respond more effectively to the needs of children affected by EVD through C4K training; 20 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 21 D Levels of community willingness to support affected county. The mayors, in turn, helped identify key community children. Percentage of community members willing to help stakeholders and local representatives at the city level, and support Ebola affected children after the training. who then were able to help us ascertain the schools and This indicator measured percentage of adults showing the individuals most in need of the program. Representatives will to help and support children affected with EVD. The of the Ministry of Education, including school principals, data was collected at the baseline and measured against were involved in the selection of teachers and students to the endline data through the baseline questionnaire and participate in C4K activities endline questionnaire. B Teachers (n=750) E Direct project beneficiaries (% female). This indicator measured the number of direct project beneficiaries It was envisaged that Teachers would receive basic C4K enrolled in the project and the proportion of females. training on how to use the workbook with children. Since Data were collected from program records of the schools class size is officially set at 40 children, our assumption registered, children working with the workbooks, parents, was that a minimum of 250 trained teachers would be needed to reach 10,000 children. If time and financial teachers and community members engaged in the trainings. capacity allowed, an additional 500 teachers would be trained to increase the general competency and awareness of education professionals in identifying and supporting D General Beneficiaries traumatized children. Selection process: Please see previous section. C4K Liberia targeted five key populations in Montserrado County: (a) children, (b) teachers, (c) health care and social welfare C Health Care and Social Welfare Professionals (n=250) professionals, (d) parents/caregivers and (e) key community stakeholders. The C4K Liberia program trained healthcare and social welfare professionals to support EVD affected children. Following are the selection criteria for participants including Selection process: The Montserrado County Health Team each of the five populations targeted by C4K Liberia and the (MCHT) is overseen by the District Health Committee characteristics of each population: (DHC). Each DHC has a certain number of Community Health Committees (CHC) with access to health facilities. A Children (n=10,000) Participants in the C4K program for Ebola were strategically 3,500 children, aged 6-9, were to be registered and given the identified from these different groups to ensure broad reach opportunity to participate in C4K workbook activities. (The of the program messaging. The health care and social individuals leading such centers were included in the training welfare professionals received basic C4K training. populations, below.) D Key Community Stakeholders (n=150) 6,500 children, aged 10-13, were to be registered and given the opportunity to participate in C4K workbook activities. These individuals are those to whom community members Many children in Liberia start school at a late age when turn for advice, guidance and support. The demographic compared to other countries with the average age of a of this group varies between different settings, but they first grader being ten years old. Consequently, this group is included religious leaders, midwives, local women, comprised of primary school classes. and elders. Selection process. During the first quarter of program Selection process: Key stakeholders were identified through implementation, C4K staff made contact with the Ministry of discussions with partners – the Ministry of Internal Affairs, INTRODUCTION Internal Affairs (MIA). Through this point of entry they were which connected the team to local area leadership (mayors, able to coordinate with the Superintendent for Montserrado commissioners and local chiefs). These stakeholders assisted County, who oversees the mayors in all the cities of the in the selection of community leaders, and the Ministry 22 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 23 of Health also provided key contact information for their community health structure’s leadership. This group of Evaluations have shown that as a result of using the C4K shareholders also participated in the basic C4K trainings. workbook, children are more focused, calmer and more likely to tell their parents and teachers what they are feeling, as E Parents and Caregivers (n=600) opposed to suppressing their feelings. The program lends itself to incorporation of supplemental activities and additional A major component of the C4K program was to improve the modules if additional funding is secured. Additionally, C4K support system available for children affected by EVD. training, and children’s use of C4K workbooks and activities, have Selection process: Parents and caregivers were identified demonstrated improvements in the understanding of children’s in consultation with community stakeholders and had to be needs by adults and concurrent improvements in children’s sense caretakers of children affected by EVD. of wellbeing. Research using the National Child Traumatic Stress Network Custom Screening Tool was undertaken to determine the prevalence of PTSS among the children of a middle school in E Project Design post-Katrina New Orleans and to evaluate the effect of a guided- workbook intervention. Pre- and post-tests used with a sampling of 6th to 8th graders that demonstrated post-traumatic symptom 1 Background level scores declining by 18.75% compared with pre-assessment scores (median of 32 to 26), (p=.0001)3 to the present. Evaluation Young children are highly vulnerable to attachment disorders and 3. Helping Children Heal Proj- tools have not been standardized across different disaster other developmental issues relevant to crisis and disaster. Children ect: A School Based Mental response situations, but there is consistent evidence of overall tend to recover more slowly than adults, and require a stable Health Recovery Effort, Tulane improvements in children’s sense of wellbeing, increased ability to University School of Medicine. environment over a sustained period to minimize disruption of their Department of Psychiatry and focus and concentrate associated with this program. healthy development. To that end, MC developed its post-crisis Neurology, New Orleans LA, psychosocial intervention program for children, “Comfort for Kids,” USA, 2006. MC designed the Comfort for Kids – Liberia program around which was first utilized in the aftermath of 9/11 in New York, and the same key activities implemented in previous programs. The has since helped children recover from traumatic events in Libya, major components of the program were, first, implementation of Japan, Haiti, Gaza, Peru, Chile, and Indonesia, China and now, workbook activities for 10,000 targeted Liberian children and, post-Ebola Liberia. second, training for teachers, parents and caregivers, social workers and healthcare professionals, and other community The Comfort for Kids (C4K) approach specifically promotes the leaders. Program materials utilized in previous iterations of the healing and resiliency of children and youth in the aftermath of C4K program were tailored to the Liberian context. These included crisis or disaster, primarily through the use of the Comfort for Kids the C4K Training Facilitator’s Guide, the Guide for Teachers, the workbook and associated classroom activities which are meant to Top Ten Tips Pamphlet, the Pamphlet for Professionals and the provide a safe space for children to express emotions and thoughts Children’s Workbook. about their experiences. The program also provides training to local professionals, paraprofessionals, parents, community A pilot of the workbook activities was carried out early in the leaders, teens and others with child caretaker responsibilities, to program implementation to test and adjust training materials understand and respond more effectively to normal and abnormal and workbooks. Subsequently, the program was rolled out to reactions to trauma by age group. C4K accelerates children’s all program participants, and following the completion of the and families’ recovery by teaching caretakers how to provide workbook activities and C4K trainings, supplementary activities comfort and security to trauma affected children of all ages. When focused on creating safe spaces for out of school children where children are helped to deal effectively with their trauma, they are they could access mentoring and other support services and INTRODUCTION less likely to require scarce mental health support, more likely to activities to increase parent participation in PTAs were carried out. return to educational activities, and less likely to suffer long-term psychological effects. 24 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 25 2 Implementing Agencies The Teacher Training Division of the MOE helped the C4K team to identify and enroll 750 teachers able to incorporate C4K into their The following actors were involved in implementing the C4K workloads. The MOE’s Early Childhood Education Department and Liberia program: the Psycho-Social Division provided monitoring to the program by meeting monthly to review progress. The MOE was instrumental The World Bank (WB). The World Bank Liberian Health Task in providing support and time to work with their teachers in Team played a number of roles within the program. First, it the program. approved annual work plans, reports and the PIM prepared by MC. Second, it disbursed funds related to the approved reporting In Liberia, the MOE is charged with providing quality education and disbursement plans. Finally, it supervised the activities of the for all and preparing future leaders who are capable of handling MC field team in Liberia through the project team progress and the task of nation building, protecting our national heritage and Quarterly reports prepared by MC, as well as conducting periodic enhancing the socio-economic growth and development for the on-site visits. sustenance of the Liberian state. Its Department of Instruction (DoI) charter includes responsibility to develop and implement Mercy Corps (MC). The MC-C4K team executed the program programs for Early Childhood Education, to develop and implement workplan with the help of the country program support teams. programs for Basic and senior Secondary Education and to develop The primary program activities included: and implement programs for Teachers Training Education. The MOE is therefore an ideal collaborating agency, ensuring that C4K 1 Adaptation and production of two C4K workbooks (one for training and activities are priorities for teachers. Without MOE’s 6–9 year olds, a second for 10–13 year olds) and development support it would have been difficult for the targeted 750 teachers to of program training material. incorporate C4K into their workloads, regardless of its value and/or 2 Engagement of the Ministries of Health and Education in their interest. program goals and execution The MOH is responsible for administering governmental activities 3 Selection of participants in the 5 beneficiary groups pertaining to the protection and improvement of public health and 4 Administration of baseline surveys social welfare. Because the C4K program aligned with its mandate and responsibilities, MOH provided support throughout the 5 Conduct pilot training and adapt model and materials as program, including guidance in identifying and enlisting 250 health needed and social welfare professionals and other para-professionals for 6 Training of teachers, health workers, parents and caregivers participation in the program. These care providers are often sought out by parents and/or communities to assist with issues with children. 7 Support of teachers and caregivers in delivery of C4K Training representatives from this strategic population helped curriculum in classrooms disseminate the key program messages to affected families and 8 Administration and analysis of endline surveys with trauma-affected children who participated in the program. 9 Execution of supplementary support activies Community Leaders, Parents, Caregivers. The C4K program trained 10 Monitoring and evaluation activities through parents, caregivers, community leaders, and teachers to identify program lifecycle abnormal behaviors and direct potential cases to clinical mental health services. Monthly meetings with the mental health division Government ministries. MC established a working partnership with in MOH facilitated monitoring and evaluation of the program. two government ministries: The Ministry of Education (MOE) and INTRODUCTION the Ministry of Health (MOH). Project staff also collaborated with the Ministry of Internal Affairs for initial community entry. 26 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 27 and applied the training received on C4K workbook 3 Revisions & Modifications implementation and utilization of the M&E tools; 2) As some teachers fell behind in the implementation of workbook activities, the team discussed with school authorities allowing Overall, the program was implemented as laid out in the students and teachers more time to complete the activities approved proposal. However, the C4K team faced a number before closing the schools/ or creating extra classes to of challenges during program implementation that required complete implementation every single day. This allowed adjustment and revision of original implementation plans. The some of the schools to make progress on the workbook challenges are described in more detail in the next section (Key implementation that they may not have otherwise made. Factors Affecting Implementation and Outcomes). Here, we Also, as some teachers were dropped from the payroll summarize the changes made. near the end of the school year by the MOE. We came to an agreement with some of the remaining teachers to take on A Implementation of follow-up activities to address large number of students for workbook activities in the final weaknesses in protection system and meet the needs of months. out-of-school children. One major modification the program was the C Certificate Ceremony implementation of supplementary activities from July of Some teachers requested compensation for their 2016 until the end of November 2016. These activities were participation in the program and their work implementing proposed to the World Bank in the summer of 2016 following workbook activities. MC addressed this issue by holding a the completion of the main program activities by the end of “certificate ceremony” for teachers and other contributors, the 2015/2016 school year. During the implementation of the which acknowledged the contribution of these actors. workbook activities and training of teachers, professionals, parents and caregivers and other community members, it became evident to the C4K team that our activities were only D Referral system reaching a subsect of the children impacted by the Ebola The limited availability of psychosocial and mental health epidemic. Many children in Liberia do not attend school services in Liberia was an ongoing issue for the program, or are unable to attend regularly, but still have a need for and it significantly impacted C4K Liberia’s ability to recruit protection and mental health services. In addition, while our staff during program startup and establish a robust trainings on supporting EVD-affected children increased referral system throughout program implementation. The caretakers’ knowledge about how to support children, program addressed this issue by attending Mental Health/ their involvement in structures such as PTAs was low. MC’s Psychosocial Cluster meetings to network with other actors supplementary activities addressed these challenges by in the field throughout the program. As a result, the program implementing “safe space” programming for out of school coordinated successfully with the MSF hospital to institute a children where they could access mentoring and training on referral system for mental health support for severe cases. life skills and discuss ongoing life challenges with peers. We We also worked in collaboration with other INGOs to institute also worked with families and in-school children to provide on-site trainings and supervision for the mental health supplementary training on coping strategies, increase clinician and a referral system in one facility, Redemption parent involvement in PTAs, and refer at-risk children to Hospital, in New Kru town. psycho-social support services. B Adjustments to workbook activities E Addition of Supplemental Activities The C4K program substantially met its workplan goals The C4K team made a number of small adjustments to the by early Fall 2016. The program had been operating main workbook activities. These included: 1) Instituting consistently at or under-budget, resulting in available regular “check-in” meetings with teachers and principals INTRODUCTION funds to continue operations through December from the schools we worked in to provide ongoing support as 2016. Consequently, the program proposed a series of they implemented activities, following feedback from some supplemental activities to be executed in October and of our site visits that not all teachers had fully understood 28 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 29 November 2016 that would strengthen the work done to date, and extend the grant’s goals of providing psycho- social support to more children and communities effected by EVD. This no-cost extension of activities was approved by World Bank, and the activities were executed in October and November 2016, culminating with a Lessons Learned Workshop on December 9, 2016. Details of the supplemental activities can be found in the annex to this report. INTRODUCTION KEY 30 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 31 FACTORS A number of factors affected the implementation of the C4K program both positively and negatively. Here, we discuss each of these factors, which were related both to challenges encountered and to some approaches of the program that turned out to be particularly effective. ×× Procurement of workbooks abroad. One difficulty encountered by the C4K program in Liberia was the acquisition of the workbooks. A tender was made for printing of the workbooks by local Liberian and international printing companies. The results of the tender demonstrated that local resources were either prohibitively expensive, or not of acceptable quality. Consequently, the books were printed AFFECTING IMPLEMENTATION in Ghana and shipped to Liberia for distribution. It took the MC team more than one month to clear the workbooks at the border which caused implementation delays for the program. ×× Challenges related to school administration. Several practical hurdles were encountered during program implementation that related to school administration. Many of these issues were out of our control and we were unable to address them all. For example, a common challenge for teachers in Liberia is late salary payments, which can be de-motivating. In addition, as mentioned above the MOE dropped some teachers from the payroll near the end of the school year, for reasons which were not communicated to the team or (to our knowledge) to the schools., It may have been related to the budget or to issues with teacher certification. AND OUTCOMES As suggested above, the C4K team did everything that was possible to work within these constraints. The certificates of appreciation were developed as an attempt to restore the morale of teachers, which was undermined by the erratic payment of salary and the fact that the C4K program did not compensate teachers for their work. Certificates were presented as part of a ceremony to celebrate the work of teachers and other adults involved in program implementation. When the MOE dropped some teachers from the payroll, the team came to an agreement with the available teachers to continue the activities with a larger number of students to complete the implementation of the activities. KEY FACTORS 32 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 33 ×× Children dropping out of school. The team observed by monitoring the attendance sheet that almost 1 out of 4 of the children registered in the workbook activities were dropping out of school in the third quarter. When the team investigated, they found that one of the causes seemed to be a lack of interest from parents in school activities. Children dropped out of school and missed sessions because of market days and the need to help their families in the market or during the crop season. To mitigate this problem, the team asked the schools to form a Parent- Teacher Association (PTA). The team also invited the school principals to organize more frequent meetings with the parents and to invite the team to talk to them about the importance of educating their children. With our extended C4K activities, we worked further with PTAs and with out-of- school children to address the needs of children who are no longer in school. ×× Effectiveness of field visits. Another strong part of the program, which enhanced the program quality, was the field visit. The team really did a job on this, developing a roadmap and a template report to document everything they did in the field. They documented every issue and they developed a model for the supervision. Moving forward, other MC programs within Liberia and outside, including future C4K programs, could benefit from the model developed by the C4K team for monitoring local implementation partners. The regular group meetings with school representatives during the workbook implementation served to reinforce the messages communicated by the C4K team about proper implementation during field visits. These group meetings were key to the program’s success. KEY FACTORS 34 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 35 The C4K project development objective was to “increase resiliency, psychosocial health and well-being in children aged 6-13 affected by EVD in Montserrado County, Liberia by building local capacity to support children.” Overall, the C4K program accomplished the program development objectives, surpassing the number of beneficiaries targeted and training a range of caregivers and stakeholders to improve their support to children affected by the Ebola epidemic. In implementing the workbook activities, training of teachers, caretakers, professionals and community members, and carrying out supplementary activities, the C4K program successfully supported this objective. Details on the program outcomes are included below, listed by outcome indicator. Our results framework also provides details on program outcomes by indicator. A Outcome 1: Improvement in psychosocial wellbeing of participating children ×× Improvement in psychosocial well-being of participating children: 91.78% at endline, an increase over 37% at baseline. (outcome indicator) ×× Children registered in and participating in C4K workbook activities: 10,597, 106% of target (output indicator) OUT ×× Perception of workbook value by children: 96% satisfaction at endline (output indicator) ×× Supervision support of teachers using workbooks: 287 site visits have been conducted to ensure the proper monitoring and implementation of the workbooks, which represents 287% of the target (output indicator) COMES Discussion To improve the psychosocial well-being of the children, the program implemented the workbook activities in schools and also trained teachers, community members, and caretakers on how to respond to children’s needs. During the first few months of program implementation, teachers were trained on how to support children affected by EVD and on how to implement the OUTCOMES workbook activities. Workbook activities with children primarily took place from January of 2015 until June of 2016. MC carried out 36 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 37 regular site visits to support teachers implementing activities, and drawings and pictures that resonate well with the average young conducted periodic review meetings with teachers and principals Liberian child and language that they could easily understand, as well, increasing support for these actors as needed. which was incorporated into the books during program startup. To measure change in the psychosocial well-being of children In addition to tracking our outcome and output indicators, MC participating in the program, MC used an overall outcome carried out a comprehensive endline evaluation at the conclusion indicator that tracked the percentage of children showing of the workbook activities that surveyed a sample of 200 adults confidence and expressing secure feelings and adaptation in and compared their responses to a range of questions on the well- their environment after the trainings of teachers and caregivers being of children, community stigma against EVD survivors and and participation in workbook activities. Baseline data showed the ability of adults to address the needs of children. The endline that 37% of children tested with the Children Checklist received responses were compared and contrasted to responses from a a composite score indicating an acceptable level of psychosocial sample of 220 adults at the baseline and 200 at the midline. well-being. At the time of the endline, this number had increased to 91.78%. This is a 54.78% improvement over the course of the The responses to three of these questions concerning children’s program. behavior are shown below, and indicate an increased number of children showing normal behavior at endline as compared to Figure 1: Change in children’s overall perception of well-being baseline. as measured by the children’s checklist Figure 2: Children’s behavior and reactions 100% Children Reactions 80% 50% 40% 0% Normal Agressive Normal Agressive Baseline Endline 0% A5.1% of How do EVD affected children generally behave? Baseline Endline A5.2% of How do children react to others? Wellbeing of affected children A5.3% of How do children react to adults? The children participating in the program were able to clearly express their feelings of their current situations based on their experiences with EVD and other situations. The program surpassed its goal of reaching 10,000 children with workbook activities, reaching 10,597 children. An overwhelming 96% of children surveyed through the children’s workbook feedback form following completion of workbook activities reported satisfaction with the activities. In our view the design and contextualization of OUTCOMES the book into Liberian context was a huge factor in the children showing positive outcomes under this indicator. This included use of 38 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 39 B Outcome 2: Improvement in adult behavior At baseline, midline and endline, MC collected data on adult behavior towards EVD-affected children, including their and attitudes toward EVD affected children knowledge about and willingness to support EVD-affected ×× Improvement in adult behavior and attitudes towards EVD children, and their adoption of supportive behavior toward affected children: 63.4% willing to support EVD affected these children, as discussed during trainings. Based on net children at endline, an increase over 42% at baseline. measurements across indicators, the team observed a positive (outcome indicator) trend in adults’ willingness to support EVD-affected children ×× Parents and caregivers receiving training: 612 parents over the course of program implementation, which was our received training on how to support children affected by primary outcome indicator. At the time of the baseline, the team EVD, which represents 102% of the target (output indicator) registered 25% of respondents expressing willingness to support EVD affected children, in the midline 44% and 67% in the endline. ×× Teachers receiving training: 753 teachers participated in At baseline, 32 percent of adult participants reported that they C4K trainings on how to use the workbook and how to support treated Ebola-affected children with patience and understanding; children affected by EVD, which represents 100.4% of the after participation, 86 percent did. target (output indicator) ×× Health personnel receiving training: 280 health and social The C4K evaluations (impact surveys, pre-and post-training) workers have received training since the beginning of the tracked the impact of training by asking adults about the ways program, representing 100.4% of the target (output indicator) in which they support children. Adults’ knowledge of support ×× C4K basic training provided: 85 C4K basic trainings covering measures described during C4K trainings was calculated as an how to provide support to children affected by EVD and, for average score which tracked the progression of participants’ teachers, how to implement workbook activities, were carried knowledge and ability to support EVD affected children. At out over the course of the program, which represents 94% of baseline, this composite score measured 50.7%, and it had risen to the target (output indicator) 67% by the endline. Discussion These results indicate that respondents to the KAP surveys could identify more ways of supporting children (such as being nice to To support children’s psychosocial recovery, the program sought children, talking to them to learn about their problems, expressing to train a range of actors in the basic C4K curriculum, developed support, giving them food or taking them to the doctor) at the and tailored to the Liberian context. The C4K training included endline than at the baseline. This indicator was monitored using the information on how to identify children experiencing difficulties, post-training evaluations and the baseline study, which included the types of reactions that are typical in post-disaster situations, questions related to adults’ attitudes towards both children and and practical advice for actions to take to address these issues. adults. We re-interviewed the participants during the midline and Parents, teachers and health personnel received this training endline. Comparison between the two results helped understand if in the first few months of program implementation, primarily their attitudes and behaviors have improved. during the period from October of 2015 through early 2016. A few health professionals were trained later, until April of 2016. In the implementation of the C4K program, 612 parents and caregivers, 280 healthcare professionals and 753 teachers received training on ways to support children affected by Ebola. Overall, the number of people trained surpassed the targets, although the number of trainings (85) was somewhat lower than the 90 targeted. OUTCOMES 40 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 41 Figure 3: Adult knowledge to support EVD-affected children C Outcome 3: Decrease in post-traumatic stress disorder (PTSD) among project Adult knowledge to support EVD affected children beneficiaries. 80% ×× Decrease in PTSD among project beneficiaries: 1.4% of project beneficiaries tested were found to have possible PTSD 67% at endline, in contrast to 1.7% at baseline (outcome indicator) ×× Completed referrals from C4K partners to referral 50.7% 40% network: 821 children have been referred to the MSF hospital 43.3% at Gardnersville, which represents 164.2% of the target (output indicator) 0% Discussion Baseline Midline Endline Behavior of Children affected by Ebola The C4K program sought to improve children’s well-being and the support provided to them by adults through the trainings and Finally, MC also tracked adults’ application of a range of activities discussed in earlier sections. While implementing the “My intervention actions for supporting EVD-affected children. From Ebola Story” workbook and activities, teachers noticed that certain baseline to endline, we found that adults were more willing to apply students were at high-risk for developing behavioral and emotional the support measures covered in C4K trainings for children in need. problems. C4K staff subsequently implemented a psychoeducation The program tracked a marked improvement in the likelihood that intervention targeted to 1,086 high-risk children and their families, adults would adopt supportive behaviors they had learned. and established a referral pathway to an MSF clinic for children in need of more intensive mental health services. Over the course of Figure 4: Change in adult behaviors from baseline to the program, 821 children were referred to the MSF hospital. endline to support EVD-affected children Time constraints did not allow for a randomized evaluation of the Change in Adult Behaviors C4K program. However, pre- and post-test evaluation results show 90% Baseline that the C4K program was successful in improving the psychosocial 86% Endline health and well-being of Ebola-affected children and in increasing community support for them. Prior to receiving the C4K workbook 69% 67% and participating in the associated activities, only 37 percent of 63% 60% 58% 50% children showed acceptable levels of psychosocial wellbeing; after 54% 52% participation, nearly 92 percent did. 43% Participating children were tested for signs of PTSD at the baseline and at endline. The C4K team, specifically the clinical team, used the Hopkins Symptom Checklist – 25(HSCL) and The Harvard 0% A7.1 A7.2 A7.3 A7.4 A7.5 A7.6 A7.7 A7.8 A7.9 Trauma Questionnaire (HTQ) to gather data on PTSD signs and Be more understading/ patient/tolerant Made a personal effort to find out more about the disease, such as from a website Had a level of contact with someone who was experiencing Ebola that increased your understanding of experience Provided support to someone experiencing and/or survived Ebola Behaved in a way that ensured someone Survived Ebola was treated with respect Looked for signs of loneliness, isolation, depression or suicide risk among family members or friends I feel I am more accepting of people who survived Ebola than I used to be No response Learn more symptoms. The team found that 1.7% of beneficiaries tested had a baseline score that indicated a possible PTSD. At the end of the program we revisited the group and found out that the number has been reduced to 1.4% with a higher number of screened/ tested populations. This decrease is not significant enough to draw OUTCOMES conclusions about the program’s impact on the rate of PTSD. 42 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 43 D Outcome 4: Level of community wake of the epidemic to decrease stigma against survivors and this community willingness to support affected children lasted through willingness to support affected children. time until the end of the project. ×× Level of community willingness to support affected children: 65% surveyed at the endline indicated willingness to support The graph below shows some of the responses to questions EVD affected children, an increase from 25% at baseline pertaining to community acceptance of EVD survivors, and shows (outcome indicator). an overall improvement over time. ×× Community stakeholders receiving training: 216 community leaders have received the trainings since the inception of Figure 5: Community acceptance of EVD survivors the program, which represents 144% of the target (output indicator) Overall Acceptance 90% ×× Dissemination of pamphlets to parents and health providers: 87% 9,153 pamphlets have been disseminated through the C4K 81% program to generate awareness and interest in the program, 71% which represents 107.7% of the target (output indicator) 64% 61% 56% 50% Discussion 49% 49% 47% 42% 40% 31% Stigma and fear caused many adults to distance themselves from 27% 25% 24% 23% Ebola-affected children. The C4K program therefore implemented 20% 8% 16% 14% 13% 13% 13% 3% 12% 11% a number of interventions aimed at increasing overall community 1% 0% willingness to support EVD-affected children. These included Yes No Don’t Yes No Don’t Yes No Don’t know know know the trainings of teachers, health professionals, and caregivers Baseline Midline Endline discussed under outcome 2. Key community stakeholders including A7.10 In a general matter do you think people are more acceting of Ebola Survivors in the community than they volunteers and teachers from the West African Ebola Survivors were before or they used to be? and Affected Organization (WAESAEO) and other community A7.11 Was there anyone in the community responsible for leaders who were identified with the help of partners also received EVD affected children? this training. To support these efforts, MC also distributed A7.12 Is there someone to help and provide support when children feel anxious of act different or as they used to? pamphlets to caregivers, community leaders, teachers and health professionals detailing ways to support children affected by EVD. These include the Top Ten Tips pamphlet and the Pamphlet As a measure of community willingness to support survivors for Professionals. Both of these documents were borrowed from and those affected by EVD, the program collected information previous C4K interventions and updated for the Liberian context. on several indicators of stigma against survivors. The results The C4K program disseminated 9,153 pamphlets. obtained from these indicators were inconclusive. Some of the indicators registered a slight improvement, while others registered Over the course of program implementation, the percentage a decrease. This inconclusive result can be attributed in our view to of community members expressing willingness to accept and uncertainty among survivors about the risk factors for Ebola and support Ebola-affected children was tracked to record an overall the possible risk of reemergence. improvement in willingness to support EVD-affected children. At the time of the baseline, the team registered 25% of respondents expressing willingness to support EVD affected children, in the midline 44% and 67% in the endline. The C4K team hypothesized OUTCOMES that willingness to support EVD affected children may have peaked at the time of the midline because during this period, there were concurrent efforts by numerous organizations working in the 44 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 45 E Outcome 5: Direct Project Beneficiaries A total of 13,611 individuals, which represents 136% of the target, benefitted from the C4K program. 46.5% of direct project beneficiaries were female. F Conclusions The above results do not capture the whole story. Project stakeholders, including representatives from the Ministries of Health and Education (MOH and MOE), health providers, school principals, community and religious leaders, and members of parent-teacher associations expressed overwhelming support for the program and a desire for its countrywide scale-up. While direct program expansion is severely constrained by a lack of resources, C4K staff and other development partners are now working with the MOH’s mental health division and the MOE’s teacher training, early childhood education, and psychosocial divisions to develop school-based mental health programs. The C4K program was a small intervention. It was, however, an important first step to rebuilding the protective factors that can help Ebola-affected children to overcoming their trauma. These children are Liberia’s future. Ensuring that they are psychologically healthy will contribute to Liberia’s continued development. OUTCOMES 46 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 47 Project Development Objective: Increase resiliency, psychosocial health and well-being in children aged 6-13 Continued from page 46 affected by EVD in Montserrado County, Liberia by building the local capacity to support children. Respon- Final Responsibil- Final Unit of End Data Source/ Unit of End Data Source/ sibility Indicator Name Baseline Cumula- Frequency ity for Data Indicator Name Baseline Cumula- Frequency Measure Target Methodology Measure Target Methodology for Data tive Collection tive Collection INTERMEDIATE INDICATORS OUTCOME INDICATORS 1. Knowledge and skills training increase confidence to support trauma affected children through Improvement in C4K basic training Twice – pre psychosocial Children’s C4K M&E % 37% 80% 91.78% & post wellbeing of par- Checklist4 Team 1.1.5. Comfort for activities Training Atten- ticipating children Kids basic training # 0 90 85 On-going C4K Trainers dance sheets provided Improvement in adult behavior Supplemental and attitudes Post-Training C4K Activities: Addition- % 42% *0% 63.4% On-going Oct.-Nov towards EVD evaluations Trainers al PTA trainings, 1068 C4K Trainers 2016 affected SafeSpace and children Mentoring activities The Hopkins 1.2 Children’s sense of well-being improved through C4K psychosocial Children’s Workbook activity Depression Symptom Checklist – post-traumatic Pre-post at %, ages, 1.7% 1.4% 25(HSCL) Project Man- 1.2.1. children stress disorder beginning C4K workbook en- gender (54.5% F, -15% (62%F, The Harvard Trau- ager, Clinical registered in and #s, ages, (PTSD) among and end of rollment form (pre ratio 45.5% M) 38%M), ma Questionnaire Trainers participating in gender 0 10,000 10,597 weekly C4K Trainers project beneficia- program & post workbook (HTQ) or PYNOOS C4K workbook ratio ries use) TBD5 at baseline activities Levels of commu- 1.2.2. Perception of %, ages, Post-work- Children’s Work- Pre-, mid Project Man- nity willingness to workbook value by gender 0 80% 96% book book Feedback M&E Team % 25% 65% 67% & end of \Baseline ager, Clinical support affected children ratio activity form project Trainers children 2.1. Improve access to educational materials on normal children and adult reactions to trauma and strategies for support- Direct project ing EVD affected children more effectively beneficiaries (of Project Num 0 11,750 13,611 Quarterly Project reports 2.1.1. Dissemination which % female) Manager of pamphlets to Project Mgr, [IDA CORE] # 0 8,750 9153 On-going Project reports parents and health C4K, Trainers professionals INTERMEDIATE INDICATORS 1. Knowledge and skills training increase confidence to support trauma affected children through 2.2. Improve community support to EVD affected children through decreased stigma C4K basic training 2.2.1. Completed referrals from C4K 1.1.1. Teachers Project Man- % 0 750 753 participants to TBA % 0 >5 821 Quarterly Project reports receiving training ager referral network or 1.1.2. Health individuals personnel receiv- MC Impact % 0 250 280 2.2.2. Supervision ing training [IDA Surveys pre- train- and support of Semi-an- CORE] pre- % 0 100 287 TBD C4K Trainers ing and, for teach- Teachers using training & nually ers, after using C4K Trainers workbook 1.1.3. Parents and 3-4 mos the workbook, for caregivers receiv- % 0 600 612 later others 2-3 month ing training after training 1.1.4. Key commu- nity stakeholders % 0 150 216 receiving training 4 This can be used by OUTCOMES non-clinicians 5 PTSD tools must be administered by clinicians LESSONS 48 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 49 LEARNED AND REC Earlier sections of this report mentioned a number of challenges encountered and adjustments subsequently made to address these challenges during the course of C4K implementation. Below, we include some information on lessons learned and recommendations for future programs based partially on these program challenges, adjustments, and successes. OMMEN Consider a more holistic approach addressing the needs of both children and parents to post-disaster psycho-social recovery. The C4K program was meant to address the needs of Ebola- affected children specifically through the implementation of the DATIONS workbook activities and the training of teachers, professionals, and community members. However, we learned during program implementation that the mental-health needs of communities in Liberia are complex and that there are few resources to support these needs. In addition to the fact that there are many Ebola- affected children who were not able to benefit from the C4K program, both children and adults suffer from multiple traumas starting with Ebola and extending back to the civil war. The protection system in Liberia is very weak and does not have the capacity to meet all these needs. For future programs, we suggest considering taking a more holistic approach, that addresses the needs of both children and adults. The team believes if we can engage the parents and the caregivers in the recovery process, and they will be more eager to help the children. In addition, a holistic approach may include more long-term planning. Future programs should start with a plan for immediate intervention, but also have in mind that ongoing assistance with a holistic community approach, possibly over the course of years, will have the most chance for making a real and lasting impact. Include a longer pre-launch timeline. We also suggest for future interventions that the organization should require more time in the pre-launch timeline to take the time to improve the program before the launching. A program whose objectives are to improve psychosocial wellbeing, promote resilience and recovery of children after a disease or natural disaster or civil/war should consider the fact that recovery is a long process and it takes time to properly LESSONS LEARNED implement activities and take action to ensure program success and sustainability. 50 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 51 Plan to address the needs of out-of-school children, and those town, Redemption Hospital. We recommend that future programs of students at risk of dropping out. As mentioned earlier in this consider the virtues of working within a wider system to connect report, we discovered over the course of program implementation beneficiaries to available services. that many children were dropping out of school. We were able to address this issue to some extent through our extended activities, Coordinate effectively and share information with local partners but we recommend that for future programs, the potential for to ensure sustainability. Throughout the program, the C4K team children dropping out of school is taken into account during the coordinated and collaborated with government partners, soliciting design or pre-launch periods. This could be taken into account by the support of the MIA, MOE and MOH in the selection of program planning workbook activities or other relevant activities for out beneficiaries and the implementation of trainings and workbook of school children in a safe space not linked to the school, or by activities, and submitting regular reports on program progress to working closely with parents and increasing their involvement in MOH and MOE. We participated in regular coordination meetings bodies such as the PTA. In Liberia, the MOE is aware of the relative with the ministries to inform them about program challenges weakness of PTAs but has not been able to address this issue and brainstorm solutions. Through these various modes of sufficiently. Thus, the C4K program could have worked to meet this collaboration and information sharing, the ministries were able to need and strengthen PTAs from the beginning. benefit from lessons learned from the program and formulated plans for future interventions. Consider the difficulties inherent in procuring materials from abroad. One weakness of the C4K program in Liberia was the The C4K team found a huge gap in psychosocial services and child- acquisition of the workbooks from Ghana, as detailed above. protection systems. To mitigate this issue, the C4K team assisted Future programs should thoroughly research potential hurdles the MOH Mental Health Department and the Ministry of Gender related to customs if there are plans to procure from abroad. and Social Protection (MOGCSP) in training community leaders Based on the current experience this approach is likely to slow the and MOGCSP volunteers at the community level on protective process down and/or drive up costs, so local alternatives should be factors, issues and mechanisms to support the population. found if possible. Following the success of the C4K workbooks implementation in the Plan for the recognition of teachers and other volunteers. Where school, the team also facilitated a collaboration between the MOE6 6 We also received outstanding compensation is not appropriate or possible, we suggest planning support from the Deputy Teacher Training, Early Childhood Education and Psychosocial for a ceremony or other end-of-program celebration to recognize Minister for Instruction (Dr. Divisions, the MOH Mental Health Department and other local and Romelle Horton). the contributions of those who volunteer their time to make the international NGOs. The partners initiated a country-wide school- program run smoothly. based mental health program and actively participated in the design of the mental health strategic plan for the next five years Institute regular information sharing and lessons learned (2016-2021) by joining the task force and expert sub-committee. meetings with schools and implementing organizations, and capitalize on field visits. As mentioned earlier in the report, our In an effort to coordinate the program activities with services regular monitoring, in the form of field visits and regular meetings provided by local or national government or other NGOs, the C4K with representatives from the schools, helped improve the quality team also partnered with two local organizations, the West African of program implementation and helped us meet our goals on time. Ebola Survivors organization (WAESAO) and the Ebola Survivors It is recommended that future programs institute a similar system. Network, within the mental health department in MOH in order to engage out-of-school children in C4K workbook activities. Coordinate with other partners to connect program participants to local services. As mentioned earlier in this report, we have LESSONS LEARNED coordinated successfully with the MSF hospital to institute a referral system. We have also continued to follow up on efforts to institute, in collaboration with other INGOs, on-site trainings and supervision for the mental health clinician in one facility in New Kru 52 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 53 Annex 1: Project Costs and Financing BUDGET SUMMARY Donor Name: World Bank Program Name: Comfort for Kids Program Dates: 1July 2015-31 Dec 2016 Cost Category Total Budget Expenditure to October 2016 a. Personnel 180,336 199,851 b. Fringe Benefits 144,042 161,733 c. Travel 15,300 24,546 d. Equipment 17,250 19,473 e. Contractual 242,000 152,958 f. Other 53,246 50,687 g. Total Direct Charges 652,174 609,249 h. Indirect Charges 97,826 91,387 TOTALS 750,000 700,637 ANNEXES ANNEXES 54 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 55 Annex 2: Outputs by Component A.2.3 Materials and art supplies distributed in the schools within Montserrado County – A.2.1 Training component outputs Liberia, including C4K workbooks Output Definition Township Schools Workbook-A Workbook-B Total WB Provided step-by-step guidelines on how to lead training C4K Training Bentol 5 157 401 558 1. sessions and/or parents’ groups, and how to train teachers to use Facilitator’s Guide: the children’s workbook. Brewerville 12 460 323 783 Contains key training themes and a step-by-step introduction to 2. Guide for Teachers the workbook, explanation of its logic, and guidelines for related Careysburg 2 90 250 340 activities. 850 copies of this will be printed Gardnersville 4 427 483 910 A 2-page pamphlet providing basic tips on beginning the healing and emotional recovery processes in very simple language 3. Top Ten Tips Pamphlet Garworlohn 11 596 507 1103 making it accessible to adults who may have low reading skills or have been so traumatized they do not want anything complex. Johnsonville 6 389 317 706 16-page resource is consistent with C4K training messages 4. Pamphlet for Professionals but being designed for mental health providers and Kingsville 4 41 260 301 other professionals Monrovia 9 386 464 850 two different workbooks were distributed in this response- a 32 pages one for younger children aged 6-9 years old: “My Story New Georgia 4 170 159 329 About Ebola in Liberia” (workbook A) and a 54 pages one for adolescents aged 10-13 years old: “How Ebola Changed my Life” 5. Children’s Workbooks (Workbook B). The workbooks guided children to document their New Kru Town 10 359 753 1112 personal experience with EVD using drawings and simple lan- guage. Children used the workbook to articulate what happened Paynesville 7 334 604 938 to them personally. Drawing and writing helped children express what they have experienced Tolberta 4 129 256 385 Virginia 6 254 682 936 A.2.2 Cover of the children’s workbook West Point 9 216 583 799 White Plains 1 29 48 77 TOTAL 94 4037 6090 10127 Additional distribution to partnering Organizations Name of organization WB "A" WB "B" Total WB Min. of Education 6 6 12 LINGO 6 6 12 WAESAO 50 50 100 SUB- TOTAL 124 ANNEXES 56 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 57 Grand total WB distributed out = 10251 A.3.2 Evaluation Tools C4K workbook and other school supplies distribution Color Sharpen- Impact Survey for WB A Copy Book WB B Pencil Eraser A pre- and post- test soliciting participants’ training and experience Pencil er Teachers (and or to-date with psychosocial activities, and materials and their perceptions 1. others using the Book pcs book pks pcs pcs pcs of their own ability to provide support. The same tool has been used for workbook and the pre and post-test. activities 4037 19978 6090 2133 10005 9855 9923 Site, date, facilitators’ names, participant’s name, organization and title (where appropriate) most important new information learned, redundant Post-Training 2. information, what they would have liked more of, how their behavior will Evaluation change as a result of the training, names of recommended participants/or- ganizations to take C4K training. Annex 3: Supporting Documents Workbook Session Site, date, facilitator’s name, child’s name, gender, age, total number of 3. Attendance Forms sessions attended. and Evaluation Tools This tool was completed after children completed their workbook activities in the classroom. Group and site, facilitator’s name, date, number A.3.1 List of supporting Documents 4. Workbook Feedback of children, age range, gender ratio. It summarized their experience with Form: the workbook activity over the project period. Data collected included information on the workbooks’ clarity and whether children enjoyed or had difficulties with it. 1 Quarterly Reports (November 2015, March 2016, June 2016, September 2016) Session Monitoring This form tracked data on both the children’s concentration, communica- Tool For Teacher, tion, cooperation, emotions and the practicality of the workbook, appropri- 2 Monthly Reports (July 2015-July 2016) 5. aka the Workbook & ateness of session duration, et al. It also collected feedback on the Work- Workbook Session book Manual. It was originally intended as a standalone form, but has been 3 Program Implementation Manual (October 2015) Feedback Form: combined with #4 to ease the monitoring burden for teachers. 4 Baseline Report (October 2015) Identification of the most (a) useful, (b) enjoyable, (c) difficult activities, Exit Activity number of children, children’s appraisal of the activities, facilitator remarks 5 Midline Report (April 2016) 6. Results Form: (includes demographic info – site, date, facilitator name, # of children, gender ratio & age range). Child’s name, gender, age, group & site, caregiver’s name and date. This Strengths & tool is an assessment of the child’s sense of wellbeing. There are 25 data 7. Difficulties points that informed (1) emotional symptoms, (2) conduct problems, Questionnaire (3) hyperactivity, (4) peer problems and (5) pro-social attitudes. Child’s name, gender, age, group and site, caregiver’s name and date. Caregiver 8. This simple 1-page tool captured information on the relationship between Questionnaire: the caregiver and the child and key data points on the child’s well-being. The Children’s Checklist is illustrative of the checklist that was developed in Liberia based on solicitation of input from children during the early phase Children’s of the program. The checklist was used to create an activity to identify which 9. Checklist: problems affect “a lot” of children, “some” children and “a few” children. This was a pre and post activity. A control group was established during the pilot phase for pre- and post-testing too. Final C4K Program 10. The team used the pre-test format for post-testing. Evaluation Form ANNEXES 58 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 59 Annex 4: C4K Target Districts Annex 5: Participating Schools UNIQUE CONTACT SCHOOL NAME TYPE LEVEL TOWNSHIP CONTACT NUMBER REFERENCE PERSON David D. Padmore C4K-PS/001 Private Elementary Bentol City Wellington Giah +231 880624541 Preparatory School Hope International C4K-PS/002 Christian Academy Private Elementary Bentol City Elijah F. Kobbia +231886830810 School Montserrado County Gbokolleh Public Ralph T. Tarniah + 231886542089 C4K-PS/003 Public Elementary Bentol City School SR. 0775250835 Youth Camp Public C4K-PS/004 Public Elementary Bentol City Janathan B. Ehais +231777205716 School Liberia Euphemia Barclay C4K-PS/005 Public Elementary Bentol City Garnayea Ccee +231886240934 Public School Mango Town \Public +23188835603/ C4K-PS/006 Public Elementary Virginia Micheal S. Gayee school 0775997012 Lawrence +231888824938/ C4K-PS/007 Private Elementary Virginia Fatu B. Kollie Hamptons School 0776198714 R.W.H. Baptist +231886873524/ C4K-PS/008 Private Elementary Virginia Prince a. Armah School 0775891624 Gbanjor Public C4K-PS/009 Public Elementary Virginia Janathan S.P Zey +231886917752 School Nathaniel Y. C4K-PS/010 Golden Age Private Elementary Virginia +231777151723 Sackloh +231886951382/ C4K-PS/011 Vonzon Public School Public Elementary Virginia David G. Saydee 776220361 Diana E. Davies +231888736435/ C4K-PS/012 Private Elementary Brewerville Raymond Modfrey School 77010234 Salem Baptist +231880420430/ C4K-PS/013 Private Elementary Brewerville John Sah Church School 775780652 All Saints Interna- C4K-PS/014 Private Elementary Brewerville Agnes A. Glay +231770726567 tional School Prime Elementary & Mohamed F. C4K-PS/015 Private Elementary Brewerville +23177782683 Junior High School Sannoh Brewerville A. G. M. +231880536528/ C4K-PS/016 Private Elementary Brewerville Issac B. Wesseh Jr. Elementary School 770406936 UNESCO Mission C4K-PS/017 Private Elementary Brewerville Ciah Cole +231886563638 School Ellen Mills Scarbor- Charka B. C4K-PS/018 Private Elementary Brewerville +231886413972 ough School Mouton Triumph Church C4K-PS/019 Private Elementary Brewerville Mr. George V. Ville +231886236141 Mission School ANNEXES 60 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 61 UNIQUE CONTACT CONTACT UNIQUE CONTACT CONTACT SCHOOL NAME TYPE LEVEL TOWNSHIP SCHOOL NAME TYPE LEVEL TOWNSHIP REFERENCE PERSON NUMBER REFERENCE PERSON NUMBER John Divine School Moses Page Tell- +231 880593106/ C4K-PS/020 Private Elementary Brewerville Abel Kpassauh +231886428813 C4K-PS/040 M.T. Institute Private Elementary Johnsonville System ewoyan 770579233 Graystone Com- James M. Wom- Saryon Advanced C4K-PS/021 Private Elementary Brewerville +231770555701 C4K-PS/041 Private Elementary Johnsonville Zee Tom Zemo +2318866755 munity School bia School Better Day Foun- Olureme Tinuba Boimah R. C4K-PS/042 Private Elementary Johnsonville Mathew B. Pajiho +231886336465 C4K-PS/022 dation Community Private Elementary Brewerville +231775740379 School Johnson School Salvation Army Mr. Alanso C4K-PS/043 Private Elementary Johnsonville +231886938762 Mt. Tegeste Stew- School Nyenah C4K-PS/023 Private Elementary Brewerville Thelma Kokulo +231886477850 ard School Johnsonville Public William Booth C4K-PS/044 Public Elementary Johnsonville William B. Siaf +231880533142 +231886707222/ School C4K-PS/024 Salvation Army Private Elementary Paynesville James S. Tailey 776155216 school Juah Sarwee Rebecca J. C4K-PS/045 Private Elementary New Kru town School Sackor St. Kathleen Mc- D. Alexin S. C4K-PS/025 Private Elementary Paynesville +231 776264410 Guire School Browne R. D. Tarpeh Com- +23188684783/ C4K-PS/046 Public Elementary New Kru Town Fancis Q. Quaye ELWUO Day Care munity School 776913552 Rev. S. David +231886475023/ C4K-PS/026 & Elementary Private Elementary Paynesville Tobey 0770978575 School Sis Comfort Me- +231886215139 C4K-PS/047 Private Elementary New Kru Town S. TayaTa Sirleaf morial school /775225850 Paynesville Com- +231880701909/ C4K-PS/027 Public Elementary Paynesville Chayee S. Shajah munity School 777727817 C4K-PS/048 King Peter School Private Elementary New Kru Town Jackson K. Miller +231886254475 Faith Christian C4K-PS/028 Private Elementary Paynesville Lorpu Sesay +23177387449 Academy Bishop N. Dixon Emmanuel N. +231886895058/ C4K-PS/049 Private Elementary New Kru Town School Guah 776895058 Liberia for Jesus C4K-PS/029 Private Elementary Paynesville School C4K-PS/050 Source Institute Private Elementary New Kru Town Romeo Nyenkan +231886605987 African Islamic Manyou V.M. C4K-PS/030 Private Elementary Paynesville School Toure First Baptist Johannes Sackor C4K-PS/051 Private Elementary New Kru Town +2310775004035 School Jr. Marie Washington Mr. Amos W. +231886572407/ C4K-PS/031 Private Elementary Gardnerville School Quaye 777572407 Trinity U.M.C. +231886358753/ C4K-PS/052 Private Elementary New Kru Town Gregory Goawah School 777031860 C4K-PS/032 PICOLI School Private Elementary Gardnerville Kebeh Fumbah +231886629950 Apostolic Faith +231880028858 / Wesleyan Elemen- C4K-PS/053 Private Elementary New Kru Town Shurina T Nimely Rev. Hosea K. Mission 770955780 C4K-PS/033 tary & Jr. High Private Elementary Gardnerville +231886648248 Taylor School St. Lawrence +231886606803/ C4K-PS/054 Private Elementary New Kru Town Tieh B. Wesseh School 770769957 Noah's Ark High +231880910388/ C4K-PS/034 Private Elementary Gardnerville John S. Randall School 775055634 Careysburg Public Shelon B. C4K-PS/055 Public Elementary Careysburg +231777970380 School Gwaikolo Early Childhood Pastor Issac C4K-PS/035 Christian Educa- Private Elementary New Georgia +231776291426 V.O.A Elementary Boima Word- Garlo C4K-PS/056 Public Elementary Careysburg +231886266051 tion Foundation Public School sworth Knowledge Foun- +231880363082/ Nyehn #1 Public Edward A. John- C4K-PS/036 Private Elementary New Georgia Luopu G. Karbah C4K-PS/057 Public Elementary Tolberta 0225/777491815 dation School 77087618 School son +231886767717/ June L. Moore C4K-PS/037 All Nation School Private Elementary New Georgia Sophia Paye C4K-PS/058 Public Elementary Tolberta Sylvester Snowe +231886726030 776627507 School Philadelphia Lucretia A. Lucy B. Gibson H. Hon N. Quoid- C4K-PS/038 Private Elementary New Georgia +23177215617 C4K-PS/039 Private Elementary Johnsonville +231777381907 School Walker School uo ANNEXES Lucy B. Gibson H. Hon N. Quoid- Augustne B. C4K-PS/039 Private Elementary Johnsonville +231777381907 C4K-PS/059 Goba Town School Public Elementary Tolberta +231886431455 School uo Frederick 62 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 63 UNIQUE CONTACT CONTACT UNIQUE CONTACT CONTACT SCHOOL NAME TYPE LEVEL TOWNSHIP SCHOOL NAME TYPE LEVEL TOWNSHIP REFERENCE PERSON NUMBER REFERENCE PERSON NUMBER Augustne B. Mary Sharp C4K-PS/059 Goba Town School Public Elementary Tolberta +231886431455 Obediah N. +231888061864/ Frederick C4K-PS/081 Memorial Mission Private Elementary West Point Darwoh 770218042 School Marveka Public C4K-PS/060 Public Elementary Tolberta George Bondo +231886643798 Success Academy Anthony D. +231088897677/ School C4K-PS/082 Private Elementary West Point School George 775672343 Palmgrove A.G. M. Mr. Anthony T. +231880711953/ Muslim Commu- C4K-PS/061 Private Elementary Kingsville Mr. Abdullah School Borbor 777821689 C4K-PS/083 nity Elementary Private Elementary West Point +231886547557 Dialloh School C4K-PS/062 Cecelia A. Dunbar Public Elementary Kingsville Ezekiel Harris +231880719782 Children Hope +231886649781/ C4K-PS/084 Private Elementary West Point Austin D. Toe Kingsville Public School 880236655 C4K-PS/063 Public Elementary Kingsville James P. Morris +231886315414 School Adam House of C4K-PS/085 Private Elementary West Point Emmanuel Toe +231886603370 Study School Mother Vic Public C4K-PS/064 Public Elementary Kingsville Pst. Jutomu Suah +231770227505 School Royal Learning C4K-PS/086 Private Elementary Monrovia City Mrs. N.J. Clarke +231886511951 Academy C.H. Henry Public C4K-PS/065 Public Elementary White Plain Moses Armah +231777646965 J.W. Pearson Me- +231886550225/ School C4K-PS/087 Public Elementary Monrovia City Rose H. Neufulle morial School 776414305 Darpo Interna- Garworlohn James G. Barl- +231886518630/ Monrovia Open Bubber N. Ga- C4K-PS/066 Private Elementary C4K-PS/088 Private Elementary Monrovia City +231886563198 tional School Town ingar 776281907 Bible School briel Momolu Dukuly Garworlohn Augutine D. God of Mercy Emmanuel C4K-PS/067 Private Elementary +231886221822 C4K-PS/089 Private Elementary Monrovia City +231886880605 School Town Johnson School Reeves Daniel K. Adjei Garworlohn Caelestina M. Patriot Foundation Samuel A.L. C4K-PS/068 Private Elementary +231886375804 C4K-PS/090 Private Elementary Monrovia City +231880318213 Memorial Institute Town Adjei School Freeman Joseph G. Cooper Emmanuel Temple Garworlohn Thomas S. Hin- +231880380056/ Abraham K. +231886734931/ C4K-PS/069 Private Elementary C4K-PS/091 Elem. & Jr. High Private Elementary Monrovia City A.G. School Town neh Jr. 777726370 Kdiego 777902248 School Garworlohn Kaduk O. Karn- +231880372546/ James McGarthy C4K-PS/070 Palm S. D.A School Private Elementary Town gar 776363771 C4K-PS/092 Efewa Mission Private Elementary Monrovia City Mr. Samuel Tarr +231886716556 School Life International Garworlohn +231886758717/ C4K-PS/071 Private Elementary David K. Kollie Supreme Islamic +231886259555/ School Town 770183427 C4K-PS/093 Private Elementary Monrovia City Alieu Kamara School 880577972 Augustus F. Cain Garworlohn Philadelphia Cen- C4K-PS/072 Private Elementary Sampson S. Wiah +231077175558 C4K-PS/094 Private Elementary Monrovia City Maude Benson +231 886516444 Primary School Town tral School Solid Education Garworlohn C4K-PS/073 Private Elementary Mr. Taplah Doe + 231777383100 School Town Clara Town Ele- Garworlohn C4K-PS/074 Public Elementary George A. Wedor mentary School Town Fanima Islamic Garworlohn Brukeya M. +231886468999/ C4K-PS/075 Private Elementary School Town Kiawu 775575157 Life and Power Garworlohn C4K-PS/076 Private Elementary Jeremiah Wleh +231776082840 School Town C.K Johnson/Kids Rev. Timothy W. +231888876062/ C4K-PS/077 Private Elementary West Point Liberia Academy Johnson 776418377 Torch World Chris- C4K-PS/078 Private Elementary West Point Divid Chayee +231777121153 tian School Central Mosque C4K-PS/079 Private Elementary West Point Mr. Sesay +231886311353 Elementary School ANNEXES Academic Trea- +231880562374/ C4K-PS/080 Private Elementary West Point Eric L, Mensah sure Academy 770586823 64 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 65 Annex 6: Report of Supplemental As of September 2016, C4K had successfully completed nearly all Activities of its program goals. During its execution phase, the program op- erated consistently on or under budget. Consequently, it retained Overview an unspent balance adequate to operate for a few extra months past the original activity end date, until the grant’s end date of For the past 18 months, and with the support of the World Bank, December 31, 2016. This presented Mercy Corps and the World the Comfort for Kids (C4K) program has worked in Montserrado Bank with an opportunity to extend the benefits of this successful County, Liberia, to promote resiliency, psychosocial wellbeing and program to its partner communities, and to solidify the new skills mental health recovery of 10,000 and resources for children affected by the EVD outbreak without children affected by the Ebola the commitment of any new or additional resources beyond the epidemic. C4K has supported over current grant. Mercy Corps Liberia’s C4K baseline survey found that 10,000 children by providing trainings children affected by Ebola are more likely to live with for 750 teachers on how to incorporate World Bank accepted the proposal by Mercy Corps C4K to use the relatives who, while providing many other forms of the Comfort for Kids methodology into remainder of the grant period and funding to extend and solidify support, are less likely to cover the costs of sending chil- their curricula. It also instructed 250 the work it has done to support EVD impacted children. As a result, dren to school. Furthermore, while survey respondents health care and social workers, 600 Mercy Corps has built upon its successful program results to sup- were often willing to accept Ebola survivors as friends, parents and caregivers and 150 key port 2,200 additional children and youth, and has strengthened the family members, students and co- workers, they were community stakeholders on topics capacity of teachers, parents and other caregivers in supporting much less willing to be accepting of them as playmates for their children, job applicants, tenants, residents related to children’s post disaster EVD impacted children. While these activities targeted additional in a half-way house on their street, or neighbors and psychosocial needs and recovery. beneficiaries, they required no additional funding. They supported patients in health care settings. More than half of More detailed information about the the program’s overall goal of promoting the resiliency, psychoso- respondents said that they would feel ashamed if they program and results are outlined in cial wellbeing and mental health recovery of children and youth in had Ebola and 3 ⁄4 would expect rejection from friends the project’s Final Report. the targeted communities. With these activities, Mercy Corps and or were unsure of their reaction. The core experiences of the World Bank capitalized on this critical opportunity to address psychological trauma are disempowerment and discon- While the Comfort for Kids program some of the unmet needs of these children, and to build upon the nection from others. Recovery, therefore, is based upon the empowerment of survivors and the creation of new has had positive impact, it is clear that successful C4K intervention in order to play an even more substan- connections. Children and adolescents affected by Ebo- there are unmet needs. For example, tial role in the country’s recovery from the Ebola outbreak. la need help reintegrating into Liberian society and cop- the program targeted children who ing with these particular life challenges in order to lead are in school, but many Ebola-affect- In acknowledgement of the myriad factors that impact children’s happy, productive lives. 81% of the respondents in our ed children and adolescents are out ability to recover from the psychosocial impacts of Ebola, the ex- baseline said they did not know of anyone in the com- of school and miss the opportunity to tended activities of the C4K program were guided by two overar- munity responsible for taking care of the EVD-affected participate in activities. Psychosocial ching theories of change: children. Nine in ten of the respondents said there is no one to help or provide support in the community when and mental health services for those children feel anxious or act differently than they used to. affected by Ebola are still lacking in “If children and adolescents acquire relevant knowledge, attitudes Programs like C4K that promote psychosocial services Liberia. And while other psychosocial and skills, then they will be able to lead secure and healthy lives for will have positive outcomes in the long run for creating a programs in addition to C4K have been themselves and their communities.” peaceful, accepting, and diverse society. implemented, many of these programs were focused on immediate emergen- “If a community’s primary support circle understands the indicators cy needs of affected people without of vulnerability, stress and life-time changing among children and dealing with the long-term nature of adolescents and is able to recognize these behaviors in themselves the psychosocial and mental health impacts of the epidemic. This and their daily community lives, then the community can heal itself situation has been aggravated by the fact that there are also la- and adopt positive and peaceful behavior change.” ANNEXES tent traumatic memories and unhealed wounds from the civil wars. 66 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 67 These guiding principles were used to continue and extend the ×× Identified and selected 1,068 at-risk, in-school children activities and impact of our programs. Activities are grouped into and adolescents from the first phase of the C4K implemen- two categories: 1) support to children and families, and 2) support tation to receive trainings on psycho-education and for schools, communities and peers in creating a healing environ- coping strategies. ment for EVD-affected children and their families. Both categories ×× Ensured a proper referral pathway to the MSF clinic in of activities are firmly rooted in the idea that recovery is most likely Barnesville for registered and identified severe cases to take place within the context of relationships. In their renewed for support and care. connections with people within their family and community, the survivors re-created the psychosocial faculties that were damaged ×× Organized parent groups through 35 existing PTAs within seven townships and cities in Montserrado County, in order by traumatic experiences, such as basic capacities for trust, auton- to teach and support parents in how to encourage children omy, initiative, competence, identity and intimacy. and adolescents to develop emotional self-regulation. This includes promoting self-regulation in parents so they become The extended activities included an additional focus in psychoso- confident, resourceful and independent problem solvers. cial and mental health support, reinforcing the referral network for mental health services in the country which is crucial to an effective ×× Relieved symptoms of Post-Traumatic Stress Disorder mental health program. This has contributed to an environment that (PTSD), depression, and general anxiety among families combats isolation, stigmatization and discrimination due to EVD, and youth exposed to stressful situations and trauma.by providing and facilitating support group discussions for and helps build social capital at various levels in the community. families. Intensive case management and individual sessions were conducted when necessary to help children and parents work on processing traumatic memories. C4K SUPPLEMENTAL ACTIVITES ×× Provided resiliency training to identified children and families by teaching them practical skills to meet the challenges of CATEGORY 1: CATEGORY 2: CHILD & FAMILY SUPPORT SCHOOL, COMMUNITY & PEER SUPPORT stress exposure and any other shock such as (public health epidemic, political violence, civil wars, economic distress, Create a family environment conducive to Build psychosocial capacity of community etc.) and to communicate and solve problems effectively phsycologigal healing from trauma. Prevent members with practical skills and strategies and successfully, set goals together and create a shared severe behavioral, emotional and develop- for supporting, identifying & creating mental problems in children by enhancing the knowledge, skills and confidence of affected protective factors and mechanisms for family story. vulnerable children, adolescents and families. children and their parents. Category 2: School, Community & Peer Support Category 1: Child and Family Supports The program worked with seven target townships to create a supportive and healing environment for children, adolescents and C4K implemented targeted support services for 1,068 children families traumatized by the EVD epidemic. The C4K team recruit- and families who had been identified as at risk or are beginning to ed and trained 15 peer mentors, established community support exhibit signs of emotional and/or behavioral problems. Interven- groups and created seven “safe spaces” where children partic- tions at this level were designed to counter that risk and promote ipated through creative arts and recreational activities. These resiliency, wellbeing and academic success and to prevent severe activities helped children and communities express the burden of behavioral, emotional and developmental problems in children by stigma and loss so that those that love them can better guide them enhancing the knowledge, skills and confidence of parents. This towards recovery and facilitate the reconnection. part of the program has: ANNEXES 68 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 69 Activities in this category included: ×× Seven children and adolescent “Friendly Spaces” were created, including specific “Girls Rock It” spaces for ×× C4K team visits to 35 schools in Sonneiwen, Todee, West adolescents girls to express themselves and discuss issues Point, New Kru Town, Gardnersville, Paynesville and they encounter in their daily lives. Participants were Brewerville to give response to the assessment made in encouraged and supported in efforts to identify and problem October regarding the PTA status at these schools. That solve regarding issues important to them. Activities included assessment showed that out of 35 schools, only 17 had a series of lectures presented by positive role models on active PTA committees. In response to this need the C4K different subjects like early pregnancy, drug abuse, civic team shared with the school administrations the findings of engagement, HIV/AIDS, among others. the assessment and provided technical support to the PTA leadership in planning to accomplish the goals of their PTA and documentation of these plans in line with C4K redesign goals of strengthening the PTAs of schools. (Table 3, Lesson Learned Workshop with Key Stakeholders below, shows a list of schools that were visited and the contact details.) As part of the closing activities of the program, the C4K team organized and hosted a one day lessons learned workshop on De- ×× 49 community leaders from 6 townships and cities in cember 9, 2016 at the Gardnersville Town Hall, Monrovia. A total of Montserrado County received TOT trainings on protective 65 participants were in attendance including representatives of the factors. (7 leaders per community, plus alternate). Trainings World Bank. This Lessons Learned Workshop provided our valued were centered on selecting, preparing, implementing and evaluating community service activities. stakeholders, beneficiaries, staff, partners, and donors the oppor- tunity to share their views about the successes, challenges, lessons ×× The 49 trained community leaders stepped the training learned, as well as require improvement to carry forward from the down to 414 additional community members to help them implementation of C4K program in Montserrado County, Liberia. improve their understanding of protection issues and referral mechanisms. (70 community members trained The participants at the workshop were divided into five groups: per community). ×× Community Leaders ×× 14 community-based adolescents and/or young adult mentors (7 pairs; 1 male and 1 female) were trained to lead ×× Parents/Teacher Association Chairpersons (PTA) Principals and cascade life skills, coping strategies, healthy life styles and Ministry of Education (MOE) Representatives and recreational activities. ×× Parents, caregivers and local organizations ×× The trained mentors worked with 988 adolescent out- of-school boys and girls, who received opportunities for ×× Mentors, Health& Social Workers, and Ministry of Health (MOH) social interaction, self-expression and development of interpersonal skills (trust, empathy, communication) through ×× Teachers the implementation of art therapy and story-telling sessions and sports based activities. ×× Facilitation of peer to peer group sessions that address the unique needs of children and adolescents regarding anxiety, behavioral problems and other difficulties for children and adolescents. Parents/caregivers sessions as well as joint parents-and-children sessions were conducted as part of the activities. ANNEXES 70 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 71 1 Outcome of Lesson Learned 2 Recommendations Group Discussions There were several recommendations made by the beneficiaries The table below outlines key findings from the groups discussion and stakeholders: on the successes, challenges, lessons learned, etc. of the Comfort 1 Teachers and schools administrations recommended that for Kids Program with a group member presenting the outcome of there should be C4K program extension to help children and their discussions. adults that were affected by Ebola virus disease (EVD) to recover from traumatic behavior or emotional problem after surviving the virus. DESCRIPTION FACTORS THAT PROMOTED SUCCESSES 2 Key stake holders also recommended for the extension of the ×× Coordination between program Mercy Corps staff and mentors, health and program in Liberia, Montserrado County and other Counties social workers, community leaders, teachers and parents/caregivers. effected by the Ebola virus (Lofa, Margibi, Cape Mount, ×× Workbooks implementation in 94 schools in fifteen (15) townships and cities with in Montserrado County. Nimba and Grand Bassa etc.) WHAT WENT WELL? ×× C4K staff supervision ×× Training of teachers, parents, caregivers, community leaders, and health/so- cial welfare professionals 3 Closing Remarks ×× Parent/caregivers talked about how this program helped them to identify children’s problems and to relate to their children more effectively The Comfort for Kids Senior Program Officer thanked the partici- PROGRAM CHALLENGES pants for being part of the program close-out discussion and them ×× Instructional time within various schools was insufficient for teachers to cover for their coordination during the program, which helped ensure the full C4K curriculum. that the program was able to achieve its goals in helping EVD ×× Workload was too high for teachers to implement the workbook activities. This affected children in the targeted communities. was aggravated by the fact that the number of students in some schools was CHALLENGES FACED too high, and many had limited literacy skills. DURING PROGRAM IMPLEMENTATION ×× Some of the children refused from the beginning to use the workbook because it reminded them of Ebola. ×× Mentors found it difficult to gather the kids at the safe site because some of the kids have a study classes after school and some needed to go and work with their parents in the market. ×× In order to implement the workbooks, the teachers talk to school’s administra- tion and parents for additional time out of their school curriculums period. ×× Teachers grouped the students according to age range to have control over them for the implementations of the workbooks. HOW DID YOU COPE WITH THESE ×× Teachers used extra time to have a one on one discussions with the children who refused to use the books, to understand their hesitancy and communicate CHALLENGES? the purpose of the workbook ×× To be able to meet the program target, mentors visited some parents/care- givers at their home to explain the importance of the program and safe space activities before they were able to allow the kids for the safe space activities. LESSONS LEARNED ×× In the future, it would be beneficial for Mercy Corps to approach school administers to ask them to include the program in their yearly plan; this will help guarantee their buy-in and ensure their support to make sure participation in the program is prioritized by teachers and students. ×× The partnering ministries, Ministry of Education (MOE) and Ministry of Health (MOH) and other key stake holders should be involved in program meetings/workshops, trainings and other program activities to un- ANNEXES derstand the value and importance of the program or project, the challenges, successes and what impact it is going to bring in the lives of their constituents. 72 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 73 Table 2: Summary of the C4K Primary & Supplemental Activities July 2015 - July 2016 July 2016-Dec. 2016 Key activities School year Achievements Achievements Partnerships with MOE, Memorandum of Understanding, Selection of Selection of 15 mentors, provision MOHSW and MIA Training participants of safe space venues 612 Parent/Caregivers (102% of target), 753 Trainings on identifying Teachers (100.4% of target) , 280 Health/ Social signs of trauma in kids and Workers (100.4% of target), and 154 Communi- N/A responding to them. ty Leaders (103% of target) trained in 85 basic trainings (94% of targeted no. of trainings) , Distribution of 10,127 workbooks, 19,978 Distribution of remaining workbooks, copybooks, 2133 pencils, 9855 eraser and 9923 Distribution pencils, eraser, and sharpener and sharpener within 94 schools to more than 10,000 safe space materials. kids within 15 townships in Montserrado County. Certification Ceremony: July 8, 2016, of 250 Workbook activity teachers that implemented workbook activities N/A with 10,597 kids in 96 schools. Total 287 supervisions of workbook activities 81 supervisions of safe space activities Supervisions within 96 schools in 15 townships and cities in in 7 townships and cities. Montserrado County. Referral of 821 children in 15 townships and Referral Activity cities in Montserrado County in 51 partnering N/A schools: July- December 2016 Working with 15 locally trained men- tors to carry out life skills training and Safe Space Activities N/A mentorship activities for 988 children within their communities. Working with 35 schools within PTA Strengthening N/A Montserrado County TOT for Community leaders N/A 414 Community leaders Dec. 9, 2016. 65 program Lessons Learned Workshop stakeholders participants. Working with 35 schools within PTA Strengthening N/A Montserrado County TOT for Community leaders N/A 414 Community leaders Dec. 9, 2016. 65 program Lessons Learned Workshop stakeholders participants. ANNEXES 74 MENTAL HEALTH LIBERIA COMFORT FOR KIDS IN THE TIME OF EBOLA 75 Table 3: C4K PTA Partner Schools C4K PTA Schools Listing No Name of School School Location Township Contact Person Position Contact No Name of School School Location Township Contact Person Position Contact Mr. Sando Bishop Grimley High 1 C.D.B. King Public School Clay Street Soniwein Principal 886959113 26 Doahn Town Gardnerville Esau T.S. Kormeh Principal 882278155 Duwana School Soniwein Community Mr. Bill 27 Noah Ark Town Hall Community Gardnerville John S. Randall V.P.I. 880910388 2 Rallay Town Market Soniwein Principal 777774890 School Massaquoi Ma Haja Massa Com. Patience Shop, Doahn Lberia Marketees Mr. Richard M. 28 Gardnerville Alieu Kengo Principal 880692603 3 Rallay Town Market Soniwein Principal 886749154 Arabic and Eng. School Town Com. Association School System Jackson Euphemia K. Abdullai Rev. Michael G. Behind Soniwein 29 Karduma Community Gardnerville Principal 880435658 4 African Glory Soniwein Mr. Aaron Quoi Principal 777246018 Primary Public School Tuweh TownHall Bar- Sud Daycare, Propri- Christ Ambassador Life Block D, Around Mother Macklyn 30 Doahn Town Gardnerville Mrs. Irene Sudeh 886654483 5 Soniwein Principal 770985409 Elementary and Jr. High etre Ministry School Soniwein Clinic Fahnboto Touch World Christian Mr. David K. 6 Fahnseh Public School Fahnseh Town Tolberta Henry Mitchell Principal 880645565 31 Zone 401, Block B West point Principal 777121153 Academy Chayee Albert J. Wash- 32 Muslim Community School Zone 401, Block B West point Abdullah Jalloh Principal 886547557 7 Pleemu Public School Pleemu Town Tolberta Principal 886854446 ington N. V. Massaquoi Public 8 Little Angel Daycare Morris’ Farm Tolberta Ruth B. Kubay Principal 886133795 33 Zone 405, Block A West point Mr. Bemmo Principal 776111970 School 886175400/ West Point Ebola Orphan Mr. Francis Lavel 9 MARCO School System Via Camp Tolberta Richard K. Flomo Principal 34 Zone 407, Block C West point Principal 776266201 77745345 School Robert Marshall Memorial F. Davidson M. Pastor Eric P. 10 Block Path Tolberta Principal 886492925 35 Children Hope Academy Zone 401, Block B West point Principal 776557818 Weslayan Institute Kpalo Johnson Mother Tegeste Mrs. Mariama Z. 11 VOA #1 Road Brewerville Principal 886452763 Stewart School Brown VOA #1 Community 12 VOA Community Brewerville Mrs Musu Coker Principal 886021100 Public School Near VOA Community Mr. Willie V. John- 13 Better Day Foundation Brewerville Principal 777744670 Football field son Apostolic Outreach School 14 VOA #1 Road Brewerville Alberta Mensco Principal 775729517 System 8863400494/ 15 VOA #1 Academy VOA #1 Road Brewerville Mrs. Hawa Fofana Principal 776030969 16 Body of Christ Rehab, Paynesville Paynesville Mr. Sayee Principal 886545573 St. Kathleen McGuire Cooper Farm, Mr. Josephus J. 777552699/ 17 Paynesville Principal Cathoolic School Paynesville Tiady 886437162 Carvery Chapel 886543922/ 18 RIA Road, Paynesville Paynesville Joseph C. Barchue Principal Mission School 777179244 Piece of Mind Cooper Farm, Rehab, Jackqueline 19 Paynesville Principal 776795014 Community School Paynesville Wonder Johnson Jackson Hill, Rehab, Mrs. Sylbes Tine 20 Kids and Us Paynesville Principal 880697201 Paynesville Johnson Kongee Konwroh 776087362/ 21 Colonel West New kru Town Eugene S. Jarboe Principal Community School 777006041 J. N. W. Elem. & 22 Popo Beach New kru Town Sam Dogba Principal 777015758 Junior High School Bishop W. Nah Pastor Abraham 0886719214/ 23 Popo Beach/Point Four New kru Town Principal Dixon Academy Nagbe 777099780 Barclay Nyenfueh Nathniel 24 Popo Beach New kru Town Principal 777232425 Institute Richardson ANNEXES Jewel Howard Taylor/Point Daniel Y. 25 Point Four Community New kru Town Principal 777145428 Four Com. Sch. Mulbah 76 MENTAL HEALTH LIBERIA