The specific objectives of the KRCT programme were to:

Raise stress management awareness amongst management and staff working in PHC services;

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

In March 2014 in the 5^th year of the programme, an evaluation was conducted to allow adjustments in the last half year of the programme. In June 2014, the results were shared with stakeholders in Pristina. Possibilities for follow up and rolling out the programme in the region or within other sectors were explored during this conference as well.

An important programme activity consisted of training. First, 18 trainers were trained over a period of three years. All trainers had a medical and/or psycho-social health background and 13 of the 18 were working within the Ministry of Health (MOH). The trainers were selected in such a way that all of Kosovo could be covered within a few hours of travelling. A group of 18 trainers were selected by KRCT based on the following criteria:

former training experience

Training of trainers was carried out with the assistance of external facilitators consisting of staff from Antares and KRTC as well as associated Antares volunteers and partners from Foundation Centrum ’45, the Dutch national expert centre for diagnostics and treatment of (complex) psychological trauma who dedicated time and human resources. Despite reduced funding, training of trainers could be implemented as planned because of extra efforts of the facilitators.

Second, health care professionals and managers/directors working in family health centres were trained by the trainers. Through this cascade approach, a relatively large number of health staff could be trained in a short time; altogether over 1100 staff (1078 family doctors and nurses and 25 managers and training coordinators) were trained. Training output is summarized in Table 2.Table 2

Training output

Trainers and health staff targeted under the programme originated from geographical locations throughout Kosovo. The number trained per region was proportional to the number of health staff in each region. Programme beneficiaries included “accepted” minorities (such as Roma), especially in Prizen, Peja, Prishtina and Gjakova areas, where these minorities are most prevalent. However, political developments between Kosovo and Serbia during the implementation phase of the programme limited the scope of the programme in Serbian enclaves. For instance, although Serbian speaking trainers and Serbian health staff were identified, circumstances did not allow their participation in the programme.

The training methodology focused on an interactive approach: Trainees were invited to share their methods and experiences, prepare case studies, try out energizers, and various relaxation techniques with many exercises were introduced. For most trainees this approach was a new concept perceived as a welcome change from the traditional lecturing workshops.

Under the programme, various materials were produced, including the following:

Stress management training curricula; these have now have been standardized, accredited and incorporated into refresher courses for family doctors and nurses and are being implemented into in-service training for family nurses and doctors (as part of the mental health module).

The initial plan was to include all family doctors and nurses working in the PHC system in the training (1150 at the time). Actual coverage was much lower, because the number of staff was more than twice as high as originally estimated based on the statistics available at the start of the programme. The trend in coverage is provided in Table 3.Table 3

Number and proportion of family doctors and nurses trained

The total cost to train one family health staff member amounted to about US$106. The costs to train one trainer of trainers, was approximately US$6,680. Reasons for the relatively high costs included the following: (i) training was carried out by international trainers, because the necessary expertise was unavailable in Kosovo; (ii) training venues were not within PHC facilities, but external; and (iii) trainees were compensated for time investments and travel. If integrated in an existing curriculum, the costs of training one health professional in stress management was estimated at US$12.50 (based on the cost of a Kosovar trainer, no external venue/catering, no compensation of trainees, and so on).

Antares and KRCT ensured ownership of the programme by involving the Ministry of Health in general and the PHC system in particular in the programme design and implementation. A steering committee composed of seven senior policy makers was established in 2009. The steering committee monitored progress, supervised the quality of the programme, and oversaw the execution of the programme. The steering committee contributed to the integration of stress management into existing human resource policies in the PHC system by embracing a draft policy paper for staff well-being for the MOH based on the Antares Guidelines: Managing Stress in Humanitarian Aid Workers, Guidelines for Good Practice [14] (http://www.antaresfoundation.org). In 2014, MOH endorsed this policy paper. The main objective of the policy paper is to prevent or mitigate the effects of staff stress and promote overall well-being. The policy paper describes indicators of success such as training on stress awareness and mainstreaming of staff well-being in all policies and practices. The policy will be monitored, evaluated and updated by the MOH. Please refer to Table 4 for a summary. To facilitate follow-up action, the steering committee sent a circular to the directors of municipal PHC centres, introducing the policy paper and suggesting in each family health centre to establish teams of staff trained in stress management and/or a focal point in order to facilitate staff well-being and stress management at the workplace.Table 4

Kosovo PHC policy on staff well-being

The steering committee also advocated for integration of staff well-being and stress management in the revised mental health strategy of 2014–2020. The strategy stipulates that in the working environment (i) stress management should be integrated into curricula for continuous training for family health staff and (ii) mechanisms for systematic assessment and evaluation of the staff’s capacity to react and cope with workload stress should be developed.

A task force consisting of five members from various primary health care institutions was established as the coordinating body at the operational level. Members of the task force, in cooperation with KRCT, have been engaged in supporting and facilitating programme implementation including identifying participants for trainings and meetings and arranging logistical support. The specific task of the task force was to safeguard the quality of the training component of the programme, while the steering committee made sure that all activities were in line with the standard operating procedures and policies within Kosovo.

Through the task force and steering committee, the programme also availed of a permanent quality monitoring system. For instance, all trainings were attended by a member of the task force, ensuring that feed-back on the quality of the training was provided on an on-going basis, which in turn allowed for further improvement/adaptation where necessary. A particular (unintended) result of the involvement of the steering committee and the task force in the training was accreditation of the training (as stress management module in the training for family health staff). The position of the members of the Steering Committee within the MOH was of great importance in facilitating the whole process of accreditation.

The adoption of the policy paper, the integration of staff well-being and stress management in the new mental health strategy, and the accreditation of the stress management module facilitated the integration of staff well-being and stress management into the primary health system.

The relevance, effectiveness, efficiency and sustainability of the programme were evaluated during the last year of implementation. The objectives of the evaluation were to (i) provide a structured and comprehensive retrospective assessment of the KRCT/Antares psycho-social capacity building programme and (ii) explore to what extent the programme has succeeded in developing a model to roll out this programme in other contexts.

For the purpose of this evaluation an online-survey among 100 randomly selected staff trained under the programme was carried out, of which 89 % responded (77 % of the questionnaires were sufficiently filled in to be processed). Findings suggest that the programme had been effective in terms of promoting team building and mutual respect amongst colleagues. 58 % of the respondents indicated that they (strongly) agreed that their organisations’ efforts to promote team-building and mutual respect had been effective. 37 % were neutral, while only 5 % disagreed. Also, a large majority (76 %) were of the opinion that managers paid attention to the importance of staff well-being in the work environment. In addition over half (56 %) of the respondents felt that staff care had improved within their organization over the past year, while 27 % was undecided and 16 % did not share this feeling.

The vast majority (80 %) of survey respondents was of the opinion that the activities proposed and implemented throughout the programme were the most efficient way to proceed (compared to alternatives) in raising awareness on stress management and staff well-being.

In-depth interviews with trainers (nine trainers, that is half of the staff trained as trainers) and beneficiary health staff (15 doctors and nurses) corroborated survey findings that the programme had contributed to raising awareness on stress management, not only on personal level, but also within teams and even, for some, amongst family members and within the community. Interviewees saw the approach of the training as efficient: “because theory was combined with practical examples, you really eliminate stressful conditions of the participants in the training”, as one respondent explained. Or as another respondent elaborated: “the activities have led to a significant improvement in the relationship between colleagues and reduced incidents with patients and colleagues”.

All interviewed trainers were satisfied about the skills they learned for training, including practical exercises and techniques. Five of the interviewed trainers mentioned that the training stimulated them to read more about stress management (and use the e-learning website). Both trainers and health staff were satisfied with the training methodology; the interactive approach was a new concept perceived as a welcome change from the traditional lecturing workshops. As some staff members said: “we forgot the world outside during training”. Participants felt energized and relaxed at the same time: “This TOT was my best experience in life. As a trainer, but also as person, it gave me more confidence, more positive feedback and energy. The work plan approach was an eye opener and I use it also in other situations”. “As a trainer I gained confidence and I am even using the relaxation techniques and exercises now within clients as well”, were some of the comments made by trainers during the interviews.

Health staff provided examples in meetings of managers who had changed their leadership style, and how the training had contributed to increasing mutual respect (both between nurses and doctors as well as between managers and other staff) following the training, positively impacting on team work. “And you are entitled to close the door and do relaxing exercises at work as well”, some staff said. Asked whether trainees actually do this, the answer was that some do indeed. Others however remarked that the training had made it easier to discuss stress (and stressors). “We are actually making jokes about stress now”.

Personal benefits mentioned included (i) experiencing fewer panic attacks; (ii) having more resilience; (iii) being more relaxed; (iv) taking better care of her/himself; (iv) being aware of consequences of stress; (v) dealing differently with stressors; (vi) being more confident as a trainer; and (vii) understanding one’s own trauma and facilitating own healing process. In-depth interviews with trainers and health staff confirmed findings from post-training evaluations carried out after each training session/workshop.

The evaluation came too early to assess whether there were any lasting changes – attributable to programming —in the lives of beneficiaries, health staff and managers of family health clinics or to measure a possible impact on their well- being. The evaluation therefore did not include an end line assessment of staff well-being.

The questions in the qualitative part of the initial needs assessment were primarily aimed at provide context of the findings of the quantitative part of the needs assessment. As such, they were less useful in providing programmatic baseline indicators. The questionnaire developed for the evaluation contained (partly) the same questions as the needs assessment questionnaire, but findings could not very well be compared.

In addition, although the initial plan was to include all family doctors and nurses in the training, actual coverage turned out to be much lower. The target based on the statistics available at that time the programme started were incomplete and the actual number of staff employed according to more reliable statistics available at the time of the evaluation revealed that only 46 % of the staff had been trained. The evaluation results are thus only representative for the staff trained under the programme.

Lastly, integration of staff support and stress management in policy and practice was only at its infancy at the time of the evaluation. Findings of the online evaluation survey confirmed this: only 15 % of the staff was very familiar with organizational policies related to staff well-being, policies being developed over the past three years. Thirty eight percent was somewhat familiar and 46 % was not familiar with any policies. Nevertheless, possibly because relatively more managers were trained, a large majority of the evaluation survey respondents (76 %) were of the opinion that managers paid attention to the importance of staff well-being in the work environment.

Table 5 provides details on the evaluation methodology.Table 5

Evaluation methodology

Lessons learned and recommendations were combined to guide the identification of building blocks (which factors to take into account) for a model for integration of staff well-being, the necessary pre-conditions and feasible approach. These issues were discussed, validated and amended during a conference attended by stakeholders in June 2014 and during workshops in October 2014. Results can be summarized as follows:I.

Building blocks

The programme needs to be context specific. A lesson learnt is that a needs assessment should include a qualitative and quantitative component. A qualitative assessment focusing on needs of the (intended) beneficiaries as well as (a limited number of) institutional characteristics (of the system the beneficiaries are part of) is the minimum required to inform the programme design. Ideally, results from the qualitative assessment feed into a quantitative assessment, which includes data on some process indicators (to be monitored annually or at least at mid-term) and impact indicators (to be measured at the end/after the finalization of the programme).

A conceptual framework (model), summarizing the building blocks and their (mutual) interdependency, is outlined in Fig. 2. The model emphasises the importance of raising awareness on the need to support health staff working in complex situations, under high work pressure, with limited resources and for a traumatised population. The needs assessment is always the starting point for a staff support programme; requests for support are fed through awareness of the need for support. The implementation of a needs assessment leads to raised awareness. With building capacity within the target group, awareness is growing both in target-group, but also within the system, since target-group(s) is/ are part of this system.Fig. 2

Antares model for integration of staff well-being