The plight of road accident victims in Kenya and their psychosocial needs
By Joseph Maina
The lack of adequate psychosocial support for victims of road accidents in Kenya, presents a yawning gap in their care and management, an investigation by ScienceAfrica Journal reveals.
Little has been done to institutionalize psychosocial support in the overall treatment regimen of a road accident victim in the country, with much of the focus and resources being invested towards their physical treatment needs.
The problem is more pronounced among critically injured people, who are forced to contend with life-altering physical injuries amid underlying psychological trauma.
Little analysis is done to assess the economic impact of road crashes, particularly at the individual and household level.
“Data analysis on the economic effects of road crashes is not efficiently done despite its obvious high social and economic costs to the country,” the National Road Safety Action Plan 2005-2010 stated.
The World Bank puts the annual casualty rate of the critically injured at 50 million people globally, with many people left permanently disabled as a result.
Compounding the problem, road accidents disproportionately affect the poor, and with many crash victims being of working age, their serious injury too frequently takes a toll on the welfare of their dependents.
The unpredictable nature of road accidents means that most people are caught off-guard, with little or no means of countering the emergent challenges.
“You can’t reason when you’ll have an accident, and you cannot necessarily precipitate it, or anticipate it, unless you go the insurance way,” said Dr Geoffrey Wango, a Senior Lecturer in counseling psychology at the University of Nairobi. “So, when an accident occurs, most people go through the stages of grief – shock, disbelief, anger, negotiation and eventually, acceptance. When people get involved in accidents, they usually don’t know how to deal with it. They may not be prepared, and their families may not know what to do.”
The typical home may not have the requisite infrastructural layout to optimally accommodate the accident victim, notes Dr Wango, saying that adjustments are usually required at the household level to assist with mobility, feeding, sleep, sanitation and other day-to-day functions. The accident itself is cause for painful recollections, but so is the reality of a new life beset with challenges.
“The person actually goes through such traumatic moments that they may not even know who they are,” stresses Dr Wango. “Imagine being a healthy, well-functioning individual, and you are suddenly confined to the house, unable to even move to the toilet. How do you accept yourself? You feel degraded. You may feel you are not of worth. In extreme cases, the patient may slink into an abyss of oblivion, marked by intense loneliness, when acquaintances and the community shuns your company. As you can imagine, the higher your social status, the lower you go in such circumstances. And, the more intensive your injury, the more people may dismiss you.”
And so the psychological trauma sets in, with the realisation of lost functionality, lost career or other developmental prospects, and a generally dented future.
Self-acceptance is a key area of focus in the psychological treatment of accident victims, geared towards building resilience. Support, says Dr Wango, should come from all possible quarters, including family and friends. He says it is particularly encouraging to see that religious formations also make a point of visiting and communing with accident victims.
“The person needs to accept what happened, what they are going through, and what they can do about their life. That’s the ultimate remedy. The more resilient individuals tend to do it better than those who refuse to accept what they are going through."
Dr Wango laments that institutions generally do not pay attention to the psychological needs of person inflicted with trauma.
“Very few organisations are bothered about psycho-traumatic support systems, including counseling and therapy,” Dr Wango said. “Hardly anybody thinks about them. When one is involved in an accident, everybody is preoccupied with healing, and they generally go for the physical, and not the psychological, which is sidestepped”.
Brian Muchiri’s experience
There’s a charming glint in his eye when he converses, a healthy gleam in his cheek, and a graceful smile bereft of remorse flashes on his face from time to time. There’s practically nothing in Brian Muchiri Waihenya’s facial aspect that would betray the catastrophic turn of events seven years ago that robbed him of the pleasures of young adulthood, and consigned him to a wheelchair – for life.
It was in February 2014 that Brian, 26, was involved in a road accident on his way home with friends after a night excursion in Nakuru town. Three of Brian’s friends died on the spot after the car they were travelling in collided head-on with a trailer along the Nakuru-Kabarak road. Brian and one friend escaped with their lives.
On the fateful eve of the accident, a friend had urged Brian to sneak into town in the night for some fun, in what would be Brian’s first night out.
“It was on a Friday night and I was already in bed, preparing to sleep. A friend called me up and asked me to join him and other friends to go out. I was apprehensive, but then I saw it as an opportunity to have fun, which was rare in the village”.
And so Brian surreptitiously joined his friends, and his parents had no idea that he wasn’t in the compound that night. The partygoers had fun all right, only to meet their accident the following morning. Brian has no recollections of the moments immediately following the crash. He was informed later on that some well-wishers took him to hospital. He surmises that, in the process of transporting him to hospital, the first responders may have handled him in a manner that could have worsened his spinal chord injury, despite their noble intentions. They put him in a sitting position in a car. His parents received a call that Saturday morning informing them of their son’s predicament in hospital.
“My injury affects my body in a big way because I have no feeling of sensation anywhere beyond or under my armpits. I’m what we call a quadriplegic; an individual with limited or no use of both limbs. I don’t have use of my lower limbs, but I have limited use of my upper limbs. The bigger muscles work – like my biceps - but I have no movement beyond my wrists. I can’t control my fingers”.
The firstborn among three boys, Brian also lost control of several body functions. At the time of the accident, Brian, then 19, was in his third year at a local university campus in Nakuru town, pursuing a course in purchasing and supplies. Depression would eventually set in, as the young Brian came to terms with his predicament.
“My youth was affected by the disability,” Brian told ScienceAfrica Journal at his home in Mangu, Nakuru County. “I can’t be at par with my peers. As they finished school I was still recovering. As they got jobs and started families, I was still here. I am a few steps backwards in terms of the milestones you may think about in the normal progression of life.”
Despite the palpable drawbacks on his young life, Brian has taken it all in his stride. He is the founder of Strong Spine Foundation, an organization that seeks to empower and advocates for inclusion and equality for people with disability.
But the toll on his family has been great. Aside from the high cost of treating his physical disability, his family has had to commit numerous resources towards his care and well-being.
He relies heavily on his wheelchair and a caregiver, a role that has been shouldered by his parents. Every morning, his father assists with his bath and dressing up. His father wakes up twice a night to help him turn in his sleep, as a way to prevent pressure wounds. He uses a catheter for his bladder and adult diapers for his bowel movements.
Asked whether he is on medical insurance cover, Brian revealed that he had signed up for the SUPA cover package of the National Hospital Insurance Fund (NHIF). He stated that he was not aware of any psychological support among medical insurance providers for his condition, and that he had not considered it before.
“I didn’t get any kind of professional support for my mental health. Maybe I didn’t realize that I was going through something so serious, or if at all I even needed it. I didn’t even know that it was an option”.
What options are available for psychosocial support?
For many stakeholders in Kenya’s road transport sector, the issue of psychosocial support for road accident victims is a matter that has been swept under the carpet for far too long.
“It is an area of concern,” said Fred Majiwa, the Head of Business Development, Programme and Emergency Services at St John Ambulance Kenya, “Over the years, most of the focus has been on the physical assistance to the victims of road accidents”.
“Psychosocial support isn’t a highly regarded subject in patient care”, stated Kevin Mubadi, the founding head of the Bodaboda Association of Kenya. “Most accident victims are left to fend for themselves in this area”.
Mubadi conceded that this is a gap that calls for redress in the overall care and management of victims of road accidents. Little options are available for the accident victim, and even where available, they are few and far between. George Mathenge of the Association for the Physically Disabled of Kenya (APDK) suggests a county-based approach as one way of availing psychosocial assistance to those in need.
“Ideally, whenever one goes for physiotherapy in a hospital, they should have the facility,” Mathenge told Science Africa.
According to Majiwa, the psychological effect of an accident extends beyond the individual casualty to include the wider family and society.
“You find that, for every one physical victim, there are at least four other psychological victims,” Majiwa told Science Africa. “This is because there are people who watch these things, and they are traumatised. There are the relatives of the person who passes on, and they too are affected. This area has not been properly managed”.
First responders may also suffer psychological pain when they encounter gory details at the scenes of accidents.
“Even first responders who are not trained may rush to an accident scene to help, but they may fail to help themselves. That’s because after this, they might be traumatised and require debrief or to see a counselor”.
Majiwa recounts a particularly serious case of a first responder in Salgaa, Nakuru County.
“We were handling some projects there and there was a gentleman who had over the years been rushing to scenes of accidents. He was downplaying the psychological effect. Later, we had to take care of him. We took him to the county referral hospital in Nakuru after noting that his behavior was not normal. This is just a case among others”.
In addition, Majiwa noted that in the typical government hospital, the emphasis is laid primarily on the physical wellbeing of an accident victim. General perceptions of psychological therapy are also to blame.
“People’s attitudes towards it also play a role in limiting the attention given to psychological help,” Majiwa said. “People may see psychological treatment to mean being treated as a mad person. So, you might find that, generally, the population is reluctant to admit that they have a psychological needs that require treatment”.
Majiwa said that the government has acknowledged the need for psychosocial support, while admitting that this is a relatively new area in overall patient care, and might take a while before it is fully integrated in mainstream patient management.
“What I understand is that in every county referral hospital, there is at least a section that handles mental health care, so that they can at least mitigate it at the very basic level”.
The key component in psychological care, Majiwa said, is referral. This is what needs to be strengthened in order to point people in need of care in the right direction as need arises.
The practice at one of East Africa’s most respected brands in the health sector aligns with Majiwa’s envisaged referral model. For an accident victim, a general physician is one way to provide assessment for possible psychological assistance on a case-by-case basis.
“Often, when a patient has outstanding psychosocial issues, the primary doctors are able to recognise that and to involve the mental health workers – be it the psychiatrist, psychologist, counselor or social worker”, Dr Ian Kanyanya, of the KNH, told Science Africa. Dr Kanyanya, himself a psychiatrist, is Head of Department of Mental Health at KNH. He however acknowledges that despite the efficacy of this approach, there are limits to how many persons in need can be reached in this way.
“As much as we recognize what KNH does, we also realize that that is what is provided to just a limited few – we are talking about those who are admitted in hospital, which is really just a fraction. We realize that many others may not have the obvious psychosocial disruptions necessitating intervention, and so they go unnoticed – they are treated for their fractures and they go home without the necessary interventions as far as their psychosocial needs are concerned”.
Dr Kanyanya revealed that both inpatient and outpatient patients are assessed for possible psychosocial care, and referred accordingly. Despite the relative successes of the KNH approach, Dr Kanyanya observes that more attention needs to be paid on the psychosocial well-being of the accident victim. He identified a need for greater advocacy on the subject. He urged a more proactive approach towards prevention, saying the community needs to be looped into the campaign.
“Unfortunately, as is the case with other mental health issues in our country and region, not much attention is paid to psychosocial support for the accident victim,” said Dr Kanyanya. “Our system is not tuned to prioritize thse issues among people whop have suffered trauma. You can get trauma from things like accidents, war-like situations, sexual violence and so on. Prevention, they say, is better than cure. Maybe we need to be more active in highlighting these things to the general public.”
Traumatic experiences have a lingering impact, in some cases leaving a long-lasting imprint on the victims.
“What happens when someone has suffered trauma is that after the patient gets well from the fractures and wounds, the assumption out there is that now you are fine - you should pick up your life and continue” Dr Kanyanya said. “But that is not true. We know that the symptoms of Post Traumatic Stress Disorder can flare up even years after the accident. Generally, it is not very obvious to many people – many people may not quickly recognize that this is connected to the accident that happened, and the patients themselves may also not connect”.
At the recommendation of a doctor, health insurance covers the financial costs of treatment prescribed by the doctor.
“For medical cover provided by insurers, the treatment covers the physiological treatment and physiotherapy as recommended by a doctor”, AKI told ScienceAfrica. “When we look at compensation of road accident victims, the amount awarded covers compensation for their pain and suffering. This compensation is mostly paid out in cash to the victims, we therefore cannot tell what happens thereafter”.
The Organic Recreational Therapy Program by The Cluster Foundation
In the taxing and oftentimes bleak environment for the critically injured road accident victims, where psychological succor is largely swept to the fringes of healthcare, a local organization has stepped in with a personalised support system for the victims as they navigate their path through the new and difficult path towards self-actualisation.
The Cluster Foundation (TCF) is a non-profit organization that inspires people with spinal cord injury to find hope in seeing the possibilities of leading an active successful life beyond their fears or barriers. Many of the beneficiaries of the program are critical road accident victims.
“We love adventure!” says Ms Njoki Mwangi, a TCF founding trustee. “Among the activities within TCF's Recreational Therapy Program is rallying people with paralysis who are stuck in their homes out and back into the mainstream of society through activities that include excursions, home visits, sports and entertainment”.
TCF excursions work two-fold. One, they motivate and raise the confidence levels of both the adult spinally injured persons (SIP) and two, for the society at large, they enable the general public to have a chance to engage with SIPs, empathize and incorporate them hence eliminating stigmatization.
Through the excursions, SIPs under the TCF family have been to the Kenya National Museums, Nairobi National Park, Kitengela Glass, Kenyatta International Conferences Centre rooftop, drives, picnics, theatre plays and movies, and lots of sports ranging from kayaking to wheelchair basketball, swimming, ice-skating and more.
TCF’s Recreational Therapy Program is currently made up of five programs: TCF ICE, TCF ROPE, TCF COTE, TCF DATE and TCF Gallery.
ICE - I Can Experience
Majority of SIPs focus on what they now cannot do since they acquired paralysis - "I can't this," "I can't that".
“TCF steps in, influencing SIPs to change their perspective about themselves,” Njoki told ScienceAfrica. “This helps them to rebuild their self-esteem and regain their self-confidence”.
Every month TCF organizes activities, events, excursions and more for SIPs to gather together and experience something new or something old in a new way. This Program enables SIPs get together to socialize, share their personal matters, learn to experience TCF activities together and to encourage and uplift one another.
ROPE - Reaching Out Post-injury Experience
This is TCF's most-intense program. It involves SIPs in their homes, their family and friends, and their personal needs. It involves TCF Volunteers visiting 2 SIPs in their homes every quarter to ensure accessibility, comfort, interaction, and all else concerning SIPs in their surroundings. This is crucial to TCF because SIPs ought to be at their best, holistically, in their own private space, while at home and while with TCF.
This holistic approach is an all-rounded approach that caters to the SIP’s psychological, personal, mental and financial needs.
COTE - Couples Out To Experience
COTE is for couples affected by paralysis. Already, all relationships between two people are entwined in delicate dynamics; now imagine the impact of paralysis on a relationship. COTE focuses on rekindling love, on learning to jointly cope with this new aspect and the impact on the family. COTE encompasses tackling and restoring every aspect of marriage – from communication to intimacy, finances, children, the spouse caring for the SIP, and more aspects of life in a typical household setting.
DATE - Disability Accessibility Training Experience
The TCF mission is rallying Spinally Injured Persons out of their homes and back into the mainstream of society. DATE targets every place within the society in preparing them to receive SIPs equitably, inclusively and without prejudice. TCF advocates that disability is the responsibility of the society - not just the affected family as has been the case based on traditional and cultural (damaging) beliefs.
TCF plans to open the first Gallery in Kenya to stock all kinds of mobility, health, leisure, skills development and more accessories for persons with disability to enable accessibility with ease and at an affordable rate. This, says Njoki, was strongly influenced by the high levels of exploitation of persons with disability who don't have a variety of options and are then forced to raise funds from family or the public. By availing these critical items of care, the organization hopes it will further lessen the burden on affected households and mitigate the resultant psychological toll from exploitative costs of care.
Japheth Mwanene’s story
For Japheth Mwanene, the TCF programme has provided an avenue for him to rediscover himself, and chart a new course in his life after he underwent a critical road accident 19 years ago. The activities in the TCF program have gradually opened his eyes to new frontiers in life.
“The experience normally helps one to move on with life,” Mwanene told ScienceAfrica Journal. “For example, last year but one, I happened to ride the Standard Gauge Railway (SGR) from Nairobi to Mombasa, something I had never imagined would happen after my spinal chord injury. It was the longest distance I’d ever travelled since I got injured.
They’ve also taken us for horse riding. I’d never known that I could ride a horse, but I did it with the support of guides. I had not even ridden a horse even prior to the accident.
Through these and other activities, one feels a sense of belonging to the society. I feel more and more like I am still part of the society.”
Thanks to the train trip, sponsored by the Kenya Railways, Mwanene had a taste of the good life in the Kenyan coast. His three-day excursion was spent in a 5-star hotel, a standard he was hitherto unaccustomed to. It was a once-in-a-lifetime thrill which made him feel important, respected and valued.
Communing with peers of similar predicament serves to boost one’s confidence further, Mwanene adds. Participating in activities with his fellow SIPs in the program has helped imbue a “can-do” attitude in the former banker.
“After joining the TCF program, I discovered there were other people of my caliber. I could see others do it, so why not me? There was one activity, for instance, in which I experienced kayaking. It involved moving the boat with one’s legs, sometimes alone, which was something I had not experienced. It instills the feeling that you too can do some of the things that able-bodied people can do.
Overall, the TCF program has helped me accept my condition. I am more conscious of the fact that life has to go on, despite my spinal chord injury”.
At the program, one meets others whose predicament might even be worse than one’s own, Mwanene said. Seeing them exerting themselves, seeing everyone striving to excel despite the enormity of their frailty, diminishes the chances of feeling self-pity, and challenges one to see themselves in a positive, capable light.
He says the build up of positive attitudes has been so big in the TCF programs that he and his peers have caught themselves contemplating achieving new feats, which they had never imagined possible in their predicaments. He has seen peers contemplating starting small businesses, and developing themselves in life.
New friends, made in the TCF program, have replaced many of his friends who slipped off his circles after his accident. Many of his friends deserted him after his accident, but he has found solace in his new company within the TCF fraternity.
Activities in the COTE program have been beneficial to Mwanene and his household. He says through COTE, he and his spouse joined other couples in learning how to rekindle love, manage finances and make adjustments in their lives post-accident.
Mwanene is confident that given the resources, TCF can do more for critically injured persons. One critical limitation in the program, he says, is financial constraints.
“Our programs mostly end with the word ‘Experience’”, says Njoki. “That's because, even though all the TCF beneficiaries have one thing in common - paralysis from a spinal cord injury - they each do not respond to the same therapy the same way. A particular method or activity and timespan may work for one SIP and not benefit another SIP at all.
"It is for this reason that TCF's core focus on the SIPs is their mind, not their condition. Yet, bringing them together is the most therapeutic experience for them. Likewise, with the choice of TCF activities, we discover along the way, drop what doesn't fit in. Thus the term ‘Organic Recreational Therapy Program’. TCF handles each SIP as an individual In short, at TCF, one shoe size does not fit all.”
Both Njoki and Nick Nguyo are the Co-Founding Trustees of The Cluster Foundation. SIP Nicky, influenced the establishment of TCF, which grew to 6 SIPs by the second year, 15 SIPs by the third year and currently stands at 82 SIPs in Nairobi, Nyeri, Embu, Murang'a, Mombasa, Bomet, Nakuru, Kericho.
TCF's maiden excursion to Mombasa in may 2019 was made possible by Kenya Railways, Sarova Whitesands, Go-Africa Safaris and ICEA LION.
Of these, 47 are paralyzed following a road accident.
Njoki says working with the human mind has enabled TCF influence SIPs to change their perspectives about their acquired injury, their lives and themselves. “Because of this intervention, 9 have become parents, 22 are driving themselves, 3 own vehicles but are driven, 16 are employed and at least 35 are running their own businesses”.