Solutions for Increasing Physical Accessibility, Capacity Building and Psychological Support in Tajikistan

by Reykhan Muminova, M.D., Ph.D. [ UNDP Support to Tajikistan Mine Action Programme ] - view pdf

In order to fulfill requirements of the U.N. Convention on the Rights of Persons with Disabilities (CRPD), the city of Dushanbe, Tajikistan, modified the architecture of three public buildings and implemented a new psychological training process for medical centers in the area to provide awareness about disability rights and increase provision of psychological aid. The desired end goal is that advocacy will allow for increased public acceptance and understanding of disability while moving Tajikistan toward signing the CRPD.

Opening ceremony at the outpatient clinic for persons with disabilities.
All photos courtesy of Safarbek Soliev.
Opening ceremony at the outpatient clinic for persons with disabilities.
All photos courtesy of Safarbek Soliev.

Following independence in 1991, Tajikistan’s civil war (1992–1997) destroyed much of the country’s infrastructure and displaced a large percentage of the population. Leftover ordnance and landmines from the conflict still inflict injuries, and thousands of survivors have yet to fully recover from the physical and psychological trauma related to the war.

The total number of registered persons with disabilities in Tajikistan is more than 147,327 according to information provided by Tajikistan’s Ministry of Health and Social Protection of the Population (MHSPP) in January 2015.1 Landmines/unexploded ordnance have injured or killed more than 850 persons since 1992 according to the Tajikistan National Mine Action Centre (TNMAC).2

Article 25 of the Tajikistan’s Law on Social Protection of People with Disabilities ensures disabled people the right to unimpeded access to social infrastructure and transportation. Providing an accessible environment is one of the fundamental requirements of the Convention on the Rights of Persons with Disabilities (CRPD) which “[recognizes] the importance of accessibility to the physical… environment in enabling persons with disabilities to fully enjoy all human rights and fundamental freedoms.”3 The CRPD also discusses accessibility in many of its articles, starting with the Preamble, but Article 9 is fully devoted to accessibility issues.4

Since 2012, the Office of Weapons Removal and Abatement in the U.S. Department of State’s Bureau of Political-Military Affairs (PM/WRA) has supported the Tajikistan victim-assistance program to provide solutions and funding for physical accessibility issues and to build capacity for doctors and nurses in mine-affected areas, increasing psychological support to landmine survivors and persons with disabilities.

A two-phased project provided for training on psychosocial assistance and accessibility solutions for those with disabilities. The Swiss Foundation for Mine Action (FSD) implemented the first phase in 2012, introducing solutions for accessibility issues, while the United Nations Development Programme: Support for Tajikistan Mine Action Program (UNDP STMAP) completed the second phase - “reconstruction” in 2015. The Disability Support Technical Working Group (TWG) considered different locations and decided as a group what public buildings would benefit most from being made accessible. The group took into account project nominations by government ministries, criteria for reconstruction, technical results from assessment trips and experts’ recommendations. Following this, TWG made the final decision to improve accessibility at the following sites in Dushanbe: the State Medical Labor Expertise Service in the National Medical Center; the Dushanbe Circus; and the Research Institute for Expertise and Rehabilitation of Persons with Disabilities.

New Solutions and Standards

In 2012, FSD began a one-year, victim-assistance project introducing physical accessibility solutions within Tajikistan based on international standards and best practices, which proved challenging for the Tajikistan Mine Action Programme (TMAP) due to new accessibility regulations introduced in the country stating that all buildings and construction should be accessible to people with limited mobility.5

UNDP STMAP and FSD organized two roundtable meetings involving disability stakeholders. The first discussion assessed current standards and recommended improvements. A second roundtable was organized in partnership with Tajikistan’s governmental ministries, agencies and organizations for persons with disabilities (OPDs). The meeting presented a draft version of the new normative requirements and proposed amendments. Following this second meeting, the Committee for Architecture and Construction wrote an action plan for the accessibility sector to be implemented in 2013–2014. The action plan includes various elements such as the new Tajik accessibility-regulations endorsement, improved control systems (system standardization and OPD inclusion), and increased awareness among the public and construction sectors.

Following Tajikistan’s adoption of these new standards, the UNDP and the Research Institute of Architecture and Reconstruction organized advanced training courses for 26 local architects and designers to address accessibility issues for those with mobility issues. In November 2014, staff from the Research Institute trained these individuals on how to use new standards and regulations on construction and accessibility for people with limited mobility. The principle of “nothing about us without us” was key throughout the training. The staff members will expand the initiative in 2015 to include organized training events in two regional centers in Tajikistan to further increase awareness about accessibility among architects and designers.

Renovation Sites

The victim assistance component of STMAP developed criteria to prioritize sites based on the estimated number of persons with disabilities accessing the site (including landmine and explosive-remnants-of-war survivors), popularity of the site, and future use of adapted sites for accessibility and CRPD-advocacy campaigns. During the first stage of this project, two sites were fully rehabilitated and made accessible: Dushanbe Central Mosque (Mosque Haji Yaqob) and the Children’s Outpatient Clinic 12. Renovations to the sites included making public restrooms and entrances accessible, installing ramps, widening elevator doors, and labeling signs in Braille.

In 2013, UNDP/STMAP and TNMAC received an additional request from MHSPP to provide support and rehabilitation to two hospitals for those with disabilities: a newly opened outpatient clinic (State Medical Labor Expertise Service) situated in the National Medical Center required a lift; and the Research Institute for Expertise and Rehabilitation of Persons with Disabilities required accessibility ramps. UNDP STMAP further developed these requests and submitted it to PM/WRA for funding.

Chairman of the Society of Persons with Disabilities, Imkoniyat Asadullo Zikrikhudoev, mentioned that when the outpatient clinic was first opened nine months prior, his greatest concern was that “the center for persons with disabilities was situated on the second floor.”

During monitoring, Qurbonaliev Azim, director of out-patient clinic, expressed his gratitude to the donors, mentioning, “Every day up to 20 persons with disabilities are visiting as outpatients. Before construction of the lift, their relatives and accompanying persons helped them to reach the second floor. The outpatient clinics provide different consultation and treatment services (therapy, neurology, gynecology, cardiology, ultrasound examination, electrocardiogram and the most advanced equipment for ear, nose and throat specialists in Tajikistan, etc.). All services and consultation are free for persons with disabilities.”

Muazzama Mirzoeva, a therapist with 45 years of experience, said that “it was an extremely important project and very good that we now have [an] elevator. From the opening day last year, it was the most challenging issue for patients with low mobility, especially wheelchair users and polio patients, because it is very difficult to carry patients to the second floor.”

Project Assessment

Persons with disabilities using new ramps to reach Dushanbe Circus.
Persons with disabilities using new ramps to reach Dushanbe Circus.

Before and after site renovations, staff from the Research Institute of Architecture and Construction conducted Knowledge, Attitude and Practices (KAP) surveys on each site to determine the projects’ outcomes. The group will conduct a follow-up KAP survey at a later date to assess the impact on those within the local community. These projects will serve as examples of effective accessibility renovations and will hopefully influence societal attitudes about disability and behavior toward those with disabilities, bringing Tajikistan one step closer to CRPD accession.

Psychosocial Support

In addition to permanent physical disabilities, survivors often show symptoms of chronic post-traumatic stress disorder and experience reduced emotional well-being including depression, anxiety, fear, anger, dependence on others, and isolation due to feelings of shame and discrimination. In addition to needing medical care and prosthetic devices, survivors often need psychological rehabilitation, which should be provided from the moment of injury.

Central district hospitals in Tajikistan are usually the first medical facilities where survivors and other people with traumatic injuries receive first aid, but like in many other post-conflict countries, the rural hospitals and clinics have no specialists in psychological support available to properly treat landmine survivors or others with disabilities in need. Therefore in 2012, UNDP STMAP requested a grant from PM/WRA to build the capacities of local doctors and nurses in mine-affected areas for provision of psychological support to landmine survivors and persons with disabilities. PM/WRA provided the financial support to the Information Management Land Release and Victim Assistance pillars of UNDP STMAP, and further, based on the UNDP tender results, part of funds were passed to the public organization, Psychological Support Center for implementation of the psychological capacity-building project.

Between 2012 and 2014, the Psychological Support Center, which has experience in organizing psychosocial support activities in emergency situations and collaborates with MHSPP and TMAP, focused on the psychosocial care component of victim assistance. The Psychological Support Center worked to cultivate the capabilities of local doctors and nurses in mine-affected areas for the provision of psychological support to landmine survivors and persons with disabilities.

Training guidelines were developed and published in cooperation with Global Initiatives in Psychiatry and the Tajik National University’s Department of Psychology before implementing the project. Training focused on adapting psychosocial support for persons with disabilities for medical and department of social protection staff from mine-affected districts. The training enables participants to assess the psychological status of persons with newly acquired disabilities, including landmine survivors. Changing societal attitudes, raising awareness and offering trainings for architects of public buildings provides the public with opportunities to learn more about those with disabilities in their community.

More than 200 doctors and nurses from trauma, surgery and anesthesiology departments received training. Additionally, staff from the department of social protection from mine-affected districts received training on providing support to patients with traumatic amputation of limbs (including landmine survivors). These trainings taught medical staff and social workers about psychological aid and psychosocial rehabilitation for persons with disabilities.

In 2013, the Psychological Support Center trained and certified 84 medical staff from nine landmine-affected districts on specialized psychosocial support for those with disabilities. In 2014, the project continued to train more doctors and nurses from mine-affected districts: Five four-day training sessions were organized in central locations of Darvoz, Khujand, Kulyab and Rasht regional hospitals, as well as the Dushanbe central hospital in August and September 2014.

A team from the Psychology Support Center conducted Capacity, Attitude and Behavior surveys twice daily to understand participants’ satisfaction levels. Results from the first training conducted in 2013 indicate that the majority of health workers, especially nurses in trauma care, need training on the use of psychological techniques to work with newly injured people. Therefore, the target group in 2014 consisted of mostly nurses (83 out of 132 participants; 64 females/68 males) from mine-affected regions. Participants reported that they enjoyed the various hands-on activities organized by the psychologists that broke up the intense course work. Alternating group work with theoretical discussion also proved useful. Participants agreed that psychological and psychosocial support is one of the key elements of victim assistance and comprehensive rehabilitation. Therefore, it was determined that health and social workers need greater training in psychology, including theoretical and practical aspects of the field, to better assist landmine survivors and others with disabilities. Other feedback received from participants included the need to train people working in other fields, such as teachers and police. Participants also spoke of the need to create psychological units in hospitals for medical staff, patients and their relatives, as well as the need to create a countrywide telephone hotline.

Following training, participants implemented the skills learned, applied them in their jobs and reported back. The Psychology Support Center staff and the participants prepared the results in a short report, including a description of the psychological trauma causes, psychological state and the support technician. Each training participant consulted two to three patients within one month after completion of training. More difficult cases were discussed with psychologists via phone consultations.

Continuation of Projects

Within the first month of completing the psychosocial training for health workers, 302 persons who underwent amputations, persons with disabilities and patients who were in need of psychological support underwent rehabilitation with the techniques taught in the trainings. Hospital staff reported significant improvements in the mental health and psychological well-being of these patients. Furthermore, the remodeled buildings not only serve those with disabilities, but also women with children in strollers and the elderly. With implementation of these projects, the hope is that public acceptance and understanding of disability will continue to grow, a greater number of patients will receive the assistance they desperately need and Tajikistan will sign the U.N. CRPD by the end of 2015. c

 

Biography

Reykhan MuminovaReykhan Muminova, Ph.D., is a psychiatrist who graduated from Tajik State Medical University in 1988. She worked as a psychiatrist for Tajikistan’s National Research Institute of Rehabilitation of Persons with Disabilities, where she started her research devoted to landmine survivors and their quality of life. She authored more than 30 scientific articles in medical journals and research papers published in Tajikistan and abroad. She has worked for TMAP since May 2006, and significantly contributed to its surveys and victim-assistance activities.

 


Contact Information

Reykhan Muminova
Victim Assistance Adviser
UNDP Support to Tajikistan Mine Action Programme
121 Ayni St.
Dushanbe 734025 / Tajikistan
Tel: +992 372 227 09 47
Fax: +992 372 221 66 87
Email: reykhan.muminova@undp.org
Website: http://mineaction.tj

 

Endnotes

  1. Muhabbatova, Soima. Phone interview with author. 30 March 2015.
  2. TMAC. “Initiative of Tajikistan on Releasing Land from Mines and Advocacy against Landmines.” Accessed 3 August 2015. http://bit.ly/1P0hrsD.
  3. United Nations Office of the High Commissioner for Human Rights. “Convention on the Rights of Persons with Disabilities.” Accessed 6 July 2015. http://bit.ly/1ebQdup.
  4. “Article 9 – Accessibility.” Convention on the Rights of Persons with Disabilities. United Nations Enable. Accessed 16 November 2015. http://bit.ly/1meIaRM.
  5. The State standards and regulations of the Republic of Tajikistan (RT) 35-01-2012 “Accessibility of buildings and constructions for people with limited mobility.”