Public perceptions, explanatory models and service utilisation regarding mental illness and mental health care in Kenya

'They tried to evil me': An explanatory model for Black Africans' mental health challenges

This paper explores the explanatory models of mental challenges among Black Africans in England. It argues that understanding these models is critical for providing culturally appropriate care to this population. The study employed qualitative methodology, and interpretative phenomenological analysis (IPA). Twelve mental health service users who are living in England and self-identified as first or second-generation Black Africans were purposively selected. The data were gathered using face-to-face semistructured interviews. Data were manually analysed in accordance with IPA concepts of searching for common, unique and idiosyncratic themes across transcripts. The findings revealed three themes Black Africans associated to their explanatory model of mental health challenges: complexities of migration, African-centred worldview and negative life experiences. To help alleviate the Eurocentric nature of mental health practice in England, it is hoped that this explanatory model will become an integral part of mental health practice in England and around the world.

Explanatory models, illness, and treatment experiences of patients with psychosis using the services of traditional and faith healers in three African countries: Similarities and discontinuities

As part of formative studies to design a program of collaborative care for persons with psychosis, we explored personal experience and lay attributions of illness as well as treatment among persons who had recently received care at traditional and faith healers' (TFHs) facilities in three cultural groups in Sub-Saharan Africa. A purposive sample of 85 individuals in Ibadan (Nigeria), Kumasi (Ghana), and Nairobi (Kenya) were interviewed. Data was inductively explored for themes and analysis was informed by the Framework Method. Across the three sites, illness experiences featured suffering and disability in different life domains. Predominant causal attribution was supernatural, even when biological causation was also acknowledged. Prayer and rituals, steeped in traditional spiritual beliefs, were prominent both in traditional faith healing settings as well as those of Christianity and Islam. Concurrent or consecutive use of TFHs and conventional medical services was common. TFHs provided services that appear to meet the therapeutic goals of their patients even when harmful treatment practices were employed. Cultural and linguistic differences did not obscure the commonality of a core set of beliefs and practices across these three groups. This similarity of core worldviews across diverse cultural settings means that a collaborative approach designed in one cultural group would, with adaptations to reflect differences in context, be applicable in another cultural group. Studies of patients' experience of illness and care are useful in designing and implementing collaborations between biomedical and TFH services as a way of scaling up services and improving the outcome of psychosis.

"There is anointing everywhere": An interpretative phenomenological analysis of the role of religion in the recovery of Black African service users in England

WHAT IS KNOWN ON THE SUBJECT?: Religion plays important role in recovery from mental illness. Religion can have both positive and negative effects on recovery. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: It is conceivable for Black African service users (BASUs) to engage with the mainstream mental health services at the onset of their symptoms. BASUs see mental illness and recovery through the lens of religion. They mostly use Pentecostalism and traditional African healing systems to aid their recovery. The mainstream mental health system and the traditional African healing system exist in harmony for BASUs who are open to simultaneously access both services. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is a need to recognize that most Black Africans have unique ways of practising their Christianity. Thus, broad changes are needed in the services to support religious coping tailored to the individual persons in their recovery journey. There is a need for service providers and healthcare professionals to integrate Pentecostalism and traditional African healing systems into the recovery processes. It should equally be recognized that such changes could trigger confusion, dilemmas and paradoxes. Service providers and healthcare professionals must build partnership and collaborative working with cultural practitioners and the clergy from the Black African communities to facilitate recovery and address any misunderstandings. ABSTRACT: Introduction Religion is an important impetus for recovery. However, there has been little work examining the role of religion in recovery for Black African service users (BASUs) in England. Aim The aim of this study was to explore how religion influences recovery from mental illness for BASUs in England. Method Twelve Black African service users were purposively selected and interviewed using face-to-face semi-structured interviews. Data were analysed using interpretative phenomenological analysis (IPA). Results The study generates fascinating insights that BASUs views about mental illness and recovery are influenced by Pentecostalism and traditional African healing systems. Discussion The participants' perceptions of their mental illness experiences and recovery which are characterized by the pragmatism of Pentecostalism and cultural beliefs are consistent with what is reported in the literature. Implications for practice The findings of the study show that broad changes are needed to accommodate the religious coping of BASUs in their recovery journey.

An ethnopsychology of idioms of distress in urban Kenya

Idioms of distress have become a central construct of anthropologists who aspire to understand the languages that individuals of certain sociocultural groups use to express suffering, pain, or illness. Yet, such idioms are never removed from global flows of ideas within biomedicine that influence how cultural idioms are conceived, understood, and expressed. This article proposes a preliminary model of ethnopsychology described by urban Kenyans, which incorporates local (traditional) and global (biomedical) idioms of distress that are both distinct and overlapping in symptomology and experience. This ethnopsychology was generated from analyzing 100 life history narrative interviews among patients seeking care in a public hospital in Nairobi, Kenya, which explicitly probed into how people experienced and expressed the Kiswahili idioms huzuni (roughly translated as sadness or grief) and dhiki (stress or agony) and English terms stress and depression. Kufikiria sana, or "thinking too much", emerged organically as a powerful cultural idiom and as a symptom or sign of other forms of psychological distress. We propose a preliminary model of ethnopsychology that: 1) highlights social and political factors in driving people to express and experience idioms of distress; 2) reveals how the English terms "stress" and "depression" have been adopted into Kiswahili discourse and potentially have taken on new meaning; 3) suggests that the role of rumination in how people express distress, with increasing severity, is closely linked to the concept of "thinking too much", and; 4) emphasizes how somatization is central to how people think about psychological suffering.

Effects of Poly-Victimization Before Age 18 on Health Outcomes in Young Kenyan Adults: Violence Against Children Survey

Children's exposure to poly-victimization, which is the experience of multiple types of victimization, has been found to be associated with negative health outcomes and risk behaviors. We examined the collective effects of childhood sexual, physical, and emotional violence on selected self-reported health outcomes among young Kenyan females and males using the Violence Against Children Survey (VACS). Overall, 76.2% of females and 79.8% of males were victims of sexual, physical, or emotional violence prior to age 18, and one-third (32.9% and 34.5%, respectively) experienced two or more types of violence. Poly-victimization was significantly associated with current feelings of anxiety, depression, and suicidal thoughts in females and males, as well as self-reported fair or poor health in males (p < .05) as compared to those who experienced no violence. The study data demonstrate an urgent need to reduce all types of violence against children, as well develop appropriate strategies for its prevention.

Mental illness and recovery: an interpretative phenomenological analysis of the experiences of Black African service users in England

Background

Research conceptualising recovery is predominantly Eurocentric. This paper develops the conceptualisation of recovery by Black African service users.

Aims

Our aim was to explore Black African service users' experiences of recovery from mental illness and to understand how they conceptualise recovery.

Methods

Using a qualitative research approach and interpretative phenomenological analysis (IPA), semi-structured interviews were conducted with 12 Black African service users recovering from mental illness in England.

Results

Participants conceptualised recovery as a pragmatic and subjective concept distributed across a continuum of clinical, functional and spiritual dimensions, resilience, identity and their social and cultural backgrounds.

Conclusions

It seems critical for all stakeholders to ensure that these components are embedded in recovery-oriented services for Black African service users.

Spiritual Explanatory Models of Mental Illness in West Nile, Uganda

Integrating indigenous cultural knowledge into conceptualizing mental illness offers highly valuable insights to better contextualize mental health. The meaning given to symptoms determines what is abnormal and requiring treatment. In Uganda, the formal health care system is neither the only nor the most widespread treatment provider. Help is often sought from traditional and religious healers, too. Despite numerous calls for cooperation between the healing systems, this has translated into reality only to a very limited degree. The purpose of this study was to gain insight into local explanatory models of mental illness, to gain an understanding of the different patients’ needs, and to develop a more comprehensive system of care. We used an ethnographic investigation approach, which allowed for a more holistic view of the research field. This was geographically delimited to the West Nile subregion in Northern Uganda. We conducted a total of 56 semistructured interviews with traditional healers ( n = 5), Christian religious healers ( n = 3), psychiatric patients ( n = 16), their attendants ( n = 16), and community members ( n = 16). In addition, we used the method of participant observation. The data collected were analyzed using Qualitative Content Analysis and Grounded Theory methodology. For the purpose of this article, we exclusively extracted the spiritual explanatory models. These were spirit possession and curse. Both were traditional concepts with a religious reinterpretation involving the action of spirits.

[Stigmatisation of mental illness by medical students in Conakry, Guinea]

INTRODUCTION

Stigmatisation of mental illness constitutes a major problem in the development of mental healthcare programs, especially when it originates from health professionals themselves. The aim of this research is to investigate possible attitudes of stigmatisation among first and final year medical students registered at the University of Conakry faculty of medicine in Guinea-Conakry (West Africa).

METHODS

Focus group discussions identified students' attitudes and perceptions in relation to mental illness, their explanatory models, their opinions concerning traditional and modern therapeutic practices with regard to mental illness, and their interest to possibly incorporate psychiatry in their future medical practice.

RESULTS

Many students explicitly regret the stigmatisation of mental health patients, but nevertheless share the general population's prevailing attitudes of discrimination. The dominant stereotype of mental illness is that of madness, although final year medical students describe a more diverse spectrum of mental health problems. There is strong adherence to secular occult explanations of mental illness and advocacy for traditional medicine in addressing these illnesses, including among final year medical students.

DISCUSSION

No student would opt for psychiatry as a specialisation, although some expressed interest in integrating psychiatry into their future medical practice. However, this research indicates that stigmatising attitudes are not cut in stone. Under the impetus of specific teaching programmes, attitudes can evolve to create room for tolerance and compassion.

Mental Health Conceptualization and Resilience Factors in the Kalasha Youth: An Indigenous Ethnic and Religious Minority Community in Pakistan

The Kalasha are a religious, ethnic, and linguistic minority community in Pakistan. They are indigenous people living in remote valleys of the Hindu Kush Mountains in northern Pakistan, neighboring Afghanistan. The Kalasha are pastoral, as well as agricultural people to some extent, although they are increasingly facing pressures from globalization and social change, which may be influencing youth and community development. Their traditional world view dichotomizes and emphasizes on the division of the pure (Onjeshta) and the impure (Pragata). There remains a scarcity of literature on mental health and resilience of indigenous communities in South Asia and Pakistan generally, and the polytheistic Kalasha community specifically. Thus, the current study was conducted with the aim to explore the cultural protective factors (resilience) of the Kalasha youth (adolescents and emerging adults) and to explore their perceived etiological understandings and preferred interventions for mental health support systems. The theoretical framework of Bronfenbrenner's (1, 2) ecological systems model was used. Interpretative Phenomenological Analysis (IPA) was conducted, considering the advantage of its idiographic approach and the “double hermeneutic” analytic process. This methodology was consistent with the aim to understand and make sense of mental health and resilience from the Kalasha indigenous perspective. A total of 12 in-depth interviews were conducted with adolescents and emerging adults (5 males, 7 females), along with ethnographic observations. The analysis revealed 3 superordinate themes of mental health perceptions and interventions, each with more specific emergent themes: (1) Psychological Resilience/Cultural Protective Factors Buffering Against Mental Health Problems (Intra-Communal Bonding & Sharing; Kalasha Festivals & Traditions; Purity Concept; Behavioral Practice of Happiness and Cognitive Patterns); (2) Perceived Causes of Mental Health Issues (Biological & Psychosocial; Supernatural & Spiritual; Environmental); and (3) Preferred Interventions [Shamanic Treatment; Ta'awiz (Amulets); Communal Sharing & Problem Solving; Medical Treatment; Herbal Methods]. The overall findings point to the need for developing culturally-sensitive and indigenous measures and therapeutic interventions. The findings highlighted the Kalasha cultural practices which may promote resilience. The findings also call for indigenous sources of knowledge to be considered when collaboratively designing public health programs.

Attributions and private theories of mental illness among young adults seeking psychiatric treatment in Nairobi: an interpretive phenomenological analysis

BACKGROUND

Mental illness affects every segment of population including young adults. The beliefs held by young patients regarding the causes of mental illness impact their treatment-seeking behaviour. It is pertinent to know the commonly held attributions around mental illness so as to effectively provide psychological care, especially in a resource constrained context such as Kenya. This helps in targeting services around issues such as stigma and extending youth-friendly services.

METHODS

Guided by the private theories interview (PTI-P) and attributional framework, individual semi-structured interviews were carried out with ten young adults of ages 18-25 years about their mental health condition for which they were undergoing treatment. Each interview took 30-45 min. We mapped four attributions (locus of control, stability, controllability and stigma) on PTI-P questions. Data was transcribed verbatim to produce transcripts coded using interpretive phenomenological analysis. These codes were then broken down into categories that could be used to understand various attributions.

RESULTS

We found PTI-P to be a useful tool and it elicited three key themes: (a) psychosocial triggers of distress (with themes of negative thoughts, emotions around mental health stigma and negative childhood experiences, parents' separation or divorce, death of a loved one etc.), (b) biological conditions and psychopathologies limiting intervention, and (c) preferences and views on treatment. Mapping these themes on our attributional framework, PTI-P themes presented as causal attributions explaining stigma, locus of control dimensions and stability. External factors were mainly ascribed to be the cause of unstable and uncontrollable attributions including persistent negative emotions and thoughts further exacerbating psychological distress. Nine out of the ten participants expressed the need for more intense and supportive therapy.

CONCLUSION

Our study has provided some experiential evidence in understanding how stigma, internal vs external locus of control, stability vs instability attributions play a role in shaping attitudes young people have towards their mental health. Our study points to psychosocial challenges such as stigma, poverty and lack of social support that continue to undermine mental well-being of Kenyan youth. These factors need to be considered when addressing mental health needs of young people in Kenya.

Depressive Symptoms, Alcohol and Drug Use, and Physical and Sexual Abuse Among Men Who Have Sex with Men in Kisumu, Kenya: The Anza Mapema Study

Men who have sex with men (MSM) are disproportionately burdened by depressive symptoms and psychosocial conditions including alcohol and substance abuse as well as physical and sexual abuse. We examined sociodemographic and psychosocial factors associated with depressive symptoms at baseline among a cohort of MSM in Kisumu, Kenya. Depressive symptoms were assessed via the Personal Health Questionnaire 9 instrument and examined dichotomously. We performed multivariable modified Poisson regression with robust standard errors for the binary outcome. Among 711 participants: 11.4% reported severe depressive symptoms; 50.1% reported harmful alcohol abuse; 23.8% reported moderate substance abuse; 80.9% reported any childhood physical or sexual abuse; and 39.1% experienced recent trauma due to same-sex behaviors. In the final multivariable model, severe depressive symptoms were more common for men who were ≥ 30 years old, had completed ≤ 8 years of education, had experienced childhood physical or sexual abuse, and had recently experienced trauma due to same-sex behaviors. Our results demonstrate that comprehensive services capable of identifying and addressing depressive symptoms, alcohol and substance abuse, and physical and sexual abuse must be expanded within this sample of MSM.

Adolescent Pregnancy and Challenges in Kenyan Context: Perspectives from Multiple Community Stakeholders

OBJECTIVE

The key objective of this paper is to provide a phenomenological account of the mental health challenges and experiences of adolescent new mothers. We explore the role of social support and the absence of empathy plays in depression among pregnant adolescents. The project also collected data on the adolescents' caregiving environment which includes the adolescents' mothers, their partners, the community, and health care workers, as well as feedback from staff nurses at the maternal and child health centers. The caregivers provide additional insight into some of the barriers to access of mental health services and pregnancy care, and the etiology of adolescents' distress.

METHODS

The interviews were conducted in two health facilities of Kariobangi and Kangemi's maternal and child health (MCH) centers that cover a huge low-income and low-middle-income formal and informal settlements of Nairobi. A grounded theory approach provided a unique methodology to facilitate discussion around adolescent pregnancy and depression among the adolescents and their caregivers. Our interviews were cut across four samples with 36 participants in total. The sample 1 comprised of eight pregnant adolescents who screened positive for depression in Kariobangi, sample 2 were six caregivers from both sites, and sample 3 were 22 new adolescent mothers from both sites. After individual interviews, we carried out one focused group discussion (FDG) in order to understand the cross-cutting issues and to gather some consensus on key issues, and the sample 4 were 20 community health workers, health workers, and nurses from both sites. We had one FGD with all health facility-based workers to understand the cross-cutting issues. The interviews in sample 1 and 2 were individual interviews with pregnant and parenting adolescents, and their caregivers. All our adolescent participants interviewed in sample 1 were screened for depression. Individual interviews followed the FGD.

FINDINGS

Pregnant and parenting adolescents faced several adversities such as social stigma, lack of emotional support, poor healthcare access, and stresses around new life adjustments. We highlighted a few useful coping mechanisms and strategies that these adolescents were thinking to reduce their stress. Primary social support for pregnant and parenting teens comes from the adolescent's mother. The external family and male partners provide negligible support in the rearing of the child. While the mother's reactions to the daughters' pregnancy were empathetic sometimes, absence of food and resources made the mother distant and constraint in lending support. For those adolescents who were living with partners, in their new mother role, they had to negotiate additional challenges such as solutions to everyday childcare responsibilities and other family duties. The health care workers and community health workers confirmed that adolescent mothers have multiple needs, but there is a lack of holistic approach of service, and that their own training and capacities were very limited.

CONCLUSIONS

Our paper highlights several individual stakeholder-related and system-level barriers in the MCH primary care setting that affect delivery of psychosocial support for pregnant adolescent. We have identified these knowledge, practice, and institutional gaps that need addressing through careful community and health service staff engagement using implementation strategies that are effective in low-resource settings. Pregnant adolescents are highly vulnerable group and mental health services needs to be understood better.

Perceptions of the causes of schizophrenia and associated factors by the Holy Trinity Theological College students in Ethiopia

INTRODUCTION

There is a cultural variability around the perception of what causes the syndrome of schizophrenia. As far as the cause of schizophrenia by the general public concerned, people living in western countries focus mainly on biological and social risk factors such as genetic vulnerability, disease of the brain, infection or stressful social conditions or personal weakness, but the predominant views held by people living in non-western countries focus mainly on supernatural and religious factors. Awareness and beliefs about the causes of mental illnesses influence the preferred treatments. The aim of this study was to determine the perceptions regarding the etiology of schizophrenia and the associated factors by theology students.

METHODS

An institution-based cross-sectional study was conducted among Holy Trinity Theological College students from May to June 2016. Self-administered Short Explanatory Model Interview was used to assess the perception of what causes the syndrome of schizophrenia. Data entry was performed by Epi-info version 3.5.3 and the Statistical Program for Social Science (SPSS version 20) was used for data clearance, and analyses.

RESULTS

A total of 409 students were involved in the survey. The mean age of the participants was 33.3 years (standard deviation ± 8.3) and almost all 94.4% of them were males. The majority (81.7%) of the participant recognized schizophrenia as a mental illness. Only 16.9% of the participants attributed supernatural phenomenon as a cause of schizophrenia and most of them 76.5% (313) thought of psychosocial problems as the cause of schizophrenia. About 40.1% of the participant endorsed biological factors as a cause of schizophrenia. About two-thirds (68.2%) of the participant thought schizophrenia as severe but not fatal illness and about 22.2% of them thought both severe and fatal illness. As far as the course concerned majority (88.5%) of the participants thought schizophrenia as a chronic illness and about 11.5% thought acute illness. Regarding the treatment, almost all (99.8%) of reported schizophrenia is treatable. Moreover, concerning the consequences of the illness about 18.8% reported the death as a consequence and about 66.7, 34.7 and 7.8% reported madness, family disintegration and losing a job, respectively. Urban residency and holding other degree were significantly associated with biological factors as a cause of schizophrenia (p < 0.05). Whereas getting information from mass media and health professional, marital status (married) and urban residence were significantly associated with psychosocial factors as the cause of schizophrenia. Furthermore, rural residency was significantly associated with the supernatural phenomenon as the cause of schizophrenia.

CONCLUSION

In the current study, the majority of the participant recognized schizophrenia as a mental illness and a treatable syndrome. A vast majority of the participant thought of psychosocial problems as the cause of schizophrenia about two-thirds of the participant thought schizophrenia as a severe but not fatal illness. As far as the course concerned majority (88.5%) of the participants thought schizophrenia as a chronic illness. Concerning the consequences of the illness, about 18.8% reported the death as a consequence and about 66.7, 34.7, and 7.8% reported madness, family disintegration and losing a job, respectively. Residency, marital status, and source of information were significantly associated with perceived causes of schizophrenia. Linking mental health service with spiritual care to address community mental health care needs and for early detection as well as referral linkage of mentally ill patients is warranted.

Mental health treatment outcome expectancies in Burundi

Best practices in global mental health stress the importance of understanding local values and beliefs. Research demonstrates that expectancies about the effectiveness of a given treatment significantly predicts outcome, beyond the treatment effect itself. To help inform the development of mental health interventions in Burundi, we studied expectancies about the effectiveness of four treatments: spiritual healing, traditional healing, medication, and selected evidence-based psychosocial treatments widely used in the US. Treatment expectancies were assessed for each of three key syndromes identified by previous research: akabonge (a set of depression-like symptoms), guhahamuka (a set of trauma-related symptoms), and ibisigo (a set of psychosis-like symptoms) . In individual interviews or written surveys in French or Kirundi with patients ( N = 198) awaiting treatment at the clinic, we described each disorder and the treatments in everyday language, asking standard efficacy expectations questions about each ("Would it work?" "Why or why not?"). Findings indicated uniformly high expectancies about the efficacy of spiritual treatment, relatively high expectancies for western evidence-based treatments (especially cognitive behavior therapy [CBT] for depression-like symptoms), lower expectancies for medicine, and especially low expectancies for traditional healing (except for traditional healing for psychosis-like symptoms). There were significant effects of gender but not of education level. Qualitative analyses of explanations provide insight into the basis of people's beliefs, their explanations about why a given treatment would or would not work varied by type of disorder, and reflected beliefs about underlying causes. Implications for program development and future research are discussed.

Research on help-seeking for mental illness in Africa: Dominant approaches and possible alternatives

There is growing concern within the global mental health arena that interventions currently being executed to scale up mental health services in Africa will be ineffective unless simultaneous steps are taken to address people's help-seeking behaviour. Drawing upon two conceptual tools arising from science and technology studies (STS), those of a "classification system" and "the black box," this paper looks critically at discursive constructions of help-seeking in Africa within mental health research over the last decade. Research in this area can be divided into two dominant traditions: the knowledge-belief-practice survey and indigenous-knowledge-system approaches. Although the content and value-codes between these approaches differ, structurally they are very similar. Both are mediated by the same kind of system of classification, which demarcates the world into homogenous entities and binary oppositions. This system of ordering is one of the most stubborn and powerful forms of classification buried in the "black box" of the modernist/colonial knowledge archive and is fraught with many questionable Eurocentric epistemological assumptions. I consider whether there might be other ways of understanding help-seeking for mental illness in Africa and discuss two studies that illustrate such alternative approaches. In conclusion, I discuss some of the challenges this alternative kind of research faces in gaining more influence within contemporary global mental health discourse and practice.

Stigmatizing attitudes toward mental illness among primary school children in Kenya

BACKGROUND

Literature describing stigmatizing attitudes towards people with mental illness by children in the developing world is lacking. Children's mental health issues in the Kenyan context are especially pertinent due to the increased likelihood of exposure to risk factors and the high prevalence of mental disorders. The objective of the current study was to examine socio-demographic factors associated with the endorsement of stigmatizing attitudes towards people with mental illness among Kenyan school children.

METHODS

We analyzed cross-sectional survey data from 4585 primary school-aged children in standards one through seven in the Eastern Province of Kenya. We examined relationships between the endorsement of stigmatizing attitudes and age, gender, district, religion, being in the standard appropriate for one's age, and parental employment status.

RESULTS

Stigma scores decreased with increasing age (β = -0.83; 95 % CI = -0.99 to -0.67). Boys had higher stigma scores compared to girls (β = 1.55; 95 % CI = 0.86-2.24). Students from the rural district had higher average stigma scores as compared to those from the peri-urban district (β = 1.14; 95 % CI = 0.44-1.84). Students who were not in the standard appropriate for their age had lower stigma scores than those who were in the standard typical for their age (β = -1.60; 95 % CI = -2.43 to -0.77).

CONCLUSIONS

Stigmatizing attitudes toward the mentally ill exist among primary school children in Kenya; thus, anti-stigma interventions are needed, and our findings highlight particular subgroups that could be targeted.

Common mental disorder in Nyanza province, Kenya in 2013 and its associated risk factors--an assessment of change since 2004, using a repeat household survey in a demographic surveillance site

BACKGROUND

Repeat household surveys are useful to assess change in prevalence over time, but there have been no repeat surveys of common mental disorder (CMD) in Kenya, or indeed sub-Saharan Africa. Therefore a repeat household survey of CMD and its associated risk factors was conducted in Maseno area, Kisumu county in Kenya, using a demographic surveillance site as the sample frame, in order to test the hypotheses that (a) the prevalence of CMD would increase between 2004 and 2013 due to the intervening political, social and economic pressures; (b) as in 2004, there would be no gender difference in prevalence of CMD.

METHODS

One thousand one hundred ninety households were selected, and 1158 adult participants consented to be interviewed with a structured epidemiological assessment while 32 refused to participate in the study interviews, giving a response rate of 97.3%.

RESULTS

The study found that the overall prevalence of CMD in 2013 was 10.3%. However, there were significantly higher rates of having any CMD in 2013 if one was female (OR 6.2, p < 0.001), divorced/widowed (OR 2.5, p < 0.003), aged over 60 (OR 2.3, p = 0.052), either self-employed (OR 3.3 p < 0.001) or employed (OR 3.3, p < 0.001), or belonged to the lowest asset quintile (OR 2.5, p = .0.004) after adjusting for other variables significant at the bivariate level. The overall prevalence in 2013 was consistent with that found in 2004, despite intervening political and community turbulence. However, this apparent consistency masks the development of a striking difference in prevalence between the genders. Over the decade 2004-13, the prevalence for men dropped from 10.9 to 3.8% (P = 0.001) and the prevalence for women increased from 10.8 to 17.5% (p = 0.001).

CONCLUSION

Common mental disorders continue to pose a significant public health burden in Kenya, and gender related vulnerability merits further research and is relevant for health worker training.

"Thinking too much": A systematic review of a common idiom of distress

Idioms of distress communicate suffering via reference to shared ethnopsychologies, and better understanding of idioms of distress can contribute to effective clinical and public health communication. This systematic review is a qualitative synthesis of "thinking too much" idioms globally, to determine their applicability and variability across cultures. We searched eight databases and retained publications if they included empirical quantitative, qualitative, or mixed-methods research regarding a "thinking too much" idiom and were in English. In total, 138 publications from 1979 to 2014 met inclusion criteria. We examined the descriptive epidemiology, phenomenology, etiology, and course of "thinking too much" idioms and compared them to psychiatric constructs. "Thinking too much" idioms typically reference ruminative, intrusive, and anxious thoughts and result in a range of perceived complications, physical and mental illnesses, or even death. These idioms appear to have variable overlap with common psychiatric constructs, including depression, anxiety, and PTSD. However, "thinking too much" idioms reflect aspects of experience, distress, and social positioning not captured by psychiatric diagnoses and often show wide within-cultural variation, in addition to between-cultural differences. Taken together, these findings suggest that "thinking too much" should not be interpreted as a gloss for psychiatric disorder nor assumed to be a unitary symptom or syndrome within a culture. We suggest five key ways in which engagement with "thinking too much" idioms can improve global mental health research and interventions: it (1) incorporates a key idiom of distress into measurement and screening to improve validity of efforts at identifying those in need of services and tracking treatment outcomes; (2) facilitates exploration of ethnopsychology in order to bolster cultural appropriateness of interventions; (3) strengthens public health communication to encourage engagement in treatment; (4) reduces stigma by enhancing understanding, promoting treatment-seeking, and avoiding unintentionally contributing to stigmatization; and (5) identifies a key locally salient treatment target.

Probable Post Traumatic Stress Disorder in Kenya and Its Associated Risk Factors: A Cross-Sectional Household Survey

This study aimed to assess the prevalence of probable post-traumatic stress disorder (PTSD), and its associated risk factors in a general household population in Kenya. Data were drawn from a cross-sectional household survey of mental disorders and their associated risk factors. The participants received a structured epidemiological assessment of common mental disorders, and symptoms of PTSD, accompanied by additional sections on socio-demographic data, life events, social networks, social supports, disability/activities of daily living, quality of life, use of health services, and service use. The study found that 48% had experienced a severe trauma, and an overall prevalence rate of 10.6% of probable PTSD, defined as a score of six or more on the trauma screening questionnaire (TSQ). The conditional probability of PTSD was 0.26. Risk factors include being female, single, self-employed, having experienced recent life events, having a common mental disorder (CMD)and living in an institution before age 16. The study indicates that probable PTSD is prevalent in this rural area of Kenya. The findings are relevant for the training of front line health workers, their support and supervision, for health management information systems, and for mental health promotion in state boarding schools.

Tedium vitae, death wishes, suicidal ideation and attempts in Kenya-prevalence and risk factors

BACKGROUND

There has been no previous household population study of suicidal ideation and attempts in Kenya. Therefore this study aimed to establish the prevalence of suicidal ideation and attempts in a rural population in Kenya, and to assess risk factors.

METHODS

An epidemiological survey of a household population, using standardised structured interviews. We examined the prevalence of suicidal ideation and suicide attempts and the predictors of suicidal thoughts and attempts, using STATA to calculate unadjusted and adjusted odds ratios.

RESULTS

A quarter of the sample (24.1 %) had thought that life was not worth living (tedium vitae) at some point in their lives, while a fifth had experienced death wishes at some stage. About 7.9 % reported suicidal thoughts and 1.9 % had made actual suicide attempts at some point in their lives. It can be seen that the prevalence of suicidal thoughts was 0.7 %, 4.2 %, 3.7 % and 7.9 % for last week, last year, at some other time, and lifetime respectively, while the prevalence of suicidal attempts was 0.5 %, 1.2 %, 0.7 and 1.9 % respectively. In the adjusted analysis of factors associated with suicidal thoughts, being female (OR 1.8, p = 0.017), having CMD (OR 2.7, p = 0.001), having a number of recent life events (OR 2.3, p = 0.001 for 2-3 life events and OR 2.6, p = 0.004 for 4 or more life events), and having a large social group size (OR 7.7, p = 0.006 for social group size of 4-8 and OR 9.1, p = 0.003 for social group size of 9 or more) were all associated with increased rates of life time suicidal thoughts, but psychotic symptoms were no longer significant after adjustment for the other variables. In the adjusted analysis of suicide attempts, having any psychotic symptoms (OR 5.1, p = 0.001) was the only factor associated with suicide attempts after adjustment for other factors significant at the bivariate level.

CONCLUSION

Suicidal ideation and attempts pose a significant public health burden in this poor rural area of Kenya. The findings are relevant for mental health promotion and prevention programmes, public education and professional training programmes in relevant sectors, especially in front line health workers and social workers.

Attention deficit hyperactivity disorder symptom self-report in adults in Kenya and its associated risk factors, an analysis from a household survey in a demographic surveillance site

BACKGROUND

There have been no household surveys of adult attention deficit and hyperactivity disorder (ADHD) in Kenya, and only one in sub-Saharan Africa.

METHODS

Data on ADHD was used from a household survey of mental disorders and their associated risk factors conducted in Maseno area (population 70 805), near Lake Victoria in Kenya, using a demographic surveillance site as the sample frame, as part of a wider survey of mental health, malaria and immunity A total of 1190 households were selected, and 1158 adult participants consented to the study while 32 refused to participate in the study interviews, giving a response rate of 97.3%. ADHD symptoms were assessed with the WHO Adult ADHD Self-Report Scale (ASRS) Screener.

RESULTS

This survey found that the overall prevalence of ADHD using the ASRS was 13.1%. This suggests a high level of ADHD in the Kenyan population which needs to be further investigated for its impact on adult mental health. In the adjusted analysis, increased odds ratios (ORs) were found in those with higher assets (OR 1.7, p = 0.023), those with life events (OR 2.4, p = 0.001 for those with 2-3 life events and OR 2.6, p < 0.001 for those with 4 or more life events), and those with common mental disorders (OR 2.3, p = 0.001).

CONCLUSION

The study demonstrates the magnitude of ADHD symptoms as a public health issue, relevant for health worker training, and the importance of further research into its prevalence in adults and associated risk factors.

Mental health service utilization in sub-Saharan Africa: is public mental health literacy the problem? Setting the perspectives right

The severely constrained resources for mental health service in less-developed regions like sub-Saharan Africa underscore the need for good public mental health literacy as a potential additional mental health resource. Several studies examining the level of public knowledge about the nature and dynamics of mental illness in sub-Saharan Africa in the last decade had concluded that such knowledge was poor and had called for further public enlightenment. What was thought to be mental health 'ignorance' has also been blamed for poor mainstream service utilization. These views however assume that non-alignment of the views of community dwellers in sub-Saharan Africa with the biomedical understanding of mental illness connotes 'ignorance', and that correcting such 'ignorance' will translate to improvements in service utilization. Within the framework of contemporary thinking in mental health literacy, this paper argues that such assumptions are not culturally nuanced and may have overrated the usefulness of de-contextualized public engagement in enhancing mental health service utilization in the region. The paper concludes with a discourse on how to contextualize public mental health enlightenment in the region and the wider policy initiatives that can improve mental health service utilization.

"…still waiting for chloroquine": the challenge of communicating changes in first-line treatment policy for uncomplicated malaria in a remote Kenyan district

Background

Widespread parasite resistance to first-line treatment for uncomplicated malaria leads to introduction of new drug interventions. Introducing such interventions is complex and sensitive because of stakeholder interests and public resistance. To enhance take up of such interventions, health policy communication strategies need to deliver accurate and accessible information to empower communities with necessary information and address problems of cultural acceptance of new interventions.

Objectives

To explore community understanding of policy changes in first-line treatment for uncomplicated malaria in Kenya; to evaluate the potential role of policy communication in influencing responses to changes in first-line treatment policy.

Methods

Data collection involved qualitative strategies in a remote district in the Kenyan Coast: in-depth interviews (n = 29), focus group discussions (n = 14), informal conversations (n = 11) and patient narratives (n = 8). Constant comparative method was used in the analysis. Being malaria-prone and remotely located, the district offered an ideal area to investigate whether or not and how policy communication about a matter as critical as change of treatment policy reaches vulnerable populations.

Results

Three years after initial implementation (2009), there was limited knowledge or understanding regarding change of first-line treatment from sulphadoxine-pyrimethamine (SP) to artemether-lumefantrine (AL) for treatment of uncomplicated malaria in the study district. The print and electronic media used to create awareness about the drug change appeared to have had little impact. Although respondents were aware of the existence of AL, the drug was known neither by name nor as the official first-line treatment. Depending on individuals or groups, AL was largely viewed negatively. The weaknesses in communication strategy surrounding the change to AL included poor choice of communication tools, confusing advertisements of other drugs and conflicts between patients and providers.

Conclusion

Effective health policy communication is important for the uptake of new drug interventions and adherence to treatment regimens. Besides, prompt access to effective treatment may not be achieved if beneficiaries are not adequately informed about treatment policy changes. Future changes in treatment policy should ensure that the communication strategy is designed to pass sustained, accurate and effective messages that account for local contexts.

Integrating community mental health within primary care in southern Malawi: a pilot educational intervention to enhance the role of health surveillance assistants

BACKGROUND

In response to the significant contribution of mental health problems to the global burden of disease, the World Health Organization (WHO, 2008) renewed its call for the integration of mental health services within primary care. The operationalization of this within resource-constrained settings such as rural Malawi, however, presents a challenge, not least the cultural acceptance of approaches to responding to psychological distress.

AIM

This study reports on the development, implementation and evaluation of a mental health care training programme for 271 health surveillance assistants (HSAs) designed to overcome such challenges.

METHOD

A structured evaluation of the impact of training on HSAs' provision of mental health care was undertaken.

RESULTS

Result's demonstrated a statistically significant positive effect on HSAs' knowledge and confidence in providing care and analysis of patient records revealed considerable mental health care and health promotion activity wherein HSAs initiated a new dialogue with the community on mental health and human rights concerns.

CONCLUSION

The HSAs' focus on the psychosocial concerns of individuals' 'distress' and 'risk' prepared the way for a practical set of culturally sensitive and therapeutic interventions and offers a potential path towards increasing the capacity of primary care mental health provision that is responsive to local understandings and experiences of distress.

Short structured general mental health in service training programme in Kenya improves patient health and social outcomes but not detection of mental health problems - a pragmatic cluster randomised controlled trial

TRIAL DESIGN

A pragmatic cluster randomised controlled trial.

METHODS

PARTICIPANTS

Clusters were primary health care clinics on the Ministry of Health list. Clients were eligible if they were aged 18 and over.

INTERVENTIONS

Two members of staff from each intervention clinic received the training programme. Clients in both intervention and control clinics subsequently received normal routine care from their health workers.

OBJECTIVE

To examine the impact of a mental health inservice training on routine detection of mental disorder in the clinics and on client outcomes.

OUTCOMES

The primary outcome was the rate of accurate routine clinic detection of mental disorder and the secondary outcome was client recovery over a twelve week follow up period. Randomisation: clinics were randomised to intervention and control groups using a table of random numbers. Blinding: researchers and clients were blind to group assignment.

RESULTS

Numbers randomised: 49 and 50 clinics were assigned to intervention and control groups respectively. 12 GHQ positive clients per clinic were identified for follow up. Numbers analysed: 468 and 478 clients were followed up for three months in intervention and control groups respectively.

OUTCOME

At twelve weeks after training of the intervention group, the rate of accurate routine clinic detection of mental disorder was greater than 0 in 5% versus 0% of the intervention and control groups respectively, in both the intention to treat analysis (p = 0.50) and the per protocol analysis (p =0.50). Standardised effect sizes for client improvement were 0.34 (95% CI = (0.01,0.68)) for the General Health Questionnaire, 0.39 ((95% CI = (0.22, 0.61)) for the EQ and 0.49 (95% CI = (0.11,0.87)) for WHODAS (using ITT analysis); and 0.43 (95% CI = (0.09,0.76)) for the GHQ, 0.44 (95% CI = (0.22,0.65)) for the EQ and 0.58 (95% CI = (0.18,0.97)) for WHODAS (using per protocol analysis).

HARMS

None identified.

CONCLUSION

The training programme did not result in significantly improved recorded diagnostic rates of mental disorders in the routine clinic consultation register, but did have significant effects on patient outcomes in routine clinical practice.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number Register ISRCTN53515024.

Health system challenges to integration of mental health delivery in primary care in Kenya--perspectives of primary care health workers

BACKGROUND

Health system weaknesses in Africa are broadly well known, constraining progress on reducing the burden of both communicable and non-communicable disease (Afr Health Monitor, Special issue, 2011, 14-24), and the key challenges in leadership, governance, health workforce, medical products, vaccines and technologies, information, finance and service delivery have been well described (Int Arch Med, 2008, 1:27). This paper uses focus group methodology to explore health worker perspectives on the challenges posed to integration of mental health into primary care by generic health system weakness.

METHODS

Two ninety minute focus groups were conducted in Nyanza province, a poor agricultural region of Kenya, with 20 health workers drawn from a randomised controlled trial to evaluate the impact of a mental health training programme for primary care, 10 from the intervention group clinics where staff had received the training programme, and 10 health workers from the control group where staff had not received the training).

RESULTS

These focus group discussions suggested that there are a number of generic health system weaknesses in Kenya which impact on the ability of health workers to care for clients with mental health problems and to implement new skills acquired during a mental health continuing professional development training programmes. These weaknesses include the medicine supply, health management information system, district level supervision to primary care clinics, the lack of attention to mental health in the national health sector targets, and especially its absence in district level targets, which results in the exclusion of mental health from such district level supervision as exists, and the lack of awareness in the district management team about mental health. The lack of mental health coverage included in HIV training courses experienced by the health workers was also striking, as was the intensive focus during district supervision on HIV to the detriment of other health issues.

CONCLUSION

Generic health system weaknesses in Kenya impact on efforts for horizontal integration of mental health into routine primary care practice, and greatly frustrate health worker efforts.Improvement of medicine supplies, information systems, explicit inclusion of mental health in district level targets, management and supervision to primary care are likely to greatly improve primary care health worker effectiveness, and enable training programmes to be followed by better use in the field of newly acquired skills. A major lever for horizontal integration of mental health into the health system would be the inclusion of mental health in the national health sector reform strategy at community, primary care and district levels rather than just at the higher provincial and national levels, so that supportive supervision from the district level to primary care would become routine practice rather than very scarce activity.

TRIAL REGISTRATION

Trial registration ISRCTN 53515024.

Madness or sadness? Local concepts of mental illness in four conflict-affected African communities

BACKGROUND

Concepts of 'what constitutes mental illness', the presumed aetiology and preferred treatment options, vary considerably from one cultural context to another. Knowledge and understanding of these local conceptualisations is essential to inform public mental health programming and policy.

METHODS

Participants from four locations in Burundi, South Sudan and the Democratic Republic of the Congo, were invited to describe 'problems they knew of that related to thinking, feeling and behaviour?' Data were collected over 31 focus groups discussions (251 participants) and key informant interviews with traditional healers and health workers.

RESULTS

While remarkable similarities occurred across all settings, there were also striking differences. In all areas, participants were able to describe localized syndromes characterized by severe behavioural and cognitive disturbances with considerable resemblance to psychotic disorders. Additionally, respondents throughout all settings described local syndromes that included sadness and social withdrawal as core features. These syndromes had some similarities with nonpsychotic mental disorders, such as major depression or anxiety disorders, but also differed significantly. Aetiological concepts varied a great deal within each setting, and attributed causes varied from supernatural to psychosocial and natural. Local syndromes resembling psychotic disorders were seen as an abnormality in need of treatment, although people did not really know where to go. Local syndromes resembling nonpsychotic mental disorders were not regarded as a 'medical' disorder, and were therefore also not seen as a condition for which help should be sought within the biomedical health-care system. Rather, such conditions were expected to improve through social and emotional support from relatives, traditional healers and community members.

CONCLUSIONS

Local conceptualizations have significant implications for the planning of mental-health interventions in resource-poor settings recovering from conflict. Treatment options for people suffering from severe mental disorders should be made available to people, preferably within general health care facilities. For people suffering from local syndromes characterized by loss or sadness, the primary aim for public mental health interventions would be to empower existing social support systems already in place at local levels, and to strengthen social cohesion and self-help within communities.

Perspectives and concerns of clients at primary health care facilities involved in evaluation of a national mental health training programme for primary care in Kenya

BACKGROUND

A cluster randomised controlled trial (RCT) of a national Kenyan mental health primary care training programme demonstrated a significant impact on the health, disability and quality of life of clients, despite a severe shortage of medicines in the clinics (Jenkins et al. Submitted 2012). As focus group methodology has been found to be a useful method of obtaining a detailed understanding of client and health worker perspectives within health systems (Sharfritz and Roberts. Health Transit Rev 4:81-85, 1994), the experiences of the participating clients were explored through qualitative focus group discussions in order to better understand the potential reasons for the improved outcomes in the intervention group.

METHODS

Two ninety minute focus groups were conducted in Nyanza province, a poor agricultural region of Kenya, with 10 clients from the intervention group clinics where staff had received the training programme, and 10 clients from the control group where staff had not received the training during the earlier randomised controlled trial.

RESULTS

These focus group discussions suggest that the clients in the intervention group noticed and appreciated enhanced communication, diagnostic and counselling skills in their respective health workers, whereas clients in the control group were aware of the lack of these skills. Confidentiality emerged from the discussions as a significant client concern in relation to the volunteer cadre of community health workers, whose only training comes from their respective primary care health workers.

CONCLUSION

Enhanced health worker skills conferred by the mental health training programme may be responsible for the significant improvement in outcomes for clients in the intervention clinics found in the randomised controlled trial, despite the general shortage of medicines and other health system weaknesses. These findings suggest that strengthening mental health training for primary care staff is worthwhile even where health systems are not strong and where the medicine supply cannot be guaranteed.

TRIAL REGISTRATION

ISRCTN 53515024.

Perceived causes of severe mental disturbance and preferred interventions by the Borana semi-nomadic population in southern Ethiopia: a qualitative study

BACKGROUND

Culture affects the way people conceptualize causes of severe mental disturbance which may lead to a variation in the preferred intervention methods. There is a seemingly dichotomous belief regarding what causes severe mental disturbance: people living in western countries tend to focus mainly on biological and psychosocial risk factors; whereas, in non-western countries the focus is mainly on supernatural and religious factors. These belief systems about causation potentially dictate the type of intervention preferred. Studying such belief systems in any society is expected to help in planning and implementation of appropriate mental health services.

METHODS

A qualitative study was conducted among the Borana semi-nomadic population in southern Ethiopia to explore perceived causes of severe mental disturbance and preferred interventions. We selected, using purposive sampling, key informants from three villages and conducted a total of six focus group discussions: three for males and three for females.

RESULTS

The views expressed regarding the causes of mental disturbance were heterogeneous encompassing supernatural causes such as possession by evil spirits, curse, bewitchment, 'exposure to wind' and subsequent attack by evil spirit in postnatal women and biopsychosocial causes such as infections (malaria), loss, 'thinking too much', and alcohol and khat abuse. The preferred interventions for severe mental disturbance included mainly indigenous approaches, such as consulting Borana wise men or indigenous healers, prayer, holy water treatment and seeking modern mental health care as a last resort.

CONCLUSIONS

These findings will be of value for health care planners who wish to expand modern mental health care to this population, indicating the need to increase awareness about the causes of severe mental disturbance and their interventions and collaborate with influential people and indigenous healers to increase acceptability of modern mental health care. It also provides information for further research in the area of mental health in this semi-nomadic population.

Community mental health provision in Pemba Island, Zanzibar: a cross-sectional survey of different stakeholder groups

There is limited information about stakeholder perceptions of health service provision in low- and middle-income countries. We conducted a cross-sectional survey of 821 stakeholders of the community mental health services in Pemba Island, Zanzibar, Tanzania. The aim was to obtain systematic information about coverage, barriers, accountability and room for improvement as a baseline before implementation of a new mental health policy to strengthen mental health services.

Public sector mental health systems in South Africa: inter-provincial comparisons and policy implications

BACKGROUND

There is growing recognition that mental health is an important public health issue in South Africa. Yet mental health services remain chronically under-resourced. The aim of this study was to document levels of current public sector mental health service provision in South Africa and compare services across provinces, in relation to current national policy and legislation.

METHODS

A survey was conducted of public sector mental health service resources and utilisation in South Africa during the 2005 calendar year, using the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS) Version 2.2.

RESULTS

South African policy and legislation both advocate for community-based mental health service provision within a human rights framework. Structures are in place at national level and in all nine provinces to implement these provisions. However, there is wide variation between provinces in the level of mental health service resources and provision. Per 100,000 population, there are 2.8 beds (provincial range 0-7.0) in psychiatric inpatient units in general hospitals, 3.6 beds (0-6.4) in community residential facilities, 18 beds (7.1-39.1) in mental hospitals, and 3.5 beds (0-5.5) in forensic facilities. The total personnel working in mental health facilities are 11.95 per 100,000 population. Of these, 0.28 per 100,000 are psychiatrists, 0.45 other medical doctors (not specialised in psychiatry), 10.08 nurses, 0.32 psychologists, 0.40 social workers, 0.13 occupational therapists, and 0.28 other health or mental health workers.

CONCLUSIONS

Although there have been important developments in South African mental health policy and legislation, there remains widespread inequality between provinces in the resources available for mental health care; a striking absence of reliable, routinely collected data that can be used to plan services and redress current inequalities; the continued dominance of mental hospitals as a mode of service provision; and evidence of substantial unmet need for mental health care. There is an urgent need to address weak policy implementation at provincial level in South Africa.