Psychosis Recovery Orientation in Malawi by Improving Services and Engagement (PROMISE) protocol

Malawi has a population of around 20 million people and is one of the world's most economically deprived nations. Severe mental illness (largely comprising psychoses and severe mood disorders) is managed by a very small number of staff in four tertiary facilities, aided by clinical officers and nurses in general hospitals and clinics. Given these constraints, psychosis is largely undetected and untreated, with a median duration of untreated psychosis (DUP) of around six years. Our aim is to work with people with lived experience (PWLE), caregivers, local communities and health leaders to develop acceptable and sustainable psychosis detection and management systems to increase psychosis awareness, reduce DUP, and to improve the health and lives of people with psychosis in Malawi. We will use the UK Medical Research Council guidance for developing and evaluating complex interventions, including qualitative work to explore diverse perspectives around psychosis detection, management, and outcomes, augmented by co-design with PWLE, and underpinned by a Theory of Change. Planned deliverables include a readily usable management blueprint encompassing education and community supports, with an integrated care pathway that includes Primary Health Centre clinics and District Mental Health Teams. PWLE and caregivers will be closely involved throughout to ensure that the interventions are shaped by the communities concerned. The effect of the interventions will be assessed with a quasi-experimental sequential implementation in three regions, in terms of DUP reduction, symptom remission, functional recovery and PWLE / caregiver impact, with quality of life as the primary outcome. As the study team is focused on long-term impact, we recognise the importance of having embedded, robust evaluation of the programme as a whole. We will therefore evaluate implementation processes and outcomes, and cost-effectiveness, to demonstrate the value of this approach to the Ministry of Health, and to encourage longer-term adoption across Malawi.

Pathways to care for psychosis in Malawi

People with psychosis in Malawi have very limited access to timely assessment and evidence-based care, leading to a long duration of untreated psychosis and persistent disability. Most people with psychosis in the country consult traditional or religious healers. Stigmatising attitudes are common and services have limited capacity, particularly in rural areas. This paper, focusing on pathways to care for psychosis in Malawi, is based on the Wellcome Trust Psychosis Flagship Report on the Landscape of Mental Health Services for Psychosis in Malawi. Its purpose is to inform Psychosis Recovery Orientation in Malawi by Improving Services and Engagement (PROMISE), a longitudinal study that aims to build on existing services to develop sustainable psychosis detection systems and management pathways to promote recovery.

Clients and carers perception of mental illness and factors that influence help-seeking: Where they go first and why

OBJECTIVE

In Northern Malawi, the duration of untreated psychosis (DUP) is longer than that in high-income countries. The reasons for the delay in help-seeking are not known, although studies show multiple reasons. This research was conducted to establish health care help-seeking behaviours and identify barriers that exist between service users and health care providers. The study also intended to establish the beliefs that clients and family members have regarding the causes of mental illness which profoundly shape help-seeking, care giving process and outcomes.

METHODOLOGY

The study employed the exploratory phenomenological method, utilizing focus group discussions (FGDs) in the sampled population. The Health Belief Model and Disease Explanatory Models were conveniently chosen a priori by researchers to develop guide questions to explore clients' and carers' perceptions of the illness and their health care help-seeking behaviours.

RESULTS

Results show a bio-psycho-social inclination of disease causation and help-seeking behaviour. Causes of mental illness are understood in three categories, namely: physical/biological, psychological and socio-cultural. The majority of participants attributed mental illness to socio-cultural factors, with witchcraft, spirit possession and curses as main determinants. Causal perceptions also influenced help-seeking pathways. Many participants reported consulting traditional healers first, for diagnosis and to know who was responsible.

CONCLUSION

In this study, it has been found that help-seeking is influenced by the understanding of the source of the illness - which has a bio-psychosocial inclination. The socio-cultural explanation of witchcraft and spirit possession is dominant and a determinant of help-seeking behaviour. While participants noted benefits to hospital treatment, barriers and bio-psychosocial in nature were also noted. Guardians and not clients hold the key to choice of treatment modality and therefore a potential ally in all treatment interventions promotive, preventive and curative. There is need for strengthening of a bio-psychosocial intervention model in the treatment of mental illness.