Hostname: page-component-745bb68f8f-cphqk Total loading time: 0 Render date: 2025-02-09T07:50:05.208Z Has data issue: false hasContentIssue false
  • English
  • Français

‘Restoring the person's life’: a qualitative study to inform development of care for people with severe mental disorders in rural Ethiopia

Published online by Cambridge University Press:  10 March 2016

S. Mall ,
M. Hailemariam ,
M. Selamu ,
A. Fekadu ,
C. Lund ,
V. Patel ,
I. Petersen  and
C. Hanlon
S. Mall
Affiliation:
Department for Psychiatry and Mental Health, University of Cape Town, Alan J. Flisher Centre for Public Mental Health, Rondebosch, South Africa
M. Hailemariam
Affiliation:
Department of Psychiatry, Addis Ababa University, College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia
M. Selamu
Affiliation:
Department of Psychiatry, Addis Ababa University, College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia
A. Fekadu
Affiliation:
Department of Psychiatry, Addis Ababa University, College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Affective Disorders Research Group, SE5 8AF, London
C. Lund
Affiliation:
Department for Psychiatry and Mental Health, University of Cape Town, Alan J. Flisher Centre for Public Mental Health, Rondebosch, South Africa Health Services and Population Research Department, King's College London, Institute of Psychiatry, Psychology and Neuroscience, SE5 8AF, London
V. Patel
Affiliation:
London School of Hygiene and Tropical Medicine, Centre for Global Mental Health, WC1E 7HT, London Public Health Foundation of India, Centre for Chronic Conditions and Injuries, New Delhi, India Sangath Centre, Goa, India
I. Petersen
Affiliation:
School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa
C. Hanlon*
Affiliation:
Department of Psychiatry, Addis Ababa University, College of Health Sciences, School of Medicine, Addis Ababa, Ethiopia Health Services and Population Research Department, King's College London, Institute of Psychiatry, Psychology and Neuroscience, SE5 8AF, London
*
*Address for correspondence: C Hanlon, Department for Psychiatry and Mental Health, University of Cape Town, Alan J. Flisher Centre for Public Mental Health, 46 Sawkins Road, Rondebosch, 7700, South Africa. (Email: charlotte.hanlon@kcl.ac.uk)
Get access Rights & Permissions [Opens in a new window]

Abstract

Aims.

In low-income countries, care for people with severe mental disorders (SMDs) who manage to access treatment is usually emergency-based, intermittent or narrowly biomedical. The aim of this study was to inform development of a scalable district-level mental health care plan to meet the long-term care needs of people with SMD in rural Ethiopia.

Methods.

The present study was carried out as formative work for the Programme for Improving Mental health CarE which seeks to develop, implement and evaluate a district level model of integrating mental health care into primary care. Six focus group discussions and 25 in-depth interviews were conducted with service planners, primary care providers, traditional and religious healers, mental health service users, caregivers and community representatives. Framework analysis was used, with findings mapped onto the domains of the Innovative Care for Chronic Conditions (ICCC) framework.

Results.

Three main themes were identified. (1) Focused on ‘Restoring the person's life’, including the need for interventions to address basic needs for food, shelter and livelihoods, as well as spiritual recovery and reintegration into society. All respondents considered this to be important, but service users gave particular emphasis to this aspect of care. (2) Engaging with families, addressed the essential role of families, their need for practical and emotional support, and the importance of equipping families to provide a therapeutic environment. (3) Delivering collaborative, long-term care, focused on enhancing accessibility to biomedical mental health care, utilising community-based health workers and volunteers as an untapped resource to support adherence and engagement with services, learning from experience of service models for chronic communicable diseases (HIV and tuberculosis) and integrating the role of traditional and religious healers alongside biomedical care. Biomedical approaches were more strongly endorsed by health workers, with traditional healers, religious leaders and service users more inclined to see medication as but one component of care. The salience of poverty to service planning was cross-cutting.

Conclusions.

Stakeholders prioritised interventions to meet basic needs for survival and endorsed a multi-faceted approach to promoting recovery from SMD, including social recovery. However, sole reliance on this over-stretched community to mobilise the necessary resources may not be feasible. An adapted form of the ICCC framework appeared highly applicable to planning an acceptable, feasible and sustainable model of care.

Keywords

Chronic care modelcommunity-based rehabilitationmental disordersprimary health carerecoveryschizophreniasocial inclusionsub-Saharan Africa
Type
Original Articles
Information
Epidemiology and Psychiatric Sciences , Volume 26 , Issue 1 , February 2017 , pp. 43 - 52
Copyright
Copyright © Cambridge University Press 2016 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Alem, A, Jacobsson, L, Araya, M, Kebede, D, Kullgren, G (1999). How are mental disorders seen and where is help sought in a rural Ethiopian community? A key informant study in Butajira, Ethiopia. Acta Psychiatrica Scandinavica (Supplementum) 397, 40–47.CrossRefGoogle Scholar
ATLAS.ti. Version 5.0 (2003). Scientific Software Development GmbH: Berlin.Google Scholar
Au, JT, Kayitenkore, K, Shutes, E, Karita, E, Peters, PJ, Tichacek, A, Allen, SA (2006). Access to adequate nutrition is a major potential obstacle to antiretroviral adherence among HIV-infected individuals in Rwanda. AIDS 20, 2116–2117.Google Scholar
Barbui, C, Dua, T, van Ommeren, M, Yasamy, MT, Fleischmann, A, Clark, N, Thornicroft, G, Hill, S, Saxena, S (2010). Challenges in developing evidence-based recommendations using the GRADE approach: the case of mental, neurological, and substance use disorders. PLoS Medicine 7, e1000322.Google Scholar
Brown, GW, Birley, JLT, Wing, JK (1972). Influence of family life on the course of schizophrenic disorders: a replication. British Journal of Psychiatry 121, 241–258.CrossRefGoogle ScholarPubMed
Central Statistical Authority (CSA) (2008). Summary and Statistical Report of the 2007 Population and Housing Census. Population Size by Age and Sex. Population Census Commission, Federal Democratic Republic of Ethiopia: Addis Ababa.Google Scholar
Cohen, A, Raja, S, Underhill, C, Yaro, BP, Dokurugu, AY, De Silva, M, Patel, V (2012). Sitting with others: mental health self-help groups in northern Ghana. International Journal of Mental Health Systems 6. doi: 10.1186/1752-4458-1186-1181.CrossRefGoogle ScholarPubMed
De Silva, M, Rathod, S, Hanlon, C, Breuer, E, Chisholm, D, Fekadu, A, Jordans, M, Peterson, I, Prince, M, Shidhaye, R, Thornicroft, G, Kigozi, F, Tomlinson, M, Lund, C, Patel, V (2015). Cross country methods to evaluate the coverage and effectiveness of district mental health care plans in 5 low and middle income countries. British Journal of Psychiatry (Supplement). DOI: 10.1192/bjp.bp.1114.153676.Google Scholar
Donnelley, J (2011). Ethiopia gears up for more major health reforms. Lancet 377, 1907–1908.Google Scholar
Epping-Jordan, JE, Pruitt, SD, Bengoa, R, Wagner, EH (2004). Improving the quality of health care for chronic conditions. Quality and Safety in Health Care 13, 299–305.Google Scholar
Farooq, S, Nazar, Z, Irfan, M, Akhter, J, Gul, E, Irfan, U, Naeem, F (2011). Schizophrenia medication adherence in a resource-poor setting: randomised controlled trial of supervised treatment in out-patients for schizophrenia (STOPS). British Journal of Psychiatry 199, 467–472.Google Scholar
Gureje, O, Nortje, G, Makanjuola, V, Oladeji, BD, Seedat, S, Jenkins, R (2015). The role of global traditional and complementary systems of medicine in the treatment of mental health disorders. Lancet Psychiatry 2, 168–177.Google Scholar
Hanlon, C, Wondimagegn, D, Alem, A (2010). Lessons learned in developing community mental health care in Africa. World Psychiatry 9, 185–189.CrossRefGoogle ScholarPubMed
Hardon, AP, Akurut, D, Comoro, C, Ekezie, C, Irunde, HF, Gerrits, T, Kglatwane, J, Kinsman, J, Kwasa, R, Maridadi, J, Moroka, TM, Moyo, S, Nakiyemba, A, Nsimba, S, Ogenyi, R, Oyabba, T, Temu, F, Laing, R (2007). Hunger, waiting time and transport costs: time to confront challenges to ART adherence in Africa. AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV 19, 658–665.Google Scholar
Kebede, D, Alem, A, Shibre, T, Negash, A, Deyassa, N, Beyero, T (2004). The sociodemographic correlates of schizophrenia in Butajira, rural Ethiopia. Schizophrenia Research 69, 133–141.Google Scholar
Kebede, D, Alem, A, Shibre, T, Deyassa, N, Negash, A, Beyero, T, Medhin, G, Fekadu, A (2006). Symptomatic and functional outcome of bipolar disorder in Butajira, Ethiopia. Journal of Affective Disorders 90, 239–249.Google Scholar
Krueger, RA, Casey, MA (2009). Focus Groups: A Practical Guide for Applied Research, 4th Edition. SAGE Publications: Los Angeles.Google Scholar
Lambert, SD, Loiselle, CG (2008). Combining individual interviews and focus groups to enhance data richness. Journal of Advanced Nursing 62, 228–237.Google Scholar
Leff, J, Wig, NN, Ghosh, A, Bedi, H, Menon, K, Kuipers, L, Korten, A, Ernberg, G, Day, R, Sartorius, N (1987). Influence of relatives’ expressed emotion on the course of schizophrenia in Chandigarh. British Journal of Psychiatry 151, 166–173.Google Scholar
Lehtinen, V, Taipale, V (2001). Integrating mental health services: the Finnish experience. International Journal of Integrated Care 1, 3.Google Scholar
Lijalem, M, Tesfaye, F, Alem, A, Kumie, A, Kebede, D (2003). Nutrition Status of Cases of Schizophrenia and Bipolar Disorders in Butajira, Rural Ethiopia. Addis Ababa University: Addis Ababa.Google Scholar
Lund, C, De Silva, M, Plagerson, S, Cooper, S, Chisholm, D, Das, J, Knapp, M, Patel, V (2011). Poverty and mental disorders: breaking the cycle in low-income and middle-income countries. The Lancet. DOI: 10.1016/S0140-6736(1011)60754-X.Google Scholar
Lund, C, Tomlinson, T, De Silva, M, Fekadu, A, Shidhaye, R, Jordans, M, Petersen, I, Bhana, A, Kigozi, F, Prince, M, Thornicroft, G, Hanlon, C, Kakuma, R, McDaid, D, Saxena, S, Chisholm, D, Raja, S, Kippen-Wood, S, Honikman, S, Fairall, L, Patel, V (2012). PRIME: A programme to reduce the treatment gap for mental disorders in five low- and middle-income countries. PLoS Medicine 9, e1001359.Google Scholar
Mall, S, Sibeko, G, Temmingh, H, Stein, D, Milligan, P, Lund, C (2013). Using a treatment partner and text messaging to improve adherence to psychotropic medication: a qualitative formative study of service users and caregivers in Cape Town, South Africa. African Journal of Psychiatry 16, 364–370.Google ScholarPubMed
Mogga, S, Prince, M, Alem, A, Kebede, D, Stewart, R, Glozier, N, Hotopf, M (2006). Outcome of major depression in Ethiopia: population-based study. British Journal of Psychiatry 189, 241–246.Google Scholar
NVivo qualitative data analysis software. Version 9 (2010). QSR International Pty Ltd.Google Scholar
Patel, V (2015). Universal health care for schizophrenia: a global mental health priority (Editorial). Schizophrenia Bulletin. doi: 10.1093/schbul/sbv1107.Google Scholar
Patel, V, Belkin, GS, Chockalingam, A, Cooper, J, Saxena, S, Unützer, J (2013). Grand challenges: integrating mental health services into priority health care platforms. PLoS Medicine 10, e1001448.Google Scholar
Pfammatter, M, Junghan, UM, Brenner, HD (2006). Efficacy of psychological therapy in schizophrenia: conclusions from meta-analyses. Schizophrenia Bulletin 32, S64–S80.Google Scholar
Selamu, M, Asher, L, Hanlon, C, Medhin, G, Hailemariam, M, Patel, V, Thornicroft, G, Fekadu, A (2015). Beyond the biomedical: community resources for mental health care in rural Ethiopia the role of resource mapping in developing a mental health care plan in a low-income setting. PLoS ONE 10(15), e0126666.Google Scholar
Shibre, T, Negash, A, Kullgren, G, Kebede, D, Alem, A, Fekadu, A, Fekadu, D, Medhin, G, Jacobsson, L (2001). Perception of stigma among family members of individuals with schizophrenia and major affective disorders in rural Ethiopia. Social Psychiatry and Psychiatric Epidemiology 36, 299–303.Google Scholar
Shibre, T, Kebede, D, Alem, A, Negash, A, Deyassa, N, Fekadu, A, Fekadu, D, Jacobsson, L, Kullgren, G (2003). Schizophrenia: illness impact on family members in a traditional society – rural Ethiopia. Social Psychiatry and Psychiatric Epidemiology 38, 27–34.Google Scholar
Shibre, T, Medhin, G, Teferra, S, Wakwoya, A, Berhanu, E, Abdulahi, A, Alem, A, Fekadu, A (2012). Predictors of carer burden in schizophrenia: a five year follow-up study in Butajira, Ethiopia. Ethiopian Medical Journal 50, 125–133.Google Scholar
Smith, J, Firth, J (2011). Qualitative data analysis: the framework approach. Nurse Researcher 18, 52–62.Google Scholar
Teferra, S, Shibre, T, Fekadu, A, Medhin, G, Wakwoya, A, Alem, A, Kullgren, G, Jacobsson, L (2011). Five-year mortality in a cohort of people with schizophrenia in Ethiopia. BMC Psychiatry 11, doi: 10.1186/1471-1244X-1111-1165.CrossRefGoogle Scholar
Teferra, S, Hanlon, C, Beyero, T, Jacobsson, L, Shibre, T (2013). Perspectives on reasons for non-adherence to medication in persons with schizophrenia in Ethiopia: a qualitative study of patients, caregivers and health workers. BMC Psychiatry 13, 168.CrossRefGoogle Scholar
Thara, R, Padmavati, R, Aynkran, JR, John, S (2008). Community mental health in India: a rethink. International Journal of Mental Health Systems 2. doi: 10.1186/1752-4458-1182-1111.Google Scholar
Thornicroft, G (2006). Shunned: Discrimination Against People with Mental Illness. Oxford University press: Oxford.Google Scholar
Wagner, EH, Austin, BT, Von Korff, M (1996). Organizing care for patients with chronic illness. Milbank Quarterly 74, 511–544.Google Scholar
Wig, NN, Suleiman, MA, Routledge, R, Srinivasa Murthy, R, Ladrido-Ignacio, L, Ibrahim, HHA, Harding, TW (1980). Community reactions to mental illness. A key informant study in three developing countries. Acta Psychiatrica Scandinavica 61, 111–126.Google Scholar
World Health Organization (2008). Mental Health Gap Action Programme (mhGAP): Scaling up Care for Mental, Neurological, and Substance use Disorders. WHO: Geneva.Google Scholar
World Health Organization (2010). Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) for Mental, Neurological and Substance use Disorders in Non-Specialized Health Settings. WHO: Geneva.Google Scholar
Zergaw, A, Hailemariam, D, Alem, A, Kebede, D (2008). A longitudinal comparative analysis of economic and family caregiver burden due to bipolar disorder. African Journal of Psychiatry 11, 191–198.Google ScholarPubMed
Supplementary material: File

Mall supplementary material

Mall supplementary material

Download Mall supplementary material(File)
File 63 KB