Background
Methods
Study setting and period
Study design and study participants
Sampling and interview procedure
Data analysis
Reflexivity statement
Results
Characteristics of participants
Variables | Categories | Number of participants |
---|---|---|
Age of the participant
| < 30 | 6 |
30–39 | 17 | |
≥ 40 | 11 | |
Gender
| Male | 21 |
Female | 13 | |
Profession
| Psychiatrist and a general practitioner (GP) | 4 |
Management and leadership | 9 | |
Psychiatry and comprehensive nursing | 5 | |
General psychology (BA) | 6 | |
MSc in mental health (ICCMH) | 2 | |
Social Work (MSc) and social science (BA) | 5 | |
Clinical, counseling, and social psychology (MSc) | 3 | |
Organization
| Ministry of Women and Social Affairs | 1 |
Addis Ababa City Administration Labor and Social Affairs Bureau | 4 | |
Addis Ababa City Administration Health Bureau | 3 | |
Eka Kotebe General Hospital | 4 | |
Mekedonia Charity Association | 4 | |
Gergesenon Charity Organization | 4 | |
Born Again Rehabilitation Center | 1 | |
Bureau of Women Children and Youth Affairs | 1 | |
Addis Ababa Mayor Office | 1 | |
St. Amanuel Mental Specialised Hospital and other charity organisations | 11 | |
Position
| Organisation founder/initiator | 3 |
Administrator | 2 | |
Association president | 1 | |
Team leader/focal person | 4 | |
Director | 4 | |
Programme coordinator | 4 | |
Clinician/counselor | 5 | |
Staff | 8 | |
Assistant head | 1 | |
Executive committee of the association | 1 | |
Volunteer/service facilitator/clinical service | 1 |
Theme 1: divergent intentions and actions
Stigma and compassion are intertwined
People with mental health conditions are stigmatised and discriminated against in the community. The common misconception is that mental illness results from sin, a curse, or evil (IDI#28, healthcare provider, charity).
In particular, women experiencing homelessness face two distinct challenges and insecurities.Besides being exposed to cruelty and violence, many homeless individuals are viewed as criminals by the community and law enforcement bodies (IDI #29).
Our examination of the fundamental interests of individuals experiencing homelessness reveals that they aspire to earn a living in any way possible. They prefer to make more money than to live in a shelter, regardless of whether they live on the streets or elsewhere. Furthermore, I do not believe rehabilitation becomes successful or effective unless people experiencing homelessness are willing to accept it. Sometimes, homeless individuals do not complete rehabilitation programs and end up on the streets (IDI #2, social rehabilitation provider, government institution).
Human rights are regarded as necessary but are not protected
Other countries have a mental health law (the mental health act) that outlines the rights of people with mental illnesses, while Ethiopia does not have one. Sometimes, we hesitate to assist homeless individuals with mental health conditions who have been seriously injured or damaged on the streets (IDI #7, service provider, government agency).
Currently, a psychiatrist promotes mental health awareness on his social media platform and is one of a few national advocates for mental health (IDI #29, service provider, government agency).
Several cases of abuse have been reported against them (women experiencing homelessness). However, the police do not want to listen to their complaints. Most of the time, they (legal bodies) do not wish to assist them (people experiencing homelessness). Moreover, they (legal bodies) are more inclined to blame people experiencing homelessness rather than listen to them (#IDI 22, service provider, charity).
The homeless as a means to an end
Establishing an appropriate financial system would answer the questions of who should fund them and how they should be provided (IDI#8 healthcare provider at the governmental organisation).
COVID-19 cases and Ethiopia’s current political instability make the campaign unlikely to continue (IDI #12, program coordinator, charity organisation).
Theme 2: problem–solution incompatibility
Stressing the complexity of the problem but favouring simple solutions
Women experiencing street homelessness face financial hardship, abuse, and isolation. Women’s insecurities include unwanted pregnancies, diseases, and drug abuse (IDI #2, social rehabilitation provider, government organisation).
There has been an increase in the number of women experiencing homelessness. As a result, the number of internal migrants has also increased, particularly from rural southern areas to Addis Ababa (IDI#15, program coordinator, government organisation).
There is also a link between homelessness and psychological problems. Several health-related issues exist, probably more than I can list. Mental health disorders are a leading cause of homelessness (IDI #18, mental healthcare provider, government organisation).
Making basic needs a priority while emphasising comprehensive needs
Mental health treatment is multidisciplinary; we provide both medical and psychosocial support. Managing mental health issues requires the collaboration of psychologists and psychiatrists (IDI #31, service provider, governmental organisation).
I agree that several problems need to be addressed. However, there is a high demand for basic needs, such as food, water, clothing, sleep, and shelter. Yes, the basics are necessary. However, they (people experiencing homelessness) also face economic difficulties (IDI #7, service provider, government organisation).
Providing mental health services is nearly impossible without adequate shelter, food, and security. Food and shelter are essential for medication adherence. In addition, the shelter simplifies access to medicine (IDI #33, Program Coordinator, charity organisation)
Mental health remains widely unrecognised, despite being a serious issue
Insufficient budgets are allocated to mental health services, and these services are not given enough attention. Our office does not place a high priority on mental health in our bureau. The government sector has difficulty obtaining sufficient funding for mental health programs (IDI #15-program coordinator, government organisation).
The Mekedonia charity organisation provides various services, including mental health and psychosocial support. The organisation assists homeless individuals with mental health conditions (IDI#7, service provider, government organisation).
Theme 3: The lack of gendered and trauma-informed care despite an acknowledgement that women face unique challenges
Acknowledging the increased burden of violence directed at women and reproductive health concerns
There are several psychological and physical consequences associated with sexual abuse. In particular, rape has a significant impact on women. Furthermore, sexual abuse may increase their risk of unintended pregnancy, HIV-AIDS, and other sexually transmitted diseases (IDI #12, Healthcare provider, government organisation).
Women experiencing homelessness encounter marginalisation due to their gender and the misperceptions of those in their communities towards women experiencing homelessness (IDI #1, social rehabilitation officer, government agency).
The lack of gender-specific trauma-informed care
Microfinance programs enable institutionalised women with lived experiences of homelessness to obtain a photocopy machine. We collaborate with microfinance institutions through our office (the Labour and Social Affairs Bureau) to train institutionalised women. Additionally, we connect women with lived experiences of homelessness with local employment opportunities and rehabilitation centres so that they may earn a living (IDI #24, program coordinator, government organisation).
Theme 4: mismanaged resources
Existing delegated body and memorandum of understanding with inadequate planning, capacity, and implementation
Several individuals experiencing homelessness have requested assistance over time; however, the office is becoming limited in providing that assistance (IDI #4, social rehabilitation provider, government organisation).
There has been an increase in the number of homeless people in Addis Ababa due to migration and displacement from nearby towns. Although support has been provided, the problem persists over time (IDI #3, social rehabilitation officer, government organisation).
St. Amanuel Mental Specialized Hospital provides psychotropic medications and mental health professionals. Additionally, St. Peter Hospital offers medical care for homeless individuals with the support of our charitable organisation. We often receive assistance from non-governmental organisations (IDI #20, social workers, and charitable organisations).
An unbalanced workload and organisational priorities impede collaboration
Neither the government nor non-governmental organisations have conducted joint assessments. A slower pace of rehabilitation has been observed than expected (IDI #2, social rehabilitation officer, government organisation).
There is a shortage of resources in rehabilitation centres. Several other actors entrust their responsibilities to the Bureau of Labour and Social Affairs (IDI #4, program coordinator of the program for social rehabilitation, government organisation).
Following the general assessment of street homeless individuals’ conditions, we (staff at Amanuel Mental Health Specialized Hospital) provided cleaning, health assessments, and psychiatric assistance. It was a successful campaign. Despite this, the hospital was under considerable pressure. The hospital staff demonstrated a high commitment and dedication to the campaign. Nevertheless, the campaign was halted by changes in management at other institutions. Although the project could not proceed, there was a positive outcome (IDI #33, service provider, government organisation).
Our mission is to assist seniors and people with disabilities. A primary focus of the Mekedonia Humanitarian Association is to provide shelter, clothing, food, and other necessities to elderly and disabled people who have no other means of supporting themselves (IDI #28, program coordinator, charity organisation).
Organisational structure constrains the availability of services
The mental health issue seems to be less of a concern among stakeholders. In addition, homeless individuals have limited access to mental health services. Furthermore, it can be challenging for mental health professionals to provide mental health services without an inclusive healthcare system (IDI #34, service provider, government organisation).
The current economic situation is characterised by high inflation, and political issues have further complicated matters. Those living on the streets face a particularly challenging problem. As a result of the country’s current state, other people who may be able to assist them (street homeless women) are affected. Their situation has worsened over the past few years (IDI #9, service provider, government organisation).
As we attempted to relocate homeless women from the streets, the community frequently asked, ‘what are you intending to do with her?’ Other questions included, ‘For what purpose are you relocating her?’ This sparked controversy, and we were arrested as a result. It was challenging to convince the community that we were taking people experiencing homelessness to a better place (a charity organisation). For this reason, we requested permission from the police station each time we performed this task (IDI #22, program coordinator, charity organisation).
I believe mission and vision are essential components of scope. We provide mental health treatment to patients who come to our facility with mental health problems. Despite this, we collaborate with other organisations. Our hospital organised a campaign to assist homeless mental health patients. Furthermore, we provide medication support to charitable organisations. Nevertheless, the number of mental health professionals sent to charity has decreased over the past few years. The hospital’s involvement in mental health services for homeless individuals is limited. Our limited resources make it impossible for us to provide comprehensive healthcare outside the hospital (#8 healthcare provider, government organisation).
Resource shortages versus low-load employees
During our supportive supervision, we learned that the outpatient mental health departments were closed during regular clinic hours. Professionals often leave the clinic during clinic hours and complain that mental health services are not in high demand in health centres (IDI #15, program coordinator, government organisation).
There are non-governmental organisations that do not fund mental health programs. I am aware of a limited number of leaders of non-governmental organisations who support the mental health initiative. They fund several projects. Nonetheless, very few NGOs provide mental health services when mental health is related to other issues, such as nutrition, HIV, and gender-based violence (IDI #15, a program coordinator in a government organisation).