Background
Methods
Study design
Study setting
Mental healthcare context of the district
Population and sample
Sampling
Study procedures
Data collection
Mode of data collection | Participant type | Gender | Age | Other characteristics | |
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Male | Female | ||||
FGD | HEWs | 0 | 12 | 25-38 | One year training after completing grade 10 or 12 |
In-depth interviews | Service users | 3 | 3 | 26-50 | All rural residents, non-literate |
Caregivers | 3 | 2 | 35-60 | Rural residents, non-literate | |
Traditional and faith healers | 3 | 0 | 36-65 | Herbalists, holy water attendants | |
Community leaders | 4 | 0 | 50-65 | 4th -8th grade | |
NGO representatives | 2 | 0 | 32, 33 | First degree | |
District health office representative | 1 | 0 | - | First degree |
Data analysis
Results
Sociodemographic characteristics of participants
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Theme I: Availability
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Most participants spoke of the current absence of a service in the district as one of the biggest barriers to accessing mental healthcare, affecting decisions about where to seek care and when to initiate help seeking. At present, only those with sufficient financial resources are able to access mental healthcare by travelling to distant places:
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If treatment starts [in the district], I can’t explain how happier I would become. Instead of travelling to far places in search of treatment and spending too much money and lose their assets in the process, it would be very good if they are treated here. People go to Amanuel [a psychiatric hospital in Addis Ababa] and other places including holy water (tsebel) places like Shenkora….People travel to different countries, regions to receive treatments. 04_community elder
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The plan to bring mental health closer to the community was expected to overcome the financial and logistical barriers associated with distant travel for many people:
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…there is no service at the health centre level. Many people are affected by the problem because there is no treatment or counselling at the health centre level. Having the service at the local level is invaluable. Mental illness is a big problem that degrades people…..Someone who cannot afford to go to Addis Ababa for treatment will [be able to] access the service. 05_religious leader, Orthodox church
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Participants suggested that making mental health services locally available would enhance the quality of life, functioning and productivity of people with severe mental disorders. It was also mentioned to reduce human rights abuses such as physical assualts and shackling. Restraining a person with mental illness, for example with chains, was reported to be a common response to the lack of accessible care. Participants also remarked that people in traditional healing places were mostly restrained when being brought to, or while attending care at traditional and faith healing sites.
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In the absence of mental health services, participants reported that people tried different avenues to find solutions for their situations. Costs associated with seeking treatment from traditional healers, including payment for gifts, traditional medicines, travel expenses and other forms of contributions were reported to be much higher than would be incurred if people were able to access modern care.
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Theme II: Affordability, Accessibility
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Participants reported sets of interwoven potential barriers to access to mental healthcare in a primary care context. Among these were challenges with leveraging social support, the severity and persistence of illness and difficulty conveying a person with severe mental disorder. Reachability of the service in terms of geographic proximity to one’s area of residence was one of the key recurring themes across the interviews. Increased accessibility and better affordability of mental health services were said to result in better help-seeking behaviour. Shorter distance travelled was also said to increase affordability due to the decline in the indirect costs of treatment.
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It was indicated that inability to pay for treatment or associated expenses is considered as one of the major potential barriers to accessing care:
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“If the family is poor it is very difficult to get treatment. I guess it is clear. It is poverty. Unless it is financial problem who would ever like to keep his/her family at home with such a suffering? It is lack of money that hinders people from getting treatment”. 02_traditional healer
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The other argument by some of the participants is that the provision of mental healthcare in the local setting would address affordability concerns. Establishing the service within reach implies reduction in the indirect costs of treatment such as transportation, meal and accommodation.
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Theme III: Acceptability and adequacy
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Excitement about the planned service was evident across the interviews. Previous encounters with mental health services and level of awareness about treatment of mental disorders were mentioned to be important predictors of acceptability. People with no previous experience of modern mental health services were said to have potential difficulty to accept health service-based care. Causal attribution of mental illnesses was underlined as an essential factor affecting help-seeking. The majority of participants considered poverty, thinking too much, anguish and adverse life events to be the causes of mental disorders. There was also a strong belief in the community that some mental illnesses were attributable to evil spirits or demonic possession.
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“Some spirit that babbles as ‘I’m Satan, or I’m a magic spirit’, a spirit that makes them feel dizzy and mentally strained would go away”. 08_holy water attendant
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The protestant church leader also confirmed this stating that some forms of mental disorders are caused by evil spirits and are healed only through prayer and exorcism. According to him, due to such overarching beliefs, people tend to seek care first at traditional healers and may not find healthcare-based treatment to be acceptable. The HEWs also emphasised that these beliefs were shared by majority of the population. However, the impact of having such beliefs on help-seeking is not discussed in the in-depth interviews.
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Various explanatory models of illness were mentioned across all the community representatives. In some cases, it was likely that one person might hold more than one explanation as to how and why illness started. One’s fate, curse, wearing perfumes during the sun, worries about life/school and falling in love were some of the explanations given to cause mental disorders. It was reported that people who hold these explanatory models strongly believe that traditional healings are more suitable than modern treatments.
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Although this could be partly linked with non-availability of modern treatment in the district, people tended to go to places as far as 300kms away from their residence to attend traditional healings. The HEWs focus group discussion also shed light into the importance of awareness of families and acceptability of services. How these two affect the decision where to seek care from is illustrated below:
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There is awareness problem in the community. This means instead of coming to health centres, the community prefers to go to holy water [tsebel] and other places. They think that tsebel is effective than modern medication. If we start service for mental illness, this may have some good thing for our community. But as our health centres do not have medication, the community may not trust them and seek service. HEW_FGD
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The decision to seek help from traditional healers could be related to lack of trust in modern medication or absence of any modern mental healthcare providers in the vicinity. Although the need for comprehensive healthcare was acknowledged by many, lack of awareness from the community’s side is presented as a potential barrier to access:
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Health by itself is a manifold issue and mental health treatment is one of it. I don’t think our community would be against having these services. They’d prefer to have it near to them. But the thing is our community has its traditions, so a lot of work should be done. Awareness creation should address this. There are people who go through a lot of stress and lose their mind. So in light of redeeming these people’s lives it will be very essential to have these services and enabling the community to understand and utilize it. 10_preacher in protestant church
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Another caregiver of a person with severe mental disorder also strengthened the above claim as:
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For the first two years, we thought it was an evil spirit and sought for traditional help. Around the end of the second year, we took him to modern treatment…..13_Caregiver
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Such attitudes were reported to be some of the potential barriers to access. The belief that mental illness is not curable contributes to the low priority given to modern medication. The health extension workers also mentioned that many families opt to seek care at traditional care providers first before they consider travelling to modern facilities.
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The participants did not prioritise concerns related to the adequacy of a primary care-based service. Availability of the service within the community was perceived to encourage early access as people would get the opportunity to witness changes in the lives of those who had been treated. The decision to access services was said to be largely influenced by the success or failure of those who had previous experience with mental health facilities. The HEWs also indicated that success stories of those treated will wipe away doubts regarding effectiveness of modern care.
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According to the community elders, the number of people treated by the programme and the impact of treatment on the lives of those treated would be considered to be the most important indicator of quality of care. Two of the religious leaders disclosed their fear that the quality of care could be compromised if the service was provided at the health centre level. This was also shared by another participant below:
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From our experiences so far, when [services] are decentralised, we face problems with maintaining the quality. This may be in terms of the health professionals; the follow up. There are instances where they neglect their responsibilities. The person with a mental illness may not get the proper treatment. This is my concern. Such problems may be faced at this level. IV11_NGO representative 2
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The above argument is based on the current lack of training and absence of psychotropic medications at the health centre level. Hence, referrals to the nearby psychiatric hospitals, supervision by trained psychiatrists and consultations with existing primary healthcare workers with better training in mental healthcare was recommended to enhance quality.
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Equitable access
If there is a pregnant woman or if there is someone who is physically weak, accessing services may be difficult. If they do not have money, that will make it even difficult. If you do not have money, you can access nothing. It is not because the person is a woman or a man. The main thing is having money. If they do not have money, they cannot benefit from the service being provided. 05_religious leader Orthodox church
Different households have various problems. They may not be able to cover the treatment costs due to poverty. The other problem is that it is a long-term illness. People will get tired of you if you are ill for longer period of time. Your relatives could help you till you get well. But, people will get tired of you when you have an illness that stayed with you for years. Female service user
“As long as the service being provided is in government health centres, it is affordable for most people as the government also subsidizes it. We do not have that poor people who fail to access the service at health centre level”. 03_community elder
“I do not believe in giving the medication for free. It should consider the economic background of families. It will be effective this way. The community does not appreciate free medication. Even when we give them vaccinations for free, they would consider it effective when they spend some money.” HEW_FGD
I don’t think so [physical disability is a problem] because mentally ill people are brought to healthcare facility by other people in most cases. We can take this one as a factor that hinders them from coming to the service for example if you don’t have money for transport it is very difficult to take your ill relative to hospital. 07_NGO representative
I was breastfeeding when I first went for treatment. My neighbours were kind enough to breastfeed my baby who I left behind. I was mentally ill. I was not willing to breastfeed or take care of him. All breastfeeding women in my neighbourhood took turns breastfeeding my baby. But the baby did not survive because he was breastfed by other people and was also malnourished. Had there been treatment in the nearby, my baby would have survived. Female service user, 01
If a woman suffers from psychosis or depression, both the community and her family may think that she should remain at home. They may think that it is costly to take her to treatment places. Therefore, they will put her in chain at home. They may think she should stay at home because staying at home does no harm to the woman or they may also take her to different worship places. They may go to tsebel places. Therefore, taking such alternatives may make treatment a difficult task. HEW_FGD
Strategies to overcome barriers
Discussion
Availability
Affordability and accessibility
Acceptability and adequacy
Equitable access
Barriers | Recommended strategies | Specific interventions |
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Theme I: Availability | ||
Absence of mental health services | Making the service locally available | Integration to primary care |
Absence of psychotropic medications | Ensure availability of medications | Include psychotropic medications in the drug list |
Theme II: Affordability and accessibility | ||
Inability to cover treatment related costs | Providing cheaper treatment | Financial support to ‘poorest of the poor’ |
Subsidising mental health treatment | ||
Longer distance travelled to access services | Establishing the service within reach | Facilitate emergency transportation |
Plan outreach mental health service | ||
Indirect expenses of seeking care | Interventions to improve household income | |
Theme III: Acceptability and adequacy | ||
Causal attribution: attribution to some evil spirits | Raise awareness | Involving HEWs in raising awareness and initiating discussions |
Engaging religious leaders in awareness raising | ||
Lack of trust in modern medication | Raise awareness | Involving service users who recovered |
Telling success stories of those treated | ||
Lack of awareness (the belief that mental illnesses are not curable) | Raise awareness | Engage traditional healers in educating the community |
Amplify success stories from treatment | ||
Engage service users who recovered in assisting HEWs in their awareness raising endeavours | ||
High regard given to traditional healing | Raise awareness | Train traditional healers on detection of core symptoms of mental disorders |
Create referral linkage framework | ||
Work with church leaders | ||
Mainstream mental health contents in community conversations | ||
Concerns about quality of the service | Supervision | Supportive supervision by psychiatric nurses |
Telephone consultations |