Introduction
When patients leave the psychiatry hospital without permission from healthcare workers, it is considered absconding (also known as escaping or eloping) [
1,
2]. In high-income countries, 1 to 15 patients per hospital abscond per year [
1]. The global annual absconding rate for psychiatry patients ranges between 2.5 to 34%. The rates are particularly high in Africa. For example, the absconding rates for psychiatric patients in South Africa is at 7.83 [
3], whereas the rates are even higher in Uganda because about 10 to 50 patients are estimated to abscond every month from the National Mental Health Referral hospital, the most secure mental facility in the country [
4,
5].
Despite the different rates and locations, knowledge about various factors associated with this phenomenon as well as the causes have remained similar over the years [
2,
3,
6‐
13]. These include younger age, male sex, longer length of hospital stay, personality disorders, substance abuse disorders, patients who have been referred to the psychiatric hospital by police, those with employment problems, and influence of psychiatric symptoms [
2,
3,
6‐
13].
Absconding from psychiatric hospitals is associated with slower recovery and prolonged hospitalization due to the interruption in treatment [
7,
14]. Despite the health challenges associated with absconding, the literature would suggest that patients’ experience at the facilities strongly affect their decisions to abscond. Patient perspectives from developed countries have reported lack of social support from friends and family, a lack of freedom, a feeling of being confined, boredom, poor doctor-patient relationships, problems with medications, disturbance from other patients, and poor quality of food within the hospital, which makes them dislike the hospital environment, thereby leading to absconding [
1,
3,
11,
15]. Some have experienced fear in response to feeling as though their safety is threatened, harassment, being overtly threatened by other patients, or having had their property stolen [
2,
12,
13]. These results have largely been obtained by using quantitative methods, although some qualitative work has looked at understanding causal factors for absconding based on informants involved in patients care and former absconders experiences [
16‐
19].
Despite the large cultural differences and employed methods in patient care across the globe, such as direct involvement of caregivers in patient care; to the best of our knowledge, there are no qualitative studies in Africa that have explored patients’ emotional experiences of psychiatric hospitalization and its relationship to absconding. This study aimed to qualitatively explore patients’ perspectives and emotional experiences related to the phenomenon of absconding from a psychiatric hospital in Uganda, as well as to understand what it means for patients to experience life in a psychiatric ward.
Methods
Study design
This was a qualitative descriptive study [
20] involving in-depth interviews with patients with mental illness who had previously absconded from the Mbarara Regional Referral Hospital (MRRH) Psychiatry Unit. This study was reported in accordance with the
COnsolidated criteria for
REporting
Qualitative research (COREQ) checklist [
21].
Study setting
This study was conducted in the Psychiatry Unit at MRRH, a hospital located in Mbarara City in southwestern Uganda. MRRH is located 270 km from Kampala, the capital city of Uganda. In MRRH’s Psychiatry Unit, psychiatric care is unique in that psychiatry patients have their caregivers directly involved in their care and all admitted patients are typically accompanied by a caregiver. The majority of patients who seek care at MRRH live in rural areas outside Mbarara Town and the surrounding districts [
22].
Participants
Participants in this study were patients with mental illness in a remission phase who were attending the outpatient mental health clinic at MRRH. We purposively selected and included patients with prior history of absconding from the psychiatry unit and stable in their course of mental illness. Eligible participants were identified by a nurse on the Psychiatry Unit from patients attending the outpatient clinic. They were given an overview of the study and, upon consent, an appointment for data collection was made. A reminder message was sent before the set date for the interview.
Participants ranged between 18 and 55 years of age. Nine participants were male, and one was female. Nine of the ten participants were unemployed and only one had attained a tertiary level of education. The median years with mental illness was eight and a median number of times that a patient had absconded was two. Five participants were single, three were separated or divorced, and two were married. The most common diagnosis among the participants was bipolar affective disorder (n = 6), while two patients were being managed for schizophrenia, and two were being managed for substance use disorders. The median number of years with mental illness was eight, and the median number of admissions was four. We excluded participants who were physically and psychologically too sick to participate in the study or give us reliable information.
Data collection
Interviews were conducted by a research assistant who was trained in qualitative data collection methods. Interviews took place between September 8th, 2020 and September 30th, 2020. The interviews were scheduled based on participants’ availability and lasted between 30 to 60 min (average: 40 min). Interviews were conducted in participants’ preferred language. The interview guide was generated through reading literature relevant to absconding of patients from psychiatric hospitals and with input from mental health experts in the region. Sample questions from the semi-structured interview guide (Supplementary Material
1) included, “Tell me about what it is like to a patient with mental illness at the Mbarara Regional Referral Hospital?” and “Tell me about the time you escaped from the psychiatry ward.”
Analysis
Interviews were audio recorded, translated when required, and transcribed into English. Only one of the participants was fluent in English and could read the transcribed interview to confirm accuracy of the translated and transcribed interview. The summaries of the interviews were read out to the participants to check if the interpretation of the information was rhyming with their experiences. Analysis occurred concurrently with data collection by the research team (MMK, SA, GZR, SH, AA) using thematic analysis [
23] to understand the patient experience and reasons for absconding from the psychiatry hospital during their admission. The specific steps involved in thematic analysis include familiarizing oneself with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report [
23]. After reading three transcripts each, the research team developed a codebook to guide analysis of the qualitative data through line-by-line coding of all the transcripts. After coding five interviews in duplicate, AA and MMK coded the remaining transcripts independently. Throughout the analytic process, the research team held regular meetings to harmonize the identified themes and to discuss their interpretations of the data, including reviewing the field memos made during data collection, and developing themes from related codes. The team reflected a collaborative effort between researchers from Mbarara University in Uganda and McMaster University in Canada, led by SA and SH, respectively. The team comprised MMK (clinical psychiatry resident), SA (PhD, experienced qualitative researcher, senior lecturer, and clinical psychiatrist), and GZR (PhD, experienced qualitative researcher, senior lecturer, and clinical psychiatrist) from Uganda and SH (experienced qualitative researcher, associate professor, and clinical psychiatrist) and AA (experienced qualitative researcher, assistant professor, and PhD-trained education scientist) from Canada. The diversity of the research team helped make more explicit researcher characteristics that influenced interpretations of the data. After analysis, member checking [
24] was done with one participant. Data were collected until no new ideas were articulated by the participants.
Ethics
The study received ethical approval from research ethics committee of Mbarara University of Science and Technology (# 17/06–20). Permission to collect data from participants was granted by the director of MRRH. All participants provided voluntary informed, written consent at study enrollment.
Discussion
Our study explored the emotional experiences associated with absconding from a psychiatric ward at a Ugandan hospital. The four study themes (stigma, experiences with caregivers: mixed emotions, poor resources and services, and the influence of mental illness symptoms) can be broadly grouped into three experience categories including the loneliness of stigma, negative emotions associated with the loss of important roles given the nature and framework of caregiving on the psychiatric ward, as well as the stress of limited resources as a salient part of the patient experience as it relates to absconding. As suggested by Brumbles et al. [
25], stigma is a motivator for absconding because patients reported feeling inferior as a result of having a mental illness. Stigma associated with mental illness in Uganda is high [
26]. Despite a patient being severely mentally ill, many patients in the current study did not want to associate with mental illness setting a scenario where absconding was perceived by the patient as an effective solution to the problem of stigma. Patients in the study described not being engaged in the psychiatric ward that eliminated their ability to engage in meaningful roles and left them bored. This loss of social status is another way in which stigma was experienced by patients. For example, in the Ugandan context, a man who is prevented from doing work associated with providing for his family is equivalent to a loss of purposeful identity. Therefore, the experience of doing nothing on the ward was also deeply distressing, which led to absconding, despite having caregivers (i.e., family members) present.
In addition, the physical structure of the facility was described as promoting stigma through the presence of the seclusion room. Simply being aware of a space that could be used to single out and separate patients from others was perceived as a threat. Patients articulated a kind of assault on their dignity when put in seclusion by healthcare workers and/or their caregivers. Although these reports are congruent with other psychiatric patient perspectives in Uganda where being put into seclusion by caregivers was described as highly stigmatizing [
27], other experiences further perpetuated the stigma experienced by patients in our study. Patients reported being fearful and vulnerable about the possibility of being put into seclusion by anyone on the ward, including by other psychiatric patients, caregivers of other patients, the patient’s own caregiver, as well as by the healthcare workers. This scenario led to a kind of experience that felt unpredictable and unsafe because of the status of being a patient. The fears and horrors of being forced into seclusion have been described in previous studies [
28,
29] as an issue of life or death. The patient experience here turns from one of unpredictability to feeling as though the hospital is associated with serious danger, the potential for assault, as well as a threat to one’s life. These kinds of traumatic emotions are understandably linked to dramatic actions described by one patient in this study who reported eating his own T-shirt while in seclusion due to hunger. Absconding for this patient is understood as the least traumatic of his encounters while in hospital. For the patients in our study, a place of ‘healing’ became a place of incarceration such that there is double stigma and makes having mental illness feel like a crime.
In most health facilities in Uganda, there is a shortage of staff, making it necessary for caregivers to be involved in patient care [
27,
30]. Caregivers of patients with mental illness, who are often their own family members, have a high burden of care characterized by multiple responsibilities, which affects their ability to provide adequate care for their patients [
31]. The burden increases with the severity of the patient’s illness [
32] but also leads to the stripping of almost all patient independence. Caregiving process is described as a process of caring for a patient with mental illness to be akin to caring for a small child (infantilization). Care involves feeding, bathing, and constantly monitoring the patient to ensure that they do not cause harm to themselves or others. Despite being in the presence of constant care [
33], patients in our study still described negative feelings such as loneliness, boredom, and even resentment as a result of having their dignity stripped away. As a result, absconding became a way for patients to return to some level of independence and control over their own lives.
In this study, the health facilities were found to have poor services that made patients have a negative experience during admission, hence motivating their desire to elope. The living conditions were poor, with questionable security, overcrowding, poor staffing, and a lack of basic services, such as cooking facilities for patients. These poor services have been identified by many researchers, and are mainly attributed to poor mental health policies and laws [
27,
33]. Uganda had taken over 50 years to update its mental health treatment policy, and the use of seclusion rooms, urgency orders, and derogatory language such as “person of unsound mind” or “idiots” to describe patients with a mental illness, continues to perpetuate stigma around the topic of mental health [
33,
34].. This is exacerbated by financial constraints, as the total amount of money allocated to mental healthcare in Uganda is less than 1% of the health budget [
33]. This is not enough to improve services offered by psychiatric facilities and perpetuates the issue of absconding. In South Africa, absconding was nearly cut in half after a change in the country’s the Mental Healthcare Act [
3]. Government intervention is urgently needed to help address the issue of absconding in Uganda.
Limitations and future direction
The study findings should be interpreted in light of some limitations. In qualitative methodology, member checking is one way of ensuring the trustworthiness of the data. While patients read their own transcripts, member checking was not completed by having patients read over the full set of themes. Although this study was intended to be descriptive, there is an inherent methodological limitation in that the prioritization of factors related to absconding could not be determined. Future studies could explore this in more detail. This was a single institution study, which may be a shortcoming in generalizing suggestions made by the authors directed at government and policy to assist with improving patient experiences.
Conclusions
Our findings indicate that absconding is a symptom of a larger problem with a mental health system that perpetuates stigma in its design, isolates patients and makes them feel lonely, and forces patients to rely on caregivers who infantilize them and take away all their freedom in a facility with no basic services. For many patients, this makes absconding the only option. Within such a system, all stakeholders (policymakers, health-care providers, caregivers, and patients) should be involved in rethinking how psychiatric facilities should be operated to make the journey of patient recovery more positive.
Acknowledgements
We would like to acknowledge Nuwagaba Gabriel for his role in data collection, transcribing, and translation. Gerald Wakweyika for his role on identification of participants. Annet Mutayomba for her role in identifying some of the research participants, and Sarah Maria Najjuka, who assisted in data collection and analysis. We would also like to acknowledge the Department of Psychiatry, Mbarara Regional Referral Hospital for providing a conducive environment for data collection. Finally, we would also like to acknowledge the patients who participated in this study. Without them this important data would not have been obtained.
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