Background
More detailed studies that are designed and powered to examine ethnic differences in pathways to care are needed to elucidate the relative contributions of immigration, culture, and social inequalities… [as well as] a more detailed examination of the complex mechanisms behind this association.
Aim
Methods
Population and setting
Recruitment and sample
Instrument
Procedures
Data analysis
Coding of material
Identification of likely psychotic symptoms/illness related by participants
Results
Psychotic symptoms/behaviors
Symptom/behavioral clusters | Specific symptoms and behaviors |
---|---|
Aggressive/agitated | Aggressive in body language; aggressive verbally (threatens; insults others; calls out people’s names; shouts at others); extreme aggression Anger: talks angrily; angry body language Violence: throws objects (e.g. food); tears up objects; bangs wall with fists and head; fights; beats wife; murder Causes trouble Change in behavior: rude, talks disrespectfully, uses vulgar language Induces fear in others Screams; shouts throughout the night Treatment noncompliance (traditional and Western-like) Demands money; demands treatment Hysterical Irritable Uncooperative and needing supervision (e.g. refusing to eat; refusing to bathe) |
Called “crazy” | Acts “nuts”, mentally disturbed (temporary), mentally ill (chronic), very sick mentally, mentally affected, mentally confused, went “crazy”, looks like a “mad person”, “fully disturbed in such a way that everything went upside down during that day” Driven “mad” by ancestral spirits; “lost his mind” after cultural ritual |
Strange behavior | Hoards rubbish Picks up paper Makes peculiar comments Writes inappropriate things Undresses in public; walks around naked or partially naked in public; walks barefoot; sleeps on grave of his murder victim; goes out in the rain; only wants to eat raw meat; sits outside people’s houses at night as if he wants to get inside; sings traditional songs never taught to him after cultural ritual; takes others’ washing from clothesline; takes children’s clothes and wears them; spits saliva, calls the name of the late radio announcer and then climbs up inside the house Involved in repeated car accidents (smashed new cars) |
Auditory hallucinations | Hears voices (i.e. grandfather, etc.); hears voices after cultural ritual Says things aloud as if he is talking to visible people Talks to self; talks to self as if talking to others Asks if you hear the people he/she hears Hears voices to kill self by going into road or hanging self (COMMAND) |
Confusion | Shows signs of mental confusion (e.g. unable to recognize photos of wife and children) Disappears from home/community Gets lost Disoriented (e.g. not knowing day’s date) |
Poor hygiene | General self-neglect Not washing Rotten teeth Wears torn clothes Wears dirty clothes |
Talking nonsense | Answers inappropriately Talks in a way that shows he is “unwell” Irrelevant talking; says nonsense; says incomprehensible things Says untrue things |
Sleep problems | Not sleeping at night Lack of sleep Restless Sleeps in street and outside in veld |
Scared | Appears frightened as if he sees something harmful Looks around frightened as if someone will listen to conversation Fears everything including a “bang” sound Traumatized |
Called “psychotic” | Psychotic behavior Appears to be in a psychotic state |
Social/occupational dysfunction | Stopped working Left job Stopped attending school |
Wandering | Wanders back and forth on road Wanders from house to house |
Visual hallucinations | Appears to see something that is not there; says people who others do not see are passing by Describes seeing invisible people from Bible Says saw invisible people after cultural ritual Says saw a snake entwining itself on bus steering wheel while driving |
Psychomotor problems | Reports blurred vision/being blind Unable to walk Feels physically sick; feels like vomiting |
Weight change | Not eating; does not eat when mentally sick |
Social withdrawal | Avoids social interaction Avoids eye contact/looks down Does not want to be touched |
Paranoia | Checks to see if people are listening Looks around in a paranoid way Says there are people who want to hurt him Answers as if someone is attacking him and out to get him |
Hypersexuality | Asks women to move around in sexual way so he can get aroused Tells women he yearns for them Wants to rape women |
Memory problems | Concentration difficulty Reports no memory of behavior during acute illness |
Lack of insight | Lacks insight about being mentally ill |
Delusions of grandeur | Says father is Nelson Mandela Says whole earth belongs to him and all these other people pay him rent |
Not communicating | Does not answer questions |
- Case 2 as described by KII ccg 2Well, there is one person who is mentally disturbed.One sort of like gets frightened as if there is something he sees.This person’s… while talking is saying there are people who want maybe…want to do something to him, but you don’t see those people.Sometimes he asks you: “do you hear these people?”And then he says, “They go past!”He says he sees Gorrah and Goriat.“Here they go past. They want me.”He wants you to help him… and look for Gorrah and Goriat and listen to what they’re saying. He wants help.He is a gentleman… it’s someone I’ve been thinking is fine because when he comes across you can’t tell that he’s mentally ill.You only… when you start talking.This… it doesn’t happen continuously.This has been going on for three months now.But he does not have insight right now that he is disturbed as he is now talking about Gorrah and Goriat.They have just gone somewhere because… now it’s a problem.He has even stopped working. These days he is not even going to work.
- Case 9 as described by KII ngo 5One example: one man was involved in a car… in a bus accident.He saw a snake twining itself whilst he was driving a busload on his steering wheel. Then it was… they say it was such a big snake—colorful.And it put his head face to face with him.And he just screamed and left the bus… to move on his ownand he lost his mind from that day.
- Case 1 as described by KII ccg 1There is another female… she doesn’t wash herself…And talks, he [she] is, you know, confusion… what he’s [she’s] telling…he [she] talks nonsense or something like that.She does talk to other people.So she says things that aren’t true.It’s a girl with rotten teeth. She doesn’t wash herself.Sometimes she goes barefooted.Wandering around… going from house to house.She tells people that they were beating her at home, they’ve stolen her money, telling lies.
- Case 3 as described by KII ccg 3The one person in my neighborhood who was mentally disturbed…was deserted by her husband… because she was… infected with HIVAnd then she was hurt.Yes, it was during that time when she became confused and eventually left the job… her job.She shouts… He [she] talks about things that are not well understood.Ja, it’s the speech that does not make sense, but the words are normal words.When you talk to her, she answers things that are not appropriate…She appears frightened sometimes as if she’s afraid.
- Case 5 as described by KII local leader 6I (Tr.): I may say it is here because I know it has happened maybe to people close to me in some years.His parents passed away and left 20 cows but he did not do any job and did nothing.They all died.After they died, he went crazy and picked up papers.
I (Tr.): Like my neighbor: he walks partially naked, what can I say.He walks and talks to girls, and does funny things… like telling them he yearns for them, let me put it that way.He does not dress; maybe he wears underwear and walks barefeet and does anything…He talks loudly and we can hear him.And sometimes he talks to himself as if he is talking to people and he says “You so and so… this and that.”He does not bathe; he is dirty.
Help-seeking behaviors
Individual (“Case”) ID number | 1st step | 2nd step | 3rd step | 4th step | 5th step |
---|---|---|---|---|---|
3 | CCG | Medical (General hospital) | Social worker | ||
25 | CCG | Medical (Clinic) | |||
1 | CCG | Medical (Mobile clinic) | |||
18 | Church | ||||
21 | Medical (Clinic) | Medical (Psychiatric hospital) | |||
15 | Medical (Clinic) | Tent church | Home cultural ritual | Medical (Psychiatric hospital) | |
13 | Medical (Clinic) | Medical (Hospital—unspecified) | Medical (Clinic) | ||
20, 26 | Medical (Clinic) | ||||
30 | Trad healer (Faith healer) | Medical (Hospital—unspecified) | Trad healer (Faith healer) | ||
29 | Trad healer (Faith healer) | ||||
4 | Medical (General hospital) | CCG | Medical (Clinic) | ||
12 | Home | Traditional healer | |||
2 | Home prayer | Trad healer (Sangomaa) | |||
11, 27, 31 | Trad healer (Inyangab) | ||||
28 | Local traditional leader | Unspecified location for pension grant | |||
14 | Police | Medical (Clinic) | |||
24 | Police | Medical (Psychiatric Hospital) | Medical (General hospital) | ||
32 | Medical (Psychiatric hospital) | Medical (Other psychiatric hospital) | Medical (General hospital) | Trad healer (Sangomaa) | Trad healer (Inyangab) |
19 | Religious leader | ||||
6 | Religious leader’s wife | ||||
7 | Trad healer (Sangomaa) | Home cultural ritual | Sangomaa
| ||
10 | Trad healer (Sangomaa and Inyangab) | Medical (General hospital) | |||
16, 22, 23 | Trad healer (Sangomaa) | ||||
8 | School | Remedial specialist teacher | Home cultural ritual | ||
17 | Traditional healer | Home cultural ritual | |||
5 | Traditional healer | ||||
9 | Witchdoctor | Medical (General hospital) |
- Case 9 as described by KII ngo 5And people said [it was] because he did not want to perform the ritual [which] his father [had] said: “when I die, you must slaughter a cow. And you must do it. You must come back from where you are working and slaughter that cow for me.”And he didn’t come back. He didn’t slaughter the cow.Now his father came in the form of a snake… and was angry with him.The witchdoctors tried to help him…. they couldn’t.The hospitals tried to help him…. they couldn’t.Up to this day, he walks the streets.That’s why I’m confirming that at times it can be the… the neglecting (of your) ancestors.
- Case 32 as described by FG ngo 7Yes it’s a girl. So with the help of tablets, being taken to Z [psychiatric hospital], Y [psychiatric hospital], X [general hospital]… there was no change.They took her to izinyanga; there still was no change.
- Case 11 as described by KII nurse 4Yeah, yeah. I remember my uncle… my mother’s brother…he just, he just got disturbed.Okay, he was talking to himself whatever, hearing voices.And then because my grandfather was from that side X… a rural area, yeah. X. And then… he [grandfather] didn’t want to take him to hospital.He just take him straight to X [geographical area]…because that’s where my grandfather was born.It was an inyanga.He just packed their things and go there and stay there.When they came, back, we didn’t know what happened there…but he was normal ‘til today…Because never went to the clinic. He never went to hospital. He never contacted any doctor.
- Case 27 as described by FG nurse 3I (Tr.): In my neighborhood, somebody killed another person. The family tried to take him to a certain inyanga to take away his lust to kill people [through cleansing]. [But there’s been no difference].
- Case 5 as described by KII local leader 6And then he was taken to a traditional healer and was told that he did not do things right: “You must do this ritual… because you did your father’s things because you took your father’s things and you did not do a Zulu cultural tradition.”…. He has slaughtered all the cows or sold all 20 of them; and he was now only left with craziness.… he is still like this even after he has consulted the traditional healers. They told him that his craziness was caused by 1 and 2. If you can do this, you will succeed. He cannot do it because he does not have anything to use towards this.
- Case 21 as described by KII religious leader 4I (Tr.): The relatives took him to where he could get help.They took him to the clinic.There was a change according to the family; he was better.I heard that he was given tablets and then he was on this treatment at home, you know.
- Case 24 as described by KII traditional healer 4It has happened within my family: my elder sister’s son who was taken from J being mentally disturbed…They tried taking him to Z [psychiatric hospital] but they couldn’t help;then they went to X [general hospital]… that didn’t help.Until he ran away from the hospital and was knocked by a car and was found dead.