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research-article2015
PED0010.1177/1757975914567179O. AtilolaOriginal Article
Original Article Mental health service utilization in sub-Saharan Africa: is public mental health literacy the problem? Setting the perspectives right Olayinka Atilola1
Abstract: The severely constrained resources for mental health service in less-developed regions like sub-Saharan Africa underscore the need for good public mental health literacy as a potential additional mental health resource. Several studies examining the level of public knowledge about the nature and dynamics of mental illness in sub-Saharan Africa in the last decade had concluded that such knowledge was poor and had called for further public enlightenment. What was thought to be mental health ‘ignorance’ has also been blamed for poor mainstream service utilization. These views however assume that non-alignment of the views of community dwellers in sub-Saharan Africa with the biomedical understanding of mental illness connotes ‘ignorance’, and that correcting such ‘ignorance’ will translate to improvements in service utilization. Within the framework of contemporary thinking in mental health literacy, this paper argues that such assumptions are not culturally nuanced and may have overrated the usefulness of de-contextualized public engagement in enhancing mental health service utilization in the region. The paper concludes with a discourse on how to contextualize public mental health enlightenment in the region and the wider policy initiatives that can improve mental health service utilization. Keywords: public enlightenment, mental illness, cultural explanatory model, mental health literacy, Africa, health promotion
Introduction There are recent reports from the developed countries of Europe and America that public knowledge of the nature and dynamics of mental illness (as understood by mainstream psychiatry) has improved in the last decade (1,2). The improved knowledge and awareness has also been observed to coincide with periods of observable improvements in mainstream mental health service utilization (1). This observation supports the earlier views that improved public knowledge and awareness about mental disorders has tremendous implications for service utilization and that it is critical to the success of mental healthcare delivery initiatives (3,4). Improving public knowledge and overcoming barriers to mental health
service utilization is even more germane in developing regions like sub-Saharan Africa, where mental healthcare resources are limited or inadequate in the first place (5–7). Poor understanding of the nature and dynamics of mental disorders has been described as a major challenge to implementation of mental health services initiatives in sub-Saharan Africa (8). The same has also been speculated as an impediment to mainstream psychiatry service utilization (9,10) and a barrier to the formulation and implementation of mental health policies in the region (11). There is a growing interest in public knowledge about mental disorders within the academic community in sub-Saharan Africa, as several studies in the region had focused on this subject in the last
1. Department of Behavioural Medicine, Lagos State University College of Medicine Ikeja, Nigeria. Email: [email protected] (This manuscript was submitted on 16 March 2014. Following blind peer review, it was accepted for publication on 25 September 2014) Global Health Promotion 1757-9759; Vol 0(0): 1 –8; 567179 Copyright © The Author(s) 2015, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975914567179 http://ghp.sagepub.com Downloaded from ped.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 14, 2015
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decade (12–20). Despite the fact that these studies were conducted in different parts of sub-Saharan Africa, their findings and recommendations were barely different. For instance, on the strength of their findings that the majority of a cohort of community dwellers in northern Nigeria attributed mental illness to supernatural factors, Kabir et al. (12) and Audu et al. (19) both concluded that public understanding of mental illness was poor. Other studies conducted in Nigeria (13,15) reported similar findings in the southern part of the country and came to similar conclusions. Abbo et al. (16) found that the predominant views about the causation of mental illness in Uganda were clan issues, supernatural causes and substance abuse. Teferra and Shibe (18) found that community dwellers in a region of Ethiopia mostly attributed mental illness to extrahuman factors like spirit possession and bewitchment. Similarly, in the view of a sample of community dwellers from the Democratic Republic of Congo, Burundi and South Sudan, the leading cause of mental illness was the effect of supernatural forces like bewitchment and attack by malevolent spirits (20). On the strength of their findings, the authors of these studies lamented the poor public knowledge and understanding of mental illness in their respective regions and called for further public enlightenment. They also mostly proposed public mental health enlightenment as a panacea to poor orthodox mental health service utilization. Within the framework of contemporary thinking in mental health literacy, we critically examined and present our perspectives on the calls for improved public mental health enlightenment in sub-Saharan Africa. Our focus was on what we thought were the assumptions underpinning such calls and a critique of such assumptions. We argue that the utility of public mental health enlightenment in advancing service utilization in the region may have been over-rated and that it can be improved when the effort is properly contextualized. We concluded by highlighting other equally important inclusive efforts needed to improve mental health service utilization in the region.
In perspective: calls for improved public enlightenment about mental disorders in sub-Saharan Africa The calls for improved public enlightenment about mental disorders in sub-Saharan Africa are no
doubt relevant, but such calls may have been underpinned by some debatable assumptions. In justifying their conclusions on a need for improved public enlightenment about mental disorders, Audu et al. (19) wrote that: ‘results showed widespread ignorance about causation, mode of transmission and remedies available for mental illness, with only 0.9% of respondents attributing mental illness to brain disease’. Gureje et al. (13) also wrote that: ‘only about one in ten respondents believed that biological factors or brain disease could be the cause of mental illness’ and concluded that ‘results suggest that knowledge about mental illness is very poor in the Nigerian community’. Kabir et al. (12) also wrote that ‘our results support the hypothesis that negative attitudes towards the mentally ill are fuelled by a lack of knowledge’. These arguments, for example, presuppose that non-alignment of the views of community dwellers with the biomedical understanding of mental illness connotes ‘ignorance’, for which they needed enlightenment. Measuring public knowledge and understanding in the context of mental health is often a function of how ‘knowledge’ is defined or conceptualized by the person making the assessment (21). In this case, the assumption that community dwellers in sub-Saharan Africa do not have adequate knowledge of mental illness is from the point of view of mainstream psychiatry. Mental health knowledge is diverse and multifaceted and includes knowledge and beliefs about mental disorders that emerge from prevalent culture-induced explanatory models (22,23). Being a multi-ethnic and multi-cultural region, there is bound to be a deluge of divergent views in sub-Saharan Africa about a deeply cultural concept like mental ill-health, which do not necessarily reflect ‘ignorance’. Considerations of cultural notions and practices continues to be relevant for a holistic appraisal of the explanatory models for mental illness (24,25). The calls for improved public enlightenment about mental disorders in sub-Saharan Africa may also have assumed that correcting the ‘ignorance’ of community dwellers about mental disorders will translate to improvements in utilization of mainstream mental health services. Hugo et al. (14), for instance, argued that: ‘more work needs to be done to educate the public about the psychobiological underpinnings of psychiatric disorders… A better understanding of these disorders amongst the public would…encourage the use of currently available and effective interventions’.
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There are many subtle socio-cultural factors that come into play when considering health-seeking behaviours (24,25), which may not necessarily reflect ‘ignorance’. The degree of alignment between strongly held cultural notions about illness and the remedy being offered can influence service uptake. For instance, there is evidence that one of the main factors promoting high patronage of alternative care practitioners in sub-Saharan Africa is the tendency of such practitioners to give explanations and remedies that are in tandem with pre-existing notions about mental illness in the region (26–28). The functional significance of the preferred treatment to the prospective service-user may also override all overtures from other service providers. For instance, beliefs in supernatural causes of mental illness in sub-Saharan Africa have been described as a way of situating the cause of mental illness within an external locus (29). This can absolve the sufferer from any form of sense of responsibility for the illness and its associated stigma. This thought contrasts sharply with the biomedical model, which placed more emphasis on personal vulnerabilities, with its attendant increased risk of real or perceived stigma (30–32). Therefore, the low level of utilization of mainstream psychiatry services in the region may not be reflective of the level of‘understanding’ or ‘ignorance’ but perhaps some degree of disconnect with the end-user’s worldview. The practice of mainstream psychiatry in subSaharan Africa has come a long way (29) and is currently taking hold (33,34). This development portends a potential for significant contribution of mainstream psychiatry to mental health services in the region. To fully tap into this potential, community dwellers will need to complement their traditional perspectives about mental ill-health with mainstream psychiatry views. To this extent, there is a genuine need to increase community awareness of the principles and practice of mainstream psychiatry as a form of mental health literacy. The issue is how this can be best achieved.
Public mental health enlightenment in sub-Saharan Africa: how can it be approached? Taking the comprehensive approach to public mental health education Taking a comprehensive approach to public mental health enlightenment in sub-Saharan Africa
entails respect for culturally entrenched explanatory models. Popular explanatory models that evolved over time will not simply yield to some biomedical explanation and this much has to be recognized in the course of any effort at public mental-health enlightenment. In pursuing public enlightenment, lay views of community dwellers should not be dismissed as ignorant views. Rather, biomedical models should be presented as points of view that are also gaining acceptance globally. In any case, there is evidence that biomedical and cultural explanatory models in sub-Saharan Africa are largely similar in their basic ontological conceptualization, except with different approaches (27,35,36). Therefore, enlightenment efforts should point out the connection between the two perspectives with a view to present biomedical models as complementary rather than superior. Furthermore, lay views about mental illness should not be seen as an impediment to mental health enlightenment. In fact, they should be seen as a crucial prerequisite for functional mental health literacy. The existence of a rich lay view about mental illness suggests that the community is familiar with mental illness and as such willing to discuss the issue. In any case, the classical definition of mental health literacy is ‘the possession of knowledge and skills about mental disorders which can aid their recognition, management or prevention’ (37). This definition did not specify which ‘knowledge and skills’ and should include all knowledge and skills from both mainstream and alternative mental healthcare perspectives. Public mental health education initiatives should therefore strive to preserve indigenous knowledge and skills about mental disorders and its management in sub-Saharan Africa, while advancing knowledge of mainstream psychiatry services. Moreover, certain aspects of the lay views of treatment may provide complementary knowledge of effective interventions in psychiatry. A good example is the traditional treatment of child soldiers in Mozambique, which involves a ‘ritual-bath’ that was believed to cleanse children of ‘evil-contacts’ during their war involvement and has actually been documented to reduce post-traumatic stress and aid in the re-integration of these child soldiers (38). The Yoruba healers of south-west Nigeria had also used therapies derived from cultural notions and symbolism to provide respite from a wide array of mental health problems (39). Rather than see alternative IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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explanations and practice as manifestation of ‘ignorance’, mainstream psychiatry should endeavour to actively search for further ways of incorporating alternative mental health perspectives into mainstream psychiatric services in sub-Saharan Africa.
Identifying potential partners Public mental health education in sub-Saharan Africa cannot be done successfully through the sole effort of mainstream mental health practitioners. This is in view of a shortage of human resources for mental healthcare in the region (6). There is therefore a need to identify potential partners who could be engaged as agents for propagating mainstream psychiatry knowledge and skill. Evidence abounds that a large proportion of persons seeking mental healthcare services in sub-Saharan Africa prefers and will consult alternative mental health practitioners (26,40,41) and that they often seek and act upon the advice of alternative mental health practitioners (41). Therefore, getting alternative practitioners to buy into mainstream psychiatry perspectives may translate to improved community dissemination of mainstream psychiatry knowledge and may improve mainstream psychiatry service utilization. This is more achievable when both alternative and mainstream practitioners are willing to engage in open and respectful discussions of their different perspectives and ways of doing things (42). Aside from alternative mental health practitioners, another potential partner in advancing public knowledge about mental illness in sub-Saharan Africa is the media industry in the region. Being the information hub of most civilized societies, the mass media reflects and also shapes public knowledge in relation to issues of life, including mental ill-health (43,44). Worldwide, the media are awash with themes of mental illness (45). The movie industry as a media outlet is particularly significant in the context of mental illness. This is because ‘in pursuit of their common subject [the intricacies of human emotions, thoughts, behaviours and experiences], movies and psychiatry have frequently intersected’ (46). The ways that mental disorders are, however, framed, construed and interpreted in the movies strongly impacts public perceptions of the illness (47). Therefore, if properly harnessed, the movie industry has tremendous potential as an agent of public mental health education.
Of particular importance in this regard in subSaharan Africa is the Nigerian movie industry, popularly called Nollywood. This industry has recently attained the enviable status of the second largest movie-producing body in the world (48). The products of this particular industry have also achieved an unparalleled ubiquity in the region of sub-Saharan Africa with continent-wide broadcast through satellite TV and other electronic media (49). Nollywood films are extremely popular among Nigerians, and content analysis showed that they often contain scenes depicting mental illness in line with culturally entrenched explanatory models, with scant representation of mainstream psychiatry perspectives (50–52). It would be incorrect to view community dwellers as gullible beings that are incapable of differentiating fictional representations of the causes and treatment modalities for mental illness as presented in the films from everyday reality. However, continued filmic portrayal of mental illness solely from the point of view of cultural explanatory models tends to provide an incomplete representation of the issue. In as much as movie directors are neither psychiatrists nor agents of public health education as it were, public mentalhealth enlightenment initiatives need to engage movie directors as agents of advancing mainstream mental health perspectives. In a group discussion with movie directors within the Nigerian and Ghanaian movie industry, Ampadu (53) documented that movie directors reported that they simply craft mentally ill characters based on what was ‘on the ground’. This often translates to some completely dishevelled, dirty, poorly clad person, with a lot of other culturally sanctioned stereotypes about causation and treatment. Efforts at engaging the movie industry could be geared towards removing unhelpful stereotypes from the depictions but, more importantly, to include mainstream psychiatry depictions – at least for balanced representation. A comprehensive review of media engagement for public mental health enlightenment has been done (54). On a different note, schoolchildren and adolescents are potential agents of public enlightenment if properly guided. They have also been described as the ‘eyes and ears’ of the community in rural areas of developing countries (55). School mental health programmes have been shown to have tremendous potential at making schoolchildren agents of advancing mental health literacy in regions with low
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general literacy (56). School-based mental health programmes are lacking in most countries of subSaharan Africa (57,58). A school health education curriculum with significant mental health content could be a very strategic and sustainable direction for advancing orthodox mental health literacy. Aside from children and youth, community health workers can be another key partner in mental health education programmes. They form the key staff of primary health centres, which account for the bulk of healthcare provisioning in most countries in subSaharan Africa. The accessibility of community health workers also makes them a key source of health education among community dwellers. They therefore do constitute a potential agent of public mental health education if properly guided and trained. There is an ongoing effort at equipping community health workers in sub-Saharan Africa with basic knowledge of mainstream psychiatry so that they can serve as potential service providers (59,60). Such programmes can also be expanded to include training them as agents of public mental health education. Unlike psychiatrists, community health workers work more closely with the community and, as such, information provided through them is less likely to be viewed as an effort at imposing ‘Western’ concepts.
Addressing structural barriers This paper has made attempts to justify the need to improve public awareness of mainstream psychiatry perspectives as one way of improving mental health service utilization in sub-Saharan Africa. We are, however, of the opinion that such efforts will be more successful if other structural barriers to service utilization are concurrently addressed. It is important, for instance, to consider ways in which present-day mainstream psychiatric service provisioning might perhaps be failing to meet the needs and expectations of potential service users in the region. The concentration of mental health services in the cities is a key barrier to effective mental health service delivery in developing regions like sub-Saharan Africa (61). Such services are hardly readily accessible and often do not accommodate the socio-cultural nuances of mental health. For as long as mental health services are still largely centralized and do not accommodate alternative views (61), any hope of improving
awareness of mainstream psychiatry perspectives among community dwellers in the region may remain unattainable. Aside from this, it is a fact that decades after the declaration of Alma Ata on the importance of primary level of care to global healthcare (62), recent evidence continues to support the classical thinking that public health initiatives are better implemented at community levels if they must reach the target population (63,64). By the same token, mainstream mental health services will be more accessible if situated within the framework of community-based health services. In any case, unlike the present day situation of concentration of mental health services in the cities of most countries in subSaharan Africa (61), community-based mental health services with a balanced appreciation of mainstream and alternative approaches to mental health services (65) was, decades ago, a highly celebrated and path-breaking contribution of subSaharan Africa to global psychiatric service. The growing consensus among psychiatrists in sub-Saharan Africa on a need to begin to re-enact models of community-based mental health services, which takes cognizance of socio-cultural realities in the region (66), is therefore a welcome development. A well-organized, community-based mainstream mental health service in sub-Saharan Africa should increase the visibility of whatever success that mainstream psychiatry may have made. It will also provide a real alternative to the ubiquitous alternative mental health services in the region (41,42) and, as such, create a balanced milieu for access to the two perspectives. In short, prospective service users will have a real choice in the type of mental health services that they want and information about the alternatives will be more readily available. Moreover, incorporating mental health into the primary healthcare system will ensure further accessibility and increase the availability of services that can match the increased demand that will come with improved awareness. It has been recommended that incorporation of mental health services into the mainstream primary health service is among the most important steps to increase service availability and service utilization in sub-Saharan Africa (67). A recent paper has made a critical appraisal of the key challenges, obstacles and lessons, as well as useful recommendations for the development of community mental health services in the region (68). IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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Conclusions This paper makes a case for a genuine need to advance public awareness of mainstream psychiatry perspectives to mental healthcare in sub-Saharan Africa. However, any effort at doing so must adopt a comprehensive approach, which includes paying due attention to both the biomedical and the culturally nuanced explanatory models. Other inclusive approaches include engagement with potential partners, especially the youth and the media, and making efforts at removing other structural barriers to awareness of and utilization of orthodox mental health services in the region. Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Angermeyer MC, Matschinger H, Schomerus G. Attitudes towards psychiatric treatment and people with mental illness: changes over two decades. Br J Psychiatry 2013; 203:146–151. 2. Pescosolido BA, Martin JK, Long JS, Medina TR, Phelan JC, Link B. ‘A disease like any other’? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. Am J Psychiatry 2010; 167: 1321–1330. 3. Jorm AF. Mental health literacy. Public knowledge and beliefs about mental disorders. Br J Psychiatry 2000; 177: 396–401. 4. Goldney RD, Fisher LJ, Wilson DH. Mental health literacy: an impediment to the optimum treatment of major depression in the community. J Affect Disord 2001; 64: 277–284. 5. Saxena S, Thornicroft G, Knapp M. Resources for mental health: scarcity, inequity, and inefficiency. Lancet 2007; 370: 878–889. 6. Okasha A. Mental health in Africa: the role of the WPA. World Psychiatry 2002; 1: 32–35. 7. World Health Organization. Mental Health Atlas. Geneva: WHO, 2005. 8. Muga FA, Jenkins R. Public perceptions, explanatory models and service utilization regarding mental illness and mental health care in Kenya. Soc Psychiatry Psychiatr Epidemiol 2008; 43: 469–476. 9. Lustig SL, Maldonado JR. Diagnoses of children and adolescents on initial presentation to a Nigerian outpatient psychiatry clinic. Int J Soc Psychiatry 1999; 45: 190–197. 10. Gureje O, Lasebikan V. Use of Mental Health Services in a Developing Country. Results from the Nigerian
survey of mental health and well-being. Soc Psychiatry Psychiatr Epidemiol 2006; 41: 44–46. 11. Gureje O, Alem A. Mental health policy development in Africa. Bull World Health Organ 2000; 78: 475–482 12. Kabir M, Iliyasu Z, Abubakar IS, Aliyu MH. (2004). Perception and beliefs about mental illness among adults in Karfi village, northern Nigeria. BMC Int Health Hum Rights 2004; 4: 3. 13. Gureje O, Lasebikan VO, Ephraim-Oluwanuga O, Olley BO, Kola L. Community study of knowledge of and attitude to mental illness in Nigeria. Br J Psychiatry 2005; 186: 436–441. 14. Hugo CJ, Boshoff DE, Traut A, Zungu-Dirwayi N, Stein DJ. Community attitudes toward and knowledge of mental illness in South Africa. Soc Psychiatry Psychiatr Epidemiol 2003; 38: 715–719. 15. Adewuya AO, Makanjuola RO. Lay beliefs regarding causes of mental illness in Nigeria: pattern and correlates. Soc Psychiatry Psychiatr Epidemiol 2008; 43: 336–341. 16. Abbo C, Okello E, Ekblad S, Waako P, Musisi S. Lay concepts of psychosis in Busoga, Eastern Uganda: A pilot study. World Cultural Psychiatr Res Rev 2008; 7: 132–145. 17. Sorsdahl K, Stein DJ, Grimsrud A, Seedat S, Flisher AJ, Williams DR, et al. Traditional healers in the treatment of common mental disorders in South Africa. J Nerv Ment Dis 2009; 197: 434–441. 18. Teferra S, Shibre T. Perceived causes of severe mental disturbance and preferred interventions by the Borana semi-nomadic population in southern Ethiopia: a qualitative study. BMC Psychiatry 2012; 12: 79. 19. Audu IA, Idris SH, Olisah VO, Sheikh TL. Stigmatization of people with mental illness among inhabitants of a rural community in northern Nigeria. Int J Soc Psychiatry 2013; 59: 55–60. 20. Ventevogel P, Jordans M, Reis R, de Jong J. Madness or sadness? Local concepts of mental illness in four conflict-affected African communities. Confl Health 2013; 18: 3. 21. Bourget B, Chenier R. Mental health literacy in Canada: Phase One Report. Mental Health Literacy Project. Montreal: Canadian Alliance on Mental Illness and Mental Health, 2007. 22. Griffiths KM, Christensen H, Jorm AF. Mental health literacy as a function of remoteness of residence: an Australian national study. BMC Public Health 2009; 9: 92. 23. Lauber C, Nordt C, Rossler W. Recommendations of mental health professionals and the general population on how to treat mental disorders. Soc Psychiatry Psychiatr Epidemiol 2005; 40: 835–843. 24. Groleau D, Kirmayer LJ. Sociosomatic theory in Vietnamese immigrants’ narratives of distress. Anthropol Med 2004; 11: 117–133. 25. Groleau D, Soulière M, Kirmayer LJ. Breastfeeding and the cultural configuration of social space among Vietnamese immigrant woman. Health & Place 2006; 12: 516–526. 26. Abbo C. Traditional healers and management of mental health problems in Uganda. Saarbrueken:
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Downloaded from ped.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 14, 2015
7
Original Article
LAP Lambert Academic Publishing; 2010. 27. Sorsdahl KR, Flisher AJ, Wilson Z, Stein DJ. Explanatory models of mental disorders and treatment practices among traditional healers in Mpumulanga, South Africa. Afr J Psychiatry 2010; 13: 284–290. 28. World Health Organization. Traditional medicine – Growing needs and potential. Geneva: WHO; 2003. 29. Odejide AO, Oyewunmi LK, Ohaeri JU. Psychiatry in Africa: an overview. Am J Psychiatry 1989; 146: 708–715. 30. Walker I and Read J. The differential effectiveness of psycho-social and biogenetic causal explanations in reducing negative attitudes towards mental illness. Psychiatry 2002; 65: 313–325. 31. Mann CE, Himelein MJ. Factors associated with stigmatization of persons with mental illness. Psychiatr Serv 2004; 55: 185–187. 32. Phelan JC, Yang LH, Cruz-Rojas R. Effects of attributing serious mental illnesses to genetic causes on orientations to treatment. Psychiatr Serv 2006; 57: 382–387. 33. Njenga F. Focus on psychiatry in East Africa. Br J Psychiatry 2002; 181: 354–359. 34. Gillis L. The historical development of psychiatry in South Africa since the 17th century. S Afr J Psychiatr 2012; 18: 78–82. 35. Morakinyo O, Akiwowo A. The Yoruba ontology of personality and motivation. A multidisciplinary study. J Soc Biol Struct 1981; 4: 19–38. 36. Abbo C. Profiles and outcome of traditional healing practices for severe mental illnesses in two districts of Eastern Uganda. Glob Health Action 2011; 4: DOI: 10.3402/gha.v4i0.7117. 37. Jorm AF, Korten AE, Jacomb PA, Christensen H, Rodgers B, Pollitt P. Mental health literacy: A survey of the public’s ability to recognize mental disorders and their beliefs about the effectiveness of treatment. Med J Austr 1997; 166: 182–186. 38. Honwana A. Culture and politics: War, reconciliation and citizenship in Mozambique. Inaugural Address – Prince Clause Chair in Development and Equity. Hague, The Netherlands: International Institute of Social Studies; 2008, pp. 14–15. 39. Makanjuola RO, Jaiyeola AA. Yoruba traditional healers in psychiatry. II. Management of psychiatric disorders. Afr J Med Sci 1987; 16: 61–73. 40. Adewuya A, Makanjuola R. Preferred treatment for mental illness among Southwestern Nigerians. Psychiatr Serv 2009; 60: 121–124. 41. Sorsdahl K, Stein DJ, Grimsrud A, Seedat S, Flisher AJ, Williams DR, et al. Traditional healers in the treatment of common mental disorders in South Africa. J Nerv Ment Dis 2009; 197: 434–441. 42. Abbo C. Profiles and outcome of traditional healing practices for severe mental illnesses in two districts of Eastern Uganda. Glob Health Action 2011; 4: DOI: 10.3402/gha.v4i0.7117 43. Hafferty FW, Foster S. Decontextualizing disability in the crime mystery genre: The case of the invisible handicap. Disabil Soc 1994; 9:185–206. 44. Klin A, Lemish D. Mental disorders stigma in the media: review of studies on production, content and
influences. J Health Commun 2008; 13: 434–449. 45. Wahl OF, Kaye AL. Mental illness topics in popular periodicals. Community Ment Health J 1992; 28: 21–28. 46. Schneider I. Foreword. In: Gabbard GO and Gabbard K (eds) Psychiatry and the cinema, 2nd ed. Washington, DC: American Psychiatric Press; 1999, pp. 15–16. 47. Sieff EM. Media frames of mental illnesses: The potential impact of negative frames. J Ment Health 2003; 12: 259–269. 48. UNESCO Institute for Statistics. Analysis of the UIS International Survey on Feature Film Statistics. Montreal, Quebec, Canada: UNESCO Institute for Statistics; 2011. Available at: http://www.uis.unesco. org/FactSheets/Documents/Infosheet_No1_cinema_ EN.pdf (accessed January 2013). 49. Atilola O, Olayiwola F. The Nigerian home video boom: Should Nigerian psychiatrists be worried? Lessons from content analysis and views of community dwellers. Int J Soc Psychiatry 2011; 58: 470–476. doi: 10.1177/0020764011408544. 50. Aina OF, Olorunshola DA. Alcohol and substance use portrayals in Nigerian video tapes: an analysis of 479 films and implications for public drug education. Int Q Community Health Educ 2008; 28: 63–71. 51. Olugbile O, Zachariah MP, Kinyinu A, Coker A, Ojo O, Isichei B. Yoruba world view and the nature of psychotic illness. Afr J Psychiatry 2009; 12: 149–156. 52. Atilola O and Olayiwola F. Frames of mental illness in the Yoruba genre of Nigerian movies: Implications for orthodox mental health care. Transcult Psychiatry 2013; 50: 442–454. 53. Ampadu VE. The depiction of mental illness in Nigerian and Ghanaian movies: A negative or positive impact on mental health awareness in Ghana? Dissertation. University of Leeds, UK; August 2012. 54. Salter M, Brian P. The stigma of mental illness: how you can use the media to reduce it. Psychiatrist 2000; 24: 281–283. 55. Mubbashar MH, Farooq S. Mental health literacy in developing countries. Br J Psychiatry 2001; 179: 75. 56. Rehman A, Mubbashar MH, Gater R, Goldberg D. Randomized trial of impact of school mental health programme in rural Rawalpindi, Pakistan. Lancet 1998; 352: 1022–1025. 57. Bakare MO, Ubochi VN, Ebigbo PO, Orovwigho AO. Problem and pro-social behavior among Nigerian children with intellectual disability: the implication for developing policy for school based mental health programs. Ital J Pediatr 2010; 36: 37. 58. Ibeziako PI, Omigbodun OO, Bella TT. Assessment of need for a school-based mental health programme in Nigeria: perspectives of school administrators. Int Rev Psychiatry 2008; 20: 271–280. 59. Makanjuola V, Doku V, Jenkins R, Gureje O. Impact of a one-week intensive ‘training of trainers’ workshop for community health workers in southwest Nigeria. Ment Health Fam Med 2012; 9: 33–38. 60. Jenkins R, Kiima D, Njenga F, Okonji M, Kingora J, Kathuku D, et al. Integration of mental health into IUHPE – Global Health Promotion Vol. 0, No. 0 201X
Downloaded from ped.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 14, 2015
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O. Atilola
primary care in Kenya. World Psychiatry 2010; 9: 118–120. 61. Saraceno B, Ommeren M, Batniji R, Cohen A, Gureje O, Mahoney J, et al. Barriers to improvement of mental health services in low-income and middleincome countries. Global Mental Health 5. Lancet 2007; 370: 1164–1174. 62. World Health Organization. Primary health care. Report of the Alma Ata international conference on primary health care. Geneva: WHO; 1978. 63. World Health Organization. Primary Health Care: Now more than ever. Geneva: WHO; 2008. 64. Frenk J. Reinventing primary health care: the need for systems integration. Lancet 2009; 13: 170–173.
65. Lambo TA. Patterns of psychiatric care in developing African countries. In: Kiev A (ed). Magic, faith and healing. Glencoe: The Free Press, 1964,pp. 443–453. 66. Alem A, Jacobsson L, Hanlon C. Community based mental health care in Africa: mental health workers’ views. World Psychiatry 2008; 7: 54–57. 67. Jenkins R, Kiima D, Okonji M, Njenga F, Kingora J, Lock S. Integration of mental health into primary care and community health working in Kenya: context, rationale, coverage and sustainability. Ment Health Fam Med 2010; 7: 37–47. 68. Hanlon C, Wondimagegn D, Alem A. Lessons learned in developing community mental health care in Africa. World Psychiatry 2010; 9: 185–189.
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research-article2015
PED0010.1177/1757975914567179O. AtilolaOriginal Article
Original Article Mental health service utilization in sub-Saharan Africa: is public mental health literacy the problem? Setting the perspectives right Olayinka Atilola1
Abstract: The severely constrained resources for mental health service in less-developed regions like sub-Saharan Africa underscore the need for good public mental health literacy as a potential additional mental health resource. Several studies examining the level of public knowledge about the nature and dynamics of mental illness in sub-Saharan Africa in the last decade had concluded that such knowledge was poor and had called for further public enlightenment. What was thought to be mental health ‘ignorance’ has also been blamed for poor mainstream service utilization. These views however assume that non-alignment of the views of community dwellers in sub-Saharan Africa with the biomedical understanding of mental illness connotes ‘ignorance’, and that correcting such ‘ignorance’ will translate to improvements in service utilization. Within the framework of contemporary thinking in mental health literacy, this paper argues that such assumptions are not culturally nuanced and may have overrated the usefulness of de-contextualized public engagement in enhancing mental health service utilization in the region. The paper concludes with a discourse on how to contextualize public mental health enlightenment in the region and the wider policy initiatives that can improve mental health service utilization. Keywords: public enlightenment, mental illness, cultural explanatory model, mental health literacy, Africa, health promotion
Introduction There are recent reports from the developed countries of Europe and America that public knowledge of the nature and dynamics of mental illness (as understood by mainstream psychiatry) has improved in the last decade (1,2). The improved knowledge and awareness has also been observed to coincide with periods of observable improvements in mainstream mental health service utilization (1). This observation supports the earlier views that improved public knowledge and awareness about mental disorders has tremendous implications for service utilization and that it is critical to the success of mental healthcare delivery initiatives (3,4). Improving public knowledge and overcoming barriers to mental health
service utilization is even more germane in developing regions like sub-Saharan Africa, where mental healthcare resources are limited or inadequate in the first place (5–7). Poor understanding of the nature and dynamics of mental disorders has been described as a major challenge to implementation of mental health services initiatives in sub-Saharan Africa (8). The same has also been speculated as an impediment to mainstream psychiatry service utilization (9,10) and a barrier to the formulation and implementation of mental health policies in the region (11). There is a growing interest in public knowledge about mental disorders within the academic community in sub-Saharan Africa, as several studies in the region had focused on this subject in the last
1. Department of Behavioural Medicine, Lagos State University College of Medicine Ikeja, Nigeria. Email: [email protected] (This manuscript was submitted on 16 March 2014. Following blind peer review, it was accepted for publication on 25 September 2014) Global Health Promotion 1757-9759; Vol 0(0): 1 –8; 567179 Copyright © The Author(s) 2015, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975914567179 http://ghp.sagepub.com Downloaded from ped.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 14, 2015
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decade (12–20). Despite the fact that these studies were conducted in different parts of sub-Saharan Africa, their findings and recommendations were barely different. For instance, on the strength of their findings that the majority of a cohort of community dwellers in northern Nigeria attributed mental illness to supernatural factors, Kabir et al. (12) and Audu et al. (19) both concluded that public understanding of mental illness was poor. Other studies conducted in Nigeria (13,15) reported similar findings in the southern part of the country and came to similar conclusions. Abbo et al. (16) found that the predominant views about the causation of mental illness in Uganda were clan issues, supernatural causes and substance abuse. Teferra and Shibe (18) found that community dwellers in a region of Ethiopia mostly attributed mental illness to extrahuman factors like spirit possession and bewitchment. Similarly, in the view of a sample of community dwellers from the Democratic Republic of Congo, Burundi and South Sudan, the leading cause of mental illness was the effect of supernatural forces like bewitchment and attack by malevolent spirits (20). On the strength of their findings, the authors of these studies lamented the poor public knowledge and understanding of mental illness in their respective regions and called for further public enlightenment. They also mostly proposed public mental health enlightenment as a panacea to poor orthodox mental health service utilization. Within the framework of contemporary thinking in mental health literacy, we critically examined and present our perspectives on the calls for improved public mental health enlightenment in sub-Saharan Africa. Our focus was on what we thought were the assumptions underpinning such calls and a critique of such assumptions. We argue that the utility of public mental health enlightenment in advancing service utilization in the region may have been over-rated and that it can be improved when the effort is properly contextualized. We concluded by highlighting other equally important inclusive efforts needed to improve mental health service utilization in the region.
In perspective: calls for improved public enlightenment about mental disorders in sub-Saharan Africa The calls for improved public enlightenment about mental disorders in sub-Saharan Africa are no
doubt relevant, but such calls may have been underpinned by some debatable assumptions. In justifying their conclusions on a need for improved public enlightenment about mental disorders, Audu et al. (19) wrote that: ‘results showed widespread ignorance about causation, mode of transmission and remedies available for mental illness, with only 0.9% of respondents attributing mental illness to brain disease’. Gureje et al. (13) also wrote that: ‘only about one in ten respondents believed that biological factors or brain disease could be the cause of mental illness’ and concluded that ‘results suggest that knowledge about mental illness is very poor in the Nigerian community’. Kabir et al. (12) also wrote that ‘our results support the hypothesis that negative attitudes towards the mentally ill are fuelled by a lack of knowledge’. These arguments, for example, presuppose that non-alignment of the views of community dwellers with the biomedical understanding of mental illness connotes ‘ignorance’, for which they needed enlightenment. Measuring public knowledge and understanding in the context of mental health is often a function of how ‘knowledge’ is defined or conceptualized by the person making the assessment (21). In this case, the assumption that community dwellers in sub-Saharan Africa do not have adequate knowledge of mental illness is from the point of view of mainstream psychiatry. Mental health knowledge is diverse and multifaceted and includes knowledge and beliefs about mental disorders that emerge from prevalent culture-induced explanatory models (22,23). Being a multi-ethnic and multi-cultural region, there is bound to be a deluge of divergent views in sub-Saharan Africa about a deeply cultural concept like mental ill-health, which do not necessarily reflect ‘ignorance’. Considerations of cultural notions and practices continues to be relevant for a holistic appraisal of the explanatory models for mental illness (24,25). The calls for improved public enlightenment about mental disorders in sub-Saharan Africa may also have assumed that correcting the ‘ignorance’ of community dwellers about mental disorders will translate to improvements in utilization of mainstream mental health services. Hugo et al. (14), for instance, argued that: ‘more work needs to be done to educate the public about the psychobiological underpinnings of psychiatric disorders… A better understanding of these disorders amongst the public would…encourage the use of currently available and effective interventions’.
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There are many subtle socio-cultural factors that come into play when considering health-seeking behaviours (24,25), which may not necessarily reflect ‘ignorance’. The degree of alignment between strongly held cultural notions about illness and the remedy being offered can influence service uptake. For instance, there is evidence that one of the main factors promoting high patronage of alternative care practitioners in sub-Saharan Africa is the tendency of such practitioners to give explanations and remedies that are in tandem with pre-existing notions about mental illness in the region (26–28). The functional significance of the preferred treatment to the prospective service-user may also override all overtures from other service providers. For instance, beliefs in supernatural causes of mental illness in sub-Saharan Africa have been described as a way of situating the cause of mental illness within an external locus (29). This can absolve the sufferer from any form of sense of responsibility for the illness and its associated stigma. This thought contrasts sharply with the biomedical model, which placed more emphasis on personal vulnerabilities, with its attendant increased risk of real or perceived stigma (30–32). Therefore, the low level of utilization of mainstream psychiatry services in the region may not be reflective of the level of‘understanding’ or ‘ignorance’ but perhaps some degree of disconnect with the end-user’s worldview. The practice of mainstream psychiatry in subSaharan Africa has come a long way (29) and is currently taking hold (33,34). This development portends a potential for significant contribution of mainstream psychiatry to mental health services in the region. To fully tap into this potential, community dwellers will need to complement their traditional perspectives about mental ill-health with mainstream psychiatry views. To this extent, there is a genuine need to increase community awareness of the principles and practice of mainstream psychiatry as a form of mental health literacy. The issue is how this can be best achieved.
Public mental health enlightenment in sub-Saharan Africa: how can it be approached? Taking the comprehensive approach to public mental health education Taking a comprehensive approach to public mental health enlightenment in sub-Saharan Africa
entails respect for culturally entrenched explanatory models. Popular explanatory models that evolved over time will not simply yield to some biomedical explanation and this much has to be recognized in the course of any effort at public mental-health enlightenment. In pursuing public enlightenment, lay views of community dwellers should not be dismissed as ignorant views. Rather, biomedical models should be presented as points of view that are also gaining acceptance globally. In any case, there is evidence that biomedical and cultural explanatory models in sub-Saharan Africa are largely similar in their basic ontological conceptualization, except with different approaches (27,35,36). Therefore, enlightenment efforts should point out the connection between the two perspectives with a view to present biomedical models as complementary rather than superior. Furthermore, lay views about mental illness should not be seen as an impediment to mental health enlightenment. In fact, they should be seen as a crucial prerequisite for functional mental health literacy. The existence of a rich lay view about mental illness suggests that the community is familiar with mental illness and as such willing to discuss the issue. In any case, the classical definition of mental health literacy is ‘the possession of knowledge and skills about mental disorders which can aid their recognition, management or prevention’ (37). This definition did not specify which ‘knowledge and skills’ and should include all knowledge and skills from both mainstream and alternative mental healthcare perspectives. Public mental health education initiatives should therefore strive to preserve indigenous knowledge and skills about mental disorders and its management in sub-Saharan Africa, while advancing knowledge of mainstream psychiatry services. Moreover, certain aspects of the lay views of treatment may provide complementary knowledge of effective interventions in psychiatry. A good example is the traditional treatment of child soldiers in Mozambique, which involves a ‘ritual-bath’ that was believed to cleanse children of ‘evil-contacts’ during their war involvement and has actually been documented to reduce post-traumatic stress and aid in the re-integration of these child soldiers (38). The Yoruba healers of south-west Nigeria had also used therapies derived from cultural notions and symbolism to provide respite from a wide array of mental health problems (39). Rather than see alternative IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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explanations and practice as manifestation of ‘ignorance’, mainstream psychiatry should endeavour to actively search for further ways of incorporating alternative mental health perspectives into mainstream psychiatric services in sub-Saharan Africa.
Identifying potential partners Public mental health education in sub-Saharan Africa cannot be done successfully through the sole effort of mainstream mental health practitioners. This is in view of a shortage of human resources for mental healthcare in the region (6). There is therefore a need to identify potential partners who could be engaged as agents for propagating mainstream psychiatry knowledge and skill. Evidence abounds that a large proportion of persons seeking mental healthcare services in sub-Saharan Africa prefers and will consult alternative mental health practitioners (26,40,41) and that they often seek and act upon the advice of alternative mental health practitioners (41). Therefore, getting alternative practitioners to buy into mainstream psychiatry perspectives may translate to improved community dissemination of mainstream psychiatry knowledge and may improve mainstream psychiatry service utilization. This is more achievable when both alternative and mainstream practitioners are willing to engage in open and respectful discussions of their different perspectives and ways of doing things (42). Aside from alternative mental health practitioners, another potential partner in advancing public knowledge about mental illness in sub-Saharan Africa is the media industry in the region. Being the information hub of most civilized societies, the mass media reflects and also shapes public knowledge in relation to issues of life, including mental ill-health (43,44). Worldwide, the media are awash with themes of mental illness (45). The movie industry as a media outlet is particularly significant in the context of mental illness. This is because ‘in pursuit of their common subject [the intricacies of human emotions, thoughts, behaviours and experiences], movies and psychiatry have frequently intersected’ (46). The ways that mental disorders are, however, framed, construed and interpreted in the movies strongly impacts public perceptions of the illness (47). Therefore, if properly harnessed, the movie industry has tremendous potential as an agent of public mental health education.
Of particular importance in this regard in subSaharan Africa is the Nigerian movie industry, popularly called Nollywood. This industry has recently attained the enviable status of the second largest movie-producing body in the world (48). The products of this particular industry have also achieved an unparalleled ubiquity in the region of sub-Saharan Africa with continent-wide broadcast through satellite TV and other electronic media (49). Nollywood films are extremely popular among Nigerians, and content analysis showed that they often contain scenes depicting mental illness in line with culturally entrenched explanatory models, with scant representation of mainstream psychiatry perspectives (50–52). It would be incorrect to view community dwellers as gullible beings that are incapable of differentiating fictional representations of the causes and treatment modalities for mental illness as presented in the films from everyday reality. However, continued filmic portrayal of mental illness solely from the point of view of cultural explanatory models tends to provide an incomplete representation of the issue. In as much as movie directors are neither psychiatrists nor agents of public health education as it were, public mentalhealth enlightenment initiatives need to engage movie directors as agents of advancing mainstream mental health perspectives. In a group discussion with movie directors within the Nigerian and Ghanaian movie industry, Ampadu (53) documented that movie directors reported that they simply craft mentally ill characters based on what was ‘on the ground’. This often translates to some completely dishevelled, dirty, poorly clad person, with a lot of other culturally sanctioned stereotypes about causation and treatment. Efforts at engaging the movie industry could be geared towards removing unhelpful stereotypes from the depictions but, more importantly, to include mainstream psychiatry depictions – at least for balanced representation. A comprehensive review of media engagement for public mental health enlightenment has been done (54). On a different note, schoolchildren and adolescents are potential agents of public enlightenment if properly guided. They have also been described as the ‘eyes and ears’ of the community in rural areas of developing countries (55). School mental health programmes have been shown to have tremendous potential at making schoolchildren agents of advancing mental health literacy in regions with low
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general literacy (56). School-based mental health programmes are lacking in most countries of subSaharan Africa (57,58). A school health education curriculum with significant mental health content could be a very strategic and sustainable direction for advancing orthodox mental health literacy. Aside from children and youth, community health workers can be another key partner in mental health education programmes. They form the key staff of primary health centres, which account for the bulk of healthcare provisioning in most countries in subSaharan Africa. The accessibility of community health workers also makes them a key source of health education among community dwellers. They therefore do constitute a potential agent of public mental health education if properly guided and trained. There is an ongoing effort at equipping community health workers in sub-Saharan Africa with basic knowledge of mainstream psychiatry so that they can serve as potential service providers (59,60). Such programmes can also be expanded to include training them as agents of public mental health education. Unlike psychiatrists, community health workers work more closely with the community and, as such, information provided through them is less likely to be viewed as an effort at imposing ‘Western’ concepts.
Addressing structural barriers This paper has made attempts to justify the need to improve public awareness of mainstream psychiatry perspectives as one way of improving mental health service utilization in sub-Saharan Africa. We are, however, of the opinion that such efforts will be more successful if other structural barriers to service utilization are concurrently addressed. It is important, for instance, to consider ways in which present-day mainstream psychiatric service provisioning might perhaps be failing to meet the needs and expectations of potential service users in the region. The concentration of mental health services in the cities is a key barrier to effective mental health service delivery in developing regions like sub-Saharan Africa (61). Such services are hardly readily accessible and often do not accommodate the socio-cultural nuances of mental health. For as long as mental health services are still largely centralized and do not accommodate alternative views (61), any hope of improving
awareness of mainstream psychiatry perspectives among community dwellers in the region may remain unattainable. Aside from this, it is a fact that decades after the declaration of Alma Ata on the importance of primary level of care to global healthcare (62), recent evidence continues to support the classical thinking that public health initiatives are better implemented at community levels if they must reach the target population (63,64). By the same token, mainstream mental health services will be more accessible if situated within the framework of community-based health services. In any case, unlike the present day situation of concentration of mental health services in the cities of most countries in subSaharan Africa (61), community-based mental health services with a balanced appreciation of mainstream and alternative approaches to mental health services (65) was, decades ago, a highly celebrated and path-breaking contribution of subSaharan Africa to global psychiatric service. The growing consensus among psychiatrists in sub-Saharan Africa on a need to begin to re-enact models of community-based mental health services, which takes cognizance of socio-cultural realities in the region (66), is therefore a welcome development. A well-organized, community-based mainstream mental health service in sub-Saharan Africa should increase the visibility of whatever success that mainstream psychiatry may have made. It will also provide a real alternative to the ubiquitous alternative mental health services in the region (41,42) and, as such, create a balanced milieu for access to the two perspectives. In short, prospective service users will have a real choice in the type of mental health services that they want and information about the alternatives will be more readily available. Moreover, incorporating mental health into the primary healthcare system will ensure further accessibility and increase the availability of services that can match the increased demand that will come with improved awareness. It has been recommended that incorporation of mental health services into the mainstream primary health service is among the most important steps to increase service availability and service utilization in sub-Saharan Africa (67). A recent paper has made a critical appraisal of the key challenges, obstacles and lessons, as well as useful recommendations for the development of community mental health services in the region (68). IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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Conclusions This paper makes a case for a genuine need to advance public awareness of mainstream psychiatry perspectives to mental healthcare in sub-Saharan Africa. However, any effort at doing so must adopt a comprehensive approach, which includes paying due attention to both the biomedical and the culturally nuanced explanatory models. Other inclusive approaches include engagement with potential partners, especially the youth and the media, and making efforts at removing other structural barriers to awareness of and utilization of orthodox mental health services in the region. Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Angermeyer MC, Matschinger H, Schomerus G. Attitudes towards psychiatric treatment and people with mental illness: changes over two decades. Br J Psychiatry 2013; 203:146–151. 2. Pescosolido BA, Martin JK, Long JS, Medina TR, Phelan JC, Link B. ‘A disease like any other’? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. Am J Psychiatry 2010; 167: 1321–1330. 3. Jorm AF. Mental health literacy. Public knowledge and beliefs about mental disorders. Br J Psychiatry 2000; 177: 396–401. 4. Goldney RD, Fisher LJ, Wilson DH. Mental health literacy: an impediment to the optimum treatment of major depression in the community. J Affect Disord 2001; 64: 277–284. 5. Saxena S, Thornicroft G, Knapp M. Resources for mental health: scarcity, inequity, and inefficiency. Lancet 2007; 370: 878–889. 6. Okasha A. Mental health in Africa: the role of the WPA. World Psychiatry 2002; 1: 32–35. 7. World Health Organization. Mental Health Atlas. Geneva: WHO, 2005. 8. Muga FA, Jenkins R. Public perceptions, explanatory models and service utilization regarding mental illness and mental health care in Kenya. Soc Psychiatry Psychiatr Epidemiol 2008; 43: 469–476. 9. Lustig SL, Maldonado JR. Diagnoses of children and adolescents on initial presentation to a Nigerian outpatient psychiatry clinic. Int J Soc Psychiatry 1999; 45: 190–197. 10. Gureje O, Lasebikan V. Use of Mental Health Services in a Developing Country. Results from the Nigerian
survey of mental health and well-being. Soc Psychiatry Psychiatr Epidemiol 2006; 41: 44–46. 11. Gureje O, Alem A. Mental health policy development in Africa. Bull World Health Organ 2000; 78: 475–482 12. Kabir M, Iliyasu Z, Abubakar IS, Aliyu MH. (2004). Perception and beliefs about mental illness among adults in Karfi village, northern Nigeria. BMC Int Health Hum Rights 2004; 4: 3. 13. Gureje O, Lasebikan VO, Ephraim-Oluwanuga O, Olley BO, Kola L. Community study of knowledge of and attitude to mental illness in Nigeria. Br J Psychiatry 2005; 186: 436–441. 14. Hugo CJ, Boshoff DE, Traut A, Zungu-Dirwayi N, Stein DJ. Community attitudes toward and knowledge of mental illness in South Africa. Soc Psychiatry Psychiatr Epidemiol 2003; 38: 715–719. 15. Adewuya AO, Makanjuola RO. Lay beliefs regarding causes of mental illness in Nigeria: pattern and correlates. Soc Psychiatry Psychiatr Epidemiol 2008; 43: 336–341. 16. Abbo C, Okello E, Ekblad S, Waako P, Musisi S. Lay concepts of psychosis in Busoga, Eastern Uganda: A pilot study. World Cultural Psychiatr Res Rev 2008; 7: 132–145. 17. Sorsdahl K, Stein DJ, Grimsrud A, Seedat S, Flisher AJ, Williams DR, et al. Traditional healers in the treatment of common mental disorders in South Africa. J Nerv Ment Dis 2009; 197: 434–441. 18. Teferra S, Shibre T. Perceived causes of severe mental disturbance and preferred interventions by the Borana semi-nomadic population in southern Ethiopia: a qualitative study. BMC Psychiatry 2012; 12: 79. 19. Audu IA, Idris SH, Olisah VO, Sheikh TL. Stigmatization of people with mental illness among inhabitants of a rural community in northern Nigeria. Int J Soc Psychiatry 2013; 59: 55–60. 20. Ventevogel P, Jordans M, Reis R, de Jong J. Madness or sadness? Local concepts of mental illness in four conflict-affected African communities. Confl Health 2013; 18: 3. 21. Bourget B, Chenier R. Mental health literacy in Canada: Phase One Report. Mental Health Literacy Project. Montreal: Canadian Alliance on Mental Illness and Mental Health, 2007. 22. Griffiths KM, Christensen H, Jorm AF. Mental health literacy as a function of remoteness of residence: an Australian national study. BMC Public Health 2009; 9: 92. 23. Lauber C, Nordt C, Rossler W. Recommendations of mental health professionals and the general population on how to treat mental disorders. Soc Psychiatry Psychiatr Epidemiol 2005; 40: 835–843. 24. Groleau D, Kirmayer LJ. Sociosomatic theory in Vietnamese immigrants’ narratives of distress. Anthropol Med 2004; 11: 117–133. 25. Groleau D, Soulière M, Kirmayer LJ. Breastfeeding and the cultural configuration of social space among Vietnamese immigrant woman. Health & Place 2006; 12: 516–526. 26. Abbo C. Traditional healers and management of mental health problems in Uganda. Saarbrueken:
IUHPE – Global Health Promotion Vol. 0, No. 0 201X
Downloaded from ped.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 14, 2015
7
Original Article
LAP Lambert Academic Publishing; 2010. 27. Sorsdahl KR, Flisher AJ, Wilson Z, Stein DJ. Explanatory models of mental disorders and treatment practices among traditional healers in Mpumulanga, South Africa. Afr J Psychiatry 2010; 13: 284–290. 28. World Health Organization. Traditional medicine – Growing needs and potential. Geneva: WHO; 2003. 29. Odejide AO, Oyewunmi LK, Ohaeri JU. Psychiatry in Africa: an overview. Am J Psychiatry 1989; 146: 708–715. 30. Walker I and Read J. The differential effectiveness of psycho-social and biogenetic causal explanations in reducing negative attitudes towards mental illness. Psychiatry 2002; 65: 313–325. 31. Mann CE, Himelein MJ. Factors associated with stigmatization of persons with mental illness. Psychiatr Serv 2004; 55: 185–187. 32. Phelan JC, Yang LH, Cruz-Rojas R. Effects of attributing serious mental illnesses to genetic causes on orientations to treatment. Psychiatr Serv 2006; 57: 382–387. 33. Njenga F. Focus on psychiatry in East Africa. Br J Psychiatry 2002; 181: 354–359. 34. Gillis L. The historical development of psychiatry in South Africa since the 17th century. S Afr J Psychiatr 2012; 18: 78–82. 35. Morakinyo O, Akiwowo A. The Yoruba ontology of personality and motivation. A multidisciplinary study. J Soc Biol Struct 1981; 4: 19–38. 36. Abbo C. Profiles and outcome of traditional healing practices for severe mental illnesses in two districts of Eastern Uganda. Glob Health Action 2011; 4: DOI: 10.3402/gha.v4i0.7117. 37. Jorm AF, Korten AE, Jacomb PA, Christensen H, Rodgers B, Pollitt P. Mental health literacy: A survey of the public’s ability to recognize mental disorders and their beliefs about the effectiveness of treatment. Med J Austr 1997; 166: 182–186. 38. Honwana A. Culture and politics: War, reconciliation and citizenship in Mozambique. Inaugural Address – Prince Clause Chair in Development and Equity. Hague, The Netherlands: International Institute of Social Studies; 2008, pp. 14–15. 39. Makanjuola RO, Jaiyeola AA. Yoruba traditional healers in psychiatry. II. Management of psychiatric disorders. Afr J Med Sci 1987; 16: 61–73. 40. Adewuya A, Makanjuola R. Preferred treatment for mental illness among Southwestern Nigerians. Psychiatr Serv 2009; 60: 121–124. 41. Sorsdahl K, Stein DJ, Grimsrud A, Seedat S, Flisher AJ, Williams DR, et al. Traditional healers in the treatment of common mental disorders in South Africa. J Nerv Ment Dis 2009; 197: 434–441. 42. Abbo C. Profiles and outcome of traditional healing practices for severe mental illnesses in two districts of Eastern Uganda. Glob Health Action 2011; 4: DOI: 10.3402/gha.v4i0.7117 43. Hafferty FW, Foster S. Decontextualizing disability in the crime mystery genre: The case of the invisible handicap. Disabil Soc 1994; 9:185–206. 44. Klin A, Lemish D. Mental disorders stigma in the media: review of studies on production, content and
influences. J Health Commun 2008; 13: 434–449. 45. Wahl OF, Kaye AL. Mental illness topics in popular periodicals. Community Ment Health J 1992; 28: 21–28. 46. Schneider I. Foreword. In: Gabbard GO and Gabbard K (eds) Psychiatry and the cinema, 2nd ed. Washington, DC: American Psychiatric Press; 1999, pp. 15–16. 47. Sieff EM. Media frames of mental illnesses: The potential impact of negative frames. J Ment Health 2003; 12: 259–269. 48. UNESCO Institute for Statistics. Analysis of the UIS International Survey on Feature Film Statistics. Montreal, Quebec, Canada: UNESCO Institute for Statistics; 2011. Available at: http://www.uis.unesco. org/FactSheets/Documents/Infosheet_No1_cinema_ EN.pdf (accessed January 2013). 49. Atilola O, Olayiwola F. The Nigerian home video boom: Should Nigerian psychiatrists be worried? Lessons from content analysis and views of community dwellers. Int J Soc Psychiatry 2011; 58: 470–476. doi: 10.1177/0020764011408544. 50. Aina OF, Olorunshola DA. Alcohol and substance use portrayals in Nigerian video tapes: an analysis of 479 films and implications for public drug education. Int Q Community Health Educ 2008; 28: 63–71. 51. Olugbile O, Zachariah MP, Kinyinu A, Coker A, Ojo O, Isichei B. Yoruba world view and the nature of psychotic illness. Afr J Psychiatry 2009; 12: 149–156. 52. Atilola O and Olayiwola F. Frames of mental illness in the Yoruba genre of Nigerian movies: Implications for orthodox mental health care. Transcult Psychiatry 2013; 50: 442–454. 53. Ampadu VE. The depiction of mental illness in Nigerian and Ghanaian movies: A negative or positive impact on mental health awareness in Ghana? Dissertation. University of Leeds, UK; August 2012. 54. Salter M, Brian P. The stigma of mental illness: how you can use the media to reduce it. Psychiatrist 2000; 24: 281–283. 55. Mubbashar MH, Farooq S. Mental health literacy in developing countries. Br J Psychiatry 2001; 179: 75. 56. Rehman A, Mubbashar MH, Gater R, Goldberg D. Randomized trial of impact of school mental health programme in rural Rawalpindi, Pakistan. Lancet 1998; 352: 1022–1025. 57. Bakare MO, Ubochi VN, Ebigbo PO, Orovwigho AO. Problem and pro-social behavior among Nigerian children with intellectual disability: the implication for developing policy for school based mental health programs. Ital J Pediatr 2010; 36: 37. 58. Ibeziako PI, Omigbodun OO, Bella TT. Assessment of need for a school-based mental health programme in Nigeria: perspectives of school administrators. Int Rev Psychiatry 2008; 20: 271–280. 59. Makanjuola V, Doku V, Jenkins R, Gureje O. Impact of a one-week intensive ‘training of trainers’ workshop for community health workers in southwest Nigeria. Ment Health Fam Med 2012; 9: 33–38. 60. Jenkins R, Kiima D, Njenga F, Okonji M, Kingora J, Kathuku D, et al. Integration of mental health into IUHPE – Global Health Promotion Vol. 0, No. 0 201X
Downloaded from ped.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 14, 2015
8
O. Atilola
primary care in Kenya. World Psychiatry 2010; 9: 118–120. 61. Saraceno B, Ommeren M, Batniji R, Cohen A, Gureje O, Mahoney J, et al. Barriers to improvement of mental health services in low-income and middleincome countries. Global Mental Health 5. Lancet 2007; 370: 1164–1174. 62. World Health Organization. Primary health care. Report of the Alma Ata international conference on primary health care. Geneva: WHO; 1978. 63. World Health Organization. Primary Health Care: Now more than ever. Geneva: WHO; 2008. 64. Frenk J. Reinventing primary health care: the need for systems integration. Lancet 2009; 13: 170–173.
65. Lambo TA. Patterns of psychiatric care in developing African countries. In: Kiev A (ed). Magic, faith and healing. Glencoe: The Free Press, 1964,pp. 443–453. 66. Alem A, Jacobsson L, Hanlon C. Community based mental health care in Africa: mental health workers’ views. World Psychiatry 2008; 7: 54–57. 67. Jenkins R, Kiima D, Okonji M, Njenga F, Kingora J, Lock S. Integration of mental health into primary care and community health working in Kenya: context, rationale, coverage and sustainability. Ment Health Fam Med 2010; 7: 37–47. 68. Hanlon C, Wondimagegn D, Alem A. Lessons learned in developing community mental health care in Africa. World Psychiatry 2010; 9: 185–189.
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