The perceived effectiveness of traditional and faith healing in the treatment of mental illness: a systematic review of qualitative studies

The Influence of Culture on the Cause, Diagnosis and Treatment of Serious Mental Illness (Ufufunyana): Perspectives of Traditional Health Practitioners in the Harry Gwala District, KwaZulu-Natal

Cultural beliefs influence the perceived cause, methods of diagnosis and treatment of mental illnesses. A qualitative study was conducted among traditional health practitioners (THPs) in the Harry Gwala District Municipality to further explore this influence. Purposive sampling assisted in the recruitment of 31 participants (9 males and 22 females). The four key themes this study investigated in relation to mental illness included its causes, methods of diagnosis, common symptoms observed and treatment approaches used by THPs, and the system of patient management. Culturally, mental illness was reported to be caused by witchcraft and an ancestral calling in this study. Mental illness was predominantly diagnosed by spiritual intervention which included divination through consultation with the ancestors, familial background, burning of incense which can also be part of communicating with the ancestors and through examining the patient. The common symptoms included aggression, hallucination and unresponsiveness. Prevalent modes of treatment included the use of a medicinal concoction and performing cultural rituals where ancestors and other spirits were assumed influential. The duration of the treatment process was dependent on guidance from the ancestors. Most causal aspects of mental illness from diagnosis to treatment seemed to be influenced by cultural beliefs and ancestors.

Indigenous mental healthcare and human rights abuses in Nigeria: The role of cultural syntonicity and stigmatization

Background

Indigenous mental healthcare using traditional non-western methods termed "unorthodox approaches" has been observed in Nigeria historically. This has been largely due to a cultural preference for spiritual or mystical rather than biomedical formulations of mental disorder. Yet, there have been recent concerns about human rights abuses within such treatment settings as well as their tendency to perpetuate stigmatization.

Aim

The aim of this review was to examine the cultural framework for indigenous mental healthcare in Nigeria, the role of stigmatization in its utilization and interrogate the issues of human rights abuses within a public mental health context.

Methods

This is a non-systematic narrative review of published literature on mental disorders, mental health service utilization, cultural issues, stigma, and indigenous mental healthcare. Media and advocacy reports related to human rights abuses in indigenous mental health treatment settings were also examined. International conventions on human rights and torture, national criminal legislation, constitutional provisions on fundamental rights and medical ethics guidelines relevant to patient care within the country were examined in order to highlight provisions regarding human rights abuses within the context of care.

Results

Indigenous mental healthcare in Nigeria is culturally syntonic, has a complex interaction with stigmatization and is associated with incidents of human rights abuses especially torture of different variants. Three systemic responses to indigenous mental healthcare in Nigeria include: orthodox dichotomization, interactive dimensionalization, and collaborative shared care. Conclusions: Indigenous mental healthcare is endemic in Nigeria. Orthodox dichotomization is unlikely to produce a meaningful care response. Interactive dimensionalization provides a realistic psychosocial explanation for the utilization of indigenous mental healthcare. Collaborative shared care involving measured collaboration between orthodox mental health practitioners and indigenous mental health systems offers an effective as well as cost-effective intervention strategy. It reduces harmful effects of indigenous mental healthcare including human rights abuses and offers patients a culturally appropriate response to their problems.

Explanatory models, illness, and treatment experiences of patients with psychosis using the services of traditional and faith healers in three African countries: Similarities and discontinuities

As part of formative studies to design a program of collaborative care for persons with psychosis, we explored personal experience and lay attributions of illness as well as treatment among persons who had recently received care at traditional and faith healers' (TFHs) facilities in three cultural groups in Sub-Saharan Africa. A purposive sample of 85 individuals in Ibadan (Nigeria), Kumasi (Ghana), and Nairobi (Kenya) were interviewed. Data was inductively explored for themes and analysis was informed by the Framework Method. Across the three sites, illness experiences featured suffering and disability in different life domains. Predominant causal attribution was supernatural, even when biological causation was also acknowledged. Prayer and rituals, steeped in traditional spiritual beliefs, were prominent both in traditional faith healing settings as well as those of Christianity and Islam. Concurrent or consecutive use of TFHs and conventional medical services was common. TFHs provided services that appear to meet the therapeutic goals of their patients even when harmful treatment practices were employed. Cultural and linguistic differences did not obscure the commonality of a core set of beliefs and practices across these three groups. This similarity of core worldviews across diverse cultural settings means that a collaborative approach designed in one cultural group would, with adaptations to reflect differences in context, be applicable in another cultural group. Studies of patients' experience of illness and care are useful in designing and implementing collaborations between biomedical and TFH services as a way of scaling up services and improving the outcome of psychosis.

Barriers and facilitators to treatment seeking behaviors for depression, epilepsy, and schizophrenia in low- and middle-income countries: A systematic review

Despite the severe consequences, the treatment gap for depression, epilepsy, and schizophrenia continues to be a major concern in low and middle-income countries (LMICs). We conducted a systematic review of literature on barriers and facilitators of treatment-seeking behaviors from the perspective of individuals living with depression, epilepsy, and schizophrenia and stakeholders in LMICs. Knowledge deficits, beliefs, and stigma were barriers to treatment-seeking across disorders. The most cited facilitators were demographics, socioeconomic status, and collaboration with traditional healers. Culturally sensitive interventions in collaboration with stakeholders within the community can facilitate treatment-seeking behaviors among people living with depression, epilepsy, and schizophrenia.

Integrating Cognitive Behavioural and Islamic Principles in Psychology and Psychotherapy: A Narrative Review

Standardisation of knowledge has become a by-product of globalisation, and western-based models are often seen as the ultimate answer to expertise and development. In light of this, some professionals have debated the feasibility of employing cognitive behavioural therapy (CBT) with Muslim communities. Debates have focused on CBT's secular roots and its compatibility with a world where Islam permeates most aspects of life. This article highlights some of the theoretical dilemmas of integration and suggests ways to bridge the existing gap between secular and Islamic literature and avoid alienating those individuals who might feel uncomfortable with secular CBT teachings.

Ease of marital communication and depressive symptom severity among men and women in rural Uganda: cross-sectional, whole-population study

PURPOSE

Depression is a major contributor to the global burden of disease. The extent to which marital communication may influence depression in contexts with little mental health support is unknown.

METHODS

We conducted a whole-population study of married adult residents of eight villages in a rural region of southwestern Uganda. Depression symptom severity was measured using a modified version of the Hopkins Symptom Checklist for Depression, with > 1.75 classified as a positive screen for probable depression. Respondents were asked to report about ease of marital communication ('never easy', 'easy once in a while', 'easy most of the time' or 'always easy'). Sex-stratified, multivariable Poisson regression models were fit to estimate the association between depression symptom severity and marital communication.

RESULTS

Among 492 female and 447 male participants (response rate = 96%), 23 women and 5 men reported communication as 'never easy' and 154 women and 72 men reported it as 'easy once in a while'. Reporting communication as 'never easy' was associated with an increased risk of probable depression among women (adjusted relative risk [ARR], 2.06; 95% confidence interval [CI], 1.08-3.93, p = 0.028) and among men (ARR, 7.10; 95% CI 1.70-29.56, p = 0.007).

CONCLUSION

In this whole-population study of married adults in rural Uganda, difficulty of marital communication was associated with depression symptom severity. Additional research is needed to assess whether communication training facilitated by local leaders or incorporated into couples-based services might be a novel pathway to address mental health burden.

Perspectives of university health care students on mental health stigma in Nigeria: Qualitative analysis

Mental illness is a significant public health burden in low- and middle-income countries. A wide treatment gap in mental health care exists within the Nigerian health care system and this gap is worsened by the presence of stigma associated with mental illness, which leads to delay in treatment or acts as a barrier to any care. In this study, our aim was to understand the factors that underlie mental illness stigma in order to inform the design of effective stigma-reducing interventions among health care students in Nigeria. We conducted four focus groups among university health care students in March 2019 in Nigeria. The students included nursing, pharmacy, and medical trainees from a university teaching hospital. We used an inductive-driven thematic analysis to identify codes and themes related to mental health stigma and conceptualization of mental health within the study group. Among the 40 participants, we identified how specific interpretations of religious and spiritual beliefs may be associated with stigmatizing behaviors such as social distancing and discrimination. Conceptualization of mental illness as a communicable disease and the attribution of mental illness to a moral failing contributed to stigma mechanisms. Overall, eight themes associated with mental health stigma and mental health-related concepts were found: spirituality, discrimination and devaluation, conceptualization of mental health, attribution theories, methods to reduce stigma, shortage of resources, violence and dangerousness, and maltreatment. We found that the co-existence of spiritual beliefs and biomedical and psychological models of mental health is a key factor to consider in the design of effective stigma-reducing interventions among university health students in Nigeria.

Self-identification, mode of diagnosis and treatment, and perceptions of relationships with medical providers of South African Xhosa-speaking traditional healers

There is widespread use of traditional medicine in treating common mental disorders in South Africa. We aimed to (i) explore the self-identification of traditional healers (THs; how they refer to themselves, e.g., as healer, spiritualist, sangoma, etc.); (ii) determine if different types of THs treat different conditions (physical/psychological) or use different modes of diagnosis and treatment; (iii) identify factors that influence the willingness of THs to refer patients to biomedical hospitals; and (iv) compare TH practices between two provinces. Participants included Xhosa-speaking THs (mean age = 54.10, SD = 13.57 years) from the Western (n = 50) and Eastern (n = 68) Cape provinces. Participants completed a questionnaire regarding self-identification, mode of diagnosis/treatment, relationship with biomedical hospitals, type of condition(s) treated, and a Patient Health Questionnaire. There were significant associations between the type of TH (as self-identified) and (i) mode of diagnosis, (ii) mode of treatment, and (iii) type of condition(s) treated. Spiritualists, male THs, and THs who had previously been hospitalised for a mental disorder were more likely to treat mental disorders. THs who had previously been hospitalised for mental disorders were more likely to report a willingness to refer patients to biomedical hospitals. Findings highlight the complex practices of Xhosa-speaking THs. Collaboration between THs and mental health care professionals could be facilitated by focusing on male THs, spiritualists, and THs who have previously been hospitalised for mental illness. Future research should provide clearer operational definitions of the type of TH included.

Reassessing the Mental Health Treatment Gap: What Happens if We Include the Impact of Traditional Healing on Mental Illness?

In this Fresh Focus, we reassess what the mental health treatment gap may mean if we consider the role of traditional healing. Based on systematic reviews, patients can use traditional healers and qualitatively report improvement from general psychological distress and symptom reduction for common mental disorders. Given these clinical implications, some high-income countries have scaled up research into traditional healing practices, while at the same time in low-and middle-income countries, where the use of traditional healers is nearly ubiquitous, considerably less research funding has studied or capitalized on this phenomena. The World Health Organization 2003-2020 Mental Health Action Plan called for government health programs to include traditional and faith healers as treatment resources to combat the low- and middle-income country treatment gap. Reflection on the work which emerged during the course of this Mental Health Action Plan revealed areas for improvement. As we embark on the next Mental Health Action Plan, we offer lessons-learned for exploring potential relationships and collaborations between traditional healing and biomedicine.

Perceptions of Ghanaian traditional health practitioners, primary health care workers, service users and caregivers regarding collaboration for mental health care

BACKGROUND

In low- and middle-income countries, the paucity of conventional health services means that many people with mental health problems rely on traditional health practitioners (THPs). This paper examines the possibility of forging partnerships at the Primary Health Care (PHC) level in two geopolitical regions of Ghana, to maximize the benefits to both health systems.

METHODS

The study was a qualitative cross-sectional survey. Eight (8) focus group discussions (FGDs) were conducted between February and April 2014. The views of THPs, PHC providers, service users (i.e. patients) and their caregivers, on the perceived benefits, barriers and facilitators of forging partnerships were examined. A thematic framework approach was employed for analysis.

RESULTS

The study revealed that underlying the widespread approval of forging partnerships, there were mutual undertones of suspicion. While PHC providers were mainly concerned that THPs may incur harms to service users (e.g., through delays in care pathways and human rights abuses), service users and their caregivers highlighted the failure of conventional medical care to meet their healthcare needs. There are practical challenges to these collaborations, including the lack of options to adequately deal with human rights issues such as some patients being chained and exposed to the vagaries of the weather at THPs. There is also the issue of the frequent shortage of psychotropic medication at PHCs.

CONCLUSION

Addressing these barriers could enhance partnerships. There is also a need to educate all providers, which should include sessions clarifying the potential value of such partnerships.

Clinical ethnography in severe mental illness: a clinical method to tackle social determinants and structural racism in personalised care

Ethnic inequalities in the experiences and outcomes of severe mental illness are well established. These include a higher incidence of severe mental illnesses (psychoses), adverse pathways into and through care, including crisis care, police and criminal justice systems involvement, and care under the powers of the Mental Health Act. The situation persists despite awareness and is driven by a mixture of the social determinants of poor health, societal disadvantage and structural racism, as well as conflictual interactions with care systems, which themselves are configured in ways that sustain or deepen these inequalities. Although training and education are often proposed, this is not shown to have sustained effects. Clinical processes (interviewing/assessment/formulation/intervention) need to address systemic influences and improve the cultural precision with which care is delivered, organised and commissioned. We discuss clinical ethnography and present evidence of its value in addressing systemic as well as individual care needs for diverse communities.

An ethnopharmacological survey and comparative analysis of plants from the Sudhnoti District, Azad Jammu and Kashmir, Pakistan

BACKGROUND

This is the first comprehensive report on the traditional and novel uses of medicinal plants practiced by the indigenous communities of the Sudhnoti district of Azad Jammu and Kashmir (AJK), Pakistan. The area is rich in folklore and indigenous medicinal knowledge due to a unique tribal composition and socioeconomic conditions. This study aimed to document traditional knowledge of native plant use by the local communities, particularly those used for therapeutic purposes.

METHODS

Field surveys were conducted from September 2015 to March 2017. Interviews with 125 local inhabitants of different tribes, age groups, genders, and occupations were conducted using structured and semi-structured questions along with group discussions. Data gathered on plant uses, local names, and modes of application of each plant species were organized in tables. Ethnobotanical indices such as use value (UV) and cultural significance index (CSI) were used to produce quantitative information on the plant use category, frequency, and cultural preference of species. Reports on therapeutic uses of medicinal plants were compared with previous studies.

RESULTS

In all, 88 plant species from 45 families were reported, out of which 67 (77%) were used in ethnomedical applications. Asteraceae, Rosaceae, Fabaceae, and Lamiaceae were the dominant families. Berberis lycium was the most valued plant species, followed by Zanthoxylum armatum and Taraxacum officinale. Mentha arvensis had the highest cultural significance, followed by Mentha longifolia, Punica granatum, and Zanthoxylum armatum. Leaves were the most preferred plant parts in the preparation of medicine exclusively or mixed with other parts. The most frequently used process of crude preparation of medicinal plants was cooking. Oral intake was the predominant route of administration.

CONCLUSIONS

Our comparative analysis confirmed that most of the plants documented have uses that match those previously reported for the region and other parts of the world, with the exception of novel medicinal uses for 11 plant species, including Verbascum thapsus for earache, Elaeagnus umbellata for hepatitis, Achillea millefolium for oral care, Dicliptera roxburghiana to prevent sunstroke in cattle, Rumex hastatus for allergy antidote, Pyrus pashia for hepatitis, and Nerium oleander for diabetes.

Becoming a Xhosa traditional healer: The calling, illness, conflict and belonging

Background

Traditional healers (THs) are an important part of the healthcare system in sub-Saharan Africa. Understanding their training, experiences of becoming healers and their perceived roles in society is critical.

Aim

This study aimed to explore the experience of becoming a TH, including accepting the calling, and sheds light on how the experience is conceptualised within the cultural and communitarian context of THs.

Setting

This study was conducted amongst Xhosa THs in the Western Cape, South Africa.

Methods

In-depth phenomenological interviews (n = 4) were conducted with Xhosa THs and analysed using Giorgi's descriptive pre-transcendental Husserlian phenomenological analysis.

Results

The experience of becoming a TH can be summarised in the context of three units of significance: (1) the gift of healing as an illness; (2) the experience of conflict (including with their families, the church and self-conflict); and (3) the experience of belonging. Familial conflict, specifically, was fuelled by the financial burden of becoming a TH and a lack of understanding of the process.

Conclusion

To develop a workable model of collaboration in the future, it is crucial that mental healthcare providers develop a better understanding of the experiences of THs in becoming care providers. The findings highlight an appreciation of the challenging process of becoming a TH. Finally, further research and culturally appropriate psychoeducation can provide trainee THs and their family members with the skills and knowledge to support each other through a difficult process.

Traditional Healers and Mental Health in Nepal: A Scoping Review

Despite extensive ethnographic and qualitative research on traditional healers in Nepal, the role of traditional healers in relation to mental health has not been synthesized. We focused on the following clinically based research question, "What are the processes by which Nepali traditional healers address mental well-being?" We adopted a scoping review methodology to maximize the available literature base and conducted a modified thematic analysis rooted in grounded theory, ethnography, and phenomenology. We searched five databases using terms related to traditional healers and mental health. We contacted key authors and reviewed references for additional literature. Our scoping review yielded 86 eligible studies, 65 of which relied solely on classical qualitative study designs. The reviewed literature suggests that traditional healers use a wide range of interventions that utilize magico-religious explanatory models to invoke symbolic transference, manipulation of local illness narratives, roles, and relationships, cognitive restructuring, meaning-making, and catharsis. Traditional healers' perceived impact appears greatest for mild to moderate forms of psychological distress. However, the methodological and sample heterogeneity preclude uniform conclusions about traditional healing. Further research should employ methods which are both empirically sound and culturally adapted to explore the role of traditional healers in mental health.

Unique collaboration of modern medicine and traditional faith-healing for the treatment of mental illness: Best practice from Gujarat

Background and Aims:

Modern psychiatry brings tremendous value to the treatment of mental illness, however, at times is inadequate in providing holistic care within a patient's broader cultural framework. Traditional healing and modern psychiatry together offer a comprehensive, patient-centred approach to treatment, which encompass a patient's spiritual and religious beliefs. In this context, “Dava-Dua” intervention—combination of psychiatric medicine and faith healing—is implemented by the Government of Gujarat at Mira Data Dargah in Mehsana District. The study assesses intervention outcomes, understand implementation challenges and patients' perspectives on the treatment.

Methods:

Using a multi-method research approach, case records from July 2008 to March 2018 were retrieved for secondary analysis of patients' profile and outcomes; 26 patients from three groups: Dava, Dua and Dava-Dua; and 6 mental health service providers were interviewed to assess perspectives of patients and service providers on mental health, implementation barriers and facilitators.

Results:

Despite some implementation challenges, the findings indicate that collaboration of modern psychiatry medicine and faith-based treatment practices certainly benefit patients with otherwise limited access to mental health care thereby protects human rights of patients.

Conclusion:

Dava-Dua model compliments existing primary healthcare services. It provides an access to modern medicine without compromising patients' religious and spiritual practices. It has the potential to scale-up and replicate where faith-healing is the prime treatment modality to cure mental illness provided implementation challenges are proactively addressed.

Traditional and biomedical care pathways for mental well-being in rural Nepal

BACKGROUND

There is increasing access to mental health services in biomedical settings (e.g., primary care and specialty clinics) in low- and middle-income countries. Traditional healing continues to be widely available and used in these settings as well. Our goal was to explore how the general public, traditional healers, and biomedical clinicians perceive the different types of services and make decisions regarding using one or both types of care.

METHODS

We conducted in-depth interviews using a pilot tested semi-structured protocol around the subjects of belief, traditional healers, and seeking care. We conducted 124 interviews comprising 40 traditional healers, 79 general community members, and five physicians. We then performed qualitative analyses according to a grounded theoretical approach.

RESULTS

A majority of the participants endorsed belief in both supernatural and medical causes of illness and sought care exclusively from healers, medical practitioners, and/or both. Our findings also revealed several pathways and barriers to care that were contingent upon patient-, traditional healer-, and medical practitioner-specific attitudes. Notably, a subset of community members duplicated care across multiple, equally-qualified medical providers before seeing a traditional healer and vice versa. In view of this, the majority of our participants stressed the importance of an efficient, medically plural society. Though participants desired a more collaborative model, no consistent proposal emerged on how to bridge traditional and biomedical practices. Instead, participants offered suggestions which comprised three broad categories: (1) biomedical training of traditional healers, (2) two-way referrals between traditional and biomedical providers, and (3) open-dialogue to foster mutual understanding among traditional and biomedical providers.

CONCLUSION

Participants offered several approaches to collaboration between medical providers and traditional healers, however if we compare it to the history of previous attempts, education and understanding between both fields may be the most viable option in low- and middle-income contexts such as Nepal. Further research should expand and investigate opportunities for collaborative learning and/or care across not only Nepal, but other countries with a history of traditional and complimentary medicine.

Pluralistic and singular causal attributions for epilepsy in Uganda

OBJECTIVE

In Uganda, causal attributions for epilepsy reflect a variety of beliefs and impact care-seeking behavior, perpetuate stigma, and undermine the effectiveness of interventions to narrow the epilepsy treatment gap. The objective of this study was to characterize beliefs about seizure etiology to gain a better understanding of how epilepsy is conceptualized in the community in order to inform culturally appropriate educational policies and interventions.

METHODS

In a community-based study, 15,383 participants were surveyed about beliefs related to 15 potential causes for epilepsy. Principal axis factor analysis (PFA) was performed to identify causative factors and then utilized to classify singular versus pluralistic belief systems related to epilepsy etiology. Analysis of variance (ANOVA) and Mann-Whitney U-tests were conducted to examine the differences in background characteristics across the etiology belief groups.

RESULTS

Three main causative factors emerged from the PFA: biological, sociospiritual, and biospiritual. Among those endorsing at least one factor (n = 13,036), the biological factor was endorsed most frequently as a potential cause for epilepsy (88.0%), followed by the sociospiritual (63.4%), then biospiritual (47.6%). Review of the patterns of endorsement found that only 22.2% endorsed the biological factor alone, 6.7% the sociospiritual factor alone, and 2.8% the biospiritual factor alone (total 31.7%). The remainder endorsed a combination of two or all three factors as being potentially causal, and most (65.7%) endorsed a pluralistic combination inclusive of a biological etiology. Group comparisons showed that endorsing only the biological factor was associated with the highest levels of education (p < 0.01), the pluralistic group had the highest ratio of people in the household who needed assistance to those that could provide aid (p < 0.01), and there were significant differences in income across specific groups (p < 0.01).

CONCLUSIONS

Pluralistic attributions for epilepsy are common in Uganda, with the majority of community members drawing from biomedical and traditional concepts to construct complex explanations for seizures that transcend discrete belief categories traditionally depicted in the literature. These findings emphasize the need to understand cultural beliefs about epilepsy in order to design contextually specific interventions and education programs, which respect the fundamental beliefs and values of the community. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda".

A systematic review of care pathways for psychosis in low-and middle-income countries

Pathways to care for psychosis in high-income countries have been well studied, with the finding of an association between longer duration of untreated psychosis (DUP) and poorer outcomes focusing interest on care pathways to minimise treatment delay. Little is known about how people with psychosis in low-to middle-income countries (LMIC) present for help and specific care pathways that might be associated with treatment delays in those contexts. We conducted a systematic review using electronic databases (MEDLINE, PsychINFO, Embase, Ovid) to explore what proportion of patients with psychosis in LMIC are accessing care through traditional healers and whether this is associated with treatment delay. Studies were included if they assessed the pathway to care for participants with a psychotic illness in a LMIC. From 3929 results, 15 studies met our inclusion criteria. In 7 out of 15 studies first contact for the majority of patients were traditional health practitioners (THPs). In 5 out of 15 studies, mental health practitioners (MHPs) were most often the initial care pathway and in 3 studies first contact was with primary care. DUP ranged from a mean of 30 weeks to 225 weeks. Accessing THPs as initial contact was associated with a longer DUP. In LMICs, a large proportion of patients use THP as their first point of contact for accessing care. This is associated with longer DUP. Services in these countries need to focus both on raising public awareness and collaborative working with THPs to facilitate access to biomedical care.

Adapting a skills-based stroke prevention intervention for communities in Ghana: a qualitative study

BACKGROUND

Stroke is a major cause of death in Ghana. Evidence-based interventions for stroke prevention have been successful in the US; however, in low- and middle-income countries (LMICs), such interventions are scarce. The "Discharge Education Strategies for Reduction of Vascular Events" (DESERVE) intervention led to a 10-mmHg reduction in systolic blood pressure (SBP) among Hispanic survivors of mild/moderate stroke and transient ischemic attack (TIA) at 1-year follow-up. Our objectives were to capture the perceptions of a diverse set of stakeholders in an urban community in Ghana regarding (1) challenges to optimal hypertension management and (2) facilitators and barriers to implementation of an evidence-based, skills-based educational tool for hypertension management in this context.

METHODS

This exploratory study used purposive sampling to enroll diverse stakeholders in Accra (N = 38). To identify facilitators and barriers, we conducted three focus group discussions: one each with clinical nurses (n = 5), community health nurses (n = 20), and hypertensive adults (n = 10). To further examine structural barriers, we conducted three key informant interviews with medical leadership. All interviews were audio recorded and transcribed. Thematic analysis was carried out via deductive coding based on Proctor's implementation outcomes taxonomy, which conceptualizes constructs that shape implementation, such as acceptability, adoption, appropriateness, cost, and feasibility.

RESULTS

Findings highlight facilitators, such as a perceived fit (appropriateness) of the core intervention components across stakeholders. The transferable components of DESERVE include: (1) a focus on risk knowledge, medication adherence, and patient-physician communication, (2) facilitation by lay workers, (3) use of patient testimonials, (4) use of a spirituality framework, and (5) application of a community-based approach. We report potential barriers that suggest adaptations to increase appropriateness and feasibility. These include addressing spiritual etiology of disease, allaying mistrust of biomedical intervention, and tailoring for gender norms. Acceptability may be a challenge among individuals with hypertension, who perceive relative advantage of alternative therapies like herbalism. Key informant interviews highlight structural barriers (high opportunity costs) among physicians, who perceive they have neither time nor capacity to educate patients.

CONCLUSIONS

Findings further support the need for theory-driven, evidence-based interventions among hypertensive adults in urban, multiethnic Ghana. Findings will inform implementation strategies and future research.

Effect of collaborative care between traditional and faith healers and primary health-care workers on psychosis outcomes in Nigeria and Ghana (COSIMPO): a cluster randomised controlled trial

BACKGROUND

Traditional and faith healers (TFH) provide care to a large number of people with psychosis in many sub-Saharan African countries but they practise outside the formal mental health system. We aimed to assess the effectiveness and cost-effectiveness of a collaborative shared care model for psychosis delivered by TFH and primary health-care providers (PHCW).

METHODS

In this cluster-randomised trial in Kumasi, Ghana and Ibadan, Nigeria, we randomly allocated clusters (a primary care clinic and neighbouring TFH facilities) 1:1, stratified by size and country, to an intervention group or enhanced care as usual. The intervention included a manualised collaborative shared care delivered by trained TFH and PHCW. Eligible participants were adults (aged ≥18 years) newly admitted to TFH facilities with active psychotic symptoms (positive and negative syndrome scale [PANSS] score ≥60). The primary outcome, by masked assessments at 6 months, was the difference in psychotic symptom improvement as measured with the PANSS in patients in follow-up at 3 and 6 months. Patients exposure to harmful treatment practices, such as shackling, were also assessed at 3 and 6 months. Care costs were assessed at baseline, 3-month and 6-month follow-up, and for the entire 6 months of follow-up. This trial was registered with the National Institutes of Health Clinical Trial registry, NCT02895269.

FINDINGS

Between Sept 1, 2016, and May 3, 2017, 51 clusters were randomly allocated (26 intervention, 25 control) with 307 patients enrolled (166 [54%] in the intervention group and 141 [46%] in the control group). 190 (62%) of participants were men. Baseline mean PANSS score was 107·3 (SD 17·5) for the intervention group and 108·9 (18·3) for the control group. 286 (93%) completed the 6-month follow-up at which the mean total PANSS score for intervention group was 53·4 (19·9) compared with 67·6 (23·3) for the control group (adjusted mean difference -15·01 (95% CI -21·17 to -8·84; 0·0001). Harmful practices decreased from 94 (57%) of 166 patients at baseline to 13 (9%) of 152 at 6 months in the intervention group (-0·48 [-0·60 to -0·37] p<0·001) and from 59 (42%) of 141 patients to 13 (10%) of 134 in the control group (-0·33 [-0·45 to -0·21] p<0·001), with no significant difference between the two groups. Greater reductions in overall care costs were seen in the intervention group than in the control group. At the 6 month assessment, greater reductions in total health service and time costs were seen in the intervention group; however, cumulative costs over this period were higher (US $627 per patient vs $526 in the control group). Five patients in the intervention group had mild extrapyramidal side effects.

INTERPRETATION

A collaborative shared care delivered by TFH and conventional health-care providers for people with psychosis was effective and cost-effective. The model of care offers the prospect of scaling up improved care to this vulnerable population in settings with low resources.

FUNDING

US National Institute of Mental Health.

Psychosocial family interventions for relatives of people living with psychotic disorders in the Arab world: systematic review

BACKGROUND

Family interventions in schizophrenia are evidence based and have been adapted to different cultural settings to improve their effectiveness and acceptability. The Arab world has a unique set of socio-cultural norms and values that cannot be ignored when developing or implementing such interventions. There is a lack of research on the feasibility of delivering family interventions for schizophrenia in the Arab region. The aim of this review is to synthesise the available evidence about culturally-adapted psychosocial family interventions in the Arab world. The review identifies the content and characteristics of these interventions, determines the strategies used to adapt them to Arab culture successfully, assesses the feasibility and acceptability of the interventions, and evaluates the effectiveness of these interventions for service users and their families.

METHOD

Five electronic databases were searched including MEDLINE, CINAHL, Cochrane Library, PsycINFO and EMBASE for articles written in Arabic and English from inception to August 2019. Data were extracted and synthesised narratively.

RESULTS

Six studies were retrieved from the search: three randomised control studies, two non-randomised studies and one qualitative study. There is limited evidence about culturally-adapted family interventions in the Arab region. However, the cultural adaptation process was comprehensive, and the implementation was reported to be feasible and acceptable. The methodological quality of the included studies was generally poor, so there is a risk of underestimating the effect size of the interventions due to lack of rigour and the presence of bias.

CONCLUSION

The present review provides the foundation for future work regarding family interventions in the Arab world, and confirms the feasibility of implementing such interventions with some modifications. Furthermore, the data suggests that any family-oriented intervention for schizophrenia is likely to be better than standard care in improving the outcome for patients and their families.

A comparative account of the traditional healing practices of healers and non-healers in the Kiudang area of Brunei Darussalam

ETHNOPHARMACOLOGICAL RELEVANCE

In this study, we compare the traditional medicinal knowledge and associated spiritual practices of healers with that of non-healers, to understand the relevance of healers in contemporary times. Given that Brunei Darussalam is well-known for its forest cover, the study also aims to understand the number of species collected from the forests, compared to those from human influenced habitats.

MATERIALS AND METHODS

A total of six specialist healers from Belait, Tutong, Dusun and Iban communities, and seven non-healers who had personal experience in self-medication using medicinal plants participated in the study. We identified the specialist healers through purposive sampling, on the basis of their reputation in the locality, while the non-healers were those experienced in self-medication, recommended by the healers. Informants were interviewed at their residences, followed by collection trips to the plant habitats. We classified the total recorded ailments into 15 disease categories. We then compared the medicinal uses cited by healers to those mentioned by non-healers, as well as with prior published records from Brunei Darussalam. We also compare the habitats of species cited by both healers and non-healers to understand the dependency of the local pharmacopoeia on forests and human-influenced habitats.

RESULTS

Our study records 175 medicinal plants belonging to 85 families, the majority of which (92) were exotic to Borneo. There were 110 species collected from disturbed, human influenced habitats such as roadsides, agricultural fields, secondary and degraded forests, and homestead lands, while 58 species were collected from the forests surrounding Kiudang. Majority of the plants used by both healers and non-healers were collected from human-influenced habitats, indicating that the local pharmacopoeia could be a disturbance one. Most of the medicinal plants recorded in this study were used to treat chronic, but non-life threatening conditions. Ailments affecting the digestive system were the most targeted group with 67 species used. All medicinal uses with more than one citation were recorded from healers. Medicinal uses cited by healers also had greater correspondence with prior published reports from Brunei Darussalam. Healers believe that combining medicinal plants can produce a synergistic effect. Our study found that traditional knowledge related to healing practices is mostly transmitted vertically from parents to children. We also show that a ritual gift (pikaras) and invocations characteristic of the beliefs of the healers play an important role in facilitating healing.

CONCLUSION

Our study adds further evidence to prior studies that the medicinal plants and healing practices in the Kiudang region could be considered as disturbance pharmacopoeia. Healers with their knowledge on both therapeutic and spiritual aspects of healing continue to play an important role in local healthcare.

Psychological interventions during COVID-19: Challenges for low and middle income countries

At the start of 2020, the 2019 coronavirus disease (COVID-19), originating from China has spread to the world. There have been increasing numbers of confirmed cases and deaths around the globe. The COVID-19 pandemic has paved the way for considerable psychological and psychosocial morbidity among the general public and health care providers. An array of guidelines has been put forward by multiple agencies for combating mental health challenges. This paper addresses some of the mental health challenges faced by low and middle income countries (LMIC). It is worthwhile to note that these are challenges at the current stage of the pandemic and may change with the course of the pandemic itself.

Knowledge, attitude, and practice towards epilepsy among religious cleric and traditional healers of Addis Ababa, Ethiopia

PURPOSE

Understanding clerics and healers' knowledge, attitude, and practice towards epilepsy are crucial to identify the mechanisms of epilepsy stigma in Ethiopia. The objective of this study is to characterize the social and demographic determinants of knowledge, attitude, and practices of clerics and healers towards people with epilepsy in Addis Ababa, Ethiopia.

METHODS

A total of 440 clerics and healers were interviewed by trained data collectors using a pretested structured questionnaire. The count sum of outcome variables was grouped into "biological and cultural" knowledge attitude and practice scores. Ordinal regression analysis was performed for each outcome variable against socio-demographic variables of interest.

RESULTS

The percentage of responses matching cultural causes (58%) surpassed biological causes. The most frequently mentioned cultural cause was an evil spirit (22.5%). While the most frequently mentioned biological cause was a head injury (12%). Consistent with the above findings, cultural treatment responses (77%) exceeded biological treatment responses. The most commonly referred cultural treatment response was Church healing session (12%). The type of faith followed by the study participants positively correlated with higher cultural knowledge, attitude, and practice score.

CONCLUSIONS

Clerics and traditional healers in Ethiopia have a partiality to the cultural epilepsy explanation model. Cultural metaphors attached to an evil spirit, curse of God, and witchcraft have formed and fostered existing 'epilepsy societal norms' in Ethiopia. The findings of this study contribute to the understanding of epilepsy stigma and treatment gap. Besides, it provided direction to design and implement epilepsy stigma intervention programs in Ethiopia.

Satisfaction in the Soul: Common Factors Theory Applied to Traditional Healers in Rural Nepal

To explore the relationship between traditional healers and conventional psychotherapy, we conducted a combined ethnographic study and structured observational rating of healers in the middle hill region of central Nepal. We conducted in-depth interviews and ethnographic observations of healing with 84 participants comprising 29 traditional healers and 55 other community members. Overall, our observations and participant responses yielded a range of interventions that improved health through belief, satisfaction in the soul, social support, transference, and symbolic narration. The findings from our overall ethnography suggest that healers offer a platform for their patients to accept a disease state, cope with it, and to experience palliation of distress. We additionally focused on one participant who saw multiple healers for a case study, during which we rated healing behavior using an observational measure of empathy, emotional validation, and therapeutic alliance. Using this measure, healers who were perceived as successful, scored high on alliance, empathy, promoting expectations of recovery, and use of cultural models of distress. The results of our structured observation suggest healers draw upon processes also observed in psychotherapy. Further research is needed to explore if these practices can be generalized to healers in other parts of Nepal and other settings. [spirituality, mental health, ethnopsychology, shamanism, mind-body relations].

Partnership for mental health development in Sub-Saharan Africa (PaM-D): a collaborative initiative for research and capacity building

AimsIn low- and middle-income countries (LMIC) in general and sub-Sahara African (SSA) countries in particular, there is both a large treatment gap for mental disorders and a relative paucity of empirical evidence about how to fill this gap. This is more so for severe mental disorders, such as psychosis, which impose an additional vulnerability for human rights abuse on its sufferers. A major factor for the lack of evidence is the few numbers of active mental health (MH) researchers on the continent and the distance between the little evidence generated and the policy-making process.

METHODS

The Partnership for Mental Health Development in Africa (PaM-D) aimed to bring together diverse MH stakeholders in SSA, working collaboratively with colleagues from the global north, to create an infrastructure to develop MH research capacity in SSA, advance global MH science by conducting innovative public health-relevant MH research in the region and work to link research to policy development. Participating SSA countries were Ghana, Kenya, Liberia, Nigeria and South Africa. The research component of PaM-D focused on the development and assessment of a collaborative shared care (CSC) program between traditional and faith healers (T&amp;FHs) and biomedical providers for the treatment of psychotic disorders, as a way of improving the outcome of persons suffering from these conditions. The capacity building component aimed to develop research capacity and appreciation of the value of research in a broad range of stakeholders through bespoke workshops and fellowships targeting specific skill-sets as well as mentoring for early career researchers.

RESULTS

In the research component of PaM-D, a series of formative studies were implemented to inform the development of an intervention package consisting of the essential features of a CSC for psychosis implemented by primary care providers and T&amp;FHs. A cluster randomised controlled trial was next designed to test the effectiveness of this package on the outcome of psychosis. In the capacity-building component, 35 early and mid-career researchers participated in the training workshops and several established mentor-mentee relationships with senior PaM-D members. At the end of the funding period, 60 papers have been published and 21 successful grant applications made.

CONCLUSION

The success of PaM-D in energising young researchers and implementing a cutting-edge research program attests to the importance of partnership among researchers in the global south working with those from the north in developing MH research and service in LMIC.

South African isiXhosa traditional healer self-identification, training, practices, and their perceptions of collaboration with medical providers: an exploratory study

In South Africa, traditional healers treat a wide range of health-related problems and culture-bound syndromes considered non-responsive to Western medicine. Given the widespread use of traditional medicine in treating common mental disorders, especially among low-income groups, it is important to explore the self-identification, training, and practices of traditional healers. We also explored traditional healers’ perceptions of collaboration with Western health care institutions (hospitals, clinics). IsiXhosa traditional healers ( n = 50, female = 40, mean age = 52.7 years, SD = 14.7 years) were interviewed using both a structured and a semi-structured interview schedule, including the Patient Health Questionnaire-9. Data were analysed using SPSS version 24 and Statistica. Interview notes were typed soon after each interview and thematically analysed. Participants described similar experiences regarding the three steps of becoming a traditional healer and treating clients with mental illness using herbs (90%), candles (82%), and prayer (78%). Self-identification as a spiritualist or sangoma, and type of church attended (African Initiated vs. Mainline Christian) were both significantly associated with traditional healers’ mode of diagnosis and/or treatment. Participants were open about collaborating with Western health care institutions around treating mental health issues. However, this was hampered by mistrust, as evidenced in the reluctance of a few participants to share detailed information about treatment methods.

Programmes that bring mental health services to primary care populations in the international setting

The last decade has witnessed an exponential growth of evidence-based care packages for mental, neurological, and substance use disorders (MNS) aimed at primary care populations; however, few have been taken to scale. Several barriers to successful integration and scale-up, such as low acceptability, poor clinical engagement process, lack of targeted resources, and poor stakeholder and policy support have been cited. This review describes and highlights common features of some of the promising programmes that deliver mental health services through primary health clinics, communities, and digital platforms, with an emphasis on those that show some evidence of complete or partial scale-up. Three distinct overarching themes and initiatives are discussed in relation to the above; primary health facilities, community (outside of primary healthcare), and digital/internet-based platforms, with a focus on how the three may interact synergistically to enhance successful integration and scale-up.