Identification of patients with recent-onset psychosis in KwaZulu Natal, South Africa: a pilot study with traditional health practitioners and diagnostic instruments

Risk factors and strategies for relapse prevention among individuals living with serious mental illness in South Africa: Qualitative inquiry from patients' and caregivers' perspectives

INTRODUCTION

Relapse among individuals with serious mental illnesses in resource-limited contexts, including South Africa, is a significant concern. To date, the risks for relapse among this population is well documented, but little is known about prevention strategies to reduce its occurrence in these resource-limited settings. Therefore, this qualitative study explores the risk factors and strategies for relapse prevention from the patients' and caregivers' perspectives.

METHODS

We conducted audio-recorded face-to-face in-depth interviews to capture the lived experience of relapse of inpatient study participants with serious mental illness (N = 24) at a public specialized psychiatry hospital in South Africa and their caregivers (N = 6). We conducted an inductive thematic analysis with two pre-specified themes (risk factors for relapse and strategies for prevention), with the codes devised from the data.

RESULTS

Six sub-themes were identified from the analysis within the two pre-specified themes(Risk factors and strategies for relapse prevention): personal-related, family-related, and health system-related risk factors and strategies for preventing relapse, respectively. To highlight some essential findings, the importance of motivation for drug adherence, family involvement, and availability of anti-psychotic drugs in public health care were noted. More importantly, this study identified important cultural complexities where traditional healers play a significant role in some cultural understanding and treatment of mental illness, affecting medication adherence.

CONCLUSION

This study calls for people-centered mental health care delivery in a public health system that listens to the voice of concern, including cultural challenges, and implements meaningful support that matters most to the patient and their family/caregivers.

Religious and Medical Pluralism Among Traditional Healers in Johannesburg, South Africa

Religion and spirituality are powerful social forces in contemporary South Africa. Traditional Health Practitioners (THPs) are commonly consulted for both spiritual and medical ailments as a first line of care. Many studies have assessed African traditional health seeking behaviors but few have examined beliefs, practices, and behaviors of THPs themselves. This study sought to explore spiritual worldviews among South African THPs. Semi-structured in-depth interviews were conducted with 18 THPs in Johannesburg, South Africa between January and May, 2022. Interviews were transcribed and translated into English. Data were managed using NVivo 12 software and thematically analyzed. The majority of THPs interviewed indicated that initiation as a THP was almost always preceded by a sickness accompanied by dreams/visions that represented an "ancestral calling" to become a healer. Most THPs also trained as both sangomas-who healed according to traditional beliefs-and prophets-who healed according to Christian beliefs. This reflects a syncretic relationship between traditional African beliefs and Christianity. However, not all churches are accepting of traditional beliefs and subsequently these THPs are members only at non-Pentecostal AIC churches who blend both African and Christian practices. Similar to these forms of religious pluralism melding Christianity and traditional beliefs, many THPs also often practice medical pluralism, mixing Western treatments with traditional practices/medicines. THPs are able to adapt elements of Western and African beliefs into healing practices that span multiple religious and medical fields. Thus, collaborative and decentralized healthcare services may be highly acceptable among such a pluralistic community.

Psychosis screening questionnaire: Exploring its factor structure among South African adults

Background

Early detection of psychosis improves treatment outcomes, but there is limited research evaluating the validity of psychosis screening instruments, particularly in low-resourced countries.

Aim

This study aims to assess the construct validity and psychometric properties of the psychosis screening questionnaire (PSQ) in South Africa.

Setting

This study was conducted at several health centres in the Western and Eastern Cape provinces in South Africa.

Methods

The sample consisted of 2591 South African adults participating as controls in a multi-country case-control study of psychiatric genetics. Using confirmatory factor analysis and item response theory, we evaluated the psychometric properties of the PSQ.

Results

Approximately 11% of the participants endorsed at least one psychotic experience on the PSQ, and almost half of them (49%) occurred within the last 12 months. A unidimensional model demonstrated good fit (root mean square error of approximation [RMSEA] = 0.023, comparative fit index [CFI] = 0.977 and Tucker-Lewis Index [TLI] = 0.954). The mania item had the weakest association with a single latent factor (standardised factor loading = 0.14). Model fit improved after removing the mania item (RMSEA = 0.025, CFI = 0.991 and TLI = 0.972). With item response theory analysis, the PSQ provided more information at higher latent trait levels.

Conclusion

Consistent with prior literature, the PSQ demonstrated a unidimensional factor structure among South Africans. In our study, the PSQ in screening for psychosis performed better without the mania item, but future criterion validity studies are warranted.

Contribution

This study highlights that PSQ can be used to screen for early psychosis.

Traditional healers working with primary care and mental health for early intervention in psychosis in young persons: protocol for the feasibility cluster randomised controlled trial

OBJECTIVES

In low/middle-income countries (LMICs), more than half of patients with first-episode psychosis initially seek treatment from traditional and religious healers as their first care. This contributes to an excessively long duration of untreated psychosis (DUP). There is a need for culturally appropriate interventions to involve traditional and spiritual healers to work collaboratively with primary care practitioners and psychiatrists through task-shifting for early detection, referral and treatment of first episode of psychosis.

METHODS

To prevent the consequences of long DUP in adolescents in LMICs, we aim to develop and pilot test a culturally appropriate and context-bespoke intervention. Traditional HEalers working with primary care and mental Health for early interventiOn in Psychosis in young pErsons (THE HOPE) will be developed using ethnographic and qualitative methods with traditional healers and caregivers. We will conduct a randomised controlled cluster feasibility trial with a nested qualitative study to assess study recruitment and acceptability of the intervention. Ninety-three union councils in district Peshawar, Pakistan will be randomised and allocated using a 1:1 ratio to either intervention arm (THE HOPE) or enhanced treatment as usual and stratified by urban/rural setting. Data on feasibility outcomes will be collected at baseline and follow-up. Patients, carers, clinicians and policymakers will be interviewed to ascertain their views about the intervention. The decision to proceed to the phase III trial will be based on prespecified stop-go criteria.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from Keele University Ethical Review Panel (ref: MH210177), Khyber Medical University Ethical Review Board (ref: DIR/KMU-EB/IG/001005) and National Bioethics Committee Pakistan (ref no. 4-87/NBC-840/22/621). The results of THE HOPE feasibility trial will be reported in peer-reviewed journals and academic conferences and disseminated to local stakeholders and policymakers.

TRIAL REGISTRATION NUMBER

ISRCTN75347421.

The incidence of non-affective psychotic disorders in low and middle-income countries: a systematic review and meta-analysis

PURPOSE

Global understanding of the epidemiological landscape of non-affective psychotic disorders (NAPD) is predominantly based on studies from high-income countries. We sought to systematically review and meta-analyse all incidence studies conducted in low and middle-income countries (LMICs).

METHODS

We systematically searched four databases using terms for NAPD, incidence and LMICs. Citations were eligible for inclusion if: published between 1 January 1960 and 31 May 2022; wholly or partially conducted in an LMIC, and; containing data on NAPD incidence in the general adult population. Two independent raters assessed study quality according to previously published criteria. We conducted a narrative synthesis and random-effects meta-analyses where sufficient studies were available (N ≥ 5).

RESULTS

We retrieved 11 421 records, of which 23 citations met inclusion criteria from 18 unique studies across 19 settings in 10 LMICs. Median study quality was 4 out of 7 (interquartile range: 3-6). The crude incidence of NAPD varied around 4.2 times, from 10.0 per 100,000 person-years (95% confidence interval [CI] 8.7-11.4) in Brazil to 42.0 (95%CI 32.2-54.8) in India, with marked heterogeneity in methodologies and rates. Our 60-year review highlights the dearth of robust evidence on the incidence of psychotic disorders in LMICs.

CONCLUSION

Without reliable, contemporary estimates of this fundamental cornerstone of population health, it is impossible to understand the true burden, distribution or causes of psychotic disorders in over 87% of the world's population. A new, more equitable global mental health evidence base for NAPD is now urgently required.

Course of psychotic experiences and disorders among apprentice traditional health practitioners in rural South Africa: 3-year follow-up study

Background

Culture is inevitably linked with the experience, interpretation and course of what modern biomedicine understands to be psychotic symptoms. However, data on psychoses in low- and middle-income countries are sparse. Our previous study showed that psychotic and mood-related experiences, symptoms and disorders are common among individuals who had received the ancestral calling to become a traditional health practitioner (THP) in rural KwaZulu-Natal, South Africa. Our related ethnographic study suggested that ukuthwasa (the training to become a THP) may positively moderate these calling-related symptoms. As far as we know, no research has been conducted into the course of psychiatric symptoms among apprentice THPs.

Objective

We studied the course of psychotic experiences, symptoms and disorders among apprentice THPs. We also assessed their level of functioning and expanded our knowledge on ukuthwasa.

Materials and methods

We performed a 3-year follow-up of a baseline sample of apprentice THPs (n = 48). Psychiatric assessments (CAPE, SCAN), assessment of functioning (WHODAS) and a semi-structured qualitative questionnaire were completed for 42 individuals.

Results

At 3-year follow-up, psychotic experiences were associated with significantly less distress and there was a reduction in frequency of psychotic symptoms compared to baseline. The number of participants with psychotic disorders had decreased from 7 (17%) to 4 (10%). Six out of seven participants (86%) with a psychotic disorder at baseline no longer had a psychiatric diagnosis at follow-up. Although the mean level of disability among the (apprentice) THPs corresponded with the 78th percentile found in the general population, 37 participants (88%) reported no or mild disability. Forty-one participants (98%) reported that ukuthwasa had positively influenced their psychiatric symptoms.

Conclusion

In rural KwaZulu-Natal, psychotic experiences, symptoms and disorders have a benign course in most individuals who are undergoing the process of becoming a THP. Ukuthwasa may be an effective, culturally sanctioned, healing intervention for some selected individuals, potentially because it reframes distressing experiences into positive and highly valued experiences, reduces stigma, and enhances social empowerment and identity construction. This implies that cultural and spiritual interventions can have a positive influence on the course of psychosis.

Patients’ and healthcare professionals’ perspectives on a community-based intervention for schizophrenia in Pakistan: A focus group study

Objective

To explore the perceptions and experiences of schizophrenia from patients, their care givers, health care providers, spiritual and traditional healers to develop a community-based intervention for improving treatment adherence for people with schizophrenia in Pakistan.

Methods

This qualitative study involved four focus group discussions (FGD) with a total of 26 participants: patients and carers (n = 5), primary care staff (n = 7), medical technicians (n = 8) and traditional and spiritual healers (n = 6). The participants were selected using purposive sampling method. FGDs were audio-recorded and transcribed. A thematic analysis was applied to the data set.

Results

The themes identified were (i) Schizophrenia is not merely a biomedical problem: participants believed that poverty and an inferiority complex resulting from social disparity caused schizophrenia and contributed to non-adherence to medications; (ii) Spiritual healing goes hand in hand with the medical treatment: participants regarded spiritual and traditional treatment methods as an inherent part of schizophrenia patients’ well-being and rehabilitation; (iii) Services for mental illness: mental health is not covered under primary health in a basic health unit: participants believed that the lack of services, training and necessary medication in primary care are major issues for treating schizophrenia in community; (iv) Barriers to community-based interventions: primary care staff believed that multiple pressures on staff, lack of incentives, non-availability of medication and lack of formal referral pathways resulted in disintegration of dealing with schizophrenia patients in primary care facilities.

Conclusion

The study has identified a number of barriers and facilitators to developing and delivering a psychosocial intervention to support people living with schizophrenia in Pakistan. In particular, the importance of involving spiritual and traditional healers was highlighted by our diverse group of stakeholders.

"If it weren't for my traditional healer, I would be dead": Engaging traditional healers to support people living with HIV in rural Mozambique

Across rural sub-Saharan Africa, people living with HIV (PLHIV) commonly seek out treatment from traditional healers. We report on the clinical outcomes of a community health worker intervention adapted for traditional healers with insight into our results from qualitative interviews. We employed a pre-post intervention study design and used sequential mixed methods to assess the impact of a traditional healer support worker intervention in Zambézia province, Mozambique. After receiving a positive test result, 276 participants who were newly enrolled in HIV treatment and were interested in receiving home-based support from a traditional healer were recruited into the study. Those who enrolled from February 2016 to August 2016 received standard of care services, while those who enrolled from June 2017 to May 2018 received support from a traditional healer. We conducted interviews among healers and participants to gain insight into fidelity of study activities, barriers to support, and program improvement. Medication possession ratio at home (based on pharmacy pick-up dates) was not significantly different between pre- and post-intervention participants (0.80 in the pre-intervention group compared to 0.79 in the post-intervention group; p = 0.96). Participants reported receiving educational and psychosocial support from healers. Healers adapted their support protocol to initiate directly observed therapy among participants with poor adherence. Traditional healers can provide community-based psychosocial support, education, directly observed therapy, and disclosure assistance for PLHIV. Multiple factors may hinder patients' desire and ability to remain adherent to treatment, including poverty, confusion about medication side effects, and frustration with wait times at the health facility.

Duration of untreated psychosis and pathways to care in Suriname: a qualitative study among patients, relatives and general practitioners

PURPOSE

Psychosis is a severe mental health problem and is responsible for poor health outcomes, premature mortality and morbidity, especially in low- and middle-income countries. The duration of untreated psychosis (DUP), that is the time period between onset of symptoms until initiation of appropriate treatment by a healthcare professional, is one of the main determinants for successful treatment in western settings. This study aims to explore the factors related to the DUP among Surinamese patients using the perspectives from patients, their families and first-line healthcare professionals in Suriname.

METHODS

Semi-structured interviews were conducted with patients having a history of psychosis, family members and general practitioners between February 2019 and April 2019 in Suriname. Interviews were tape-recorded and transcribed verbatim. Data were analysed using a thematic analysis for which an inductive and deductive approach was applied.

RESULTS

In total, 28 patients, 13 family members and 8 general practitioners were interviewed. Five patients were excluded from the study. A median DUP of 4 months was found (IQR 1-36). Identified themes related to DUP included presentation of symptoms and illness awareness, help-seeking behaviour and alternative medicine, social support and stigma, financial and practical factors.

CONCLUSION

Multiple factors were related to DUP, of which poor illness awareness, traditional medicine, stigma and social support were predominant. Poor illness awareness and use of alternative medicine were related to a longer DUP. Stigma was often an obstacle for patients and their families. Social and family support was important in helping patients to get medical help sooner. Other explored factors including financial and practical factors did not contribute to DUP.

Addressing the Needs of People with Schizophrenia in South Africa During the COVID-19 Pandemic

Research indicates that most people with Schizophrenia from low to middle-income countries do not receive adequate healthcare. Inadequate policies, lack of funding, poor service planning and neglect are some barriers to adequate care. Intrinsic barriers to care include stigma, lack of insight, and pathways to care that are often driven by cultural beliefs, and many systemic challenges. South Africa was not spared from the scourge of COVID-19, hosting a third of all reported cases in Africa. In a country with disparities, it would be of interest to get insight into the situation concerning the healthcare needs of people with Schizophrenia during the pandemic. A pandemic such as COVID-19 placed enormous strains on already limited and unequally distributed health care resources. In this paper, we discuss: (1) The South African healthcare system (with respect to Schizophrenia care). (2) COVID-19 policies related to the care of people with Schizophrenia (testing, access to vaccine). (3) Managing people with Schizophrenia amid the COVID-19 pandemic. (4) Recommendations.

Psychopathology among apprentice traditional health practitioners: A quantitative study from rural KwaZulu-Natal, South Africa

Sociocultural context seems to influence the epidemiology, phenotype, treatment, and course of psychosis. However, data from low- and middle-income countries is sparse. This research is part of a multidisciplinary and multimethod study on possible mental disturbances, including hallucinations, among (apprentice) traditional health practitioners (THPs) who have experienced the "ancestral calling to become a THP" in rural KwaZulu-Natal, South Africa. The aim of the current article is to examine whether the calling-related experiences can be assessed according to a psychiatric taxonomy. We included individuals who were identified with the calling and who were undergoing training to become a THP (ukuthwasa). IsiZulu-speaking formal mental health practitioners conducted thorough psychiatric interviews that measured psychological experiences with and without distress using the Community Assessment of Psychic Experiences, and psychiatric symptoms and disorders using the Schedule for Clinical Assessment in Neuropsychiatry. Of the 48 individuals who participated, 92% had psychotic experiences (PE), causing distress in 75%; and 23% met DSM-5 criteria for an unspecified psychotic disorder (15%) or mood disorder (8%). In conclusion, in rural KwaZulu-Natal, the ancestral calling may resemble phenomena that psychiatry would understand in the context of psychosis, ranging from subclinical PE to clinical psychotic disorder. Ukuthwasa might have a beneficial influence on the course of psychotic symptoms in some individuals, potentially because it reduces stigma and promotes recovery. Further multidisciplinary research is needed to investigate the psychopathology of the apprentice THPs and the underlying processes of ukuthwasa.

Patient patronage and perspectives of traditional bone setting at an outpatient orthopaedic clinic in Northern Tanzania

Background

Much of Sub-Saharan Africa meets the rising rates of musculoskeletal injury with traditional bone setting, especially given limitations in access to allopathic orthopaedic care. Concern for the safety of bone setter practices as well as recognition of their advantages have spurred research to understand the impact of these healers on public health.

Objectives

Our study investigates the role of bone setting in Tanzania through patient utilization and perspectives.

Methods

We surveyed 212 patients at the outpatient orthopaedic clinic at Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania. Surveys were either self-administered or physician-administered. Summary statistics were calculated using XLSTAT. Open responses were analyzed using a deductive framework method.

Results

Of all surveys, 6.3% (n=13) reported utilizing traditional bone setting for their injury prior to presenting to KCMC. Of the self-administered surveys, 13.6% (n=6) reported utilizing bone setting compared to 4.3% (n=7) of the physician-administered surveys (p=0.050). Negative perceptions of bone setting were more common than positive perceptions and the main reason patients did not utilize bone setting was concern for competency (35.8%, n=67).

Conclusion

Our study found lower bone setting utilization than expected considering the reliance of Tanzanians on traditional care reported in the literature. This suggests patients utilizing traditional care for musculoskeletal injury are not seeking allopathic care; therefore, collaboration with bone setters could expand allopathic access to these patients. Patients were less likely to report bone setter utilization to a physician revealing the stigma of seeking traditional care, which may present an obstacle for collaboration.