Traditional healers' and biomedical practitioners' perceptions of collaborative mental healthcare in low- and middle-income countries: A systematic review

Health professionals' attitudes towards traditional healing for mental illness: A systematic review protocol

BACKGROUND

Mental illness is a global problem that receives less attention, particularly in developing countries. Integrating modern treatment with traditional healing approaches has been proposed as one way to address mental health problems, especially in developing countries. Despite health professionals' participation in traditional healing being crucial to integrative approaches, their participation is limited to date. This review protocol is designed to explore the attitudes of health professionals towards traditional healing practices in mental health services.

METHODS

The review will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Searching databases, including PubMed/Medline, PsychINFO, EMBASE, Scopus, and the Web of sciences will be conducted. Additionally, Google and Google Scholar will be searched for other information, including grey literature. Moreover, a manual search of identified articles' reference lists will also be conducted to help ensure all potential papers are included in the review. Qualitative, quantitative, and mixed study methods published in English between January 2014 and April 2024 will be included. The qualities of the included studies will be assessed using the Mixed Methods Appraisal Tool (MMAT) Version 2018. A mixed-method synthesis will be used to synthesis the results.

DISCUSSION

It is crucial for healthcare professionals to provide culturally sensitive care to empower people to manage their health. This systematic review will summarize the attitudes of health professionals towards the adoption and delivery of traditional healing approaches to people experiencing mental illness. Therefore, the findings of this review will support integration between traditional healers and modern mental health practitioners for the treatment of mental illness.

TRIAL REGISTRATION

Protocol registration number: CRD42024535136.

The socio-cultural contexts shaping health-seeking behaviours among community members regarding childhood cancer in Tanzania: A qualitative study

BACKGROUND

Timely diagnosis of childhood cancer, early hospital presentation and completion of treatment significantly improve outcomes. Unfortunately, in Tanzania, thousands of children die of cancer each year without ever being diagnosed or treated. To reduce childhood death from cancer, it is important to understand the social-cultural context, values and beliefs that influence healthcare-seeking behaviours among the Tanzanian community.

METHODS

This was a cross-sectional qualitative study conducted in Mwanza, Kilimanjaro and Dar-es-Salaam regions between March and June 2021. We purposively selected community members aged ≥18 years from three rural and three urban settings to participate in seven focus group discussions (each with eight to 12 respondents). The participants were from communities without any affiliation to the treatment of children with cancer or treatment facilities. We transcribed, coded and analyzed data using a thematic-content approach with the support of NVIVO 12 software.

RESULTS

Many had heard of breast or cervical cancer; however, most were unaware of childhood cancer. Adults believe that cancer in children is caused by witchcraft and cannot be cured by modern medicines available at hospitals. These beliefs lead parents to first seek care from traditional healers, which hence delay presentation to the hospital. Other community concerns included the cost of transportation, investigation-related costs, and the long duration of treatment. These have an influence on treatment adherence leading to seeking alternative treatment, such as spiritual or traditional treatment.

CONCLUSION

Low community awareness, late hospital presentation, and treatment abandonment remain a challenge in childhood cancer in most parts of Tanzania. Belief about childhood cancer being a result of witchcraft and superstition contributes to limited health-seeking behaviours. Cultural and contextually relevant awareness campaign interventions are needed to increase cancer knowledge in Tanzanian communities.

The Epidemiology of Spinal Neurosurgery in Nigeria: A Systematic Review and Patient-Level Analysis

OBJECTIVE

Spinal pathologies are prevalent in Nigeria, though epidemiological data remains sparse. This systematic review used pooled patient-level data from across the country to generate a standardized epidemiological reference.

METHODS

Four research databases and gray literature sources were searched. Risk of bias assessment was conducted using Risk of Bias in Non-Randomised Studies - of Interventions and Cochrane's risk of bias tool. We descriptively analyzed all article metrics and statistically analyzed relevant data variables via paired t-test and χ2 independence tests (α = 0.05).

RESULTS

One hundred twenty-seven articles, comprising a patient cohort of 8425 patients, were analyzed. Most were retrospective cohort studies (46.5%) and case reports/series (31.5%), with an overall moderate-high risk of bias. Most studies were published in the last 20 years. Most patients were male (∼2.5 males per female), with an average age of 43.2 years (±16.4). Clinical diagnoses spanned the breadth of spinal neurosurgery. Approximately 45.0% of patients had complete spinal impairment. Pain (41.7%) was the most reported presenting feature. X-ray (45.1%) was the most common investigation used. Intervertebral disc herniation (18.9%) was the most prevalent imaging finding on MRI. Most patients were managed nonoperatively (57.8%), with a favorable outcome in 27.4% of patients. Posttreatment complications included pressure sores, infection, and motor deficits.

CONCLUSIONS

This systematic review and pooled analysis provide an epidemiological overview of spinal neurosurgery in Nigeria over the last 60 years and serves as a useful reference to direct future global research in this arena.

'We are all working toward one goal. We want people to become well': A visual exploration of what promotes successful collaboration between community mental health workers and healers in Ghana

The practices of traditional and faith-based healers in low- and middle-income countries in Africa and elsewhere have come under intense scrutiny in recent years owing to allegations of human rights abuses. To mitigate these, there have been calls to develop collaborations between healers and formal health services to optimise available mental health interventions in poorly resourced contexts. For various reasons, attempts to establish such partnerships in a sustainable manner in different countries have not always been successful. In this article, we present findings from the Together for Mental Health visual research project to showcase examples of healer-health worker collaborations in Ghana that have been largely successful and discuss the barriers and facilitators to establishing these partnerships. Data reported in this article were collected using visual ethnography and filmed individual interviews with eight community mental health workers, six traditional and faith-based healers and two local philanthropists in the Bono East Region. The findings suggest that successful collaborations were built through mutually respectful interpersonal relationships, support from the health system and access to community resources. Although these facilitated collaboration, resource constraints, distrust and ethical dilemmas had to be overcome to build stronger partnerships. These findings highlight the importance of dedicated institutional and logistic support for ensuring the successful integration of the different health systems in pluralistic settings.

Barriers and facilitators to accessing adolescents' mental health services in Karachi: users and providers perspectives

INTRODUCTION

Adolescents' Mental Healthcare (MHC) is influenced by numerous factors, and adolescents occasionally seek professional help for mental health (MH) issues. These factors become more complex within low-middle-income countries (LMICs); therefore, this study aims to understand barriers and facilitators to access mental health services among adolescents aged 10 to 19 years old from the perspective of users (parents) and providers (Mental Healthcare Providers - MHPs).

METHOD

Using a qualitative exploratory design, a semi-structured interview guide was developed using Andersen's health service utilization model. In-depth interviews were conducted with MHPs (n = 21) and parents of adolescents (n = 19) in the psychiatry department of public and private hospitals in Karachi, from October-December 2021. Data was thematically analyzed using an inductive approach.

RESULT

The findings revealed a consensus of users and providers in all three categories of the Andersen model and referred the compulsion as the major driving force to MHC access and utilization rather than personal choices. Within pre-disposing, need, and enabling factors; the participants highlighted a unique perspective; users regarded frequent migration, daily wage loss, and women's societal status as barriers while the need for marriage and patient willingness were stated as facilitators. Whereas, MHPs indicated societal tolerance, the burden on the health system, and the absence of Child and Adolescent Mental Health (CAMH) services as major gaps in service delivery.

CONCLUSION

Service utilization is mainly facilitated by the severity of illness rather than healthy choices and beliefs, and accessibility and affordability. It is therefore imperative to prioritize adolescent MH through promotion and prevention approaches and address service delivery gaps to prevent treatment delays via task-shifting and capacity building of the health workforce.

Traditional health practitioners' training needs on biomedical knowledge and skills in a South African township

BACKGROUND

Traditional health practitioners (THPs) play an important role in communities by providing necessary health services for a variety of health problems. Possessing complementary biomedical knowledge and skills is vital in saving lives of patients. However, less is known about biomedical knowledge and skills among THPs.

AIM

This study aimed to explore and describe the training needs of THPs on biomedical knowledge and skills in urban townships in South Africa.

SETTING

The study was conducted in a township in the City of Tshwane Metropolitan Municipality of Gauteng province, South Africa.

METHODS

A qualitative, explorative, descriptive design with 18 THPs was employed through snowballing sampling. Data were collected through a lekgotla group discussion and thematic content analysis undertaken.

RESULTS

Themes that emanated include knowledge of the basic physiological functioning of the human body; biomedical knowledge and skills required for the assessment of patients; managing emergency health conditions and understanding diagnostic concepts used in traditional health practice versus biomedical systems.

CONCLUSION

Traditional health practitioners have demonstrated interest in being trained on certain skills used within the biomedical system to care for patients. Performing the necessary first-aid skills by THPs will assist patients in the communities while waiting for emergency services or referrals. Provision of training programmes for THPs on first aid interventions during emergencies is therefore recommended.Contribution: The study revealed that capacitating THPs with biomedical knowledge and skills can improve their ability to promote healthy living and prevent health problems in communities where access to resources is limited.

Experiences and practices of traditional healers on snakebite treatment and prevention in rural Malawi

Snakebite envenoming remains a public health threat in many tropical countries including Malawi. Traditional healers (THs) have been consulted by victims of snakebites as primary caregivers for millennia. There are no studies in Malawi to understand this phenomenon, therefore, our study aimed to explore the experiences and practices of THs regarding snakebite treatment and prevention in rural Malawi. Between August and September 2022, we conducted semi-structured interviews with 16 THs who were purposefully selected from various locations across Neno District, Malawi. We analysed the interview data using Dedoose software, where we generated codes and grouped them into themes. Out of the 16 THs interviewed, 68.8% (n = 11) were male, and 43.8% were aged between 40 and 60 years. Our study identified five themes: THs' knowledge of snakes and treatment, the continuum of care they provide, payment procedures, snakebite prevention, and their relationship with health facilities. They claimed a good understanding of the snakes in their area, including the seasons with more snakebites, and were confident in their ability to provide treatment, however, this was not scientifically proven. They offered a comprehensive care package, including diagnosis, first aid, main treatment, and follow-up care to monitor the victim's condition and adjust treatment as needed. THs provide free treatment for snakebites or use a "pay later" model of service delivery. All THs claimed a "vaccine" for snakebites that could prevent bites or neutralize the venom. However, no formal relationship existed between THs and Health Care Workers (HCWs). We recommend collaboration between HCWs and THs, establishing clear referral pathways for snakebite victims and educating THs on identifying danger signs requiring prompt referral to healthcare facilities.

Mental illness stigma in Bangladesh: Findings from a cross-sectional survey

Background

Mental illness stigma is universally prevalent and a significant barrier to achieving global mental health goals. Mental illness stigma in Bangladesh has gained little attention despite its widespread impact on seeking mental health care in rural and urban areas. This study aimed to investigate mental illness stigma and the associated factors in rural and urban areas of Bangladesh.

Methods

The study areas were divided into several clusters from which 325 participants (≥18 years) were recruited with systematic random sampling. The Bangla version of the Days' Mental Illness Stigma Scale was used to collect data. Independent-samples t-test, ANOVA, and multiple regression were performed.

Results

Results suggest that gender, age, geographical location, socioeconomic status, and occupation significantly differed across subscales of stigma. Age, gender, seeking treatment of mental illness, having knowledge on mental health, and socioeconomic status were predictive factors of mental illness stigma. The results also showed a high treatment gap in both rural and urban areas.

Conclusion

This study supports that mental illness stigma is prevalent in Bangladesh, requiring coordinated efforts. Results can inform the development of contextually tailored mental health strategies to reduce stigma and contribute to the promotion of mental health of individuals and communities across Bangladesh.

The Trends of Suicidality Over the Past 10 Years (1999-2022) in the Ethiopian General Population and the Way Forward in Tackling It

Suicide is defined as a death caused by willful acts of taking one's own life. It might be a way for people to get away from suffering or anguish. Globally, an estimated a million people individuals lose their life due to suicide annually. Before the age of 50 years old more than half (58%) of all suicide deaths occur. This commentary aims to highlight the Ethiopian context, feasible preventive measures, and the way forward in tackling suicidal behavior. Worldwide in adolescent age groups between the ages of 15 and 29, suicide is the fourth leading cause of death. Even though suicide occurs everywhere in the world, according to data in 2019, 77% of all suicides that occurred in the world reside in developing countries. Due to the numerous psychosocial pressures present in Ethiopia, one in four citizens suffers from a mental disorder. According to Ethiopian national data figures, suicide ideation affects 9%, 5-16% of people, whereas suicidal attempt affects 4%, 1-8%. Even though, there is a variation of prevalence over the years based on the variation in design, settings, and sample size. There is an increment in the prevalence's suicidal ideation and attempts in the past 10 years. The country's Ministry of Health needs to act to address and prevent this urgent public health situation. The prevention of suicide should be a top concern, and working with numerous stakeholders is an efficient and practical approach.

Patterns and factors associated with consulting traditional healers on the care pathway of psychiatric patients in the United Arab Emirates

BACKGROUND

Despite the availability of mental health services in the United Arab Emirates (UAE), reluctance in seeking a mental health professional is widely prevalent. In many countries, psychiatric patients consult Traditional Healers (THs) prior to seeing mental health professionals. Data from the UAE on the pattern of consulting THs is limited.

AIMS

To investigate patterns and factors for visiting THs in psychiatric patients in Abu Dhabi, the capital of UAE.

METHOD

We conducted a cross-sectional study of patients attending the adult psychiatry clinic, Maudsley Health, Abu Dhabi. We assessed 214 patients for the pattern and possible factors for contact with THs on their pathway to psychiatric care.

RESULTS

There were 58 males and 156 females. Most (43.5%) had a depressive disorder. Prior to consulting a mental health professional, 28% had seen a TH, of whom 36.7% had only one visit and 60% had seen only one TH. Advice from a friend or family member was the commonest reason for consulting THs (81.7%). Envy was the commonest explanation given by THs for symptoms (26.7%). Female gender and having a high school education or less significantly predicted contact with THs.

CONCLUSIONS

Almost a third of our sample consulted THs prior to seeking psychiatric care. Closer collaboration with THs could help bridge the gap with psychiatrists to avoid delays in patients accessing psychiatric care, however caution is needed to mitigate the possible negative effects of such a collaboration.

Community and provider perceptions and experiences of cervical cancer screening in Rural Bolivia: a qualitative study

BACKGROUND

Despite efforts to increase cervical cancer screening access in rural Bolivia, uptake remains low. Bolivia has one of the highest cervical cancer mortality rates in the Americas. As it redoubles efforts to deliver Universal Health Care, the Bolivian government needs information on the factors constraining cervical cancer screening access and utilization, especially in rural areas.

METHODS

Our qualitative study explored cervical cancer screening barriers and described community and provider perceptions and experiences of care. Bolivian and US researchers analyzed data collected from eight focus groups with male and female community members (n = 80) and interviews with healthcare providers (n = 6) in four purposively selected rural communities in Hernando Siles, Bolivia. Deductive and inductive codes were used to thematically analyze data using MaxQDA software.

RESULTS

Four themes emerged from the data: lack of knowledge/misconceptions, health system inadequacy, lack of confidence in providers, and opportunities for improvement. Both men and women displayed misconceptions about the causes of cervical cancer, its consequences, the recommended screening frequency, and the means of accessing care. Providers noted community members' lack of knowledge and low risk-perception as utilization barriers but also highlighted poor health service quality and inconsistent health education as factors. Poor healthcare quality was a significant barrier; this included poor patient-provider communication, lack of transportation to screening facilities, and severe delays in receiving test results. Providers also noted problems with provider training and physical space for screening. Community members reported low confidence in nurses to perform screening, preferring doctors and specialists. They also expressed discomfort in having male healthcare providers conduct screening. Suggestions for improvements included more intensive cervical cancer outreach to rural areas and having specialists train lower-level providers to perform screening.

CONCLUSIONS

Our findings suggest that poor healthcare quality has affected screening uptake in addition to physical barriers to care. They indicate a need for initiatives to reduce reporting time for Pap test results, the incorporation of community-based HPV self-sampling into screening protocols, and the implementation of programs to improve community confidence in providers' ability to perform screening.

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.

Traditional healers' explanatory models of intellectual disability in Cape Town

While intellectual disability is experienced worldwide, with much greater rates in contexts of poverty, relatively few studies on intellectual disability have been conducted in low- and middle-income countries. High levels of intellectual disability in South Africa exist alongside high levels of poverty, malnutrition and poor or inaccessible healthcare services. The lack of access to services partly explains why many turn to traditional healers. Within this context there is very limited research on the role that traditional healers play in relation to intellectual disability in South Africa. The current study investigated traditional healers' understanding and beliefs about intellectual disabilities and the treatment modalities that they use. An exploratory qualitative research design was used to examine the views and perspectives of traditional healers on intellectual disability. Fifteen traditional healers participated in the study. Key findings show that the naming of and the terminology used to describe and identify intellectual disability are very much similar to what has been observed in African cultures in general where intellectual disability is identified as an abnormality. Some traditional healers located the presentation of intellectual disability within the biomedical sphere while others gave supernatural explanations for how intellectual disability presents in children and for its causes. All traditional healers expressed a willingness to work with the Western formal healthcare system. Findings on traditional healers' views on future collaborations with the formal health system provide opportunities for these two forms of healthcare services to be synergised for the strengthening and improvement of services provided to children with intellectual disability and their families.

Individual and community experiences and the use of language in understanding diabetes and depression in rural Kenya

As the prevalence of long-term conditions continues to rise it becomes increasingly important to identify ways to mitigate their effects, including the psychological impact. In rural Kenya identifying people with diabetes or mental health problems is challenging due to the stigma and negative experiences within community settings.Four broad themes were identified; (1) misconceptions and stigma: the use of language, (2) treatment and medications, (3) community beliefs and alternative treatment pathways, (4) the role of informal and formal care.Our study demonstrated the detrimental effect of the use of stigmatising language and misconceptions surrounding diabetes and depression at both the individual and community levels. Inequalities in health care access were observed and a lack of resources in rural communities was evident. Improvements in support for health care workers at the community level as well as acknowledging the importance of informal care could help improve the psychological and emotional impact of diabetes and depression.

Public mental health: required actions to address implementation failure in the context of COVID-19

Mental disorders account for at least 18% of global disease burden, and the associated annual global costs are projected to be US$6 trillion by 2030. Evidence-based, cost-effective public mental health (PMH) interventions exist to prevent mental disorders from arising, prevent associated impacts of mental disorders (including through treatment), and promote mental wellbeing and resilience. However, only a small proportion of people with mental disorders receive minimally adequate treatment. Compared with treatment, there is even less coverage of interventions to prevent the associated impacts of mental disorders, prevent mental disorders from arising, or promote mental wellbeing and resilience. This implementation failure breaches the right to health, has increased during the COVID-19 pandemic, and results in preventable suffering, broad impacts, and associated economic costs. In this Health Policy paper, we outline specific actions to improve the coverage of PMH interventions, including PMH needs assessments, collaborative advocacy and leadership, PMH practice to inform policy and implementation, training and improvement of population literacy, settings-based and integrated approaches, use of digital technology, maximising existing resources, focus on high-return interventions, human rights approaches, legislation, and implementation research. Increased interest in PMH in populations and governments since the onset of the COVID-19 pandemic supports these actions. Improved implementation of PMH interventions can result in broad health, social, and economic impacts, even in the short-term, which support the achievement of a range of policy objectives, sustainable economic development, and recovery.

We love orthodox medicine but still use our 'Elewe omo': Utilization of traditional healers among women in an urban community in Nigeria

Background:

Traditional Medicine refers to knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures. Women have been reported to utilize orthodox health care facilities more hence this study in an urban center.

Objective:

To determine the utilization of traditional healers, preference of healthcare and co-utilization of traditional and orthodox medicine among women in an urban community in Lagos, Nigeria.

Method:

A cross sectional design using a multistage sampling to select 270 women in Mosan Okunola, Lagos, Nigeria in 2019. A pretested semi-structured intervieweradministered questionnaire and an in-depth interview were used to obtain data from participants. Utilization of traditional healers was referenced within the last 12 months.

Result:

Sixty three percent (63.2%) of the study population utilized traditional healers and 80.6% of respondents that accessed healthcare utilized traditional healers. The Traditional Medicine ingredient dealer was the most patronized (74.6% of respondents). Eighty three percent (83.3%) of study participants indicated preference for orthodox medicine and 53.1% of the study respondents co-utilized both traditional healers and orthodox medicine. Concurrent use of both traditional and orthodox medicine was not a common practice among the women. Level of education, monthly income and means of payment for treatment had a statistical significant association (P < 0.05) with utilization of traditional healers but means of payment for treatment was the singular predictive factor of utilization of traditional healers.

Conclusion:

Utilization of traditional healers among women in this community was high with majority indicating a preference for orthodox medicine. It is recommended that an in-depth history of remedies used by patients should be delved into by orthodox health practitioners.

Suicidal ideation and behavior in youth in low- and middle-income countries: A brief review of risk factors and implications for prevention

Although global rates of suicide have dropped in the last 30 years, youth in low- and middle-income countries (LMICs) continue to be highly represented in suicide statistics yet underrepresented in research. In this review we present the epidemiology of suicide, suicidal ideation, and suicide attempts among youth in LMICs. We also describe population-level (attitudes toward suicide, socioeconomic, and societal factors) and individual-level clinical and psychosocial risk factors, highlighting specific considerations pertaining to youth in LMICs. These specific considerations in risk factors within this population can inform how multi-level prevention strategies may be targeted to meet their specific needs. Prevention and intervention strategies relying on the stepped-care framework focusing on population-, community-, and individual level targets while considering locally- and culturally relevant practices are key in LMICs. In addition, systemic approaches favoring school-based and family-based interventions are important among youth. Cross-culturally adapted multimodal prevention strategies targeting the heterogeneity that exists in healthcare systems, suicide rates, and risk factors in these countries should be accorded a high priority to reduce the burden of suicide among youth in LMICs.

Complementary health approaches use in Turkish patients with mental disorders: Related factors and perceived benefits

PURPOSE

The present study was performed to determine the prevalence, characteristics, perceived benefits, and predictors of complementary health approaches use (CHA) in Turkish patients with mental disorders.

DESIGN AND METHODS

The present study was performed with 413 patients with mental disorders.

FINDINGS

In the present study, 62.2% of the patients had used CHA in the last 12 months. The most common types of CHA used were religious/spiritual activities and herbs. According to the multivariate logistic regression model, sex, education level, marital status, employment status, medical diagnoses, and duration of diagnoses were significantly associated with increased CHA use.

PRACTICE IMPLICATIONS

The CHA use by patients should be investigated, and education and counseling should be provided by health professionals to improve patient safety and patient outcomes.

"Medical treatments are also part of God's gift": Holy water attendants' perspectives on a collaboration between spiritual and psychiatric treatment for mental illness in Ethiopia

In Ethiopia, traditional and spiritual treatments, such as holy water, are used by people with mental disorders instead of, or alongside, psychiatric services. Collaborations between traditional and psychiatric providers may increase access to evidence-based treatments and address human rights abuses. This study aimed to explore the perspectives of holy water attendants on a novel collaboration between holy water and psychiatric care, at St Mary's Clinic, Entoto, Ethiopia, and to characterize the users of this service. Semi-structured interviews were conducted with 14 holy water attendants, who run group houses for holy water residents and are paid by family members. A thematic analysis was conducted. Socio-demographic and clinical data were extracted from the records of all service users who had attended the clinic. A total of 174 individuals have attended the clinic in the three years since it opened. The majority were diagnosed with schizophrenia. Holy water attendants provide a partial gatekeeping role to psychiatric care, selecting which of their clients they think will benefit and, for these individuals, facilitating attendance to the clinic and antipsychotic medication adherence. Psychiatric care was felt to be compatible with holy water by some, but not all, attendants. However, family members often had the "final say" in individuals attending the clinic, in some cases putting up strong resistance to using psychiatric care. A novel collaboration is acceptable to some holy water attendants and may increase access to psychiatric care amongst people with mental illness living at a holy water site in Ethiopia.

A Digital Toolkit (M-Healer) to Improve Care and Reduce Human Rights Abuses Against People With Mental Illness in West Africa: User-Centered Design, Development, and Usability Study

BACKGROUND

The resources of West African mental health care systems are severely constrained, which contributes to significant unmet mental health needs. Consequently, people with psychiatric conditions often receive care from traditional and faith healers. Healers may use practices that constitute human rights violations, such as flogging, caging, forced fasting, and chaining.

OBJECTIVE

The aim of this study is to partner with healers in Ghana to develop a smartphone toolkit designed to support the dissemination of evidence-based psychosocial interventions and the strengthening of human rights awareness in the healer community.

METHODS

We conducted on-site observations and qualitative interviews with healers, a group co-design session, content development and prototype system build-out, and usability testing.

RESULTS

A total of 18 healers completed individual interviews. Participants reported on their understanding of the causes and treatments of mental illnesses. They identified situations in which they elect to use mechanical restraints and other coercive practices. Participants described an openness to using a smartphone-based app to help introduce them to alternative practices. A total of 12 healers participated in the co-design session. Of the 12 participants, 8 (67%) reported having a smartphone. Participants reported that they preferred spiritual guidance but that it was acceptable that M-Healer would provide mostly nonspiritual content. They provided suggestions for who should be depicted as the toolkit protagonist and ranked their preferred content delivery modality in the following order: live-action video, animated video, comic strip, and still images with text. Participants viewed mood board prototypes and rated their preferred visual design in the following order: religious theme, nature motif, community or medical, and Ghanaian culture. The content was organized into modules, including an introduction to the system, brief mental health interventions, verbal de-escalation strategies, guided relaxation techniques, and human rights training. Each module contained several scripted digital animation videos, with audio narration in English or Twi. The module menu was represented by touchscreen icons and a single word or phrase to maximize accessibility to users with limited literacy. In total, 12 participants completed the M-Healer usability testing. Participants commented that they liked the look and functionality of the app and understood the content. The participants reported that the information and displays were clear. They successfully navigated the app but identified several areas where usability could be enhanced. Posttesting usability measures indicated that participants found M-Healer to be feasible, acceptable, and usable.

CONCLUSIONS

This study is the first to develop a digital mental health toolkit for healers in West Africa. Engaging healers in user-centered development produced an accessible and acceptable resource. Future field testing will determine whether M-Healer can improve healer practices and reduce human rights abuses.

Exploration of recovery of people living with severe mental illness (SMI) in low/middle-income countries (LMICs): a scoping review

OBJECTIVE

To examine the literature on how recovery of people with severe mental illness (SMI) is conceptualised in low/middle-income countries (LMICs), and in particular what factors are thought to facilitate recovery.

DESIGN

Scoping review.

DATA SOURCES AND ELIGIBILITY

We searched 14 electronic databases, hand searched citations and consulted with experts during the period May-December 2019. Eligible studies were independently screened for inclusion and exclusion by two reviewers. Unresolved discrepancies were referred to a third reviewer.

DATA EXTRACTION AND SYNTHESIS

All bibliographical data and study characteristics were extracted using a data charting form. Selected studies were analysed through a thematic analysis emerging from extracted data.

RESULTS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram offers a summary of the results: 4201 titles, 1530 abstracts and 109 full-text articles were screened. Ten articles were selected for inclusion: two from Turkey, two from India, and one each from China, Swaziland, Indonesia, Egypt, South Africa and Vietnam. Although most studies used qualitative methods, data collection and sampling methods were heterogeneous. One study reported on service provider perspectives while the rest provided perspectives from a combination of service users and caregivers. Three themes emerged from the data analysis. First, studies frame recovery as a personal journey occurring along a continuum. Second, there was an emphasis on social relationships as a facilitator of recovery. Third, spirituality emerged as both a facilitator and an indicator of recovery. These themes were not mutually exclusive and some overlap exists.

CONCLUSION

Although there were commonalities with how high-income countries describe recovery, we also found differences in conceptualisation. These differences in how recovery was understood reflect the importance of framing the personal recovery concept in relation to local needs and contextual issues found in LMICs. This review highlighted the current sparse evidence base and the need to better understand recovery from SMI in LMICs.

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.