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The Issues Affecting Mental Health Nursing in Uganda
Abstract
Estimates are that up to 35% of the Ugandan populations have a mental health condition; however access to psychiatric care, particularly for people living in rural areas, is poor. Additionally, cultural and lay beliefs and stigma affect both the individual with mental illness and healthcare professionals. The Ugandan government has recognized the need to modernize legislation and develop policies designed to provide modern psychiatric services to the whole population. Strategies include, passing new legislation, integrating services into primary care, including psychiatric illness in nurse education. Nevertheless, evidence suggests that this rhetoric is not being fully enacted. This paper reviews the issues affecting the development and delivery of improved mental health services, with a particular focus on psychiatric nursing. Actions that have already successfully addressed issues with psychiatric services in Uganda are highlighted and conclusions drawn regarding the development of future services.
... Uganda, like many nations within East Africa, has seen a signi cant increase in population over the last few decades, from 36 million to 45 million people since 2014 [6]. It is estimated that up to 35 percent of the Ugandan population suffers from at least one mental illness, resulting in a critical need for increased use of effective psychiatric services throughout the country [7]. This issue is exacerbated by the country's lack of trained healthcare professionals as there are only 0.78 psychiatric nurses per 100,000 individuals, primarily concentrated in the country's one psychiatric hospital, Butabika National Referral Mental Hospital located in the capital, Kampala [7]. ...
... It is estimated that up to 35 percent of the Ugandan population suffers from at least one mental illness, resulting in a critical need for increased use of effective psychiatric services throughout the country [7]. This issue is exacerbated by the country's lack of trained healthcare professionals as there are only 0.78 psychiatric nurses per 100,000 individuals, primarily concentrated in the country's one psychiatric hospital, Butabika National Referral Mental Hospital located in the capital, Kampala [7]. As a result, rural areas of Uganda are disproportionately affected by this treatment gap, due to long travel distances, high levels of poverty, and stigma around mental illness [7]. ...
... This issue is exacerbated by the country's lack of trained healthcare professionals as there are only 0.78 psychiatric nurses per 100,000 individuals, primarily concentrated in the country's one psychiatric hospital, Butabika National Referral Mental Hospital located in the capital, Kampala [7]. As a result, rural areas of Uganda are disproportionately affected by this treatment gap, due to long travel distances, high levels of poverty, and stigma around mental illness [7]. ...
Purpose
Evaluate the long-term effectiveness of a community-led theatrical intervention in reducing mental health stigma in a low-income setting in Uganda.
Methods
A follow-up survey of study participants was conducted 12 months after the initial community-led theatrical intervention measuring the primary outcomes of mental illness stigma using the Broad Acceptance Scale (BAS) and the Personal Acceptance Scale (PAS).
Results
Of the initial 57 participants, 46 (80%) completed the follow-up survey. The average improvement in Broad Acceptance Scale and Personal Acceptance Score observed from baseline to twelve months after the intervention was 1.435 (95% CI: 0.826–2.044, p < 0.0001, SD: 1.64) and 2.152 (95% CI: 1.444–2.860, p < 0.0001, SD: 1.93), respectively. Both effect sizes were within the confidence intervals of the average improvement observed one week after the intervention.
Conclusion
Exposure to the community-led theatrical intervention continued to confer a significant and substantial reduction in mental illness stigma.
... The benefit of multi-disciplinary teams is that they can provide holistic care, promoting the recovery of individuals and in doing so also enhance the skills and experience of the team members. 8 Appropriately trained social workers can support people in the community; perhaps even preventing hospital admission, as well as helping them reintegrate into society at hospital discharge. 8 Psychological therapies for mental disorder have a good evidence base and may be particularly important where drug supplies are inconsistent. ...
... 8 Appropriately trained social workers can support people in the community; perhaps even preventing hospital admission, as well as helping them reintegrate into society at hospital discharge. 8 Psychological therapies for mental disorder have a good evidence base and may be particularly important where drug supplies are inconsistent. Similarly, occupational therapy promotes recovery and rehabilitation. ...
... Inability to refer to other services may increase their workload and the scope of issues nurses are expected to address, creating additional pressure on an already stretched workforce. 8 6 ...
This survey of hospitals affiliated to the Uganda Protestant Medical Bureau to assess their provision of mental health care found that about ⅔ of hospitals had some mental health care clinics. Only two hospitals had beds designated for patients with a mental illness. Staffing with appropriately trained staff, and funding were the main limiting factors. The most common diagnosis was epilepsy, followed by psychosis and depression
... Primary health care (health care outside of hospitals) should include mental health care if it is to be accessible to those who need it (5)(6)(7)(8). The main barriers to accessing mental health services include centralization of mental health services in hospitals, lack of available medicines, inadequate number of mental health trained staff, mental health not being a priority for policy makers, and beliefs around the causation and appropriate treatment of mental illness which result in seeking alternative treatments such as from religious and traditional healers (4,(8)(9)(10)(11). ...
... Primary health care (health care outside of hospitals) should include mental health care if it is to be accessible to those who need it (5)(6)(7)(8). The main barriers to accessing mental health services include centralization of mental health services in hospitals, lack of available medicines, inadequate number of mental health trained staff, mental health not being a priority for policy makers, and beliefs around the causation and appropriate treatment of mental illness which result in seeking alternative treatments such as from religious and traditional healers (4,(8)(9)(10)(11). ...
Background
Mental, neurological, and substance-use disorders cause medium to long term disability in all countries. They are amenable to treatment but often treatment is only available in hospitals, as few staff feel competent to give treatment. The WHO developed the “Mental Health GAP” (mhGAP) course to train non-specialist clinical staff in basic diagnosis and treatment. At Bwindi Community Hospital, in south-west Uganda, mental health care was initially only provided at the hospital. It was extended outside the hospital in two implementation phases, initially by establishing 17 clinics in the community, run by qualified mental health staff from the hospital. In the second implementation phase staff in 12 health centers were trained using mhGAP and ran their own clinics under supervision.
Methods
Using routine data the defined data variables for the individuals attending the clinics was extracted.
Results
A total of 2,617 people attended a mental health care clinic in the study period between January 2016 and March 2020. Of these 1,051 people attended more than once. The number of patients attending clinics increased from 288 during the baseline to 693 in the first implementation phase then to 839 patients in the second implementation phase. After mhGAP training, about 30% of patients were seen locally by mhGAP trained healthcare personnel. The average number of mental health patients seen each month increased from 12 to 65 over the time of the study. The number of patients living >20 km from the hospital increased from 69 in the baseline to 693 in the second implementation phase. The proportion of patients seen at the hospital clinic dropped from 100% to 27%.
Conclusions
Providing mental health care in the community at a distance from the hospital substantially increased the number of people accessing mental health care. Training health center-based staff in mhGAP contributed to this. Not all patients could appropriately be managed by non-specialist clinical staff, who only had the five-day training in mhGAP. Supplies of basic medicines were not always adequate, which probably contributed to patients being lost to follow-up. About 50% of patients only attend the clinic once. Further work is required to understand the reasons.
... One referral hospital for mental illness services the entire country: Butabika National Referral Hospital in the capital city of Kampala (Murray, Ainslie, Alpough, Schramm, & Showalter, 2015). The hospital has a bed capacity of 550, but at any given time there are as many as 1200 patients admitted (Bailey, 2014). Only an estimated 1% to 20% of physician-based primary health-care clinics in the country have assessment and treatment protocols in place for mental health conditions (World Health Organization and Ugandan Ministry of Health, 2006) and they have a reputation of providing poor quality care (Nsereko et al., 2011). ...
... Only an estimated 1% to 20% of physician-based primary health-care clinics in the country have assessment and treatment protocols in place for mental health conditions (World Health Organization and Ugandan Ministry of Health, 2006) and they have a reputation of providing poor quality care (Nsereko et al., 2011). Bailey (2014) observed that patients with mental illness were given a lower priority in hospitals; psychiatric centers were understaffed and undertrained; and administrators were dismissive of patients with mental health issues. ...
Media are a major purveyor of information about mental health. Recognizing what messages media are disseminating about mental illness, therefore, is a step toward raising mental health literacy in a population. Most research about media coverage of mental illness, however, has taken place in Western nations. Differences in cultural views of mental illness and severely strained mental health-care resources in sub-Saharan African make it likely that media coverage of mental illness there will differ substantially from Western contexts. This study investigated the coverage of mental illness in the two largest circulation newspapers in Uganda: The Monitor and The New Vision. Analysis of the entire contents of every issue of both papers from January 1, 2017 to June 30, 2019 revealed just 53 articles addressing mental illness. Although types of mental illness addressed did not differ greatly from coverage in Western newspapers, causes to which mental illness was attributed included war, poverty, and witchcraft, none of which appears in content analyses in other contexts. Also, different than Western media, most articles were thematically rather than episodically framed, especially in the government-owned paper, and individuals with mental illness themselves were regularly cited.
... Governments' underinvestment in adequate mental health provision must be taken into consideration. For example, in Uganda the tackling of the mental health problems of people seems overwhelming due to a severe shortage of mental health professionals and primary care providers' reluctance to deal with mental health care (Blain, 2014;Kaggwa et al., 2022;Wagner et al., 2014). WHO Regional Director Moeti stated that "Suicide is a major public health problem and every death by suicide is a tragedy. ...
Introduction
Suicide is globally a severe problem with an estimated 700.000 deaths annually. Six of the 10 countries with the highest suicide rates worldwide are in Africa, though, reliable statistics are scarce.
Method
In this qualitative interview study in Uganda, we analysed the stories of 16 people admitted to hospital following a serious suicide attempt. We focussed especially on each person’s decision process towards their resolution to attempt suicide.
Findings
Despite the huge heterogeneity of the narratives, we could identify problems regarding the sense of belonging and mattering in all the stories. Both the sense of belonging and mattering have been related to suicidal behaviour in earlier theories, but they were never studied together or under consideration of the influence of this specific cultural context. We found that the participants’ sense of belonging and mattering to a large degree was influenced by their traditional communalistic context with a worldview where the line between the natural and spiritual world was blurry.
Conclusion
This kind of knowledge could be a valuable source for health professionals in their treatment of suicidal persons; it could direct their approach to the core of each person’s relational problems and meaning-making, which is crucial for their decisions with regard to suicide.
... Although the hospital treats many patients who have depression on its own, it is also comorbid with chronic illnesses such as HIV, cancer, or diabetes. Over one-third of the population in Uganda is affected by mental illness with depression being one of the most common; however, not even half of these individuals seek professional help (Bailey, 2014;Murray et al., 2015). This exemplifies Uganda's need to keep improving and emphasizing its mental health care system on a national scale. ...
Mental health is a crucial part of overall wellbeing. Canada’s mental health system has progressed over the last decade but still has room for improvement. In comparison, developing countries, such as Uganda, have not shown the same progression with their mental health systems. The embedded experience, together with expert consultations in the field, was conducted over several months at a human immunodeficiency virus (HIV) specialized hospital, the Joint Clinical Research Center (JCRC) in Kampala, Uganda on the topic of mental health systems. The observations and consultations were thematically analyzed into four main themes: cultural attitudes towards mental illness, the interconnectedness of childhood HIV and mental health, a gap in education for mental health professionals to become certified, and barriers to addressment of mental health issues at the JCRC. The main barriers for Ugandans seeking professional treatment were also identified, which included the accessibility and availability of professional treatment. Local solutions are outlined, as well as recommendations for improvements and future research.
This study examined the relationship between home roles, stress and coping strategies among 100 nurses in Kampala selected using stratified and random sampling techniques. Data was analyzed using Spearman rank order correlation and regression used to test coping as a moderation in the relationship between home roles and stress. Results revealed that home roles are not significantly related. However, results also revealed that both home roles and stress were both significantly related to coping strategies. Results revealed that coping predicts insignificant effect on the relationship between home roles and stress. Also, the relationship between home roles and stress was inverse. This study finding explores strategies that could aid nurses to deal with work stress, strengthen nurses and clients’ relationship which ultimately could influence effective Counselling and Psychotherapy.
Mental illness in Uganda affects over one-third of the population. Less than half of these individuals seek intervention because of the lack of mental health services, including providers of care, such as nurses; psychotropic medicines; psychosocial interventions; and psychotherapies. Stigma associated with mental illness also is a significant barrier to care. The purpose of this article is to describe the scope of mental illness and the status of psychiatric care in Uganda as well as to provide implications for mental health nursing.
Aims and method
A cross-sectional, interview survey of the beliefs, knowledge, attitudes and practice towards mental illness of 29 traditional healers in the Pallisa district of Uganda was carried out.
Results
Many of the healers had experienced emotional problems that had been treated by other healers. Almost all had a family member who was also a traditional healer. They treated a wide range of conditions and all dealt with mental illness. Most believed that mental disorders were caused by supernatural processes. Many recognised the role of environmental agents. Their diagnosis and management of mental illness was eclectic. The healers were either traditional herbalists or spirit diviners or a mixture of both. Almost all referred patients to the district hospitals and were willing to work with government health services.
Clinical implications
The results of the survey suggest the presence of fertile ground on which to build cooperation between traditional healers and medical services. Such cooperation may harness primary care resources more effectively. Sequential or simultaneous models of collaboration (or combinations of both) may be considered. Further work on specific treatments, their outcomes and the evaluation of collaborative models is needed.
Background
Despite significant investments and reforms, health care remains poor for many in Africa. To design an intervention to improve access and quality of health care at health facilities in eastern Uganda, we aimed to understand local priorities for qualities in health care, and factors that enable or prevent these qualities from being enacted.
Methods
In 2009 to 2010, we carried out 69 in-depth interviews and 6 focus group discussions with 65 health workers at 17 health facilities, and 10 focus group discussions with 113 community members in Tororo District, Uganda.
Results
Health-care workers and seekers valued technical, interpersonal and resource qualities in their aspirations for health care. However, such qualities were frequently not enacted, and our analysis suggests that meeting aspirations required social and financial resources to negotiate various power structures.
Conclusions
We argue that achieving aspirations for qualities valued in health care will require a genuine reorientation of focus by health workers and their managers toward patients, through renewed respect and support for these providers as professionals.
As one article in an ongoing series on Global Mental Health Practice, Joshua Ssebunnya and colleagues provide a case study from Uganda that describes their work developing a national mental health policy.
Integrating mental health into primary health care is widely promoted for a host of reasons, chief among which is providing a more comprehensive health care service. However, only a few countries have adequate mental health resources to undertake the integration of mental health into primary health care in a uniform manner, with wide variations among countries. This paper examines the extent to which two low-income countries (Ghana and Uganda) and one middle-income country (South Africa) are managing the integration of mental health into primary health care using the recommendations of the WHO World Health Report, 2001. Primary and secondary data sources from a situational analysis of mental health services in the three countries were analysed. The findings indicate that significant challenges remain in integrating mental health care into primary health care. Poor or uneven implementation of policy, inadequate access to essential drugs and lack of mental health specialists are some of the reasons advanced. Aside from better human resource planning for mental health, integration may be advanced by the development of packages of care which adopt a task-shifting approach suited to a country's needs.
Makerere University College of Health Sciences (MakCHS) in Uganda is undergoing a major reform to become a more influential force in society. It is important that its medicine and nursing graduates are equipped to best address the priority health needs of the Ugandan population, as outlined in the government's Health Sector Strategic Plan (HSSP). The assessment identifies critical gaps in the core competencies of the MakCHS medicine and nursing and ways to overcome them in order to achieve HSSP goals.
Documents from the Uganda Ministry of Health were reviewed, and medicine and nursing curricula were analyzed. Nineteen key informant interviews (KII) and seven focus group discussions (FGD) with stakeholders were conducted. The data were manually analyzed for emerging themes and sub-themes. The study team subsequently used the checklists to create matrices summarizing the findings from the KIIs, FGDs, and curricula analysis. Validation of findings was done by triangulating information from the different data collection methods.
The core competencies that medicine and nursing students are expected to achieve by the end of their education were outlined for both programs. The curricula are in the process of reform towards competency-based education, and on the surface, are well aligned with the strategic needs of the country. But implementation is inadequate, and can be changed:• Learning objectives need to be more applicable to achieving competencies.• Learning experiences need to be more relevant for competencies and setting in which students will work after graduation (i.e. not just clinical care in a tertiary care facility).• Student evaluation needs to be better designed for assessing these competencies.
MakCHS has made a significant attempt to produce relevant, competent nursing and medicine graduates to meet the community needs. Ways to make them more effective though deliberate efforts to apply a competency-based education are possible.
Mental health facilities in Uganda remain underutilized, despite efforts to decentralize the services. One of the possible explanations for this is the help-seeking behaviours of people with mental health problems. Unfortunately little is known about the factors that influence the help-seeking behaviours. Delays in seeking proper treatment are known to compromise the outcome of the care.
To examine the help-seeking behaviours of individuals with mental health problems, and the factors that may influence such behaviours in Uganda.
Sixty-two interviews and six focus groups were conducted with stakeholders drawn from national and district levels. Thematic analysis of the data was conducted using a framework analysis approach.
The findings revealed that in some Ugandan communities, help is mostly sought from traditional healers initially, whereas western form of care is usually considered as a last resort. The factors found to influence help-seeking behaviour within the community include: beliefs about the causes of mental illness, the nature of service delivery, accessibility and cost, stigma.
Increasing the uptake of mental health services requires dedicating more human and financial resources to conventional mental health services. Better understanding of socio-cultural factors that may influence accessibility, engagement and collaboration with traditional healers and conventional practitioners is also urgently required.
There has been increased global concern about the human rights violations experienced by people with mental disorders. The aim of this study was to analyse Uganda's mental health care system through a human rights lens. A survey of the existing mental health system in Uganda was conducted using the WHO Assessment Instrument for Mental Health Systems. In addition, 62 interviews and six focus groups were conducted with a broad range of mental health stakeholders at the national and district levels. Despite possessing a draft mental health policy that is in line with many international human rights standards, Uganda's mental health system inadequately promotes and protects, and frequently violates the human rights of people with mental disorders. The mental health legislation is offensive and stigmatizing. It is common for people accessing mental health services to encounter physical and emotional abuse and an inadequate quality of care. Mental health services are inequitably distributed. Within Ugandan society, people with mental disorders also frequently experience widespread stigma and discrimination, and limited support. Promoting and protecting the rights of people with mental disorders has ethical and public health imperatives. A number of policy, legislative and service development initiatives are required.
Background
Mental illnesses are increasingly recognised as a leading cause of disability worldwide, yet many countries lack a mental health policy or have an outdated, inappropriate policy. This paper explores the development of appropriate mental health policies and their effective implementation. It reports comparative findings on the processes for developing and implementing mental health policies in Ghana, South Africa, Uganda and Zambia as part of the Mental Health and Poverty Project.
Methods
The study countries and respondents were purposively selected to represent different levels of mental health policy and system development to allow comparative analysis of the factors underlying the different forms of mental health policy development and implementation. Data were collected using semi-structured interviews and document analysis. Data analysis was guided by conceptual framework that was developed for this purpose. A framework approach to analysis was used, incorporating themes that emerged from the data and from the conceptual framework.
Results
Mental health policies in Ghana, South Africa, Uganda and Zambia are weak, in draft form or non-existent. Mental health remained low on the policy agenda due to stigma and a lack of information, as well as low prioritisation by donors, low political priority and grassroots demand. Progress with mental health policy development varied and respondents noted a lack of consultation and insufficient evidence to inform policy development. Furthermore, policies were poorly implemented, due to factors including insufficient dissemination and operationalisation of policies and a lack of resources.
Conclusions
Mental health policy processes in all four countries were inadequate, leading to either weak or non-existent policies, with an impact on mental health services. Recommendations are provided to strengthen mental health policy processes in these and other African countries.
Limited evidence about mental health finances in low and middle-income countries is a key challenge to mental health care policy initiatives. This study aimed to map mental health finances in Ghana, Uganda, India (Kerala state), Sri Lanka and Lao PDR focusing on how much money is available for mental health, how it is spent, and how this impacts mental health services.
A researcher in each region reviewed public mental health-related budgets and interviewed key informants on government mental health financing. A total of 43 key informant interviews were conducted. Quantitative data was analyzed in an excel matrix using descriptive statistics. Key informant interviews were coded a priori against research questions.
National ring-fenced budgets for mental health as a percentage of national health spending for 2007-08 is 1.7% in Sri Lanka, 3.7% in Ghana, 2.0% in Kerala (India) and 6.6% in Uganda. Budgets were not available in Lao PDR. The majority of ring-fenced budgets (76% to 100%) is spent on psychiatric hospitals. Mental health spending could not be tracked beyond the psychiatric hospital level due to limited information at the health centre and community levels.
Mental health budget information should be tracked and made publically accessible. Governments can adapt WHO AIMS indicators for reviewing national mental health finances. Funding allocations work more effectively through decentralization. Mental health financing should reflect new ideas emerging from community based practice in LMICs.
Objective:
Approximately one in five children and adolescents (CA) suffer from mental disorders. This paper reports on the findings of a situational analysis of CA mental health policy and services in Ghana, Uganda, South Africa and Zambia. The findings are part of a 5 year study, the Mental Health and Poverty Project, which aims to provide new knowledge regarding multi-sectoral approaches to breaking the cycle of poverty and mental ill-health in Africa.
Method:
The World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS) Version 2.2 was used to collect quantitative information on mental health resources. Mental health policies and legislation were analysed using the WHO Policy and Plan, and Legislation Checklists. Qualitative data were collected through focus groups and interviews.
Results:
Child and adolescent mental health (CAMH) - related legislation, policies, services, programmes and human resources are scarce. Stigma and low priority given to mental health contribute to low investment in CAMH. Lack of attention to the impoverishing impact of mental disorders on CA and their families contribute to the burden.
Conclusion:
Scaling up child and adolescent mental health services (CAMHS) needs to include anti-stigma initiatives, and a greater investment in CAMH. Clear policy directions, priorities and targets should be set in country-level CAMH policies and plans. CAMHS should be intersectoral and include consideration of the poverty- mental health link. The roles of available mental health specialists should be expanded to include training and support of practitioners in all sectors. Interventions at community level are needed to engage youth, parents and local organizations to promote CAMH.
Objective:
Mental health has been identified as a major priority in the Ugandan Health Sector Strategic Plan. Efforts are currently underway to integrate mental health services into the Primary Health Care system. In this study, we report aspects of the integration of mental health into primary health care in one rural district in Uganda.
Method:
Qualitative methods were used for data collection. Semi-structured interviews and focus group discussions were conducted with various stakeholders within the ministry of health as well as line ministries. Data analysis was done using Nvivo 7, specifically adopting framework analysis approach.
Results:
Attempts to offer organized mental health services were found to be present in only a few health facilities. The district had only a single mental health nurse, and very few General Health Workers adequately equipped with the knowledge and skills to provide mental health services. The vertical referral system was not being followed as planned and there was no evidence of any organized community interventions for those with mental disorders. The mental health nurse and a few PHC nurses however expressed interest and commitment to providing services for persons with mental illness, despite the challenges.
Conclusion:
Although mental health is expected to be integrated into primary health care, mental health services in this district have not yet achieved the expected level of integration. This implies that this important policy requirement has not yet been effectively realized in this rural district, which could be the case in many other districts of a similar status. There is thus a need to direct more efforts towards realization of this important policy requirement.
The Ugandan government recognizes mental health as a serious public health and development concern, and has of recent implemented a number of reforms aimed at strengthening the country's mental health system. The aim of this study was to provide a profile of the current mental health policy, legislation and services in Uganda.
A survey was conducted of public sector mental health policy and legislation, and service resources and utilisation in Uganda, in the year 2005, using the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS) Version 2.2.
Uganda's draft mental health policy encompasses many positive reforms, including decentralization and integration of mental health services into Primary Health Care (PHC). The mental health legislation is however outdated and offensive. Services are still significantly underfunded (with only 1% of the health expenditure going to mental health), and skewed towards urban areas. Per 100,000 population, there were 1.83 beds in mental hospitals, 1.4 beds in community based psychiatric inpatient units, and 0.42 beds in forensic facilities. The total personnel working in mental health facilities were 310 (1.13 per 100,000 population). Only 0.8% of the medical doctors and 4% of the nurses had specialized in psychiatry.
Although there have been important developments in Uganda's mental health policy and services, there remains a number of shortcomings, especially in terms of resources and service delivery. There is an urgent need for more research on the current burden of mental disorders and the functioning of mental health programs and services in Uganda.
Ugandan health workers are dissatisfied with their jobs, especially their compensation and working conditions. About one in four would like to leave the country to improve their outlook, including more than half of all physicians. In this paper we report differences by type of health worker, sex, age, sector (public or nonprofit), and location. Policy strategies to strengthen human resources for health in Uganda should focus on salary and benefits (especially health coverage), working conditions and workload, facility infrastructure (including water and electricity), management, and workforce camaraderie.
World wide, there is plentiful evidence regarding the role of stigma in mental illness, as well as the association between poverty and mental illness. The experiences of stigma catalyzed by poverty revolve around experiences of devaluation, exclusion, and disadvantage. Although the relationship between poverty, stigma and mental illness has been documented in high income countries, little has been written on this relationship in low and middle income countries.The paper describes the opinions of a range of mental health stakeholders regarding poverty, stigma, mental illness and their relationship in the Ugandan context, as part of a wider study, aimed at exploring policy interventions required to address the vicious cycle of mental ill-health and poverty.
Semi-structured interviews and focus group discussions (FGDs) were conducted with purposefully selected mental health stakeholders from various sectors. The interviews and FGDs were audio-recorded, and transcriptions were coded on the basis of a pre-determined coding frame. Thematic analysis of the data was conducted using NVivo7, adopting a framework analysis approach.
Most participants identified a reciprocal relationship between poverty and mental illness. The stigma attached to mental illness was perceived as a common phenomenon, mostly associated with local belief systems regarding the causes of mental illness. Stigma associated with both poverty and mental illness serves to reinforce the vicious cycle of poverty and mental ill-health. Most participants emphasized a relationship between poverty and internalized stigma among people with mental illness in Uganda.
According to a range of mental health stakeholders in Uganda, there is a strong interrelationship between poverty, stigma and mental illness. These findings re-affirm the need to recognize material resources as a central element in the fight against stigma of mental illness, and the importance of stigma reduction programmes in protecting the mentally ill from social isolation, particularly in conditions of poverty.
The shift in emphasis to universal primary health care in post-apartheid South Africa has been accompanied by a process of
decentralization of mental health services to district level, as set out in the new Mental Health Care Act, no. 17, of 2002
and the 1997 White Paper on the Transformation of the Health System. This study sought to assess progress in South Africa
with respect to deinstitutionalization and the integration of mental health into primary health care, with a view to understanding
the resource implications of these processes at district level. A situational analysis in one district site, typical of rural
areas in South Africa, was conducted, based on qualitative interviews with key stakeholders and the World Health Organization's
Assessment Instrument for Mental Health Systems (WHO-AIMS). The findings suggest that the decentralization process remains
largely limited to emergency management of psychiatric patients and ongoing psychopharmacological care of patients with stabilized
chronic conditions. We suggest that, in a similar vein to other low- to middle-income countries, deinstitutionalization and
comprehensive integrated mental health care in South Africa is hampered by a lack of resources for mental health care within
the primary health care resource package, as well as the inefficient use of existing mental health resources.
The elderly are vulnerable to illness and particularly to psychiatric illness. Many mentally ill elderly patients end up on non-psychiatric wards owing to somatization of their illnesses. Even for these patients, a psychiatric diagnosis may not be made. The literature on the elderly in Uganda is very scanty. This study aims to establish the prevalence and factors associated with psychiatric disorders among elderly patients admitted to non-psychiatric wards.
We carried out a descriptive cross-sectional study of 127 consenting elderly patients. They were administered a standardized questionnaire comprising the Self Reporting Questionnaire 25, the Mini-mental State Examination and the Structured Clinical Interview for the Diagnostic and Statistical Manual IV. Study variables included socio-demographic characteristics, physical illnesses, psychiatric disorders and the treatment given.
The rate of psychiatric morbidity was 48%. The sex ratio was 1:1; however, women had a higher rate of psychiatric illness than men, 54.6% and 41.3% respectively. Being widowed or separated and having cancer were associated with SRQ>5, p=0.02 and p=0.04 respectively. Depressive disorders were the most common at 25.2% and were more common in women. Increasing age was associated with dementia (p<0.00).
There is a high rate of psychiatric morbidity among the elderly in Uganda. Particular attention should be given to the psychological health of elderly people admitted to general hospitals.
This article reports the findings from a participatory action research study concerning the experience of Ugandan nurses caring for individuals with HIV illness. Six key informants from government and non-governmental organizations were interviewed using a semistructured format. Six nurses from a large national referral hospital in Kampala, Uganda, participated in 10 focus group meetings during a period of 11 months. In-depth interviews, focus groups, and photovoice were used to collect the data. Findings indicate that nurses faced many challenges in their daily care, including poverty, insufficient resources, fear of contagion, and lack of ongoing education. Nurses experienced moral distress due to the many challenges they faced during the care of their patients. Moral distress may lead nurses to quit their jobs, which would exacerbate the acute shortage of nurses in Uganda. This study provides important knowledge for guiding clinical practice and nursing education in resource-constrained countries like Uganda.
Despite the publication of high-profile reports and promising activities in several countries, progress in mental health service development has been slow in most low-income and middle-income countries. We reviewed barriers to mental health service development through a qualitative survey of international mental health experts and leaders. Barriers include the prevailing public-health priority agenda and its effect on funding; the complexity of and resistance to decentralisation of mental health services; challenges to implementation of mental health care in primary-care settings; the low numbers and few types of workers who are trained and supervised in mental health care; and the frequent scarcity of public-health perspectives in mental health leadership. Many of the barriers to progress in improvement of mental health services can be overcome by generation of political will for the organisation of accessible and humane mental health care. Advocates for people with mental disorders will need to clarify and collaborate on their messages. Resistance to decentralisation of resources must be overcome, especially in many mental health professionals and hospital workers. Mental health investments in primary care are important but are unlikely to be sustained unless they are preceded or accompanied by the development of community mental health services, to allow for training, supervision, and continuous support for primary care workers. Mobilisation and recognition of non-formal resources in the community must be stepped up. Community members without formal professional training and people who have mental disorders and their family members, need to partake in advocacy and service delivery. Population-wide progress in access to humane mental health care will depend on substantially more attention to politics, leadership, planning, advocacy, and participation.
There is significant concern about the worldwide migration of nursing professionals from low-income countries to rich ones, as nurses are lured to fill the large number of vacancies in upper-income countries. This study explores the views of nursing students in Uganda to assess their views on practice options and their intentions to migrate.
Anonymous questionnaires were distributed to nursing students at the Makerere Nursing School and Aga Khan University Nursing School in Kampala, Uganda, during July 2006, using convenience sampling methods, with 139 participants. Two focus groups were also conducted at one university.
Most (70%) of the participants would like to work outside Uganda, and said it was likely that within five years they would be working in the U.S. (59%) or the U.K. (49%). About a fourth (27%) said they could be working in another African country. Only eight percent of all students reported an unlikelihood to migrate within five years of training completion. Survey respondents were more dissatisfied with financial remuneration than with any other factor pushing them towards emigration. Those wanting to work in the settings of urban, private, or U.K./U.S. practices were less likely to express a sense of professional obligation and/or loyalty to country. Those who have lived in rural areas were less likely to report wanting to emigrate. Students with a desire to work in urban areas or private practice were more likely to report an intent to emigrate for financial reasons or in pursuit of country stability, while students wanting to work in rural areas or public practice were less likely to want to emigrate overall.
Improving remuneration for nurses is the top priority policy change sought by nursing students in our study. Nursing schools may want to recruit students desiring work in rural areas or public practice to lead to a more stable workforce in Uganda.
Introduction: Biomedically based interventions are the officially accepted form of health care for psychosis in most African countries. However, many people who present psychotic symptoms use traditional healing services. Understanding how lay people view psychosis is important not only for epidemiological research but also for understanding health-seeking behaviour. Objective: To explore and describe lay concepts of psychosis among the Basoga. Method: A qualitative study using Focus Group Discussions and case vignette techniques. Four focus group discussions were held; two for traditional healers and two for the general community, totalling 31 participants. Results: The Basoga differentiated schizophrenia from mania and psychotic depression, giving names for each disorder and describing the symptomatology and natural course. Schizophrenia (eddalu or ilalu) was viewed as a more serious illness, with the possibility of not recovering, mania (kazoole), as less serious mental illness, with normality between episodes. Psychotic depression was seen as illness caused by too much thinking. Clan/family/cultural issues were mentioned as causing schizophrenia and psychotic depression, while physical causes and a failed relationship with God were mentioned for mania. Other causes were witchcraft, genetics and substance misuse. Choice of care depended on what was believed to be the cause of the psychotic symptoms. Conclusion: These findings provide insight into Basoga lay concepts of psychosis and will be used in the main study to modify the Western instruments, thereby making them more culturally sensitive, applying an emic and etic approach.
We have created a new column that will focus on the state of psychiatric nursing around the world and on the increasingly important need for all of us, the family of psychiatric nurses, to begin to explore more deeply, and strengthen in more focused ways, the ties that bind all of us. We begin with an article that presents an international perspective on psychiatric illness and mental health promotion and ends by identifying common concerns often shared by the world's psychiatric nurses. Susan McCabe has a unique ability to blend the hard-core facts with a compassionate and intelligent point of view that is compelling and understandable. She is currently an associate professor at the Fay W. Whitney School of Nursing, University of Wyoming. She is an international speaker who presented at many international venues including the Sigma Theta Tau International Nursing Research Conference in the Virgin Islands in 2003 and the International Conference for Mental Health Nurses in Malta in 2002, a gathering that explored and discussed global issues of mental illness and psychiatric nursing. She is also frequently a keynote speaker or presenter at numerous psychiatric nursing conferences and has published extensively in several refereed journals and book chapters. She has expressed a deep desire for other psychiatric nurses to add their voices to hers and to comment and dialogue about our practice lives via the journal.
In 2008, the local nongovernmental organisation TPO Uganda and the Uganda Ministry of Health began a project aimed of improving the availability of mental health services in three districts in Northern Uganda. The project consisted of: 1) training of general health workers in the primary health care system in mental health; 2) strengthening the capacity of the specialised mental health workers to deliver and supervise mental health outreach services; and 3) increasing the capacity of community members to respond effectively to mental health and psychosocial needs of people within their communities. The project provided assistance to ‘patient support groups’ that then provided support to patients with mental disorders.
At the end of the 22 month project, the capacities of health workers and Village Health Teams to provide mental health services were strengthened. Major gaps, that still need to be addressed, were attrition of government health workers and a lack of drugs. Lessons learnt also include: the importance of coordination and joint planning between nongovernmental organisations and the government; the importance of support supervision; the important role of village health team members in community mobilisation and sensitisation; and the roles of patient support groups in complementing medical/clinical activities.
In Uganda, the rates of mental illness are high due to poverty, high prevalence of HIV/AIDS and long-term exposure to civil wars and armed rebellion. The cost of mental health services in urban hospitals remains prohibitive for the rural poor who resort to traditional healers, and many mental health workers prefer working in urban areas. In response, a community outreach program has been developed in rural, southwestern Uganda to deliver e¡ective mental health care. The programme was aimed at improving access to psychiatric care by taking services to communities where the majority of the rural population live, yet where services were non-existent. Baseline information on the training needs was collected by interviewing health workers in rural health units, and the need for a mental health service was assessed by interviewing members of the community and local leaders. Records of local health units were also reviewed. The result of the programme has shown that marginalized and neglected people with mental disorders have been able to access mental health care. Through increasing knowledge and access to psychiatric services in the community, mental health problems and psychological problems can be managed e¡ectively with little need for referral to larger hospitals.
East Africa is made up of Kenya, Uganda and Tanzania, all previous colonies of the British Empire which attained their independence in the early 1960s. At the time of independence, the East African community held the three countries together. Political expedience broke up the community in 1977 but greater wisdom and economic reality have brought the three countries back together in December 2001, in the form of a common Legislative Assembly and Court of Appeal. A Customs Union is expected soon, ahead of full political integration.
We have created a new column that will focus on the state of psychiatric nursing around the world and on the increasingly important need for all of us, the family of psychiatric nurses, to begin to explore more deeply, and strengthen in more focused ways, the ties that bind all of us. We begin with an article that presents an international perspective on psychiatric illness and mental health promotion and ends by identifying common concerns often shared by the world's psychiatric nurses. Susan McCabe has a unique ability to blend the hard-core facts with a compassionate and intelligent point of view that is compelling and understandable. She is currently an associate professor at the Fay W. Whitney School of Nursing, University of Wyoming. She is an international speaker who presented at many international venues including the Sigma Theta Tau International Nursing Research Conference in the Virgin Islands in 2003 and the International Conference for Mental Health Nurses in Malta in 2002, a gathering that explored and discussed global issues of mental illness and psychiatric nursing. She is also frequently a keynote speaker or presenter at numerous psychiatric nursing conferences and has published extensively in several refereed journals and book chapters. She has expressed a deep desire for other psychiatric nurses to add their voices to hers and to comment and dialogue about our practice lives via the journal.
Community-based models of providing mental health services are widely considered effective ways of serving individuals diagnosed with mental illness, but more comprehensive literature on these models in low- and middle-income countries is needed. This study is a systematic review of the effects of community-based models on health outcomes of adults with depression, schizophrenia, panic disorder, or bipolar disorders in middle- and low-income countries. PubMed, PsycINFO, and Cochrane Reviews were searched, returning 500 articles. The seventeen interventions included in this review in 14 countries show us that community-based mental health services can provide improvements in mental health outcomes, and the limited cost analyses suggest cost savings associated with community models of care. These findings are in line with much of the research on higher income countries. In addition, the studies also point to the gaps in the literature on costs, rural areas, bipolar disorders, and panic disorders, and note the need for further reviews of interventions targeting additional diseases, children, and adolescents as well as studies published in languages other than English. This review of the literature serves as a stepping stone for further research in community-based mental health services in low- and middle-income countries. The works reviewed here provide a base of knowledge that will assist us in taking the important next steps in program implementation and evaluation.
A qualitative study, investigating the representations and explanatory models of ;madness' held by indigenous and religious healers, was undertaken in urban Uganda. Case vignettes of individuals with a diagnosis of a psychotic disorder were discussed by the healers in terms of phenomenology, causality, intervention and outcome. Indigenous healers primarily understood ;madness' as spiritual or physiological, whereas religious healers also held psychological models. Healers' understandings of ;madness' are inextricably linked with the historical and sociopolitical context and may be useful to individuals with psychotic experiences, however, it is likely that these models are dynamic and continually changing.
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