Table of Contents
2 Causes of mental health disorders
3 Barriers to mental health services
4 Mental illness and perception
5 Intervention strategies to mental health in low income communities
Globally mental health illnesses affect more than 25% of all people during their lifetime. Issues on mental health are increasing worldwide and the causes are varied and many. Many young people today are vulnerable as they meet challenges which they are unable to cope with and in many cases leading to mental breakdown. Mental disorders entail a wide range of conditions that may affect mood, thinking, and behavior. Today there are many situations that trigger feelings of worry, anxiety or fear interfering with ones personality. The percentage of people experiencing mental disorders is devastating ranging between 5% - 25% of the population totaling to about 44 million and more in the world. Western Kenya is not exempted and people with mental disorders can be seen in market places, funeral places, on the roads and towns. A qualitative survey was carried out among 114 individuals in western region among them lecturers, medics, university students, social workers and parents to find out barriers to accessing health services in western Kenya. Causes of mental disorders from the research findings were majorly attributed to witchcraft, punishment for evil deeds from God, curses and strange immoral deeds. Among low income communities intervention for those suffering from mental disorders was either postponed or ignored due to the perceptions about the condition. Some resorted to cheaper and crude ways of dealing with the condition which in many cases did not assist clients adequately. Some are too embarrassed to expose their relatives with mental disorders because of the stigma associated with the condition. Other factors contributing to delayed intervention are lack of awareness on where to access help, financial constraints, inadequate trained personnel, lack of drugs in health facilities, scarcity of centers dealing with mental disorders in the country among others. The recommendations were to create awareness on causes of the condition, increase service centers and subsidize the cost of medicines.
Key words: Mental disorders, Well being, low income communities, health services
Increasing, health and socio-economic burden of mental illnesses and disorders have become a major concern in both developed and developing countries. Globally, it is estimated that more than 450 million people suffer from mental illness or behavioural disorders and one in four families has at least one member with a mental disorder (WHO, 2003). According to WHO (2012), mentally ill people often lack access to education, healthcare and opportunities to earn a decent living, which limits their chances of economic development and deprives them of social protection and recognition within the community. They often have their human rights violated, including being subjected to unhygienic and inhuman living conditions, physical and sexual abuse, neglect, social isolation, as well as stigma and discrimination in health care facilities, in homes and the community at large (Bhugra,1989). The conditions under discussion in this paper include mental illness, depression and extreme aggressive behavior disorders.
The Goal of study
The goal of the study was to find out the barriers to accessing mental health services among low income communities in western Kenya. The survey was carried out through interviews, from a sample of 114 respondents who included lecturers, university students, local leaders, community members, medical personnel and community health workers and spiritual leaders in the western part of Kenya.
The objectives were:
i) Causes of mental health disorders in western Kenya
ii) Intervention strategies to mental health disorders in low income communities in western Kenya
iii) Barriers to accessing mental health services among low income communities in western Kenya
2 Causes of mental health disorders
Traditionally families have been seen as contributing to mental illness - either as causing it or aggravating it (Riebschleger, 2001; Marshall, Solomon et al. 2003; Rethink, 2003).
They have, at various times in the history of mental illness supported institutionalization (by sending their relatives to psychiatric institutions (Jones, 2002), or been major players in deinstitutionalization (more recently). Many families have assumed a caring role for people with experience of mental illness (Mason, 1996).
In Kenya a pioneer hospital based study was carried out by Omar (2003) in western Kenya. The author found that negative opinions about mental illness were widely held among relatives of mentally ill patients. The respondents had varied opinions on the causation of mental illness. Drug abuse, demons, stress and inheritance were thought to cause mental illness by 38%, 32%, 18% and 10% respectively prayers were suggested as a form of treatment by 76% of the respondents. In western Kenya some of the causes of mental illnesses cited were as follows:
Table 1: Responses on causes of mental disorders
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Majority of the respondents prioritized witchcraft as the main cause of mental illness, followed by punishment from God, curses, demonic manifestation and substance abuse as major causes to mental illness. These were followed by inheritance, diseases and abnormal hormonal functions in individuals. The perceptions held traditionally that any form of mental illness is caused by witchcraft, curses and demonic forces causes a lot of stigma towards individuals affected and families. Families blame themselves for the condition and also the communities they live in blame them. The perception about the cause of mental illness to a certain extent determines the treatment strategy.
Many youth in western Kenya cited social causes such as drastic life changes, experiences, family issues, loss of parents/relatives, divorce, drugs and alcohol abuse, loneliness, personality disorders, job loss, failed societal expectations, rejection, false esteem, breakups, and failure to get white collar jobs. Many youth felt depressed from the social issues cited above and expressed concern about inability to access health service due to financial constraints. Joblessness is cited to be one of the leading causes to mental disorders due to financial challenges especially among youths from low income communities.
The youth from able families cited family issues, divorce and societal expectations as major causes of mental illness. Many alluded to the above issues as some of the causes to drug and alcohol abuse which may eventually lead to mental illness and personality disorders.
Some youth also cited low self esteem, breakups in relationships and extreme life changes as some of the causes to depression and mental illnesses.
Some of the medical causes to mental health were prolonged illnesses like cancer, ulcers, migraine headaches, high blood pressure, HIV & AIDS, physical trauma and accidents.
The economic causes to mental illness cited were financial losses and inadequate finances to meet basic needs, medical bills and fees and failure in business.
3 Barriers to mental health services
Both Bower (1998) and Phelan, Bromet et al (1998) report from their respective studies, that family members often try to conceal their relative’s mental illness or hospitalization. This is more likely to happen if the person is not living with them, or when the disclosure is avoidable (Phelan, Bromet et al. 1998). The implications of this are that family members in this situation may be more likely to withdraw social contact and are less likely to support their relative with their experience of mental illness (Phelan, Bromet et al. 1998).
The fear may also be due to challenges involved in treating it and that fact that it has no definite treatment. Surprisingly some mentally ill individuals at market places or in communities have always been there since time immemorial. This further makes people believe the condition cannot be cured. There is an unfortunate statement that states “Once mentally ill, always mentally ill”. This conclusion is made from the many cases which after treatment, reoccur from time to time. In another study, Ostman and Kjellin (2002) found that 18 percent of respondents thought that, at times, their relative would be better off dead.
In the Western part of Kenya responses on barriers to accessing mental health services among low income communities were given as follows in the order of priority.
Table 2: Responses on barriers to accessing mental health services
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Inadequate funds, poverty, stigma attached to mental health conditions, lack of faith in mental health services, high cost of medication and inadequate mental health facilities in western region were major barriers to accessing mental health services. These were followed by inadequate trained personnel, drugs and lack of awareness in the region. The poverty level in most communities in western region is high with most families hardly able to raise one decent meal a day.
On the issue of medical treatment many families cannot afford the medical bills of their family members and in most cases they have to fundraise to pay them. Many (65%) of the respondents raised concern on the high cost of medication for mental illness which makes them opt for cheaper means of treatment. Another shocking revelation by 68% of the respondents was that they did not have faith in medical services for mental illness. They observed that the condition keeps recurring in most of the patients and therefore not effective.
Other responses on barriers to accessing mental health services were 49% of the respondents who cited lack of awareness on mental health facilities. Information on such services has not reached majority of low income communities. In western region there is only one medical facility with admits and treats persons with mental illness.
About 56% of the respondents indicated that there were inadequate trained personnel in the region. The country in general has few psychiatrists and psychologists to handle the rising numbers of people with mental illness. The fear of rejection, negative attitudes, lack of commitment by family members and responsibility over relatives with mental conditions also affects and delays in intervention. The New Zealand discrimination survey (Peterson, Pere et al. 2004) found that 59 percent of people with experience of mental illness reported discrimination from friends and family. This happens a lot among families especially in issues to do with inheritance of property. Many cannot be trusted with family property and are usually left out or given to the guardian. Findings from the New Zealand discrimination survey (Peterson, Pere et al. 2004) suggest that discrimination against people with experience of mental illness is an issue no matter what ethnic or cultural group the person identifies with.
Families share much of the discrimination that people with experience of mental illness face, by being associated with them (Angermeyer, Schulze et al. 2003) and this is discrimination by association (BC Minister of Health's Advisory Council on Mental Health 2002; Ostman and Kjellin, 2002). Many families tend to treat mental illness as a source of shame and embarrassment (Wahl, 1999). Some also indicated that there are no support systems for Persons with mental disorders and inadequate budgetary allocation towards treatment of mental disorders.
Majority of the respondents indicated they lacked funds to take their patients to clinics.
4 Mental illness and perception
Many mental health professionals view families as an ‘irritation’ (Angermeyer, Schulze et al. 2003). Families are considered by mental health professionals to be interfering and over-protective (Rethink, 2003), and are regarded as being uninformed about mental illness and treatment (Riebschleger, 2001). Family members also report a strained relationship with mental health professionals, who are perceived as being discriminatory towards family members (Angermeyer, Schulze et al. 2003). This may be because the family is perceived by health professionals to be contributing to their relative’s mental illness.
It is also perceived to cause poor relations at workplace as colleagues may avoid the individual with mental illness for fear of physical harm. Some respondents also raised concern that individuals with a history of mental illness may not easily get employment and even if employed by chance once discovered the employers find a way of laying them off. There is a wrong perception that such individuals are sick. They are believed to be disabled and unreasonable. This condition is sometimes mistaken for mental retardation which cannot be treated.
One respondent also indicated that they are always careful in the presence of a person with a history of mental illness. One student with a history of mental illness stated that:
“most times l feel colleagues never believe me even when l am genuinely happy or sad. They are always suspicious of my behavior. He also added that l find it difficult getting a girlfriend as fellow colleagues warn them of my past and makes them turn me down. They also avoid sharing a room with me for imagining l will harm them”.
He added that even family members were apprehensive of him and treated him with a lot of caution for fear of the unknown. He felt that people around him were observing him all the time for signs of the condition. In Peterson, Pere et al (2004), people with experience of mental illness reported being rejected by friends and family, being called names, being treated as if they were incapable or incompetent, and having family members trying to take control of their lives. He added that his greatest anxiety is the feeling that he might exhibit symptoms of his condition without his conscience. He sometimes appreciates to some extent the concern of people who look out for him. But many times it frustrates him.
He also added that most of the time he found himself explaining his previous history each time he met new friends. But he also observed that whenever he did this some of the friends changed their behavior towards him. He was in a dilemma and found himself lonely and contemplating suicide. Such perception is a result of belief in the stereotypes of people with experience of mental illness leading to prejudice, which in turn leads to discrimination (Schumacher, Corrigan et al. 2003).
Discrimination against, and the stigma of, people with experience of mental illness is widespread (Sayce, 1998; Crisp, Gelder, et al. 2000). It has an impact on the self- esteem (Link, Struening, et al. 2001) and recovery (Perlick, 2001) of people with experience of mental illness, as well as affecting all aspects of people’s lives (Penn and Wykes, 2003). Discrimination occurs when a person is treated differently from another person in the same or similar circumstances. For discrimination to occur however, the person with the prejudice must be in a position of power, which must then be exercised (Link and Phelan, 2001). It is clear from the literature that any understanding of stigma and discrimination must include an analysis of power.