Predicting referral practices of traditional healers of their patients with a mental illness: an application of the Theory of Planned Behaviour.

OBJECTIVE: Although many studies indicate that traditional healers are willing to collaborate with Western practitioners in South Africa, none focus specifically on mental health care, and none use a theory of health behaviour to explain their findings. The present study applies the Theory of Planned Behaviour (TPB) to predict traditional healer referral practices of patients with a mental illness. METHOD: One hundred traditional healers were first interviewed to assess the TPB variables and were contacted again 5 months later to measure self-reported behaviour. RESULTS: Herbalists were less likely than other types of healers to refer patients with a mental illness to Western health professionals. From the TPB application, the following cognitive variables were found to predict intentions: attitudes (ß = 0.612, p< 0.01); perceived behavioural control (ß = 0.355, p< 0.01); and past behaviour (ß = 0.704, p< 0.01). Subjective norms and knowledge of mental illness did not predict intentions. Finally, past behaviour (ß = 0.297, p = 0.040) and intentions to refer patients (ß = 0.758, p< 0.01) predicted greater self-reported behaviour. CONCLUSION: The TPB may be a useful theoretical model for predicting the referral practices of traditional healers. The empirical data here may be useful for future work designing interventions to provide traditional healers with the information and skills they require to appropriately refer patients with mental illness.

Test-retest reliability of the Xhosa version of the Diagnostic Interview Schedule for Children.

BACKGROUND: The Diagnostic Interview Schedule for Children (DISC-IV) is a widely used structured psychiatric diagnostic instrument for children that is designed to be administered by non-clinicians. Although reliability data on several versions of the DISC are available, none have assessed the Xhosa version for use in the South African context. The objective of this study was to examine the test-retest reliability of the Xhosa version of the DISC-IV. METHODS: Test-retest reliabilities were documented for a sample of 105 parent/care giver and youth pairs. The research assistants worked in pairs, one interviewed the parent and the other interviewed the youth. The same researchers returned after approximately 2 weeks to conduct the second interviews. RESULTS: The DISC-IV was reliable across informants for many psychiatric disorders. Kappa coefficients ranged from 0.448 (any anxiety disorder) to 0.662 (major depressive disorder) for parent reports and from 0.145 (anxiety) to 0.661 (major depressive disorder) for child reports. CONCLUSION: The results of this study suggest that the test-retest reliability of the Xhosa version of the DISC-IV is similar to the reliability reported in other translated versions of the instrument. The satisfactory reliability and straightforward application make this instrument suitable for use in South Africa.

Effects of the SATZ teacher-led school HIV prevention programmes on adolescent sexual behaviour: cluster randomised controlled trials in three sub-Saharan African sites.

In this study, the effects on young adolescent sexual risk behaviour of teacher-led school HIV prevention programmes were examined in two sites in South Africa (Cape Town and Mankweng) and one site in Tanzania (Dar es Salaam). In Cape Town, Dar es Salaam and Mankweng, 26, 24 and 30 schools, respectively, were randomly allocated to intervention or comparison groups. Primary outcomes were delayed sexual debut and condom use among adolescents aged 12-14 years (grade 8 in South Africa and grades 5 and 6 in Tanzania). In total, 5352, 4197 and 2590 students participated at baseline in 2004 in Cape Town, Dar es Salaam and Mankweng, respectively, and 73% (n = 3926), 88% (n = 3693) and 83% (n = 2142) were retained 12-15 months later. At baseline, 13% (n = 224), 5% (n = 100) and 17% (n = 164) had had their sexual debut, and 44% (n = 122), 20% (n = 17) and 37% (n = 57) of these used a condom at last sex, respectively. In Dar es Salaam, students in the intervention were less likely to have their sexual debut during the study (OR 0.65, 95% CI 0.48-0.87). In Cape Town and Mankweng, the intervention had no impact. The current interventions were effective at delaying sexual debut in Dar es Salaam but not in South Africa, where they need to be supplemented with programmes to change the environment in which adolescents make decisions about sexual behaviour.

Methamphetamine use and sexual risk behaviour in Cape Town, South Africa: a review of data from 8 studies conducted between 2004 and 2007.

OBJECTIVE: Community studies and studies of admissions to drug treatment centers indicate a dramatic increase in the prevalence of methamphetamine use in Cape Town since 2003. There has also been a substantial increase over this time period in the prevalence of HIV infection among women attending public antenatal clinics in the Western Cape province. This study aimed to review research conducted in Cape Town on the link between methamphetamine use and sexual risk behaviour. METHOD: A review of published research conducted in Cape Town between 2004 and 2007 was undertaken using PubMed, EBSCOhost and Science Direct. RESULTS: Eight studies were identified, both quantitative and qualitative, and focusing on diverse populations, such as learners in school, out of school youth, adults in the community, men who have sex with men and sex workers. The total sample across the studies was 8153. Across multiple studies methamphetamine was fairly consistently associated with early vaginal sex, condom use during sex, having casual sex and other HIV risk behaviours. For some sub-groups the direction of the relationship was in an unexpected direction. CONCLUSION: The consistency of the findings across studies highlights the increased risk for contracting HIV among methamphetamine users, and reinforces the importance of interventions addressing both methamphetamine use and unsafe sexual behaviour among young people and other sectors of the population. The need for further research is also considered, particularly research that will explain some of the racial differences that were found.

The neurobiology of HIV dementia: implications for practice in South Africa.

In this review, the neuropathogenesis of HIV dementia (HIV-D) is discussed in the context of the local epidemic. HIV-D continues to be prevalent in the era of highly active anti-retroviral therapy. HIV neuro-invasion into the central nervous system may result in the development of separate HIV genotypes in an individual through compartmentalisation. The blood brain barrier continues to limit penetration of anti-retroviral drugs into the cerebrospinal fluid. Individuals with active neuro-inflammation appear to respond well to HAART. In some cases low grade neuro-degeneration persists with consequent clinical deterioration. In South Africa, the emergence of a sub-epidemic of HIV-D is being driven by various factors, including the incomplete coverage of HAART to all who need it, the late stage presentation of people living with HIV/AIDS (PLWHA) and a co-occurring methamphetamine epidemic. Differences in viral subtype do not appear to confer protection against HIV-D. Implications for PLWHA who are at risk for HIV-D in South Africa are explored, with a view to providing suggestions for improving practice and research into this area.

From mental health policy development in Ghana to implementation: what are the barriers?

OBJECTIVE: This paper identifies the key barriers to mental health policy implementation in Ghana and suggests ways of overcoming them. METHOD: The study used both quantitative and qualitative methods. Quantitatively, the WHO Mental Health Policy and Plan Checklist and the WHO Mental Health Legislation Checklist were employed to analyse the content of mental health policy, plans and legislation in Ghana. Qualitative data was gathered using in-depth interviews and focus group discussions with key stakeholders in mental health at the macro, meso and micro levels. These were used to identify barriers to the implementation of mental health policy, and steps to overcoming these. RESULTS: Barriers to mental health policy implementation identified by participants include: low priority and lack of political commitment to mental health; limited human and financial resources: lack of intersectoral collaboration and consultation; inadequate policy dissemination; and an absence of research-based evidence to inform mental health policy. Suggested steps to overcoming the barriers include: revision of mental health policy and legislation; training and capacity development and wider consultation. CONCLUSION: These results call for well-articulated plans to address the barriers to the implementation of mental health policy in Ghana to reduce the burden associated with mental disorders.

Mental illness--stigma and discrimination in Zambia.

OBJECTIVE: The aim of this qualitative study was to explore the presence, causes and means of addressing individual and systemic stigma and discrimination against people with mental illness in Zambia. This is to facilitate the development of tailor-made antistigma initiatives that are culturally sensitive for Zambia and other low-income African countries. This is the first in-depth study on mental illness stigma in Zambia. METHOD: Fifty semi-structured interviews and 6 focus group discussions were conducted with key stakeholders drawn from 3 districts in Zambia (Lusaka, Kabwe and Sinazongwe). Transcripts were analyzed using a grounded theory approach. RESULTS: Mental illness stigma and discrimination is pervasive across Zambian society, prevailing within the general community, amongst family members, amid general and mental health care providers, and at the level of government. Such stigma appears to be fuelled by misunderstandings of mental illness aetiology; fears of contagion and the perceived dangerousness of people with mental illness; and associations between HIV/AIDS and mental illness. Strategies suggested for reducing stigma and discrimination in Zambia included education campaigns, the transformation of mental health policy and legislation and expanding the social and economic opportunities of the mentally ill. CONCLUSION: In Zambia, as in many other low-income African countries, very little attention is devoted to addressing the negative beliefs and behaviours surrounding mental illness, despite the devastating costs that ensue. The results from this study underscore the need for greater commitment from governments and policy-makers in African countries to start prioritizing mental illness stigma as a major public health and development issue.

Explanatory models of mental disorders and treatment practices among traditional healers in Mpumulanga, South Africa.

OBJECTIVE: In many traditional belief systems in Africa, including South Africa, mental health problems may be attributed to the influence of ancestors or to bewitchment. Traditional healers are viewed as having the expertise to address these causes. However, there is limited information on their explanatory models and consequent treatment practices. The present study examines traditional healers' explanatory models (EMs) and treatment practices for psychotic and non-psychotic mental illnesses. METHOD: 4 focus group discussions (8 healers in each group) and 18 in-depth interviews were conducted. Four vignettes were presented (schizophrenia, depression, panic and somatisation) and traditional healers' views on the nature of the problem, cause, consequence, treatment and patient expectations were elicited. RESULTS: Traditional healers held multiple explanatory models for psychotic and non-psychotic disorders. Psychotic illnesses appear to be the main exemplar of mental illness and were treated with traditional medicine, while nonpsychotic illnesses were not viewed as a mental illness at all. Additionally, traditional healers do not only use herbs and substances solely from "traditional" sources but rather have incorporated into their treatment practices modern ingredients that are potentially toxic. CONCLUSION: Interventions aimed at increasing the mental health literacy of traditional healers are essential. In addition, investigations of the effectiveness of traditional healer treatment for psychiatric disorders should be conducted.

Scaling up community-based services and improving quality of care in the state psychiatric hospitals: the way forward for Ghana.

OBJECTIVE: This paper aims to explore the options available for developing community-based care and improving the quality of care in psychiatric hospitals in Ghana. METHOD: Semi-structured interviews (SSIs) and focus group discussions (FGDs) were conducted: with a cross-section of stakeholders including health professionals, researchers, policy makers, politicians, users and carers. The SSIs and FGDs were recorded digitally and transcribed verbatim. Apriori and emergent themes were coded and analysed with NVivo version 7.0, using a framework analysis. RESULTS: Psychiatric hospitals in Ghana have a mean bed occupancy rate of 155%. Most respondents were of the view that the state psychiatric hospitals were very congested, substantially compromising quality of care. They also noted that the community psychiatric system was lacking human and material resources. Suggestions for addressing these difficulties included committing adequate resources to community psychiatric services, using psychiatric hospitals only as referral facilities, relapse prevention programmes, strengthening psychosocial services, adopting more precise diagnoses and the development of a policy on long-stay patients. CONCLUSION: There is an urgent need to build a credible system of community-based care and improve the quality of care in psychiatric hospitals in Ghana.

Mental health stigma: what is being done to raise awareness and reduce stigma in South Africa?

OBJECTIVE: Stigma plays a major role in the persistent suffering, disability and economic loss associated with mental illnesses. There is an urgent need to find effective strategies to increase awareness about mental illnesses and reduce stigma and discrimination. This study surveys the existing anti-stigma programmes in South Africa. METHOD: The World Health Organization's Assessment Instrument for Mental Health Systems Version 2.2 and semi-structured interviews were used to collect data on mental health education programmes in South Africa. RESULTS: Numerous anti-stigma campaigns are in place in both government and non-government organizations across the country. All nine provinces have had public campaigns between 2000 and 2005, targeting various groups such as the general public, youth, different ethnic groups, health care professionals, teachers and politicians. Some schools are setting up education and prevention programmes and various forms of media and art are being utilized to educate and discourage stigma and discrimination. Mental health care users are increasingly getting involved through media and talks in a wide range of settings. Yet very few of such activities are systematically evaluated for the effectiveness and very few are being published in peer-review journals or in reports where experiences and lessons can be shared and potentially applied elsewhere. CONCLUSION: A pool of evidence for anti-stigma and awareness-raising strategies currently exists that could potentially make a scientific contribution and inform policy in South Africa as well as in other countries.

A situational analysis of child and adolescent mental health services in Ghana, Uganda, South Africa and Zambia.

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.

A qualitative assessment of perspectives on the inclusion of adolescents in HIV vaccine trials in South Africa.

Adolescents are at high risk for HIV acquisition, and thus need to be included in HIV vaccine trials. In preparation for inclusion of adolescents in HIV vaccine trials in an urban community in Cape Town with a high antenatal HIV prevalence, the study assessed the attitudes towards the inclusion of adolescents in HIV vaccine trials. A total of 18 focus group discussions were conducted using a semistructured interview guide. The participants (n = 200) were adolescents, young adults, parents and other key informants. Participants from all groups welcomed the inclusion of adolescents in HIV vaccine trials due to their high-risk status. There were, however, concerns about sexual disinhibition, fear of side-effects, fear of HIV testing and disclosure of HIV status, mistrust of nurses and clinics. The study highlighted a number of ethical and social issues that need to be addressed before the trials.

Scaling up community-based services and improving quality of care in the state psychiatric hospitals: the way forward for Ghana

Objective: This paper aims to explore the options available for developing community-based care and improving the quality of care in psychiatric hospitals in Ghana. Method: Semi-structured interviews (SSIs) and focus group discussions (FGDs) were conducted with a cross-section of stakeholders including health professionals; researchers; policy makers; politicians; users and carers. The SSIs and FGDs were recorded digitally and transcribed verbatim. Apriori and emergent themes were coded and analysed with NVivo version 7.0; using a framework analysis. Results: Psychiatric hospitals in Ghana have a mean bed occupancy rate of 155. Most respondents were of the view that the state psychiatric hospitals were very congested; substantially compromising quality of care. They also noted that the community psychiatric system was lacking human and material resources. Suggestions for addressing these difficulties included committing adequate resources to community psychiatric services; using psychiatric hospitals only as referral facilities; relapse prevention programmes; strengthening psychosocial services; adopting more precise diagnoses and the development of a policy on long-stay patients. Conclusion: There is an urgent need to build a credible system of community-based care and improve the quality of care in psychiatric hospitals in Ghana

Mental health stigma: what is being done to raise awareness and reduce stigma in South Africa?

Objective: Stigma plays a major role in the persistent suffering; disability and economic loss associated with mental illnesses. There is an urgent need to find effective strategies to increase awareness about mental illnesses and reduce stigma and discrimination. This study surveys the existing anti-stigma programmes in South Africa. Method: The World Health Organization's Assessment Instrument for Mental Health Systems Version 2.2 and semi-structured interviews were used to collect data on mental health education programmes in South Africa. Results: Numerous anti-stigma campaigns are in place in both government and non-government organizations across the country. All nine provinces have had public campaigns between 2000 and 2005; targeting various groups such as the general public; youth; different ethnic groups; health care professionals; teachers and politicians. Some schools are setting up education and prevention programmes and various forms of media and art are being utilized to educate and discourage stigma and discrimination. Mental health care users are increasingly getting involved through media and talks in a wide range of settings. Yet very few of such activities are systematically evaluated for the effectiveness and very few are being published in peer-review journals or in reports where experiences and lessons can be shared and potentially applied elsewhere. Conclusion: A pool of evidence for anti-stigma and awareness-raising strategies currently exists that could potentially make a scientific contribution and inform policy in South Africa as well as in other countries

A situational analysis of child and adolescent mental health services in Ghana, Uganda, South Africa and Zambia

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

From mental health policy development in Ghana to implementation: what are the barriers?

Objective: This paper identifies the key barriers to mental health policy implementation in Ghana and suggests ways of overcoming them. Method: The study used both quantitative and qualitative methods. Quantitatively; the WHO Mental Health Policy and Plan Checklist and the WHO Mental Health Legislation Checklist were employed to analyse the content of mental health policy; plans and legislation in Ghana. Qualitative data was gathered using in-depth interviews and focus group discussions with key stakeholders in mental health at the macro; meso and micro levels. These were used to identify barriers to the implementation of mental health policy; and steps to overcoming these. Results: Barriers to mental health policy implementation identified by participants include: low priority and lack of political commitment to mental health; limited human and financial resources; lack of intersectoral collaboration and consultation; inadequate policy dissemination; and an absence of research-based evidence to inform mental health policy. Suggested steps to overcoming the barriers include: revision of mental health policy and legislation; training and capacity development and wider consultation. Conclusion: These results call for well-articulated plans to address the barriers to the implementation of mental health policy in Ghana to reduce the burden associated with mental disorders

Mental illness - stigma and discrimination in Zambia

Objective: The aim of this qualitative study was to explore the presence; causes and means of addressing individual and systemic stigma and discrimination against people with mental illness in Zambia. This is to facilitate the development of tailor-made antistigma initiatives that are culturally sensitive for Zambia and other low-income African countries. This is the first in-depth study on mental illness stigma in Zambia. Method: Fifty semi-structured interviews and 6 focus group discussions were conducted with key stakeholders drawn from 3 districts in Zambia (Lusaka; Kabwe and Sinazongwe). Transcripts were analyzed using a grounded theory approach. Results: Mental illness stigma and discrimination is pervasive across Zambian society; prevailing within the general community; amongst family members; amid general and mental health care providers; and at the level of government. Such stigma appears to be fuelled by misunderstandings of mental illness aetiology; fears of contagion and the perceived dangerousness of people with mental illness; and associations between HIV/AIDS and mental illness. Strategies suggested for reducing stigma and discrimination in Zambia included education campaigns; the transformation of mental health policy and legislation and expanding the social and economic opportunities of the mentally ill. Conclusion: In Zambia; as in many other lowincome African countries; very little attention is devoted to addressing the negative beliefs and behaviours surrounding mental illness; despite the devastating costs that ensue. The results from this study underscore the need for greater commitment from governments and policy-makers in African countries to start prioritizing mental illness stigma as a major public health and development issue

Explanatory models of mental disorders and treatment practices among traditional healers in Mpumulanga, South Africa

Objective: In many traditional belief systems in Africa; including South Africa; mental health problems may be attributed to the influence of ancestors or to bewitchment. Traditional healers are viewed as having the expertise to address these causes. However; there is limited information on their explanatory models and consequent treatment practices. The present study examines traditional healers' explanatory models (EMs) and treatment practices for psychotic and non-psychotic mental illnesses. Method: 4 focus group discussions (8 healers in each group) and 18 in-depth interviews were conducted. Four vignettes were presented (schizophrenia; depression; panic and somatization) and traditional healers' views on the nature of the problem; cause; consequence; treatment and patient expectations were elicited. Results: Traditional healers held multiple explanatory models for psychotic and non-psychotic disorders. Psychotic illnesses appear to be the main exemplar of mental illness and were treated with traditional medicine; while nonpsychotic illnesses were not viewed as a mental illness at all. Additionally; traditional healers do not only use herbs and substances solely from ""traditional"" sources but rather have incorporated into their treatment practices modern ingredients that are potentially toxic. Conclusion: Interventions aimed at increasing the mental health literacy of traditional healers are essential. In addition; investigations of the effectiveness of traditional healer treatment for psychiatric disorders should be conducted

Cultural factors and home-brewed alcohol use in a rural community in South Africa.

This paper presents an analysis of the relationship between cultural orientation and home- brewed alcohol use among adolescents in a rural setting. The study involved 1263 students from 30 high schools in Mankweng District in Limpopo Province of South Africa. Boys formed 48% of the sample. Means ages were 16.7 and 16.0 years for boys and girls respectively. A 16 item scale focusing on language, mass media and music preferences was constructed to measure cultural orientations. There was an integration of western and traditional/local activities by respondents who reported having used home-brewed alcohol in the past 12 months. In some respects the sample had western tendencies i.e. English newspapers were read more than no-English newspapers and funky music tended to be preferred to traditional South African music, while in others the reverse was true i.e. Radio Thobela (a radio station that uses vernacular languages) was listened to more than Radio Metro (a radio station that uses English language only). There were significant differences between boys and girls in the use of western media. Older adolescents (18 years or older) used more home brewed alcohol than the younger ones. The concept of culture and its associations with alcohol use invites a critical view on cultural values among adolescents. The positive association with home-brewed alcohol use among secondary school students in our sample has been demonstrated for an orientation towards external cultural influence. Educators and learners need to increase their consciousness on the problematic side of cultural import.

Pathways to psychiatric care in Ethiopia.

BACKGROUND: Understanding the pathways to psychiatric care and recognition of delay points are crucial for the development of interventions that aim to improve access to mental health-care services. METHOD: Over a 2-month period in 2003, a total of 1044 patients at the commencement of new episodes of care at Amanuel Specialized Mental Hospital in Addis Ababa, Ethiopia were interviewed using the encounter form that was developed by the World Health Organization (WHO) for the study of pathways to psychiatric care. RESULTS: The mental hospital was contacted directly by 41% of patients. The remaining patients sought care from up to four different caregivers before arriving at the psychiatric hospital. Where the initial service was not received at the psychiatric hospital, 30.9% of patients sought care from priests/holy water/church. The median delay between onset of illness and arrival at the psychiatric hospital was 38 weeks. The longest delays before arriving at the mental hospital were associated with having no formal education, joblessness, and diagnoses of epilepsy and physical conditions. CONCLUSIONS: Implementing a robust referral system and establishing a strong working relationship with both traditional and modern health-care providers, as well as designing a service delivery model that targets particular segments of the population, such as those who are uneducated, jobless and/or suffer from epilepsy and somatic conditions, should be the most important strategies towards improving mental health service delivery and shortening of undue delay for patients receiving psychiatric care in Ethiopia.