- Email: [email protected]
Exploring barriers to utilization of mental health services in Malawi: A qualitative exploratory study
Mental Health & Prevention 5 (2017) 52–62
Contents lists available at ScienceDirect
Mental Health & Prevention journal homepage: www.elsevier.com/locate/mhp
Exploring barriers to utilization of mental health services in Malawi: A qualitative exploratory study
MARK
⁎
Omero Gonekani Mwalea, , Lilian T. Mselleb a b
Faculty of Nursing and Midwifery, Department of Community and Mental Health, The Catholic University of Malawi, Limbe, Malawi Department of Clinical Nursing, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
1. Background Mental health is fundamental to health and wellbeing of a person. This is reflected by the World Health Organization (WHO) which defines mental health as “a complete state of wellbeing in which the individual realizes his or her own abilities, can work productively and fruitfully, and is able to contribute to his or her community”, (World Mental Health, 2005). Mental health therefore addresses issues that affect a person's ability and potential to be as productive as possible. It is generally recognised that mental health is intimately connected with other conditions of global health importance with neuropsychiatric conditions accounting for 14% of the global burden of disease (WHO, 2000). Over 70% of this burden lies in low and middle income countries (LAMICS) (Lopez, Mathers & Ezzati, 2006), and is projected to increase by 2030 (Mathers & Loncar, 2006). Despite this fact, mental health remains a neglected aspect of human wellbeing with mental health services being one of the least developed in developing countries (Bandawe, 2010). Resources are inadequate, insufficient and inequitably distributed (WHO, 2005). Mental illness increases the risk of communicable and non-communicable diseases. People with poor mental health are not able to fully participate in preventative strategies for diseases like HIV/AIDS, and Malaria and are unable to attend maternal and child health care. Data from developed countries show that mental health problems contribute about a quarter to a third of all patients seen in primary health care settings (WHO, 2005). Despite having qualified doctors working in primary care, 10% of patients presenting with mental health problems are misdiagnosed (Bandawe, 2010). The situation in developing countries like Malawi is worse and it is likely that the misdiagnosed patients contribute a high percentage of re-attendants to the clinics straining further the limited resources available (Bandawe, 2010). This also leads to congestion in the psychiatric units leading to high mortality rates in admitted patients from infectious diseases (Bandawe, 2010). Mental and neurological disorders are responsible for 13% of the global burden of disease. In addition, more than half of the 10 leading risk factors that cause about one third of premature death worldwide
⁎
have major behavioral determinants such as unsafe sex, tobacco use and alcohol consumption (WHO, 2002). Despite this evidence, mental health is a neglected and under researched area of public health, particularly in developing countries (WHO, 2005). WHO's Atlas of mental resources showed that 37% of 203 countries do not have a mental health policy and 25% of the 101 countries that reported their mental health budget spend less than 1% of the total health budget on mental health (WHO, 2005). Malawi's mental health services started in 1910 at the central prison, Zomba, when disturbed prisoners were moved into a special wing of the prison, Zomba Lunatic Asylum (Maclachlan, 1993). In 1943 an annex provided improved conditions, and ten years later Zomba mental Hospital was built. According to Maclachlan (1993), the paucity of institutionalized mental health services gave rise to the development of a district mental health service. In these mental hospitals effective interventions such as counseling, rehabilitation, and substance abuse treatment are available, but are not accessible to the majority of the people who need them (WHO, 2002). These interventions can be made accessible through changes in policy and legislation, service development, adequate financing and training of appropriate personnel (WHO, 2002). Today mental health services are provided at Zomba Mental Hospital, district hospital and non- governmental hospital and also at the health center level, though the latter is not fully developed (WHO Mental Health Atlas, 2005). Most districts are provided by district visiting mental health service, whereby the district health officers are usually accompanied by a psychiatric nurse while visiting the district health centers (Herzig, 2003). Despite the presence of mental health system, mental health services are inadequately offered in Malawi, and not regarded as a priority (Bandawe, 2010). For trainee health workers too, the service is inadequate, depriving them of opportunities to observe and participate in effective mental health care (Herzig, 2003). In 2005, there were no any psychiatrists in Malawi (WHO, 2005). Currently there are two full time psychiatrists in service and 39 psychiatric nurses working in mental hospitals (MOH, 2012). Although there are only few mental health professionals in the country, general doctors are not deployed to the mental health service area
Corresponding author. E-mail addresses: [email protected] (O.G. Mwale), [email protected] (L.T. Mselle).
http://dx.doi.org/10.1016/j.mhp.2017.01.004 Received 1 June 2016; Received in revised form 11 January 2017; Accepted 18 January 2017 Available online 20 January 2017 2212-6570/ © 2017 Elsevier GmbH. All rights reserved.
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
operate at two levels, at the facility and the community. Furthermore, this framework was used to identify any possible relationship or contribution to the existing health system on the utilization of mental health services. The barriers could originate from the way the mental health services are offered by health care providers and how they are accessed by the communities. At facility level this could relate to the availability of services as well as health care providers’ issues. On the other hand, at the community level, some socio-cultural factors were identified in relation to the utilization of mental health services such as awareness, cost of treatment, social support, stigma and culture (Fig. 1). The conceptual framework was used as a guide throughout the research process and during discussion of the findings.
(Bandawe, 2010). The Government of Malawi trains 10 psychiatric nurses every year (MOH, 2012). To supplement the numbers of health care workers, government also trains psychiatric clinical officers in psychiatry up to Bachelors degree level. Under this program, 10 psychiatric clinical officers are trained per year (MOH, 2012). The Government has made a rule that nursing curricula should include a compulsory component of training on mental health and psychiatric nursing (MOH, 2012). This allows the nurses to get basic mental health and psychiatric knowledge and be able to handle patients before referring them for specialized management. Mental disorders account for a significant burden of disease in all societies. It causes significant costs to the personal suffering, and families due to the shift of burden of care and life-time lost productivity, and on the society at large (Cuijpers & Stam, 2003; Foldemo, Gullberg, & Bogren, 2005). Although the burden of mental health problems is not documented in Malawi, hospital based figures suggest a prevalence rate of 3.6% and 5% per 100,000 populations served by hospitals catchment area for acute psychotic conditions and schizophrenia respectively (MOH, 2002). It has been also documented that less than 10% of persons with mental health problems receive treatment in mental hospitals and only 1.5% maintain follow-up treatment over a period of one year (MOH, 2001). Utilization of mental health services is however affected by many interacting factors such as individual, help seeking preferences, access, availability and referral practices (Saunders & Browersox, 2007). Mental hospitals in Malawi are urban based. Individuals do not seek mental health services due to health system and cost factors (Nuhu et al., 2010). This service gap is often filled by traditional, spiritual, faith healing and complementary medicine (Adewuya et al., 2006; Gureje et al., 2006; Kabir, Iliyasu, Abubakar, & Aliyu, 2004). Recognizing the seriousness of the mental health problems, the Malawi government launched its ever mental health policy in 2001. This was in ratification to the Alma Ata Declaration for primary health care in order to direct mental health program development. The aim was to provide comprehensive and accessible mental health care to the citizens of Malawi, through the existing primary health care system. By the end of 2004, when a new program cycle was to be started after evaluation of the existing policy, it was noted that most crucial target activities from the mental health policy, still remained undone. The accessibility of mental health services in public mental hospitals still remains a problem. Wandering persons with mental health problems are rampant on streets of Malawi. There could be still some barriers to utilization of mental health services. Studies on utilization of mental health services have been done in other countries (Uys & Jack-Ide, 2012). There was no documented research study that looked at barriers to utilization of mental health services in Malawi. Therefore, this qualitative study provides knowledge on barriers to utilization of mental health services at facility level in Malawi. It was against this background that this exploratory descriptive study was conducted with the purpose of exploring barriers that affect utilization of mental health services at facility level in Malawi. Specifically this study aimed at describing: (1) factors that affect utilization of mental health services in a mental hospital from the health care providers’ perspective. (2) Describing barriers to utilization of mental health services in a mental health hospital as perceived by caregivers of mentally ill clients. This current study was guided by the following research question. What are the factors that affect the utilization of mental health services at facility level in Malawi? The researchers employed the conceptual framework for exploring factors affecting the utilization of mental health services at facility and community levels in Malawi (Abdelgadir, 2012). See Fig. 1. The above conceptual framework was based on different potential factors that were thought to affect mental health service utilization. These factors
2. Methods 2.1. Study design and context This current study employed qualitative exploratory descriptive research design because little was known on factors affecting utilization of mental health services in Malawi (Burns & Grooves, 2005). The study was conducted at Zomba mental hospital which is the major referral mental hospital in Malawi. The common mental disorders that are treated at Zomba mental Hospital are schizophrenia, mania, substance abuse, affective disorders and anxiety disorders. Currently there is no psychiatrist at Zomba mental hospital. However there are 5 psychiatric clinical officers and 11 state registered mental health nurses. 2.2. Participants Twelve participants were recruited for the qualitative study, among them (n=6) were health care providers working at Zomba mental hospital, and (n=6) caregivers who came to the hospital to collect medications for their relatives. Among the health care providers, three were women and three men. They had between 4−18 years of working experience as clinical officers, and as nurses, in a mental hospital respectively. For the caregivers, 5 participants were men and only one was a woman. All of them came from the rural areas (see Tables 3 and 4). 2.3. Sampling In this study, purposeful sampling method was used to recruit health care providers. In particular the researcher used criterion strategy to recruit the health care providers. Health care providers were those who had worked at Zomba mental hospital for more than 6 months and who were willing to participate in the study. Snowball strategy was appropriate to recruit caregivers because of difficulties in obtaining this category of participants. Caregivers were those who had accompanied their sick relatives in outpatient clinic to seek mental health services at Zomba mental health hospital for more than 1 year. In snowball sampling the researcher identified one caregiver, who was then asked to provide names of other caregivers known to him/her. The identified participant was then approached by the researcher and requested to participate in the study. Written consent was mandatory for enrollment for the study. The sample size for qualitative research was not predetermined and therefore sampling was done until saturation, when no new data emerged, but previously collected data were repeatedly reintroduced (Polit & Beck, 2010). Guest, Bunce, & Johnson (2006), states that data saturation has “become the gold standard by which purposive sample sizes are determined in health science research” and they suggest that data saturation can occur after 12 interviews. According to these authors, smaller sample sizes can be sufficient in providing complete and accurate information within a particular cultural context, 53
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
Fig. 1. Conceptual framework of the potential factors affecting m mental Health Service Utilization at facility and community levels in Malawi adopted from (Abdelgadir, 2012) and modified by 2014).
interviews were read and re-read to allow the researchers to familiarise with the data. This strategy meets Lincoln and Guba's 1985 as cited in Polit and Beck (2010), requirement of data immersion being an inductive rather than deductive activity that requires repeated exposure to and engagement with the data. Immersion in the data enabled the researcher to see how the participants’ perceived factors and barriers that affect utilization of mental health services. It also allowed the researchers to fully comprehend how insights were grounded in and developed from the data with the emphasis on understanding participants’ experiences through their descriptions Polit and Beck (2010); Bogdan and Taylor (1984). The researchers read each transcript as a whole while listening to the audiotape to gain a sense of the participant's entire story and to reflect on comments, phrases and any associated vocal qualities that stood out. Patterns and themes that emerged from the data were noted and highlighted in different colours and ideas and thoughts were noted next to particular parts of the text in order to clearly track the researcher's emerging observations about the data, rather than searching for instances that reflected a previous theoretical position (Lincoln and Guba 1985 cited in Polit and Beck, 2010); Bogdan & Taylor, 1984). Key terms or phrases together with the corresponding text that illustrated the key terms and phrases were highlighted and then assigned a code Bogdan and Biklen (2007). Transcripts and codes were discussed by the research team and reviewed accordingly. The results of the preliminary coding by the researcher and supervisor were then compared and any differences discussed until consensus was reached. Coded concepts from each transcript were identified and Sub-themes derived from the codes. Nine sub-themes were identified from the health care providers’ (See Table 1) and eight sub-themes from caregivers’ (See Table 2). The data was then re-examined with the research objectives and aim in mind. Major theme headings were identified to develop the overall story of the participant's perceptions on factors and barriers that affect utilization of mental health services in Malawi.
as long as participants possess a certain degree of expertise about the domain of inquiry. It is argued that these experiences contribute to the participants’ sense of reality and “truth” (Guest et al., 2006). After the 12th interview there was no new information that was emerging. Therefore, the researcher recruited twelve participants in this study. 2.4. Data collection Data were collected using a semi structured interview guide. The guides had nine open ended questions for the health care providers (see Appendix A) and four open ended questions for caregivers (see Appendix B). Interviews were done in two categories, health care providers and caregivers. Semi structured interview guide was prepared and revised during the course of data collection. It included topics and probing questions on perception of utilization of mental health services at Zomba mental hospital. Interviews with health care providers were moderated in English language as most of them were able to communicate fluently and that of caregivers were conducted in “Chichewa” a national vernacular language for Malawi. 2.5. Data analysis In exploring barriers to utilization of mental health services in Malawi, thematic analytic steps of Aronson (1994) and Bogdan and Biklen (2007) guided analysis of data. The transcribed data and written file notes made by the researcher following each interview provided the means to begin exploring the data obtained. These reflections resulted in refinements to the interview schedule during the first two health care providers’ interviews. Each interview was conducted by the researcher and then transcribed. This approach of re-reading the transcript allowed the researcher to view the preliminary data and highlight any initial ideas as they became evident. Importantly, it also enabled the exploration of other issues that may not have initially been considered central to the research question (Grbich, 2007). The transcribed
54
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
Committee of Malawi (NHSRCM) (Ref. no NHSRC1259). Following approval, permission to conduct the study was also sought from the Director of Zomba mental hospital. Health care providers and caregivers who participated in this study were explained of the aim of the study. Participants were also informed that participation was voluntary, anonymity was guaranteed as their names did not appear in the report and that they were at liberty to withdrawal or cancel their participation at any time even after they had signed the consent form. Further, participants were made clear that they were not to receive any remuneration for participating in the study. All participants who agreed to take part in this study signed an informed consent. Special permission was obtained from participants on the use of audio recorder.
Table 1 Themes and sub-themes on factors affecting utilization of mental health services health care providers’ perspective. Theme
Subthemes
Hospital based factors affecting utilization of mental health services
Inadequate skills by health care workers Inadequate trained mental health professional in a mental hospital Negative attitudes of health care providers Stigma and discrimination Unavailability of antipsychotic drugs Lack of mental health policy
Non hospital related factors affecting utilization of mental health services
Lack of mental health services in the community Lack of knowledge on mental health problems by the community Inadequate funding by the ministry of health
3. Results 3.1. Factors affecting utilization of mental health services at Zomba mental hospital: Perspectives of Health care providers Under this theme there were a number of issues that come into view as subthemes from the health care providers’ accounts. Direct quotes from the participants are italicized. These factors are both hospital based and non-hospital related factors and are described below.
Table 2 Themes and subthemes on barriers to utilization of mental health services from care givers perspective. Theme
Subthemes
Practical barriers
Poor knowledge on mental health services Inadequate mental health services Long waiting time
Financial constraints
Long distance/ transportation high cost of services loss of productive income
Cultural factors
4. Hospital based factors 4.1. Inadequate trained mental health professionals Shortage of skilled mental health professionals was reported as a factor that affected utilization of mental health services at Zomba mental hospital. This inadequacy of mental health professionals hinders the delivery of quality mental health services. This was learned from health care provider 4 who said:
Stigma/ discrimination feeling of embarrassment
“currently this hospital has only four registered mental health nurses for the entire hospital” of course there are other general nurses but they don’t have enough knowledge on mental health, so they are not able to provide the necessary care to the clients”, “and also we do not have a psychiatrist, psychologist, mental health social worker, so there is no multidisciplinary approach care so it becomes a challenge to manage the patients”.
2.6. Strategies that the researcher applied to enhance trustworthiness The researcher engaged both the health care providers and caregivers in a discussion in such a way that they were motivated to give their inputs spontaneously and enthusiastically. This face to face interview was verified by means of triangulation which is one of the strategies used to enhance the trustworthiness of any research. The health care providers proceeded to discuss the facts that constituted the truth and various means that one can use to minimize or eliminate bias (Polit & Beck, 2010). The significance of this group was that it allowed the researcher to collect date from experienced and professional practitioners who were very different in their outlook because their experience, knowledge and wisdom from the caregivers who constituted the second interview. The health care providers discussed several barriers they encounter when providing the services to the mentally ill clients and their family members. Likewise the caretakers also discussed their views in regard to barriers to utilization of mental health services. During the discussion they contributed their inputs on how possible could the mental health services be made locally available in their communities.
4.2. Inadequate knowledge and skills by health care providers Health care providers acknowledged their inadequate knowledge and skills in assessing and managing mentally ill patients. As reported by health care provider 4: who said, “we lack knowledge and skills in managing some clients,” Even the referral system is not good, “What do I mean is that the health care providers from the general hospitals who refer clients to Zomba mental hospital do not have knowledge and skills to assess these clients as well”. 4.3. Stigma and discrimination
2.7. Ethical considerations Stigma and discrimination of mentally ill patients by the community as well as among health care workers managing these patients were reported to be common. As reported by health care provider 4:
In order to conform to the ethical and legal standards of a scientific research, ethical approval to conduct the study was sought from research and publications committee of Muhimbili University of Health and Allied Sciences (MUHAS) (Ref no, MU/PGS/SAEC/ VOL.IX/), and from the National Health Scientific Research
“stigma is very high, because we observe that most of the times, guardians don’t bring mentally ill patients to seek medical attention
55
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
but rather to leave them here (Zomba hospital), we have several situations where the guardians they even tell us, we have brought this patient and we want you to cut off the nerves” or just give him medication to reduce his strength”.
“You know there is no current mental health policy to be followed in the implementation of the planned procedures and activities in this hospital.
Stigma and discrimination has been reported to be an important contributing factor to the treatment gap. This prevents the affected individuals to receive care as well as leading to social exclusion. Stigma exists at all levels. Even health care providers working in a mental hospital are equally stigmatized by their fellow health care workers from general hospitals. This was also reported by health care provider 6 who said:
“We are lacking current mental health policy and that has to be integrated into the national health plan”.
Another health care provider 5 said:
5. Non Hospital related factors 5.1. Lack of mental health services in the community
“working in a mental hospital is also a source of stigma to us, and you are equally stigmatized by other health care providers from the general hospitals so this affects our morale”
Health care providers who were interviewed reported that at community level, the mental health services were not present. This meant that when people were sick are compelled to travel long distances to seek mental health services which are located in the urban. While there were mixed views on this area, health care providers felt that there was a need for fully integration of mental health services into primary health care to enable the people in the communities to easily access these services. Health care provider 4 illustrated that:
4.4. Negative attitudes of health care providers Negative attitudes of some health care providers at Zomba mental hospital was reported as another factor affecting utilization of mental health services by clients. This in turn negatively influence the quality of care rendered to persons with mental health problems. As reported by health care provider 2 who said:
“if mental health services were integrated into primary health care was going to improve service utilization, as the services will be closer to the people who need them and will therefore be cheaper, hence improving utilization of mental health services”.
“Even trained nurses, most of them have negative attitudes towards mentally ill clients, so this affects the care they render to patients”.
He continued to say that: “integrating mental health services into primary health care or in the communities was good; because at primary level a lot of people are seen, so if primary health care workers can be trained to recognize symptoms, then it will also lessen the burden on part of the guardian, because this institution (Zomba hospital) is very far”.
In addition, health care provider 6 said: “I think may be is the attitude that we have towards mental illness or towards people who have mental illness. I think most of the health professionals have a negative attitude, because why treating somebody who is behaving abnormally, inhumane; it is this attitude that also makes many families not to bring their patients here instead take them to traditional healers”.
Similarly health care provider 6 said this on lack of mental health services in the community. “Having mental health services in the community or integrating mental health services into primary health care was very important because it would help to reduce congestion in the ward”.
4.5. Unavailability of antipsychotic drugs
He further added:
Availability of antipsychotic drugs was pointed out by the health care providers who were interviewed to be erratic. Unavailability of antipsychotic drugs affects patient care as some clients who need antipsychotics may go without them and thus making their condition worse. From the health care providers account it was noted that this was a major challenge that affects delivery of care to the patients with mental health problems who utilize mental health services at Zomba mental hospital. As noted by health care provider 5 who reported this:
“it will be cheaper as the clients will be treated in their own communities so it will be very important by the end of the day”. “We also should not forget that when we treat people with mental disorders they do well when they are treated close to their homes or to their relatives”. Likewise, another health care provider felt that community psychiatric nurses were key in ensuring that mentally ill patients seek and receive adequate and continuous mental health services. He said:
“The other challenge has been erratic antipsychotic medication supply even though the situation has slightly improved recently. This problem is even worse in the district hospitals and health centers”.
“one of the factors that affect utilization of mental health services is lack of community psychiatric nurses who could be working in the community, We expect the client to be followed up to see whether is taking medication or is having side effects but this is not done” and he concluded by saying “we do not have community psychiatric nurses as a result it is difficult for the client to be followed up in the community”.
4.6. Outdated mental health policy The health care providers had the opinion that lack of current mental health policy was a critical factor that was affecting negatively utilization of mental health services. Mental health policy and plan is essential to coordinate all services and activities related to mental health. Without policies and plans, mental disorders are likely to be treated in an inefficient and fragmented manner. Heath care provider 1 reported this:
5.2. Lack of knowledge on mental health problems by the community Participants had the view that lack of knowledge on mental health problems by the community was one of the factors that affect
56
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
services mentioned by the caregivers were practical, financial and cultural barriers (See Table 3). Direct participants quotes are italicized (Table 4).
Table 3 Socio Demographic details of Health Care Providers who participated in the study. Health Care Providers No
Age
Sex
Education preparation
Work Experience
HCP 1
49 years
Female
4 years
HCP 2
45 years
Female
HCP HCP HCP HCP
53 30 53 37
Female Male Male Male
Bsc Mental Health Psychiatric Nursing Bsc Mental Health Psychiatric Nursing Cert in psychiatry Bsc in clinical Psychiatry Diploma in Psychiatry Bsc in clinical Psychiatry
3 4 5 6
years years years years
5.5. Practical barriers The factors relating to practical barriers to mental health services utilization consisted of the awareness about mental illness and the ability to access mental health services with three sub-themes which emerged namely; poor knowledge of mental health services, inadequate mental health services and long waiting time.
18 years 21 years 5 years 18 year 5 years
5.6. Poor knowledge of mental health services Caregivers who were interviewed expressed that poor knowledge of available mental health services, and the mental illness itself and uncertainty where to go for treatment being reasons for not seeking the needed care as quickly as possible. As it was noted by one caregiver 3 who said:
Key HCP= Health care provider
utilization of mental health services in Malawi. It was reported by health care provider 2 that: “the community does not have knowledge about mental illness as a result they believe in their cultural beliefs and they take their relative to the traditional healer instead of taking them to the hospital”.
“ for example when my child was sick, I did not know that it was mental illness all what I thought was malaria and I went to the traditional healer then to the general hospital where after the doctors examined my child they sent me to this mental hospital”.
Likewise health care provider 6 pointed out that: “due to lack of knowledge these people report to the hospital with their patients in a very bad state and upon asking the relatives they will tell you that we have delayed to come here or were trying native herbs or we were at the traditional healer”.
5.7. Inadequate Mental Health Services Caregivers observed that in most areas where they stay there were no drugs for their clients. This was pointed out by almost all caregivers. Caregivers had these to share:
5.3. Inadequate funding by the Ministry of health
“I have come here; because where I stay the government does not offer us with the adequate drugs”. “In my area, there is no hospital and this is a very big problem for the people in this Area. The government should consider building a hospital in this area as people are suffering not only from mental illness but even other physical illness as they travel long distances to seek for treatment, while others do not afford and continue to suffer there”.
Another factor that hindered utilization of mental health services in Malawi was in adequate funding to mental health department. In the current study it was reported by the majority of the respondents that mental health services were not adequately funded by the government as a result it makes the services to be compromised. Health care provider 4 observed this: “in the first place mental health is a neglected field in our situation, the budget that comes to mental health is not enough; previously, we could have only 2% of the total budget, which needs to be desired”.
5.8. Waiting time Long waiting time for mental health services at the mental hospital was raised as a significant issue by the caregivers. One caregiver 6 complained that:
5.4. Barriers to utilization of mental health services: caregivers’ perspective
“I left home around 5 am with the aim that I should go back early, but until this time 8:30 am I have not been assisted. I feel the health care providers are not attending to us as it is expected”.
Three major themes on barriers to utilization of mental health Table 4 Socio demographic details of caregivers who participated in the study.
5.9. Financial constraints Long distance to the health facility and lack of transport, and cost associated with transportation were reported by participant as barriers to utilization of mental health services. Caregivers mentioned that the long distance to the hospital was costly, and that lack of money for transport to the hospital meant that they could not always access the needed services. One caregiver 2 reported that:
Caregivers No Caregiver Caregiver Caregiver Caregiver Caregiver Caregiver
1 2 3 4 5 6
Age
Sex
Occupation
47 22 51 51 22 39
Female Male Male Male Male Male
Farmer Teacher Farmer Primary Teacher Student Farmer
years years years years years years
“it is 130 km from home to the hospital and it is not possible to come with the client”. “Sometimes these clients need to be seen by the doctors and that is not possible because of money difficulties”.
57
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
should be made available at primary health care level. This accessibility is also implicated by long distances and financial constraints. This confirms to Kishore Kumar et al. (2005), in their study in India which showed that distance travelled to access the services was a barrier as a result the family could not sustain treatment. This is also true in Malawian setting whereby many families could not afford to find money for transport to the mental hospitals that are urban based, as a result clients default treatment and eventually relapse. Another finding that was uncovered in this study was lack of knowledge on mental illness by the communities which is also associated with access to mental health services. As reported by one participant in this study, that most of the communities lack knowledge on mental health and mental illness as well as where to get the mental health services. Research in other developing countries shows increasing public understanding of mental health conditions and awareness that effective treatment is available and is important. Gureje and Alem (2000) argue that public education on mental health and mental illness should be given importance by policies so as to support affected clients and their families. It is therefore, necessary for people in Malawi to be aware about what services are available and what can be expected from them as well as know when to seek profession help. Similarly, Aida et al. (2010) in their study on barriers to utilization of primary care services for mental health problems among adolescents in a secondary school in Malaysia, observed similar findings that learners were not aware of the services availability in the primary health care. Therefore, active community education programs could be vital to improve knowledge of mental disorders and available resources. Consequently, lack of knowledge about mental illness and its treatment could prevent people with mental health problems to seek help early for their mental health problems. Interestingly it was also found out that there was no mental health policy to guide the implementation of mental health services. It suffices to say that without a policy and plans the provision of the services could be fragmented. It meant that clients could not access the quality mental health care services they need. This finding reflects Jenkins (2003), findings who observed that both in low and middle income countries, the health policy focus towards communicable diseases that cause high morbidity and mortality rates. This in turn has contributed to a lack of attention from policy makers and the public; in turn leading to a lack of resources and poor staff morale in mental health. This could be the case in Malawian mental health system. Human resources are the most valuable asset of a mental health service. Such a service relies on the competence and motivation of its personnel to promote mental health, prevent disorders and provide care for people with mental health problems (WHO, 2005). Yet, in most developing countries in Africa the major challenges in delivery of mental health services is lack of trained mental health professionals (WHO, 2005). Likewise, in this study it was found that one of the barriers to utilization of mental health services was inadequate trained mental health professionals. In the absence of trained mental health professionals it is likely that patients with mental health problems would not get the necessary mental health services. This finding is supported by Sadovoy et al. (2004), who found that the key barrier to adequate care included inadequate numbers of trained and acceptable mental health workers. If the government of Malawi through the ministry of health could train more mental health professionals, they will be able to assist in the identification, management and prevention of mental illness at all levels of care. The study also revealed that the health care workers had inadequate knowledge and skills. When health care providers, lack knowledge and skills, it affects service delivery as most common mental disorders are
Caregivers felt that where the services require them to pay it is hard: “to find money to pay for the services at the private clinic is not easy”. Therefore one caregiver suggested that mental health services should be solely free particularly for the poor from the villages in order to combat the burden of the illness on their families. Some caregivers reported that coming to the hospital to get the drugs for the client, meant that they have abandon their work, which resulted in loss of income. One caregiver 5 indicated that: “today I did not go to school because I had to come here to collect the drugs for my brother”.
5.10. Cultural factors In the current study two issues concerning cultural was observed, that affect utilization of mental health services in Malawi. 5.11. Stigma/discrimination Participants observed that stigma due to some beliefs prevent them from seeking mental health services from the hospital. Many families with clients with mental health problems are given all sorts of names by other members of the community because of their relative who is sick mentally. One caregiver 4 reported that: “Even clients are stigmatized and discriminated by their relatives as they do not want to come to collect the drugs for their patient. Is that fair”? Feeling of embarrassment Caregivers held a view that feeling of shame of being seen in the mental hospital as being one main barrier to accessing mental health services. Mental hospitals were regarded to be places for those people who are mad; and therefore not ideal place for receiving treatment. Caregiver 1 observed that the fear of being seen by friends and neighbors makes many patients opt out of treatment. This was leant from caregiver 1 who said: “Like my son stopped taking the medication because I feel he is ashamed of by his friends”. 6. Discussion Good mental health care is significant for the entire population and in particular for the affected individuals. In order to achieve this optimal level of service the mental health services should be utilized effectively. According to the findings of this study; lack of mental health services in the community was observed to be outstanding as far as utilization of mental health services is concerned. The unavailability of mental health services in rural areas has made many families to use whatever might be present in their communities. Mwape et al. (2011) asserts that integrating mental health services into primary health care as a way of facilitating early identification and intervention for mental disorders is crucial to improving and promoting the mental health of the population. However in Malawi this is not the case as the mental health services have not been fully integrated into primary health care to enable clients’ access mental health services. As such families with their relatives have to travel to the urban to look for the mental health services. Therefore, if mental health services are to genuinely prioritize wellbeing and prevention of mental health problems then services
58
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
7. Limitations and strength
undetected and untreated. Farroq (2013), holds a view, that a public health approach to mental health care, including integration with primary health care system, as well as including integrated care of mental illness along with care of other non-communicable disorders is essential. Further, Kagee et al. (2013), argue that treatment gap is not only a function of poor health systems and access to treatment but also of the poor detection of common mental disorders. Additionally, the study revealed that there were no antipsychotics in the mental hospital as well as in most districts and health centers. This unavailability of drugs meant that the affected clients could not get the needed treatment. Shortage of antipsychotic drugs could be due to the fact that mental health services were not given priority, evidenced by 1.5% budget allocation to mental health department. If mental health policy and plans were available and being implemented the shortage of antipsychotic drugs could be minimized, as the policy would guide the policy makers to budget enough money to purchase the drugs. Mental health services are widely underfunded, especially in developing countries (WHO, 2005). Expenditure on mental health amounts to under 1% of the health budgets in 62% of developing countries and 16% of developed countries. Thus a significant discrepancy exists between the burden of mental disorders and the resources dedicated to mental health services. Similarly, in this study it was found that the mental health services at Zomba mental hospital were inadequately funded. Therefore, without adequate financing, mental health policies and plans remain in the realm of rhetoric and good intentions. As such the affected individual would likely not get the mental health services that they ought to have. An important contributing factor to the treatment gap is the extent to which mental illness is stigmatized, a leading significant barrier to accessing care (Thorncroft et al., 2009). Stigma occurs at different levels of the society. In this study, the participants acknowledged high degree of stigma and discrimination not only in the communities but also among some mental health professionals. This in turn negatively affects the quality of care provided to persons with mental health problems. This finding is supported by Kapungwe et al. (2011), findings in their study conducted in Zambia on health care workers attitudes towards the mentally ill clients. They had uncovered that there was very high level of stigma among the health care workers towards the mentally ill clients. Hence, there is dire need for the public to change their attitude towards mental health problems. Fear of stigma/ discrimination was an important reason for not seeking or continuing treatment; due to fear of what others may think, thereby preventing many clients from sustaining their treatment. This was evident in this study. The experience associated with stigma /discrimination negatively impacted on their social wellbeing, resulting in families not coming to the hospital to take the drugs for their ill relatives, hence affecting their wish to look for appropriate mental health care. It is important therefore, for the society in Malawi to appreciate how stigma impact on people with mental health problems and need for change in public attitude. Negative attitudes by health care providers and the related concept of stigma have a substantial impact on the care of people with mental health problems. It was expected that mental health professionals could have positive attitudes towards people with mental health problems than other health professionals and lay persons. This was contrary to the findings of this study as stigma was eminent from the community and among the mental health professionals. This finding is supported by Birch et al. (2005) who found that health care providers who have a role in treatment and support of the mentally ill share the same stigmatizing attitudes as the public which affects the quality of care these professionals provide. It would appear, then, that theoretical education and contact with people with mental health problems in the usual psychiatry setting are not enough to reduce stigma in health care providers (Arboleda-Florez & Satorius, 2008).
The researcher is a mental health qualified nurse as such this research is credible as this was carried out with all the authority of mental health in Malawi. However, one of the limitations was of subjectivity and potential bias regarding researcher's own involvement in this study first as a student and currently as mental health nurse profession. A related limitation was that, health care providers’ interviewees may have had difficulty, adjusting to the researcher taking on the role of interviewer, a phenomenon referred to by Maxwell (1996), as participant reactivity. Because a few health care providers knew the researcher, their responses may have been influenced or affected. They may have tried overly hard to cooperate with the researcher by offering him responses they perceived he was seeking or which they perceived might be helpful to him. The study was conducted at one facility. Therefore, transferability was limited, but as a first study in Malawi, the findings could have the implications that could influence both subsequent research, practice and policy innovations for care. Lastly, the policy makers were not involved in this study due to political factors that were beyond the researchers control at the time this research was being conducted. The policy makers would be ideal to inform the researcher on policy issues that guide the implementation of mental health services in Malawi.
8. Recommendations 8.1. Nursing research Since this study was conducted at one government mental hospital, it is recommended that another study should be conducted on a large scale to assess the views of the general public on utilization of mental services in Malawi.
8.2. Nursing practice It is further recommended that the mental health policy and plans have to be revised in order to guide the implementation and evaluation of mental health services in Malawi and it has to be periodically revised. Furthermore, social education needs to be done for people to overcome cultural barriers that affect those with mental health problems and highlights the need to change in public attitude to support help seeking behavior.
8.3. Nursing education Since shortage and knowledge gap were identified in this study, it is further recommended that the government of Malawi through the ministry of health should strive to train more mental health professionals with positive attitudes who would deliver the quality mental health services to the Malawian population.
9. Conclusion Successful utilization of mental health services need to be supported by enough resourced and staffed facilities that promote good health seeking behavior and continued treatment and community follow-up. Therefore, providing mental health services, locally and affordably throughout the health care system, will allow persons with mental health problems live productive and enjoyable lives. 59
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
Appendix A. Semi-structured interview guide for health care providers on barriers to utilization of mental health services at facility level
.
60
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
Appendix B. Semi-structured interview schedule for caregivers on barriers to utilization of mental health services at facility level
References Foldemo, A., Gullberg, M., AC, E. K., & Bogren, L. (2005). Quality of life and burden in parents of outpatients with schizophrenia. Social Psychiatry Epidemiology, 40(2), 133–138. Grbich, C. (2007). Qualitative data analysis. An introduction Los Angeles: SAGE Publications. Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are enough? An experiment with data saturation and variability [electronic version]. Field Methods, 59–82. Gureje, O., & Alem, A. (2000). Mental health policy development in Africa, 78. Bull World Health Organ, 475–482 (PubMed |Google Scholar). Gureje, O., Lasebikan, V. O., Ephraim-Oluwanuga, O., Oley, O. B., & Kola, L. (2006). Community Study of Knowledge and Attitudes of Mental Illness in Nigeria. British Journal of Psychiatry, 186, 436–441. Herzig, H. (2003). Teaching psychiatry in poor countries: Priorities and needs. A Description of how mental health is taught to medical students in Malawi, Central Africa. Education for Health, 16(1), 32–39. Jenkins, R. (2003). Supporting governments to adopt mental health policies. World Psychiatry, 2, 14–19. Kagee, A., Tsai, A. C., Lund, C. et al. (2013). Screening for common mental disorders in low resource settings: Reasons for caution and a way forward. International Journal of Health, 11–14.
Adewuya, A., Ola, B., Mosaku, S., Fatoye, F., & Eegunranti, A. (2006). Attitude towards antipsychotic among out-patients with schizophrenia in Nigeria. Acta Psychiatrica Scandinavica, 3, 207–211. Arboleda-Florez, J., & Sartirius, N. (2008). Understanding the stigma of mental illness: theories and interventions. John Wiley and Sons Ltd. Bandawe, R. C. (2010). Gap analysis for the national health research agenda of Malawi: research priorities for the theme of mental health Malawi: Lilongwe. Birch, S., Lavender, T., & Cupitt, C. (2005). The physical health care experience of women With mental health problems: Status vs Stigma. Journal of Mental Health. Bogdan, R., & Taylor, S. J. (1984). Qualitative research for education: An introduction to theory and methods Boston: Allyn and Bacon. Bogdan, R. C., & Biklen, S. K. (2007). Qualitative research for education. An introduction to theories and methods (5th ed.) Boston: Allyn Bacon. Burns, N., & Grove, S. K. (2005). The practice of nursing research: conduct, critique and utilization (5th ed.) Philadelphia: Elsevier Saunders. Cuijpers, P., & Stam, H. (2003). Burnout among relatives of psychiatric patients attending psychoeducational support groups. Psychiatric Services, 51(3), 375–379. Farroq, S. (2013). Collaborative care for depression: a literature review and model for implementation in developing countries. International Mental Health, 5, 24–25.
61
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
Saunders, S., & Browersox, N. (2007). The process of seeking treatment for mental health problems. Mental Health and Learning Disabilities Research and Practice, 4(2), 99–123. Uys, l, & Jack-Ide, I. O. (2012). barriers to mental health services utilization in the niger delta region of Nigeria service users’ perspective. Pan African Medical Journal, 14, 159. http://dx.doi.org/10.11604/panj.2013.14.159.1970. World Health Organization (2002). The world health report 2002: Reducing risks, promoting healthy life Geneva: World Health Organization. World Health Organization (2005). Mental health atlas Geneva: World Health Organization, 2005. World Health Organization (2005). Promoting mental health: concept, emerging evidence, practice: Report of the World Health Organization, Dept of Mental Health and Substance Abuse in collaboration with Victorian Health Promotion Foundation and the University of Melbourne. Geneva. World Health Organization. World Health Organization (2000). Mental health: new understanding, new hope Geneva: World Health Organization (World Health Report (1020-3311)).
Lopez, D. A., Mathers, D. C., Ezzati, M., Jamison, D., & Murray, JL. C. (2006). Global burden of disease and risk factors New York: Oxford university press and Washington DC: The World Bank. Maclachlan, M. (1993). Mental health in Malawi. Which way forward. Journal of Mental Health, 2, 3. Mathers, C. D., & Loncar, D. (2006). Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med., 3, e442. Maxwell, J. A. (1996). Qualitative research design: An interactive approach (2nd ed.) Thousand Oaks, CA: Sage. MOH (2002). National Mental Health Policy. Republic of Malawi. Lilongwe. Malawi. MOH (2001). National Mental Health Policy. Republic of Malawi. Lilongwe, Malawi. MOH (2012). The Malawi Human Rights Commission Report. Republic of Malawi Lilongwe. Malawi. Mwape et al. (2011). Attitudes of Primary Health Care Providers towards people with mental illness. Africa Journal of Psychiatr, 14, 290–297. Polit, F. D, Beck, T. C., 2010. Essentials of Nursing Research. Appraising evidence for Nursing Practice. 7th Edition. Lippincott: William Wilkins.
62
Contents lists available at ScienceDirect
Mental Health & Prevention journal homepage: www.elsevier.com/locate/mhp
Exploring barriers to utilization of mental health services in Malawi: A qualitative exploratory study
MARK
⁎
Omero Gonekani Mwalea, , Lilian T. Mselleb a b
Faculty of Nursing and Midwifery, Department of Community and Mental Health, The Catholic University of Malawi, Limbe, Malawi Department of Clinical Nursing, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
1. Background Mental health is fundamental to health and wellbeing of a person. This is reflected by the World Health Organization (WHO) which defines mental health as “a complete state of wellbeing in which the individual realizes his or her own abilities, can work productively and fruitfully, and is able to contribute to his or her community”, (World Mental Health, 2005). Mental health therefore addresses issues that affect a person's ability and potential to be as productive as possible. It is generally recognised that mental health is intimately connected with other conditions of global health importance with neuropsychiatric conditions accounting for 14% of the global burden of disease (WHO, 2000). Over 70% of this burden lies in low and middle income countries (LAMICS) (Lopez, Mathers & Ezzati, 2006), and is projected to increase by 2030 (Mathers & Loncar, 2006). Despite this fact, mental health remains a neglected aspect of human wellbeing with mental health services being one of the least developed in developing countries (Bandawe, 2010). Resources are inadequate, insufficient and inequitably distributed (WHO, 2005). Mental illness increases the risk of communicable and non-communicable diseases. People with poor mental health are not able to fully participate in preventative strategies for diseases like HIV/AIDS, and Malaria and are unable to attend maternal and child health care. Data from developed countries show that mental health problems contribute about a quarter to a third of all patients seen in primary health care settings (WHO, 2005). Despite having qualified doctors working in primary care, 10% of patients presenting with mental health problems are misdiagnosed (Bandawe, 2010). The situation in developing countries like Malawi is worse and it is likely that the misdiagnosed patients contribute a high percentage of re-attendants to the clinics straining further the limited resources available (Bandawe, 2010). This also leads to congestion in the psychiatric units leading to high mortality rates in admitted patients from infectious diseases (Bandawe, 2010). Mental and neurological disorders are responsible for 13% of the global burden of disease. In addition, more than half of the 10 leading risk factors that cause about one third of premature death worldwide
⁎
have major behavioral determinants such as unsafe sex, tobacco use and alcohol consumption (WHO, 2002). Despite this evidence, mental health is a neglected and under researched area of public health, particularly in developing countries (WHO, 2005). WHO's Atlas of mental resources showed that 37% of 203 countries do not have a mental health policy and 25% of the 101 countries that reported their mental health budget spend less than 1% of the total health budget on mental health (WHO, 2005). Malawi's mental health services started in 1910 at the central prison, Zomba, when disturbed prisoners were moved into a special wing of the prison, Zomba Lunatic Asylum (Maclachlan, 1993). In 1943 an annex provided improved conditions, and ten years later Zomba mental Hospital was built. According to Maclachlan (1993), the paucity of institutionalized mental health services gave rise to the development of a district mental health service. In these mental hospitals effective interventions such as counseling, rehabilitation, and substance abuse treatment are available, but are not accessible to the majority of the people who need them (WHO, 2002). These interventions can be made accessible through changes in policy and legislation, service development, adequate financing and training of appropriate personnel (WHO, 2002). Today mental health services are provided at Zomba Mental Hospital, district hospital and non- governmental hospital and also at the health center level, though the latter is not fully developed (WHO Mental Health Atlas, 2005). Most districts are provided by district visiting mental health service, whereby the district health officers are usually accompanied by a psychiatric nurse while visiting the district health centers (Herzig, 2003). Despite the presence of mental health system, mental health services are inadequately offered in Malawi, and not regarded as a priority (Bandawe, 2010). For trainee health workers too, the service is inadequate, depriving them of opportunities to observe and participate in effective mental health care (Herzig, 2003). In 2005, there were no any psychiatrists in Malawi (WHO, 2005). Currently there are two full time psychiatrists in service and 39 psychiatric nurses working in mental hospitals (MOH, 2012). Although there are only few mental health professionals in the country, general doctors are not deployed to the mental health service area
Corresponding author. E-mail addresses: [email protected] (O.G. Mwale), [email protected] (L.T. Mselle).
http://dx.doi.org/10.1016/j.mhp.2017.01.004 Received 1 June 2016; Received in revised form 11 January 2017; Accepted 18 January 2017 Available online 20 January 2017 2212-6570/ © 2017 Elsevier GmbH. All rights reserved.
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
operate at two levels, at the facility and the community. Furthermore, this framework was used to identify any possible relationship or contribution to the existing health system on the utilization of mental health services. The barriers could originate from the way the mental health services are offered by health care providers and how they are accessed by the communities. At facility level this could relate to the availability of services as well as health care providers’ issues. On the other hand, at the community level, some socio-cultural factors were identified in relation to the utilization of mental health services such as awareness, cost of treatment, social support, stigma and culture (Fig. 1). The conceptual framework was used as a guide throughout the research process and during discussion of the findings.
(Bandawe, 2010). The Government of Malawi trains 10 psychiatric nurses every year (MOH, 2012). To supplement the numbers of health care workers, government also trains psychiatric clinical officers in psychiatry up to Bachelors degree level. Under this program, 10 psychiatric clinical officers are trained per year (MOH, 2012). The Government has made a rule that nursing curricula should include a compulsory component of training on mental health and psychiatric nursing (MOH, 2012). This allows the nurses to get basic mental health and psychiatric knowledge and be able to handle patients before referring them for specialized management. Mental disorders account for a significant burden of disease in all societies. It causes significant costs to the personal suffering, and families due to the shift of burden of care and life-time lost productivity, and on the society at large (Cuijpers & Stam, 2003; Foldemo, Gullberg, & Bogren, 2005). Although the burden of mental health problems is not documented in Malawi, hospital based figures suggest a prevalence rate of 3.6% and 5% per 100,000 populations served by hospitals catchment area for acute psychotic conditions and schizophrenia respectively (MOH, 2002). It has been also documented that less than 10% of persons with mental health problems receive treatment in mental hospitals and only 1.5% maintain follow-up treatment over a period of one year (MOH, 2001). Utilization of mental health services is however affected by many interacting factors such as individual, help seeking preferences, access, availability and referral practices (Saunders & Browersox, 2007). Mental hospitals in Malawi are urban based. Individuals do not seek mental health services due to health system and cost factors (Nuhu et al., 2010). This service gap is often filled by traditional, spiritual, faith healing and complementary medicine (Adewuya et al., 2006; Gureje et al., 2006; Kabir, Iliyasu, Abubakar, & Aliyu, 2004). Recognizing the seriousness of the mental health problems, the Malawi government launched its ever mental health policy in 2001. This was in ratification to the Alma Ata Declaration for primary health care in order to direct mental health program development. The aim was to provide comprehensive and accessible mental health care to the citizens of Malawi, through the existing primary health care system. By the end of 2004, when a new program cycle was to be started after evaluation of the existing policy, it was noted that most crucial target activities from the mental health policy, still remained undone. The accessibility of mental health services in public mental hospitals still remains a problem. Wandering persons with mental health problems are rampant on streets of Malawi. There could be still some barriers to utilization of mental health services. Studies on utilization of mental health services have been done in other countries (Uys & Jack-Ide, 2012). There was no documented research study that looked at barriers to utilization of mental health services in Malawi. Therefore, this qualitative study provides knowledge on barriers to utilization of mental health services at facility level in Malawi. It was against this background that this exploratory descriptive study was conducted with the purpose of exploring barriers that affect utilization of mental health services at facility level in Malawi. Specifically this study aimed at describing: (1) factors that affect utilization of mental health services in a mental hospital from the health care providers’ perspective. (2) Describing barriers to utilization of mental health services in a mental health hospital as perceived by caregivers of mentally ill clients. This current study was guided by the following research question. What are the factors that affect the utilization of mental health services at facility level in Malawi? The researchers employed the conceptual framework for exploring factors affecting the utilization of mental health services at facility and community levels in Malawi (Abdelgadir, 2012). See Fig. 1. The above conceptual framework was based on different potential factors that were thought to affect mental health service utilization. These factors
2. Methods 2.1. Study design and context This current study employed qualitative exploratory descriptive research design because little was known on factors affecting utilization of mental health services in Malawi (Burns & Grooves, 2005). The study was conducted at Zomba mental hospital which is the major referral mental hospital in Malawi. The common mental disorders that are treated at Zomba mental Hospital are schizophrenia, mania, substance abuse, affective disorders and anxiety disorders. Currently there is no psychiatrist at Zomba mental hospital. However there are 5 psychiatric clinical officers and 11 state registered mental health nurses. 2.2. Participants Twelve participants were recruited for the qualitative study, among them (n=6) were health care providers working at Zomba mental hospital, and (n=6) caregivers who came to the hospital to collect medications for their relatives. Among the health care providers, three were women and three men. They had between 4−18 years of working experience as clinical officers, and as nurses, in a mental hospital respectively. For the caregivers, 5 participants were men and only one was a woman. All of them came from the rural areas (see Tables 3 and 4). 2.3. Sampling In this study, purposeful sampling method was used to recruit health care providers. In particular the researcher used criterion strategy to recruit the health care providers. Health care providers were those who had worked at Zomba mental hospital for more than 6 months and who were willing to participate in the study. Snowball strategy was appropriate to recruit caregivers because of difficulties in obtaining this category of participants. Caregivers were those who had accompanied their sick relatives in outpatient clinic to seek mental health services at Zomba mental health hospital for more than 1 year. In snowball sampling the researcher identified one caregiver, who was then asked to provide names of other caregivers known to him/her. The identified participant was then approached by the researcher and requested to participate in the study. Written consent was mandatory for enrollment for the study. The sample size for qualitative research was not predetermined and therefore sampling was done until saturation, when no new data emerged, but previously collected data were repeatedly reintroduced (Polit & Beck, 2010). Guest, Bunce, & Johnson (2006), states that data saturation has “become the gold standard by which purposive sample sizes are determined in health science research” and they suggest that data saturation can occur after 12 interviews. According to these authors, smaller sample sizes can be sufficient in providing complete and accurate information within a particular cultural context, 53
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
Fig. 1. Conceptual framework of the potential factors affecting m mental Health Service Utilization at facility and community levels in Malawi adopted from (Abdelgadir, 2012) and modified by 2014).
interviews were read and re-read to allow the researchers to familiarise with the data. This strategy meets Lincoln and Guba's 1985 as cited in Polit and Beck (2010), requirement of data immersion being an inductive rather than deductive activity that requires repeated exposure to and engagement with the data. Immersion in the data enabled the researcher to see how the participants’ perceived factors and barriers that affect utilization of mental health services. It also allowed the researchers to fully comprehend how insights were grounded in and developed from the data with the emphasis on understanding participants’ experiences through their descriptions Polit and Beck (2010); Bogdan and Taylor (1984). The researchers read each transcript as a whole while listening to the audiotape to gain a sense of the participant's entire story and to reflect on comments, phrases and any associated vocal qualities that stood out. Patterns and themes that emerged from the data were noted and highlighted in different colours and ideas and thoughts were noted next to particular parts of the text in order to clearly track the researcher's emerging observations about the data, rather than searching for instances that reflected a previous theoretical position (Lincoln and Guba 1985 cited in Polit and Beck, 2010); Bogdan & Taylor, 1984). Key terms or phrases together with the corresponding text that illustrated the key terms and phrases were highlighted and then assigned a code Bogdan and Biklen (2007). Transcripts and codes were discussed by the research team and reviewed accordingly. The results of the preliminary coding by the researcher and supervisor were then compared and any differences discussed until consensus was reached. Coded concepts from each transcript were identified and Sub-themes derived from the codes. Nine sub-themes were identified from the health care providers’ (See Table 1) and eight sub-themes from caregivers’ (See Table 2). The data was then re-examined with the research objectives and aim in mind. Major theme headings were identified to develop the overall story of the participant's perceptions on factors and barriers that affect utilization of mental health services in Malawi.
as long as participants possess a certain degree of expertise about the domain of inquiry. It is argued that these experiences contribute to the participants’ sense of reality and “truth” (Guest et al., 2006). After the 12th interview there was no new information that was emerging. Therefore, the researcher recruited twelve participants in this study. 2.4. Data collection Data were collected using a semi structured interview guide. The guides had nine open ended questions for the health care providers (see Appendix A) and four open ended questions for caregivers (see Appendix B). Interviews were done in two categories, health care providers and caregivers. Semi structured interview guide was prepared and revised during the course of data collection. It included topics and probing questions on perception of utilization of mental health services at Zomba mental hospital. Interviews with health care providers were moderated in English language as most of them were able to communicate fluently and that of caregivers were conducted in “Chichewa” a national vernacular language for Malawi. 2.5. Data analysis In exploring barriers to utilization of mental health services in Malawi, thematic analytic steps of Aronson (1994) and Bogdan and Biklen (2007) guided analysis of data. The transcribed data and written file notes made by the researcher following each interview provided the means to begin exploring the data obtained. These reflections resulted in refinements to the interview schedule during the first two health care providers’ interviews. Each interview was conducted by the researcher and then transcribed. This approach of re-reading the transcript allowed the researcher to view the preliminary data and highlight any initial ideas as they became evident. Importantly, it also enabled the exploration of other issues that may not have initially been considered central to the research question (Grbich, 2007). The transcribed
54
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
Committee of Malawi (NHSRCM) (Ref. no NHSRC1259). Following approval, permission to conduct the study was also sought from the Director of Zomba mental hospital. Health care providers and caregivers who participated in this study were explained of the aim of the study. Participants were also informed that participation was voluntary, anonymity was guaranteed as their names did not appear in the report and that they were at liberty to withdrawal or cancel their participation at any time even after they had signed the consent form. Further, participants were made clear that they were not to receive any remuneration for participating in the study. All participants who agreed to take part in this study signed an informed consent. Special permission was obtained from participants on the use of audio recorder.
Table 1 Themes and sub-themes on factors affecting utilization of mental health services health care providers’ perspective. Theme
Subthemes
Hospital based factors affecting utilization of mental health services
Inadequate skills by health care workers Inadequate trained mental health professional in a mental hospital Negative attitudes of health care providers Stigma and discrimination Unavailability of antipsychotic drugs Lack of mental health policy
Non hospital related factors affecting utilization of mental health services
Lack of mental health services in the community Lack of knowledge on mental health problems by the community Inadequate funding by the ministry of health
3. Results 3.1. Factors affecting utilization of mental health services at Zomba mental hospital: Perspectives of Health care providers Under this theme there were a number of issues that come into view as subthemes from the health care providers’ accounts. Direct quotes from the participants are italicized. These factors are both hospital based and non-hospital related factors and are described below.
Table 2 Themes and subthemes on barriers to utilization of mental health services from care givers perspective. Theme
Subthemes
Practical barriers
Poor knowledge on mental health services Inadequate mental health services Long waiting time
Financial constraints
Long distance/ transportation high cost of services loss of productive income
Cultural factors
4. Hospital based factors 4.1. Inadequate trained mental health professionals Shortage of skilled mental health professionals was reported as a factor that affected utilization of mental health services at Zomba mental hospital. This inadequacy of mental health professionals hinders the delivery of quality mental health services. This was learned from health care provider 4 who said:
Stigma/ discrimination feeling of embarrassment
“currently this hospital has only four registered mental health nurses for the entire hospital” of course there are other general nurses but they don’t have enough knowledge on mental health, so they are not able to provide the necessary care to the clients”, “and also we do not have a psychiatrist, psychologist, mental health social worker, so there is no multidisciplinary approach care so it becomes a challenge to manage the patients”.
2.6. Strategies that the researcher applied to enhance trustworthiness The researcher engaged both the health care providers and caregivers in a discussion in such a way that they were motivated to give their inputs spontaneously and enthusiastically. This face to face interview was verified by means of triangulation which is one of the strategies used to enhance the trustworthiness of any research. The health care providers proceeded to discuss the facts that constituted the truth and various means that one can use to minimize or eliminate bias (Polit & Beck, 2010). The significance of this group was that it allowed the researcher to collect date from experienced and professional practitioners who were very different in their outlook because their experience, knowledge and wisdom from the caregivers who constituted the second interview. The health care providers discussed several barriers they encounter when providing the services to the mentally ill clients and their family members. Likewise the caretakers also discussed their views in regard to barriers to utilization of mental health services. During the discussion they contributed their inputs on how possible could the mental health services be made locally available in their communities.
4.2. Inadequate knowledge and skills by health care providers Health care providers acknowledged their inadequate knowledge and skills in assessing and managing mentally ill patients. As reported by health care provider 4: who said, “we lack knowledge and skills in managing some clients,” Even the referral system is not good, “What do I mean is that the health care providers from the general hospitals who refer clients to Zomba mental hospital do not have knowledge and skills to assess these clients as well”. 4.3. Stigma and discrimination
2.7. Ethical considerations Stigma and discrimination of mentally ill patients by the community as well as among health care workers managing these patients were reported to be common. As reported by health care provider 4:
In order to conform to the ethical and legal standards of a scientific research, ethical approval to conduct the study was sought from research and publications committee of Muhimbili University of Health and Allied Sciences (MUHAS) (Ref no, MU/PGS/SAEC/ VOL.IX/), and from the National Health Scientific Research
“stigma is very high, because we observe that most of the times, guardians don’t bring mentally ill patients to seek medical attention
55
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
but rather to leave them here (Zomba hospital), we have several situations where the guardians they even tell us, we have brought this patient and we want you to cut off the nerves” or just give him medication to reduce his strength”.
“You know there is no current mental health policy to be followed in the implementation of the planned procedures and activities in this hospital.
Stigma and discrimination has been reported to be an important contributing factor to the treatment gap. This prevents the affected individuals to receive care as well as leading to social exclusion. Stigma exists at all levels. Even health care providers working in a mental hospital are equally stigmatized by their fellow health care workers from general hospitals. This was also reported by health care provider 6 who said:
“We are lacking current mental health policy and that has to be integrated into the national health plan”.
Another health care provider 5 said:
5. Non Hospital related factors 5.1. Lack of mental health services in the community
“working in a mental hospital is also a source of stigma to us, and you are equally stigmatized by other health care providers from the general hospitals so this affects our morale”
Health care providers who were interviewed reported that at community level, the mental health services were not present. This meant that when people were sick are compelled to travel long distances to seek mental health services which are located in the urban. While there were mixed views on this area, health care providers felt that there was a need for fully integration of mental health services into primary health care to enable the people in the communities to easily access these services. Health care provider 4 illustrated that:
4.4. Negative attitudes of health care providers Negative attitudes of some health care providers at Zomba mental hospital was reported as another factor affecting utilization of mental health services by clients. This in turn negatively influence the quality of care rendered to persons with mental health problems. As reported by health care provider 2 who said:
“if mental health services were integrated into primary health care was going to improve service utilization, as the services will be closer to the people who need them and will therefore be cheaper, hence improving utilization of mental health services”.
“Even trained nurses, most of them have negative attitudes towards mentally ill clients, so this affects the care they render to patients”.
He continued to say that: “integrating mental health services into primary health care or in the communities was good; because at primary level a lot of people are seen, so if primary health care workers can be trained to recognize symptoms, then it will also lessen the burden on part of the guardian, because this institution (Zomba hospital) is very far”.
In addition, health care provider 6 said: “I think may be is the attitude that we have towards mental illness or towards people who have mental illness. I think most of the health professionals have a negative attitude, because why treating somebody who is behaving abnormally, inhumane; it is this attitude that also makes many families not to bring their patients here instead take them to traditional healers”.
Similarly health care provider 6 said this on lack of mental health services in the community. “Having mental health services in the community or integrating mental health services into primary health care was very important because it would help to reduce congestion in the ward”.
4.5. Unavailability of antipsychotic drugs
He further added:
Availability of antipsychotic drugs was pointed out by the health care providers who were interviewed to be erratic. Unavailability of antipsychotic drugs affects patient care as some clients who need antipsychotics may go without them and thus making their condition worse. From the health care providers account it was noted that this was a major challenge that affects delivery of care to the patients with mental health problems who utilize mental health services at Zomba mental hospital. As noted by health care provider 5 who reported this:
“it will be cheaper as the clients will be treated in their own communities so it will be very important by the end of the day”. “We also should not forget that when we treat people with mental disorders they do well when they are treated close to their homes or to their relatives”. Likewise, another health care provider felt that community psychiatric nurses were key in ensuring that mentally ill patients seek and receive adequate and continuous mental health services. He said:
“The other challenge has been erratic antipsychotic medication supply even though the situation has slightly improved recently. This problem is even worse in the district hospitals and health centers”.
“one of the factors that affect utilization of mental health services is lack of community psychiatric nurses who could be working in the community, We expect the client to be followed up to see whether is taking medication or is having side effects but this is not done” and he concluded by saying “we do not have community psychiatric nurses as a result it is difficult for the client to be followed up in the community”.
4.6. Outdated mental health policy The health care providers had the opinion that lack of current mental health policy was a critical factor that was affecting negatively utilization of mental health services. Mental health policy and plan is essential to coordinate all services and activities related to mental health. Without policies and plans, mental disorders are likely to be treated in an inefficient and fragmented manner. Heath care provider 1 reported this:
5.2. Lack of knowledge on mental health problems by the community Participants had the view that lack of knowledge on mental health problems by the community was one of the factors that affect
56
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
services mentioned by the caregivers were practical, financial and cultural barriers (See Table 3). Direct participants quotes are italicized (Table 4).
Table 3 Socio Demographic details of Health Care Providers who participated in the study. Health Care Providers No
Age
Sex
Education preparation
Work Experience
HCP 1
49 years
Female
4 years
HCP 2
45 years
Female
HCP HCP HCP HCP
53 30 53 37
Female Male Male Male
Bsc Mental Health Psychiatric Nursing Bsc Mental Health Psychiatric Nursing Cert in psychiatry Bsc in clinical Psychiatry Diploma in Psychiatry Bsc in clinical Psychiatry
3 4 5 6
years years years years
5.5. Practical barriers The factors relating to practical barriers to mental health services utilization consisted of the awareness about mental illness and the ability to access mental health services with three sub-themes which emerged namely; poor knowledge of mental health services, inadequate mental health services and long waiting time.
18 years 21 years 5 years 18 year 5 years
5.6. Poor knowledge of mental health services Caregivers who were interviewed expressed that poor knowledge of available mental health services, and the mental illness itself and uncertainty where to go for treatment being reasons for not seeking the needed care as quickly as possible. As it was noted by one caregiver 3 who said:
Key HCP= Health care provider
utilization of mental health services in Malawi. It was reported by health care provider 2 that: “the community does not have knowledge about mental illness as a result they believe in their cultural beliefs and they take their relative to the traditional healer instead of taking them to the hospital”.
“ for example when my child was sick, I did not know that it was mental illness all what I thought was malaria and I went to the traditional healer then to the general hospital where after the doctors examined my child they sent me to this mental hospital”.
Likewise health care provider 6 pointed out that: “due to lack of knowledge these people report to the hospital with their patients in a very bad state and upon asking the relatives they will tell you that we have delayed to come here or were trying native herbs or we were at the traditional healer”.
5.7. Inadequate Mental Health Services Caregivers observed that in most areas where they stay there were no drugs for their clients. This was pointed out by almost all caregivers. Caregivers had these to share:
5.3. Inadequate funding by the Ministry of health
“I have come here; because where I stay the government does not offer us with the adequate drugs”. “In my area, there is no hospital and this is a very big problem for the people in this Area. The government should consider building a hospital in this area as people are suffering not only from mental illness but even other physical illness as they travel long distances to seek for treatment, while others do not afford and continue to suffer there”.
Another factor that hindered utilization of mental health services in Malawi was in adequate funding to mental health department. In the current study it was reported by the majority of the respondents that mental health services were not adequately funded by the government as a result it makes the services to be compromised. Health care provider 4 observed this: “in the first place mental health is a neglected field in our situation, the budget that comes to mental health is not enough; previously, we could have only 2% of the total budget, which needs to be desired”.
5.8. Waiting time Long waiting time for mental health services at the mental hospital was raised as a significant issue by the caregivers. One caregiver 6 complained that:
5.4. Barriers to utilization of mental health services: caregivers’ perspective
“I left home around 5 am with the aim that I should go back early, but until this time 8:30 am I have not been assisted. I feel the health care providers are not attending to us as it is expected”.
Three major themes on barriers to utilization of mental health Table 4 Socio demographic details of caregivers who participated in the study.
5.9. Financial constraints Long distance to the health facility and lack of transport, and cost associated with transportation were reported by participant as barriers to utilization of mental health services. Caregivers mentioned that the long distance to the hospital was costly, and that lack of money for transport to the hospital meant that they could not always access the needed services. One caregiver 2 reported that:
Caregivers No Caregiver Caregiver Caregiver Caregiver Caregiver Caregiver
1 2 3 4 5 6
Age
Sex
Occupation
47 22 51 51 22 39
Female Male Male Male Male Male
Farmer Teacher Farmer Primary Teacher Student Farmer
years years years years years years
“it is 130 km from home to the hospital and it is not possible to come with the client”. “Sometimes these clients need to be seen by the doctors and that is not possible because of money difficulties”.
57
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
should be made available at primary health care level. This accessibility is also implicated by long distances and financial constraints. This confirms to Kishore Kumar et al. (2005), in their study in India which showed that distance travelled to access the services was a barrier as a result the family could not sustain treatment. This is also true in Malawian setting whereby many families could not afford to find money for transport to the mental hospitals that are urban based, as a result clients default treatment and eventually relapse. Another finding that was uncovered in this study was lack of knowledge on mental illness by the communities which is also associated with access to mental health services. As reported by one participant in this study, that most of the communities lack knowledge on mental health and mental illness as well as where to get the mental health services. Research in other developing countries shows increasing public understanding of mental health conditions and awareness that effective treatment is available and is important. Gureje and Alem (2000) argue that public education on mental health and mental illness should be given importance by policies so as to support affected clients and their families. It is therefore, necessary for people in Malawi to be aware about what services are available and what can be expected from them as well as know when to seek profession help. Similarly, Aida et al. (2010) in their study on barriers to utilization of primary care services for mental health problems among adolescents in a secondary school in Malaysia, observed similar findings that learners were not aware of the services availability in the primary health care. Therefore, active community education programs could be vital to improve knowledge of mental disorders and available resources. Consequently, lack of knowledge about mental illness and its treatment could prevent people with mental health problems to seek help early for their mental health problems. Interestingly it was also found out that there was no mental health policy to guide the implementation of mental health services. It suffices to say that without a policy and plans the provision of the services could be fragmented. It meant that clients could not access the quality mental health care services they need. This finding reflects Jenkins (2003), findings who observed that both in low and middle income countries, the health policy focus towards communicable diseases that cause high morbidity and mortality rates. This in turn has contributed to a lack of attention from policy makers and the public; in turn leading to a lack of resources and poor staff morale in mental health. This could be the case in Malawian mental health system. Human resources are the most valuable asset of a mental health service. Such a service relies on the competence and motivation of its personnel to promote mental health, prevent disorders and provide care for people with mental health problems (WHO, 2005). Yet, in most developing countries in Africa the major challenges in delivery of mental health services is lack of trained mental health professionals (WHO, 2005). Likewise, in this study it was found that one of the barriers to utilization of mental health services was inadequate trained mental health professionals. In the absence of trained mental health professionals it is likely that patients with mental health problems would not get the necessary mental health services. This finding is supported by Sadovoy et al. (2004), who found that the key barrier to adequate care included inadequate numbers of trained and acceptable mental health workers. If the government of Malawi through the ministry of health could train more mental health professionals, they will be able to assist in the identification, management and prevention of mental illness at all levels of care. The study also revealed that the health care workers had inadequate knowledge and skills. When health care providers, lack knowledge and skills, it affects service delivery as most common mental disorders are
Caregivers felt that where the services require them to pay it is hard: “to find money to pay for the services at the private clinic is not easy”. Therefore one caregiver suggested that mental health services should be solely free particularly for the poor from the villages in order to combat the burden of the illness on their families. Some caregivers reported that coming to the hospital to get the drugs for the client, meant that they have abandon their work, which resulted in loss of income. One caregiver 5 indicated that: “today I did not go to school because I had to come here to collect the drugs for my brother”.
5.10. Cultural factors In the current study two issues concerning cultural was observed, that affect utilization of mental health services in Malawi. 5.11. Stigma/discrimination Participants observed that stigma due to some beliefs prevent them from seeking mental health services from the hospital. Many families with clients with mental health problems are given all sorts of names by other members of the community because of their relative who is sick mentally. One caregiver 4 reported that: “Even clients are stigmatized and discriminated by their relatives as they do not want to come to collect the drugs for their patient. Is that fair”? Feeling of embarrassment Caregivers held a view that feeling of shame of being seen in the mental hospital as being one main barrier to accessing mental health services. Mental hospitals were regarded to be places for those people who are mad; and therefore not ideal place for receiving treatment. Caregiver 1 observed that the fear of being seen by friends and neighbors makes many patients opt out of treatment. This was leant from caregiver 1 who said: “Like my son stopped taking the medication because I feel he is ashamed of by his friends”. 6. Discussion Good mental health care is significant for the entire population and in particular for the affected individuals. In order to achieve this optimal level of service the mental health services should be utilized effectively. According to the findings of this study; lack of mental health services in the community was observed to be outstanding as far as utilization of mental health services is concerned. The unavailability of mental health services in rural areas has made many families to use whatever might be present in their communities. Mwape et al. (2011) asserts that integrating mental health services into primary health care as a way of facilitating early identification and intervention for mental disorders is crucial to improving and promoting the mental health of the population. However in Malawi this is not the case as the mental health services have not been fully integrated into primary health care to enable clients’ access mental health services. As such families with their relatives have to travel to the urban to look for the mental health services. Therefore, if mental health services are to genuinely prioritize wellbeing and prevention of mental health problems then services
58
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
7. Limitations and strength
undetected and untreated. Farroq (2013), holds a view, that a public health approach to mental health care, including integration with primary health care system, as well as including integrated care of mental illness along with care of other non-communicable disorders is essential. Further, Kagee et al. (2013), argue that treatment gap is not only a function of poor health systems and access to treatment but also of the poor detection of common mental disorders. Additionally, the study revealed that there were no antipsychotics in the mental hospital as well as in most districts and health centers. This unavailability of drugs meant that the affected clients could not get the needed treatment. Shortage of antipsychotic drugs could be due to the fact that mental health services were not given priority, evidenced by 1.5% budget allocation to mental health department. If mental health policy and plans were available and being implemented the shortage of antipsychotic drugs could be minimized, as the policy would guide the policy makers to budget enough money to purchase the drugs. Mental health services are widely underfunded, especially in developing countries (WHO, 2005). Expenditure on mental health amounts to under 1% of the health budgets in 62% of developing countries and 16% of developed countries. Thus a significant discrepancy exists between the burden of mental disorders and the resources dedicated to mental health services. Similarly, in this study it was found that the mental health services at Zomba mental hospital were inadequately funded. Therefore, without adequate financing, mental health policies and plans remain in the realm of rhetoric and good intentions. As such the affected individual would likely not get the mental health services that they ought to have. An important contributing factor to the treatment gap is the extent to which mental illness is stigmatized, a leading significant barrier to accessing care (Thorncroft et al., 2009). Stigma occurs at different levels of the society. In this study, the participants acknowledged high degree of stigma and discrimination not only in the communities but also among some mental health professionals. This in turn negatively affects the quality of care provided to persons with mental health problems. This finding is supported by Kapungwe et al. (2011), findings in their study conducted in Zambia on health care workers attitudes towards the mentally ill clients. They had uncovered that there was very high level of stigma among the health care workers towards the mentally ill clients. Hence, there is dire need for the public to change their attitude towards mental health problems. Fear of stigma/ discrimination was an important reason for not seeking or continuing treatment; due to fear of what others may think, thereby preventing many clients from sustaining their treatment. This was evident in this study. The experience associated with stigma /discrimination negatively impacted on their social wellbeing, resulting in families not coming to the hospital to take the drugs for their ill relatives, hence affecting their wish to look for appropriate mental health care. It is important therefore, for the society in Malawi to appreciate how stigma impact on people with mental health problems and need for change in public attitude. Negative attitudes by health care providers and the related concept of stigma have a substantial impact on the care of people with mental health problems. It was expected that mental health professionals could have positive attitudes towards people with mental health problems than other health professionals and lay persons. This was contrary to the findings of this study as stigma was eminent from the community and among the mental health professionals. This finding is supported by Birch et al. (2005) who found that health care providers who have a role in treatment and support of the mentally ill share the same stigmatizing attitudes as the public which affects the quality of care these professionals provide. It would appear, then, that theoretical education and contact with people with mental health problems in the usual psychiatry setting are not enough to reduce stigma in health care providers (Arboleda-Florez & Satorius, 2008).
The researcher is a mental health qualified nurse as such this research is credible as this was carried out with all the authority of mental health in Malawi. However, one of the limitations was of subjectivity and potential bias regarding researcher's own involvement in this study first as a student and currently as mental health nurse profession. A related limitation was that, health care providers’ interviewees may have had difficulty, adjusting to the researcher taking on the role of interviewer, a phenomenon referred to by Maxwell (1996), as participant reactivity. Because a few health care providers knew the researcher, their responses may have been influenced or affected. They may have tried overly hard to cooperate with the researcher by offering him responses they perceived he was seeking or which they perceived might be helpful to him. The study was conducted at one facility. Therefore, transferability was limited, but as a first study in Malawi, the findings could have the implications that could influence both subsequent research, practice and policy innovations for care. Lastly, the policy makers were not involved in this study due to political factors that were beyond the researchers control at the time this research was being conducted. The policy makers would be ideal to inform the researcher on policy issues that guide the implementation of mental health services in Malawi.
8. Recommendations 8.1. Nursing research Since this study was conducted at one government mental hospital, it is recommended that another study should be conducted on a large scale to assess the views of the general public on utilization of mental services in Malawi.
8.2. Nursing practice It is further recommended that the mental health policy and plans have to be revised in order to guide the implementation and evaluation of mental health services in Malawi and it has to be periodically revised. Furthermore, social education needs to be done for people to overcome cultural barriers that affect those with mental health problems and highlights the need to change in public attitude to support help seeking behavior.
8.3. Nursing education Since shortage and knowledge gap were identified in this study, it is further recommended that the government of Malawi through the ministry of health should strive to train more mental health professionals with positive attitudes who would deliver the quality mental health services to the Malawian population.
9. Conclusion Successful utilization of mental health services need to be supported by enough resourced and staffed facilities that promote good health seeking behavior and continued treatment and community follow-up. Therefore, providing mental health services, locally and affordably throughout the health care system, will allow persons with mental health problems live productive and enjoyable lives. 59
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
Appendix A. Semi-structured interview guide for health care providers on barriers to utilization of mental health services at facility level
.
60
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
Appendix B. Semi-structured interview schedule for caregivers on barriers to utilization of mental health services at facility level
References Foldemo, A., Gullberg, M., AC, E. K., & Bogren, L. (2005). Quality of life and burden in parents of outpatients with schizophrenia. Social Psychiatry Epidemiology, 40(2), 133–138. Grbich, C. (2007). Qualitative data analysis. An introduction Los Angeles: SAGE Publications. Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are enough? An experiment with data saturation and variability [electronic version]. Field Methods, 59–82. Gureje, O., & Alem, A. (2000). Mental health policy development in Africa, 78. Bull World Health Organ, 475–482 (PubMed |Google Scholar). Gureje, O., Lasebikan, V. O., Ephraim-Oluwanuga, O., Oley, O. B., & Kola, L. (2006). Community Study of Knowledge and Attitudes of Mental Illness in Nigeria. British Journal of Psychiatry, 186, 436–441. Herzig, H. (2003). Teaching psychiatry in poor countries: Priorities and needs. A Description of how mental health is taught to medical students in Malawi, Central Africa. Education for Health, 16(1), 32–39. Jenkins, R. (2003). Supporting governments to adopt mental health policies. World Psychiatry, 2, 14–19. Kagee, A., Tsai, A. C., Lund, C. et al. (2013). Screening for common mental disorders in low resource settings: Reasons for caution and a way forward. International Journal of Health, 11–14.
Adewuya, A., Ola, B., Mosaku, S., Fatoye, F., & Eegunranti, A. (2006). Attitude towards antipsychotic among out-patients with schizophrenia in Nigeria. Acta Psychiatrica Scandinavica, 3, 207–211. Arboleda-Florez, J., & Sartirius, N. (2008). Understanding the stigma of mental illness: theories and interventions. John Wiley and Sons Ltd. Bandawe, R. C. (2010). Gap analysis for the national health research agenda of Malawi: research priorities for the theme of mental health Malawi: Lilongwe. Birch, S., Lavender, T., & Cupitt, C. (2005). The physical health care experience of women With mental health problems: Status vs Stigma. Journal of Mental Health. Bogdan, R., & Taylor, S. J. (1984). Qualitative research for education: An introduction to theory and methods Boston: Allyn and Bacon. Bogdan, R. C., & Biklen, S. K. (2007). Qualitative research for education. An introduction to theories and methods (5th ed.) Boston: Allyn Bacon. Burns, N., & Grove, S. K. (2005). The practice of nursing research: conduct, critique and utilization (5th ed.) Philadelphia: Elsevier Saunders. Cuijpers, P., & Stam, H. (2003). Burnout among relatives of psychiatric patients attending psychoeducational support groups. Psychiatric Services, 51(3), 375–379. Farroq, S. (2013). Collaborative care for depression: a literature review and model for implementation in developing countries. International Mental Health, 5, 24–25.
61
Mental Health & Prevention 5 (2017) 52–62
O.G. Mwale, L.T. Mselle
Saunders, S., & Browersox, N. (2007). The process of seeking treatment for mental health problems. Mental Health and Learning Disabilities Research and Practice, 4(2), 99–123. Uys, l, & Jack-Ide, I. O. (2012). barriers to mental health services utilization in the niger delta region of Nigeria service users’ perspective. Pan African Medical Journal, 14, 159. http://dx.doi.org/10.11604/panj.2013.14.159.1970. World Health Organization (2002). The world health report 2002: Reducing risks, promoting healthy life Geneva: World Health Organization. World Health Organization (2005). Mental health atlas Geneva: World Health Organization, 2005. World Health Organization (2005). Promoting mental health: concept, emerging evidence, practice: Report of the World Health Organization, Dept of Mental Health and Substance Abuse in collaboration with Victorian Health Promotion Foundation and the University of Melbourne. Geneva. World Health Organization. World Health Organization (2000). Mental health: new understanding, new hope Geneva: World Health Organization (World Health Report (1020-3311)).
Lopez, D. A., Mathers, D. C., Ezzati, M., Jamison, D., & Murray, JL. C. (2006). Global burden of disease and risk factors New York: Oxford university press and Washington DC: The World Bank. Maclachlan, M. (1993). Mental health in Malawi. Which way forward. Journal of Mental Health, 2, 3. Mathers, C. D., & Loncar, D. (2006). Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med., 3, e442. Maxwell, J. A. (1996). Qualitative research design: An interactive approach (2nd ed.) Thousand Oaks, CA: Sage. MOH (2002). National Mental Health Policy. Republic of Malawi. Lilongwe. Malawi. MOH (2001). National Mental Health Policy. Republic of Malawi. Lilongwe, Malawi. MOH (2012). The Malawi Human Rights Commission Report. Republic of Malawi Lilongwe. Malawi. Mwape et al. (2011). Attitudes of Primary Health Care Providers towards people with mental illness. Africa Journal of Psychiatr, 14, 290–297. Polit, F. D, Beck, T. C., 2010. Essentials of Nursing Research. Appraising evidence for Nursing Practice. 7th Edition. Lippincott: William Wilkins.
62