Community perception towards mental health problems in Ethiopia: a mixed-method narrative synthesis | BMC Psychiatry
Summary of findings
The initial search yielded 11,335 records, of which 6270 were identified as duplicates. After screening the titles and abstracts of the remaining 5065 records, we eliminated 4997 records that did not appear to contain relevant information for this review, conference papers, and reviews that did not report original data. Among 49 records, 17 of them were included after full text screening (Fig. 2). Five qualitative [19, 21, 23, 37, 38] (Table 1) and twelve quantitative studies were included in the review [16, 22, 39,40,41,42,43,44,45,46,47,48] (Table 2).
Narrative synthesis
Domain 1: perceptions of the causes of mental health problems
Sixteen out of seventeen included studies discussed the participants’ perceived causes of mental health problems, which can be classified under three themes: spiritual, socio-economic, and biochemical factors.
Theme 1(supernatural agents)
Participants from sixteen studies mentioned supernatural agents like God’s punishment for sinful people, the acts of evil spirits, and the works of witchcraft (an individual who uses evil spirits to harm targeted individuals) as the causes of mental health problems. The findings from twelve studies attribute the causes of MHPs to God’s punishment [16, 19, 21,22,23, 38,39,40, 44, 45, 47, 48]. The findings from six studies attribute MHPs to the acts of evil spirits [16, 19, 22, 23, 39, 47]. In addition, the result from three studies shows the causes of MHPs as the works of witchcraft (locally called “Tenkoay, Debtera, or Metsihaf Gelach, and Mora”) [16, 19, 38], curses from elders [38, 44] and the results from one study attribute it to evil eye(locally called “Buda”) [21] (Suppl. file 4).
“Living against God’s law, engaging in evil deeds, and disobeying his commands and his teachings all of this, as communicated by religious preachers, can lead to mental illness.” FGDs-farmer, 33 years old, rural; Kasa and Kaba, p. 563.
Theme 2 (socio-economic factors)
Another perceived cause of MHPs among study participants was socio-economic factors like financial scarcity due to poverty, daily distress due to a poor work environment, lack of jobs, etc., which were mentioned in thirteen studies. The findings from four [19, 22, 38, 44] studies present traumatic events like disaster problems, displacement, war, rape, kidnapping, sudden loss of possession, loss of loved ones, and physical injury that can cause MHPs. Daily stress and overthinking were mentioned as causes of MHPs in seven studies [16, 19, 21, 23, 38, 39, 44]. In addition, causes of mental health problems were attributed to low social relationships in six studies [15, 19, 21, 22, 38, 44], poverty in seven studies [19, 21,22,23, 43, 44, 48], childhood abuse and neglect in five studies [19, 22, 38, 43, 44], too much education or knowledge in two [19, 44] studies, and a poor living environment in two [21, 43] studies (Suppl. file 4).
“….Poverty exposes people to too much work time and too much thinking which is the main cause of mental illnesses’’ FGD participant; Yeshanew et al. 2020, p. 8.
Theme 3 (biochemical factors)
In fourteen studies, biochemical factors, which comprise hereditary diseases, physical illnesses, substance abuse, and too much knowledge, were mentioned as causes of MHPs. Particularly, participants from four studies [19, 21, 43, 48] show MHPs as hereditary diseases, and participants from eight studies [15, 16, 22, 39, 43, 44, 47, 48] attribute it to physical illnesses. In addition, participants from eight studies [16, 19, 22, 23, 39, 42, 43, 48] mentioned substance abuse as a cause of mental health problems (Suppl. file 4).
“it is obvious to happen mental health problems on the children when there is problem in the parents during the stages in the life time because, the father harvested what he sowed in the ground”. Interview participant; Kahsay W. Hailemariam, p. 38.
Domain 2: community’s perceptions on the identification of MHPs
We have categorized the study participants’ perceptions of the identification of people with MHPs into two themes (overt and covert symptoms). Overt behavior is directly observable behavior by the observer, while covert behavior is those that can only be inferred by the observer or reported by the exhibiting person.
Theme 1(overt behaviors)
The participants from seven studies [19, 23, 37,38,39,40, 48] mentioned overt behaviors that attract public attention, like talking and laughing alone, showing unusual behavior, talkativeness, aggression, restlessness, convulsions, etc. In such a context, a person who has no drive or courage to display symptoms in public will most probably not be identified as a mentally ill person (Suppl. File 4).
Theme 2 (Covert behaviors)
In addition to overt behaviors, participants from four studies [38, 40, 42, 48] mentioned covert behaviors like hopelessness, self-neglect, suicidal ideation, poor appetite, etc. as symptoms of MHPs. This helps to identify people with MHPs at an early level before they are exposed to the public or develop observable unusual behaviors (Suppl. File 4).
Domain 3: Community’s perception of the severity of MHPs
The public’s perception of the severity of mental health problems shows a variation among types of mental health problems. Participants’ perceptions of the severity of mental health problems from ten studies were categorized into three themes: threats to health, curability, and impacts on quality of life.
Theme 1 (threats on health)
The findings from five studies [15, 16, 39, 41, 47] explained that participants perceive MHPs as severe disorders. A majority of study participants from three studies [15, 16, 39] explained schizophrenia as the most serious problem, followed by depressive disorder and anxiety disorder(Suppl. file 4).
Theme 2 (curability)
The findings from three studies [40, 41, 48] show that the proportion of respondents who perceive MHPs as treatable is higher than that of those who perceive them as untreatable (Suppl. 4).
Theme 3 (impacts on quality of life)
Regarding the consequences of MHPs on quality of life, findings from four studies [37, 41, 45, 47] show that participants perceive that MHPs can have long-term effects on work opportunities, marital prospects, the chance for education, and living with people in one house or as neighbors. Particularly, the findings from two studies [45, 47] show MHPs can result in embarrassment for the family of a mentally ill person. However, the finding from one study [40] shows that nearly half of respondents perceive that people with depression can function fairly in society if treated and medicated (Suppl. file 4).
Domain 4: community perceptions of treatment methods
The findings from most of the included studies show that participants’ preferences for treatment options were highly associated with their perceptions of the causes of MHPs. For instance, participants who have strong beliefs in the biochemical model of causes of mental illness opined on the effectiveness of modern medicine’s treatment. About three themes emerged from diverse perceptions of treatment options: modern medicine, supernatural agents and/or traditional treatment, and psychosocial support.
Theme 1 (modern medicine)
The finding from eight studies [15, 16, 19, 22, 39, 43, 45, 47] shows a majority of participants who have strong beliefs in the biochemical model of the causes of mental illness prefer modern medicine’s treatment options (Suppl. file 4). “Taking mentally ill people to magicians and sorcerers is duplicating the devil and it is good only to take them to the hospital”. A 25-years-old female radiographer; Yeshanew et al. 2020; p. 9. In another way, the findings from three studies [21, 23, 38] show that study participants have negative attitudes towards medical treatments. “Most patients seeking treatment at hospitals, including the Amanuel hospital, find it difficult to make significant progress, and most of them discontinue taking their prescribed drugs. Other problems include the adverse effects of the drugs recommended for mental illness, the lengthening of the appointment time as more drugs are taken, and the insufficient concern shown and given at this”. FGDs-Rural 42-years old Merchant; Kasa and Kaba, 2023; p.563).
Theme 2 (supernatural agents and/or traditional treatment)
The majority of participants from four studies [21, 23, 37, 38] who consider the causes of mental illness to be the result of supernatural powers prefer to seek help from supernatural agents like holy water sprinkling, fasting, praying in holy places, and consulting spiritual agents. A 43 years old, Self-employee urban resident explained this: “The best location for mental illness patients to receive care is by praying to God for assistance because anything is possible for him because he knows everything…” (Kasa and Kaba, 2023; p.563). In addition, the findings from nine studies [15, 39,40,41, 44, 45, 47, 48] show that traditional treatments like using traditional medicine, consulting sorcery, and using traditional healers were held by a significant proportion of the community (Suppl. file 4). A 29-year-old hotel receptionist supported the traditional saying as follows: “… I think the best and ultimate treatment of mental illness is taking to sorcerer unless the rest of the treatment methods are nothing. We took my brother to the hospital, holy water but nothing we get…”. (Yeshanew et al. 2020; p. 9)
Theme 3 (psychosocial support)
The findings from three studies [19, 40, 41] show that the majority of study participants perceive psychosocial support like establishing a good family, building marriage relationships, having enough economic resources, and getting professional help to forget traumatic life events as primarily preferable options. While findings from three studies [21, 22, 39] show psychosocial support is an alternative preferable treatment option following either modern medicine or spiritual/traditional treatment options(Suppl. file 4).
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