Mental Health National Communication Framework

January 2012 – January 2015

1 Table of Contents

2 List of Abbreviations

AIDS Acquired Immune Deficiency Syndrome ART Anti-Retroviral Therapy HEP Health Extension Professional HEW Health Extension Worker HIV Human Immunodeficiency Virus IPC/C Interpersonal Communication and Counseling skills mhGAP Mental Health Gap Action Program (WHO) M&E Monitoring and Evaluation MDG Millennium Development Goals FMoH Federal Ministry of Health NGO Non-Governmental Organization NIFMH National Initiative for Mental Health PEPFAR U.S. President’s Emergency Plan for AIDS Relief PITC Provider-Initiated Testing and Counseling PLHIV People Living with HIV PSA Public Service Announcement SWOT Strengths, Weaknesses, Opportunities and Threats WHO World Health Organization WrHO Woreda Health Office

3 Introduction and Background This framework is planned to contribute to the efforts being made in the World Health Organization’s Mental Health Gap Action Program (mhGAP). The framework will guide and coordinate all mental health communication efforts in the country.

This framework was developed in collaboration with key stakeholders including: the Federal Ministry of Health (FMoH), Amanuel Hospital, Addis Ababa University, The Ethiopian Orthodox Church, JHU Tsehai, I-Tech and JHU∙CCP. The framework materialized through a literature review and a framework development workshop that was held with key stakeholders. A draft of the framework was circulated among all who participated in the development discussions and workshops for review and input, which this document reflects.

The FMoH has embarked on a program to expand mental health services nationally. This will greatly improve accessibility and uptake of these services. This National Strategic Framework for Mental Health and Wellbeing Communication is designed to address behavioral and attitudinal barriers to maintaining good mental health, uptake of available services and adherence to initiated health care.

1.1. Mental Health in Ethiopia The High Burden of Mental Illness According to the World Health Organization (WHO), 14% of the burden of disease worldwide is attributed to mental health problems, of which 75% are in low-income countries. [28] It is estimated that approximately 450 million people worldwide have a mental health problem and 1 in 4 families worldwide is likely to have at least one member with a behavioral or mental health problem. [18]

Even though the majority of the burden of disease in Ethiopia is from communicable diseases, the prevalence of non-communicable diseases is escalating dramatically. The leading non-communicable disorders in Ethiopia are caused by mental illnesses, accounting for 11% of the total disease burden. Schizophrenia and depression are ranked in the ten most burdensome disorders, above even HIV/AIDS. [1]

Although these statistics are startling, they most likely do not capture the entire disease burden caused by mental illnesses in the country. It is probable that the actual figures are even higher; suggesting that mental illnesses are a major health concern and have not received adequate attention so far. [22]

4 Despite recent efforts to improve the quality and availability of mental health services, the coverage of services is still very low. There are only 40 psychiatrists for the whole of the Ethiopian population, which has now escalated to 80 million. [28] Currently only one in 10 of those severely affected by mental illnesses can receive the treatment they require. [22]

At present, only 1% of individuals with mental illnesses in rural Ethiopia access the necessary services and are adherent to mental health treatment. Of those who have ever accessed any form of health services, 9% are lost to follow up. The number of those who have never accessed services are unknown, but is estimated to be quite high. The major reasons for poor service uptake and poor adherence to treatment among mental health clients include: lack of available and accessible services, poverty, lack of knowledge about mental illnesses and excessive stigma and discrimination within communities. [15, 22]

Culture and Mental Health in Ethiopia Within the community, it is commonly believed that severe mental illnesses such as schizophrenia and bipolar disorder are caused by supernatural causes, for example by spirit possession, bewitchment or evil eye. This often results in affected individuals seeking help from religious and traditional healers, rather than from health facilities. [5] Such beliefs within communities often result in the marginalization of people with mental illnesses. [22, 23]

Other mental illnesses such as depression are not well recognized by individuals and the community, which makes it difficult to treat. [22]

Most Vulnerable Groups to Mental Illnesses in Ethiopia The table below displays a brief audience analysis of populations most at risk of mental illnesses:

People with severe Severe mental illness (SMI) refers to mental illnesses that are mental illness (SMI) persistent and debilitating, and require long-term interventions.

Treatment for persons with SMI has four goals: (1) reduce or eliminate symptoms, (2) maximize quality of life and adaptive functioning, (3) promote and maintain recovery from the debilitating effects of illness to the maximum extent possible, and (4) include education for persons with SMI and their families. Appropriate treatment will be provided for the care of persons with SMI based on best practices. People with substance Predominantly, the individuals who suffer from substance abuse abuse problems disorders are the youth and commercial sex workers in Ethiopia. It has been noted that those with substance abuse disorders

5 commonly also suffer with mental illnesses. [16, 2] Children and Adolescents Mental illnesses amongst children and adolescents are shockingly high in Ethiopia, and it is assumed that it is due to complications during pregnancy and childbirth. [21] Children with depressed parents have a 50% greater risk of developing depression themselves before the age of 20. [26] People living with HIV People living with HIV/AIDS are more prone to developing mental disorders such as depression and anxiety which, in turn, impair their immune function, reduce their quality of life and adherence to treatment and contribute significantly to their premature deaths. In Ethiopia, additionally, HIV and other opportunistic infections common amongst HIV positive individuals, as well as side effects of ARTs, can affect the brain and the nervous system, resulting in disorders like dementia. [22, 6] It should be noted that some individuals suffering from a mental illness, such as depression (possibly as a result of or exacerbated by being HIV+), may display riskier behavior or intentionally put themselves or others in risky situations or environments (fatalistic attitude). Women during More than one in ten pregnant women and one in 20 postnatal pregnancy and after women in Ethiopia suffer from undetected depression. Around child birth half of those affected by depression have thoughts of ending their life. In Ethiopia, perinatal mental disorders contribute to maternal morbidity, in terms of poorer health, increased disability and prolonged labor. [12] Perinatal mental disorders have also been shown to negatively impact on children’s health in Ethiopia, e.g. increasing episodes of diarrhea, interfering with initiation of breast-feeding and negatively affecting child cognitive and motor development. [21, 12] People in prisons People in prisons are highly prone to having mental illnesses. [4] This could be a result of overcrowding, various forms of violence, enforced solitude or conversely lack of privacy, lack of meaningful activity, isolation from social networks, insecurity about future prospects (work, relationships, etc), and inadequate health services - especially mental health services - in prisons. [22] Victims of violence and Victims of violence and abuse often also develop mental illnesses abuse due to the harshness of their experiences. Women who have been abused when they were children are likely to develop major depression in adulthood. [27] People with epilepsy It is estimated that approximately 25% of the patients receiving treatment at Amanuel Hospital are treated for epilepsy. Those suffering from epilepsy are traditionally believed to have a demonic possession and that their condition is contagious, making them a stigmatized and ostracized group. [22] Elderly Life expectancy in Ethiopia is increasing and more people are living into old ages. Although several non-governmental organizations are now providing services for the elderly mentally

6 ill in Addis Ababa, demand for mental health services by the elderly is very low and does not reflect the likely burden in the population. Studies from Ethiopia have shown that increasing age appears to be a risk factor for poorer mental health.

Mental Health Services There is one specialized psychiatric hospital in Addis Ababa, the Amanuel Specialized Mental Hospital. Additionally, psychiatric and substance abuse services are provided at St. Paul Hospital, Zewditu Hospital, and the Armed Forces Hospital, as well as in the prison and police services in Addis Ababa. Outside of Addis Ababa, mental health care is provided in Adama, Harar, Hawassa, Jimma and Mekelle. A new hospital is in the process of being built with anticipated completion date of 2012. [22]

The lack of high-level mental health professionals is being addressed through the Psychiatric Nurse Training Program, sponsored by the WHO, which has increased the number of trained psychiatric nurses in Ethiopia over the last 5 years. [22] Although these units have provide services in different parts of the country reducing the patient load in Addis Ababa, it is evident that the units are often weakened by high staff turnover and lack of opportunities for career progression. [3]

In the past 5 years, psychotropic medication availability has improved drastically; however, there are some inconsistencies in drug availability, accessibility and affordability throughout the country. [22]

Mental Health, a National Priority According to the National Mental Health Strategy (2011), mental health should be a national priority especially since it is an area that has been overlooked and relates directly and indirectly to a number of the Millennium Development Goals (MDG):

MDG 1 - To Eradicate Extreme Poverty and Hunger - This MDG associates very well with mental health. Poverty can both aggravate existing mental health problems and can increase the chances that people develop mental illnesses. It has been observed that many people diagnosed with mental illnesses such as depression, bipolar disorder, and schizophrenia in Ethiopia are unemployed either as a result of being unable to engage in work and take responsibilities, or because they are marginalized by the community due to their condition. [14, 15]

MDG 2 - To Achieve Universal Primary Education - This MDG is closely related to the mental health of children. Undetected and untreated mental illnesses increase the likelihood that children will drop out, under-perform and fail to register for school. [24, 25]

7 MDG 3 - To Promote Gender Equality and Empower Women - This MDG is also very closely related to mental illnesses. In Ethiopia, where gender violence is common, men who suffer from depression and substance abuse disorders are more likely to abuse their wives or partners.Women who have suffered abuse, especially if often, are at a high risk of developing mental illnesses like depression and anxiety. [7]

MDG 4 - To Reduce Child Mortality - This MDG is highly affected by the health and well-being of mothers. Child illnesses and mortality increase substantially if mothers have undetected and untreated mental illnesses. [8]

MDG 5 - To Improve Maternal Health - This MDG is also greatly affected by maternal mental health; especially since one in 20 women in Ethiopia is affected by depression after complications during childbirth. [12]

MDG 6 - To Combat HIV/AIDS, Malaria and other Diseases - Communicable diseases represent the leading cause of disease burden in countries like Ethiopia. However, such diseases have been noted to either cause additional health concerns, like mental illnesses, or intensify existing mental illnesses. It is estimated that a third of HIV positive people on antiretroviral therapy (ART) are suffering from undiagnosed mental illnesses. [13] The health of HIV positive people who also have mental illnesses is greatly affected as they tend not to adhere to their ARTs. [9] In general, individuals who suffer from mental illnesses are at high risk of contracting other communicable diseases as a result of their behavior being influenced by their mental illness. Lack of mental health services and stigma and discrimination towards people with mental illnesses also increases their vulnerability to acquiring HIV, malaria and other diseases. People with mental illness may often be targeted in violence and abuse, including sexual abuse and neglect. If stigma toward people with severe mental illness is strong in the community, including internalized stigma among those with severe mental illness, that creates a power dynamic that increases the power of the perpetrator and the vulnerability of the person with mental illness.

Scaling up treatment for mental illnesses will consequently improve the quality of life for individuals with mental illnesses and their caregivers, as well as decrease the mortality rate, as it is evident that the provision of psychiatric medications saves lives. Increasing the availability of services will also contribute to the eradication of stigma and discrimination. [23]

Political Commitment and Efforts Currently Being Made It is evident that there is very high political commitment to improving mental health care and increasing coverage of service availability. A Mental Health Technical Working Group has

8 been created with various key stakeholders and the aim of bringing the national health strategy into reality. [22]

The FMoH is currently planning a significant scale-up of mental health services in collaboration with mhGAP, whose aim is to scale up services for mental health, neurological and substance use disorders for low and middle income countries. [28]

The National Initiative for Mental Health (NIFMH) was established with the guidance and sponsorship of the First Lady, Azeb Mesfin, to guide the development of national mental health services in Ethiopia. NIFMH has initiated the construction of the new Gefersa Psychiatric Rehabilitation Hospital, a state of the art facility, which will be fully equipped to provide medical help to individuals and families seeking mental health services. [22]

The Psychiatric Nurse Training Program, sponsored by the WHO, has trained psychiatric nurses who provide services in established psychiatric units in various regional states. [3] These units receive technical support and mentoring from psychiatrists and senior psychiatric nurses from Addis Ababa. Amanuel Hospital also organizes various workshops annually, which provide opportunities for psychiatric nurses to discuss various case studies and share their experiences with each other. [22]

Alongside the Psychiatric Nurse Training Program, Addis Ababa University has additionally started a small postgraduate training in psychiatry and neurology for medical doctors. Furthermore, in a collaborative agreement between the JHU-Tsehai project and Amanuel Hospital, a training curriculum has been developed and pilot tested to improve the competence of service providers to diagnose and treat mental illnesses. Both urban and rural health extension workers are currently being trained.

Communication Efforts Very little effort has gone into developing communication materials for mental health in the country. Amanuel Hospital has drafted the content for drug information booklets for individuals diagnosed with a mental illness and who are prescribed medication for their condition. These need to be reviewed and completed. Furthermore, JHU-Tsehai has developed a training curriculum and service provider handbook.

SWOT According to the analyses undertaken in the development of the National Mental Health Strategy, the following strengths, weaknesses, opportunities and threats were identified for strengthening and expanding mental health services.

9 Strengths Weaknesses  Recent expansion of training  Low resources; inaccessible services programs  Most of the budget used by hospital  Appropriate use of allocated budget  Lack of parity  Inadequate quality of care  Expanding centers for the treatment  Limited resources for non-medication of substance use disorders alternatives (e.g., rehabilitation; psychological treatment)  Lack of organized referral system  Difficulties in staff retention  Inadequate focus on supervision and ongoing training in PHC Opportunities Threats  Political commitment  Low budget and other resources  Improving infrastructure  Lack of alternative services  Expanding health sector  Stigma and abuse of mentally ill  Decentralization persons  Becoming a leader in providing  Poor implementation or use of available research evidence mental health services  Lack of evidence base for evaluating health service developments

1.2. Problem Statement: This National Strategic Framework for Mental Health Communication addresses issues surrounding the high prevalence of mental illnesses, the low uptake of available mental health services, poor adherence to medication among mental health clients, frequent loss to follow-up, stigma and discrimination toward people with mental illnesses, and a general lack of knowledge about mental illnesses in communities.

1.3. Conceptual Model – Pathways for Mental Health Care and Treatment A workshop was held in Addis Ababa to develop the Ethiopia National Strategic Framework for Mental Health Communication. The development took place in partnership with communication and health experts from governmental and non-governmental organizations (NGO), including clinical service providers and representatives of implementing partners.

The Framework development process employed the ‘Communication Pathways Model’, a conceptual communication model used worldwide, and applied it to the Ethiopian context. The model (shown below) envisages three domains for communication interventions: 1. Social/Political/Environmental

10 2. Services 3. Community/Individual

The National Strategic Framework is designed to identify schemes for communicating with priority audiences in each of these domains.

11 12 2.1. Overarching Goal and Objectives Communication interventions outlined in this Strategic Framework will contribute to the following goal and objectives:

Goal: All Ethiopians will benefit from a comprehensive mental health care and treatment services.

Social/Political/Environmental Objective: To make mental health among priorities so that it is addressed publicly on a national scale by decision makers and federal and regional levels in order to foster awareness and understanding around mental health as well as compassion for mental illness

Service Delivery Objective: To provide reliable and client-friendly mental health care and treatment services that are accessible to all Ethiopians and to improve service linkages and referrals nationally.

Community/Individual Objective: To adopt an accepting and supportive community for individuals with mental illnesses and their families as well as achieve and maintain good mental health and wellbeing at the household level.

According to WHO’s definition of mental health, “Mental health is a state of well-being in which an individual can realize his or her own abilities, interact positively with others, cope with the stressors of life and study, work productively and fruitfully, and contribute to his or her own family and community.” This definition does not refer to the absence of mental illness, but addresses “mental well-ness”. Thus, this framework does not exclusively address those already affected by mental illnesses, but the larger community as well, in an effort to create awareness about and prevent mental illnesses and promote mental health and wellbeing.

2.2. Guiding Principles The Ethiopia National Strategic Framework for Mental Health Communication and its implementation will be guided by the following principles:

Behavior change-oriented: For maximum impact, communication interventions should have specific and measurable behavioral objectives, address factors that influence behavior, and reflect a multi-channeled approach. Channels and interventions should be complementary and mutually reinforcing. Audience-centered: The design of messages, materials, and communication interventions will rely on a thorough understanding of the audiences for which they are intended. This

13 includes pretesting messages and materials, as well as involving audience members in the development of approaches and materials. Evidence-based: Communication interventions and strategies will be based on research and lessons learned through prior and ongoing programs. Culturally appropriate: Communication will take into account cultural norms, beliefs, and practices that influence attitudes toward and the uptake and adherence to mental health care and treatment services, and will be delivered in a culturally sensitive manner. Community participation: The engagement of communities is essential in formulating a strong response that is locally appropriate and draws on available resources. Communities must be involved in addressing stigma and care-related issues. Services-linked: All communication will refer mental health clients and caregivers to service providers and/or will be implemented at the service delivery sites. Human rights: The framework reinforces equity of access, confidentiality of services and information, and gender-sensitivity. Commitment and Coordination: Commitment to building local capacity and coordinating partner efforts in mental health communication is essential. Community Involvement: Community leaders and caregivers contribute to the success of the mental health program. Community leaders, including religious leaders, and caregivers are well-suited for refer individuals with suspected mental illnesses to mental health services.

2.3. Creative Briefs by Audience

2.3.1. Priority audiences by domain: I. Environmental: a. Federal and regional level policy/decision makers b. Journalists

II. Service delivery: a. Service Providers b. Outreach Workers

III. Community/Individual: a. Community Leaders b. Traditional Healers c. Caregivers d. Individuals who have not accessed any mental health services b. Individuals who have accessed mental health services

14 2.3.2. Strategies by Audience for Each Domain:

Political/Social/Environmental Domain

Audience 1: Federal and Regional Level Policy/Decision Makers Most policy makers in Ethiopia are adult men living in urban areas; however, in recent years, more and more women are becoming involved in the country’s policy and decision making process as ministers, parliamentarians, heads of directorates and heads of regional health bureaus. These policymakers are usually older than age 30, have a high level of education (i.e. typically a university degree or higher), and their incomes tend to be above the average wage. In terms of politics, they tend to be loyal to their political party and possess significant decision-making power. They also believe that Ethiopia can be transformed into a middle- income country and are interested in contributing to that goal. Most policymakers are concerned with meeting development targets. Parliamentarians who are members of the budget and health committees have the most influence on the health budget as well as its allocation within the health sector.

Policymakers are committed to growth and transformation and understand that healthy families and children are the cornerstone of this goal. However, policymakers may not know the significance of mental health in maintaining the overall health of families and communities and hence have not prioritized it.

Communication Objectives:  Policymakers will believe that mental health is a serious problem.  Policymakers will believe that the expansion of mental health services is a priority.  Policymakers will allocate additional resources for the expansion and improvement of mental health services nationally.

Key Messages:  The allocation of additional resources for mental health will create healthy and productive citizens who will directly contribute to the growth and transformation of Ethiopia.  There is no health without mental health.  By availing mental health services, you are relieving some of the “burden” on families to care for individuals with mental illnesses and be able to better contribute to the growth of the country as individuals with mental illnesses, their caregivers can be more productive. It will also relieve the burden in health facilities saving time and other resources.

15 Strategic Approaches Channels Illustrative Activities Advocacy Interpersonal Advocacy video to be disseminated to policymakers Media-focused/Evidence-TV/Radio Panel discussions and based briefings for policymakers Journals/Newsletters Experience-sharing tours to countries that have strong mental health services Events

Audience 2: Journalists Media professionals in Ethiopia have diverse demographic characteristics. They include both males and females; some are well educated whilst others have a high school degree. They are typically between the ages of early twenties to late forties, are of middle income and live in urban settings. Most media institutions are profit-making and focus on news that contributes to higher sales volumes. The media lack accurate, up-to-date information on mental health and mental illnesses, which can lead to dissemination of misinformation that fosters misconceptions and stigma. Although media personnel tend to be closely in touch with realities at the community level, they are also subject to strong cultural and personal values, beliefs, norms, and perceptions that may affect objectivity in reporting. Immediate influencers of media personnel are managers in the workplace and funding/sponsoring organizations. The media in Ethiopia is very powerful and can be used as a useful tool to influence the public.

Communication Objectives:  Increase awareness and knowledge of mental illnesses among media professionals.  Improve and increase accurate and influential reporting on mental health, well-being and mental illnesses.  Increase interaction of media with other key stakeholders (policymakers, community groups, donors, etc.) to facilitate dialogue and partnership around mental health, wellbeing and mental illnesses.  Additional resources will be made available for the expansion and improvement of mental health services nationally.

16 Key Messages:  Learning more about mental health and mental illnesses will enable you to give accurate information to the public and become a trusted source of information.  You have a powerful and influential role in minimizing stigma, decreasing discrimination and increasing demand for mental health services.  You can directly contribute to enhancing the quality of life of people living with mental illnesses and their caregivers.

Strategic Approach Channels Illustrative Activities Advocacy Trainings Orientation through training, newsletters Evidence-based Meetings, workshops Press kits and briefings for media professionals Events Competitions for excellence in reporting on mental health Print materials (fact Coverage of personal sheets, newsletters) success stories that can influence personal and community action Electronic media websites, satellite video conferences, CD-ROM videos Resource center Resources on MH and related issues housed somewhere in different formats

Service Delivery Domain

Audience 1: Service Providers (General Practitioners, Nurses, Health Officers) Most service providers are men, with ages ranging from 25 to 45. Most have over 12 years of education and are married with children. Most service providers are dedicated and well-respected by their communities.

For the most part, service providers care about their clients, despite difficult conditions in their work environment, such as lack of necessary equipment or medications, insufficient human resources for health, and inadequate supportive supervision that hinders them from maximizing their potential to

17 serve their clients. Similarly, many lack confidence to provide any mental health services, and consider it the job of more specialized facilities. Although service providers are fairly compensated as compared with civil servants, their remuneration is not commensurate with their workload and responsibilities. Generally, they lack incentives and recognition for good performance and have limited opportunities for self-development or education.

Communication Objectives:  Improve service providers’ mental illnesses diagnosis skills.  Enable service providers to provide the necessary treatment, if available at their facility, to patients diagnosed with mental illnesses.  If the appropriate treatment or services are not available at their own facility, enable service providers to refer individuals diagnosed with mental illnesses to facilities that can provide the necessary care and support.  Reduce stigma among service providers towards individuals with mental illnesses

Key Messages:  By diagnosing and treating individuals with mental illnesses, you will be decreasing the burden on health facilities in the long run. Many individuals who repeatedly return to services are those who have mental illnesses, have not been diagnosed yet and have not received the treatment for their condition.  Severe mental illnesses can be prevented by diagnosing and treating patients with mental illnesses early.  Be conscious and empathetic to the emotional, psychological and economic conditions of the patient.  Encourage patients to come with their caregivers when appropriate and involve the caregivers in the treatment and follow-up of the patients.  Improve the knowledge and understanding of caregivers towards the patients in order to support the health and well-being of the patients.  Maintain good relationships, communication and rapport with patients and their caregivers to help improve the quality of care you provide. This will directly reflect on the patient’s improvement in health.  You can improve the quality of life of patients with mental health illnesses.  Improving the health of a patient, physically and mentally, is rewarding.

Strategic Approach Channels Illustrative Activities Advocacy Interpersonal Organizing experience

18 Strategic Approach Channels Illustrative Activities sharing meeting and creating opportunities to share best practices Skill building Trainings Trainings covering technical issues related to mental health as well as IPC/C skills Jobaids Print materials Medical journal/Newsletter on mental health issues and latest developments Printed materials with relevant information on mental health and pocket references Development of directory (living document available online and in print) of mental health and supportive services to which individuals diagnosed with mental illnesses may be referred Media Oriented TV/radio TV/radio spots that show the importance of mental health and the role that all health service providers can play to ensure mental wellbeing of individuals that seek services Panel discussions on dealing with MH issues and delivering high quality service that broadcasted on TV and Radio Evidence Based Hotline Providing information on Mental Health and related issues Resource Center Resources on MH and related issues housed somewhere in different formats

19 Audience 2: Outreach Workers (Health Extension Workers (Rural) & Health Extension Professionals (Urban)) The country-led Health Extension Program (HEP) has trained and deployed over 34,000 Health Extension Workers (HEWs) throughout the country – two for each village (i.e. one HEW for 500 households) since 2003. HEWs are predominantly young women between the ages of 18 and 30 and are high school graduates. HEWs complete a Health Promotion and Disease Prevention Interventions package followed by a one-year intensive training. The package is comprised of 16 key components, including maternal and child health, hygiene and environmental sanitation, referral services, and health education and communication.

Health Extension Professionals are nurses who work in urban areas. The majority of these health workers come from the communities that they serve.

Communication Objectives:  Improve mental illnesses diagnosis skills of outreach workers.  Empower outreach workers to refer individuals diagnosed with, or those suspected to have, mental illnesses to facilities that could provide the necessary care and support.  Provide outreach workers with the necessary skills to provide care and support to individuals and their caregivers at the home level.

Key Messages:  Improving the health of your patients (objectively and subjectively) is rewarding.  You can improve the quality of life of your patients.  Severe mental illnesses can be prevented by diagnosing and treating patients with mental illnesses early.  Be conscious and empathetic to the emotional, psychological and economic conditions of the patient and their caregivers.  Involve the caregivers of patients in the treatment and follow-up of your patients.  Improving the knowledge and understand of the caregivers of your patients will support the health and well-being of your patients.  Maintaining good relationships, communication and rapport with your patients will help improve the quality of care you provide. This will directly reflect on the improvement of health of your patients.

Strategic Approaches Channels Illustrative Activities Advocacy Interpersonal Organizing experience sharing meeting and

20 Strategic Approaches Channels Illustrative Activities creating opportunities to share best practices Skill building Trainings Trainings covering technical issues related to mental health as well as IPC/C skills Jobaids Print materials Print job aids and pocket references Development of directory (living document available online and in print) of mental health and supportive services to which individuals diagnosed with mental illnesses may be referred Media Oriented TV/radio TV/radio spots Panel Discussions Evidence Based Hotline Providing information on Mental Health and related issues

Community/Individual Domain

Audience 1: Community Leaders Typically community leaders are men between 25 and 80 years of age. Most are married with children, have completed secondary education or higher, and earn an income slightly above the minimum wage. They are usually well accepted and influential in their communities, and are often committed to community mobilization and taking ownership for change. Most of their work is resource constrained due to inadequate funding, lack of skilled manpower, and poor linkages to services. They have a tendency to be conservative and highly religious which makes them slow adopters of new ideas. They have a tendency to believe that mental illnesses are a result of curses that can only be treated by traditional and religious methods.

Communication Objectives:  Improve the knowledge of community leaders (religious, elders, etc.) on mental illnesses and available care and treatment.

21  Empower community leaders to promote available diagnosis and treatment services at health facilities.  Empower community leaders to establish support groups at the community level amongst those who have mental illnesses as well as those caring for individuals with mental illnesses.  Encourage community leaders to contribute to reducing misconceptions and stigma around mental illnesses.  Advocate for an informed, accepting and supportive environment for individuals with mental illnesses.  Increase empathy among community leaders towards the community’s needs and advocate for them to create support platforms (e.g. facilitating community discussions about mental health illnesses; planning activities or events that address emotional, religious and economic concerns).  Increase awareness of community leaders on how to maintain good mental health and wellbeing so that they can set a positive example for others.

Key Messages:  Learn the facts about mental illnesses and share this knowledge with others in the community.  Assist community groups in organizing and addressing mental illnesses in the community (e.g. encouragement to go to health services for professional treatment, care and support, stigma reduction).  By taking action for recognition of mental health illnesses as well as promoting treatment and support, you will be addressing a problem that is typically hidden in the community and you will be more respected by community members who rely on you to protect the community and help those in need.  You can improve the quality of life of the community.  Encourage community support for mental illnesses in order to help families of individuals with mental illnesses are not stigmatized and benefit from shared community responsibility to care for individuals with mental illnesses, therefore creating a healthier and happier community.

Strategic Approaches Channels Illustrative Activities Advocacy Interpersonal Organizing experience sharing meeting and creating opportunities to share best practices Skill building Trainings Trainings covering technical issues related

22 Strategic Approaches Channels Illustrative Activities to mental health as well as IPC/C skills Print materials Print job aids and pocket references Development of directory (living document available online and in print) of mental health and supportive services to which individuals diagnosed with mental illnesses may be referred Media Oriented TV/radio TV/radio spots Panel Discussions Evidence Based Hotline Providing information on Mental Health and related issues

Audience 2: Traditional Healers Traditional healers comprise both men and women who have very little or no formal educational backgrounds, with mid-level economic status. They are typically conservative, highly religious, and supportive of traditional and cultural values and ways. As traditional healers, they are strong advocates of traditional medicine and suspicious of modern medicine. They may have a tendency to view health facilities and health professionals as competitors that also negatively influence the community. They are usually well respected and influential among community members, especially those who have minimal education and the elderly, who also have very strong traditional and cultural values and beliefs.

Communication Objectives:  Respectfully improve the knowledge of traditional healers on the available care and treatment for mental illnesses at health facilities that could support their traditional treatments.  Increase understanding among traditional healers that modern and traditional treatments can supplement one another.  Promote services at health facilities as being supportive to the services and treatment that they offer.  Empower traditional healers to refer patients to modern health facilities for second opinions.

23  Encourage traditional healers to provide an accepting and supportive environment for individuals with mental illnesses.

Key Messages:  Learn the scientific facts about mental illnesses and share this knowledge with other traditional healers and community members.  By taking action for recognition of mental health illnesses as well as promoting treatment and support, you will be addressing a problem that is typically hidden in the community and you will be more respected by community members.  Establish and maintain a working partnership with modern medicine that will strengthen and complement traditional health.  Become informed about mental illnesses and use that knowledge to address the community’s needs directly, therefore regaining the faith of the younger, formally educated people in the community.

Strategic Approaches Channels Illustrative Activities Entertainment Community gatherings, Community community conversations and conversations supportive low literacy materials Informal education TV/radio TV/radio spots (dramas) Establish linkage between traditional healers and health facilities

Audience 3: Caregivers As a result of the widespread prevalence of mental illness in the country, and the diverse economic statuses in the country, caregivers of individuals who have mental illnesses include a wide mix of people of all ages, economic statuses, living environment and education levels. Likewise, these individuals represent diverse religions and ethnicities. Caregivers face very strong stigma and discrimination the community as well as health workers and may often feel that they are the only one who has someone with a mental illness under their care. Stigma toward oneself for relation to and caring for an individual with a mental health illness may also cause caregivers to live in shame and hide the truth from the rest of the community. They choose to hide the people under their care, including locking them away from the world.

Communication Objectives:

24  Increase awareness among caregivers about mental illnesses and available care and treatment.  Increase awareness of caregivers about signs and symptoms that indicate a need to access mental health services.  Empower caregivers to seek the necessary care and treatment for individuals under their care and support.  Encourage caregivers to discuss concerns and share what they have learnt about caring for someone with mental illnesses with other community members who may have similar concerns and insight.  Enable caregivers to identify which health facilities provide mental health services, and what specific services are provided at each facility.  Increase understanding among caregivers that caring for someone with mental illnesses is challenging and that they need to prioritize their own health and wellbeing.  Empower caregivers to maintain good mental health and wellbeing and set a positive example for others.  Caregivers should feel proud of themselves for caring and supporting someone who needs their help.  Empower caregivers to break the stigma from the community and self stigma by sharing their experiences and educating other community members about mental health illnesses and advocating for an increase or improvement of mental health services available in their community.

Key Messages:  Caring for someone who has one or more mental illnesses can be very challenging. Make sure to prioritize your own health and wellbeing by taking good care of yourself and seeking the support of other community members, support groups or services. The healthier you are, the more able you will be to care for others.  Improving the health and quality of life of the people under your care is rewarding.  You can improve the quality of life of the people under your care.  Severe mental illnesses may be prevented by diagnosing and treating patients with mental illnesses early.  Mental illnesses can be managed with appropriate treatment obtained from health facilities providing mental health services.  Be conscious and empathetic to the emotional and psychological conditions of the people under your care.  It is very important to help the people under your care to stick to the advice that their service providers provide them. Make an effort to go with them for their check-

25 ups and health visits.  It is very important to understand the condition of the people you care for and to know about the symptoms that their illness causes.  Seek medical attention as soon as you realize that their symptoms are coming back or if you observe any other strange symptoms.  If the people you are caring for are taking medicines for their mental health condition, it is very important to consult their health provider if they want to take other drugs or medications, even if they are over the counter drugs.  Feel free to talk to your service provider about any questions and concerns that you might have.  Share with others how mental health services have helped you and the people for whom you care.  Encourage people to discuss their challenges with a community leader who may be able to influence individuals with a mental illness to seek care.

Strategic Approaches Channels Illustrative Activities Community Mobilization Community outreach Community activities conversations and supportive materials Establishment of support groups Media-oriented TV/Radio TV/radio spots (dramas) Testimonials of other caregivers Clinic-focused Face-to-face counseling Print materials with facts at health services about mental illnesses and their prevalence, prevention of mental illness, promotion of mental health and wellbeing, location of facilities that provide mental health care

Audience 4: Individuals who have not accessed any mental health services This group represents a diverse range of ethnicities, ages, genders, religions and socio-economic

26 statuses. They may be medically eligible for mental health services or not.

The mental health of those eligible for services can range from very severe mental illnesses to more minor and often overlooked illnesses. Individuals with severe, undiagnosed mental illnesses are often locked up and hidden away from the rest of the community, due to the belief that they have been cursed with their condition.

Individuals who have not accessed any mental health services are likely to have incomplete information about available mental health services or have misconceptions about mental illnesses in general. This group comprises most of the community and is likely to be influenced by the media, community leaders, family members and peers.

Communication Objectives:  Increase awareness among individuals who have not accessed any mental health services about mental illnesses and available care and treatment.  Increase awareness of individuals and their families about signs and symptoms that indicate a need to access mental health services and empower them to seek services for themselves and others.  Enable individuals and families to identify which health facilities provide mental health services.  Empower individuals and families to discuss concerns and share what you have learnt about maintaining mental and emotional wellbeing, signs and symptoms that indicate the need to access mental health services as well as available services with other community members.  Empower individuals and families to maintain good mental health and wellbeing and set a positive example for others.

Key Messages:  Make sure to prioritize your health and wellbeing by taking good care of yourself and seeking the support of other community members, support groups or services.  You can maintain your own mental health and emotional wellbeing by adopting healthier lifestyle.  Severe mental illnesses can be prevented by diagnosing and treating symptoms early.  Mental illnesses can be managed with correct treatment obtained from health facilities providing mental health services

Strategic Approach Channels Illustrative Activities Community mobilization Community outreach Community

27 Strategic Approach Channels Illustrative Activities activities gatherings/conversations and supportive materials Media-oriented TV/radio TV/radio spots (dramas) Face-to-face counseling at Print materials with facts health services about mental illnesses and their prevalence, prevention of mental illness, promotion of mental health and wellbeing, location of facilities that provide mental health care Print materials Materials with information on how individuals can maintain mental health and emotional wellbeing by adopting simple lifestyle, signs and symptoms that require accessing mental health services, and available services

Audience 5: Individuals who have accessed mental health services

The number of people currently using mental health services is increasing steadily. They are mostly adults, residing predominantly in urban areas. It is very likely that this group faces a number of challenges around stigma, gender inequality, and, on the whole, fear of letting others know about their condition. In instances of moderate to severe mental illness, it is possible that this group of people was, or still is, hidden away from the rest of the community, suffering feelings of disgrace and humiliation. Lack of community support is very prominent and problems with accessibility and affordability of services are common. Therefore, individuals with mental illnesses may routinely engage with traditional healers and practice religious rites such as fasting and using Holy Water in an attempt to cure their illness. Among the groups that influence their behavior are their caregivers, family members, peers, health care providers, and religious and community leaders.

Communication Objectives:  Enable individuals with mental illnesses know more about their mental illness and others as well as available care and treatment.

28  Empower individuals who started treatment to adhere to medication and advice provided to by health service providers.  Increase awareness among individual who have already accessed mental health services about signs and symptoms that indicate a need to return to mental health services.  Empower individuals with mental illnesses and who have accessed mental health services to discuss your concerns and share what they have learnt with people who are close to them.  Empower people who have accessed mental health services to maintain good mental health and wellbeing and set a positive example for others.

Key Messages:  Take your medication as advised by your service provider in order to help improve your quality of life.  Taking your medication is a commitment and you should not stop unless your service provider advises you to do so, even if you feel better.  Understand your condition and know about the symptoms it causes.  Seek medical attention as soon as you realize that your symptoms are coming back or if you feel any other strange symptoms.  If you are taking medicines for your mental health condition, it is very important for you to consult your health provider if you want to take other drugs or medications, even if they are over the counter drugs.  Feel free to talk to your service provider about any questions and concerns that you might have.  It is your responsibility to maintain good health and a good quality of life.  Share with others how mental health services have helped you.  Try to involve a person who is close to you in your health care by talking to them about how you feel, telling them about your condition and asking them to support you.

Strategic Approach Channels Illustrative Activities Clinic-focused Face-to-face counseling at Counseling and clinic- health facilities based client education Community mobilization Community outreach Print materials to support activities drug adherence

29 Strategic Approach Channels Illustrative Activities Community gatherings Community Community conversations gatherings/conversations and supportive materials

Media-oriented TV/radio TV/radio spots (dramas) Print materials Print materials with facts about mental illnesses and their prevalence, prevention of mental illness, promotion of mental health and wellbeing, location of facilities that provide mental health care

Notes  Communication interventions should maintain a balance between service demand creation and available services.  The WHO yearly mental health themes should be considered during the design of communication interventions (for example, depression - a global crisis, for October 10, 2012).

Implementation 3.1. Links with Service Implementation of this Strategic Framework will only succeed if MH communication is closely linked to available services. During the design workshop, partners identified two means of creating a strong linkage with services as they become increasingly available:

 Provide a list of facilities offering mental health services to all health care providers including HEWs and HEPs.  Provide referral services and other relevant information to health facilities offering mental health services through the Wegen AIDS Hotline and the Fitun Warmline.

30 The Federal Ministry of Health regularly tracks availability of mental health services through reports from Regional Health Bureaus. This information can be used to compile a list of health facilities offering mental health services, and can be updated annually and provided to the hotline, warmline and health providers.

3.2. Research, Monitoring and Evaluation Formative Research: Prior to implementing this communication framework, it is recommended that some qualitative research be undertaken to support the development of specific interventions. For example, information derived from focus group discussions or in- depth interviews with health workers, WHO officers, Health Extension Workers, Health Extension Professionals, caregivers, individuals who have not initiated care and treatment, and individuals who have initiated care and treatment will be useful in designing specific materials and activities for them. In addition, all materials and communication tools should be pretested among audience representatives prior to finalization.

Monitoring and Evaluation: In order to track progress, effectiveness, and reach of communication interventions, it is necessary to develop a strong monitoring and evaluation (M&E) system. The M&E system should measure output indicators as well as behavioral outcome indicators based on the framework objectives. The output and outcome indicators could include:

Output Indicators:  Number of people reached through meetings or group discussions.  Number of radio and/or television programs/PSAs broadcast.  Number of communities implementing mental health communication activities.  Number of mental health communication materials produced and distributed.  Number of mental health advocacy meetings held.  Percent of audience reached with media messages about mental health and wellbeing.

Outcome Indicators:  Percent of audience with positive attitudes toward mental health and wellbeing.  Number of individuals who have accessed health care.  Number of individuals with mental health illnesses on proper treatment.  Percent of the community that knows where to go for mental health services.  Rate of loss to follow-up among individuals on treatment.  Percent of WHO officers who demonstrate mental health as a priority.

31  Amount of federal budget allocated to mental health services.  Number of individuals seeking mental health care and treatment from traditional healers  Percent of caregivers who feel overburdened  Percent of caregivers who feel there is adequate support services available to them and the people under their care.  Percent of Health Extension Workers who refer clients to mental health services.  Percent of Health Extension Professionals who refer clients to mental health services.  Percent of doctors who refer patients to mental health services

3.3. Sustainability, Roles and Resources In order to ensure maximum efficiency of programming, avoid duplication of efforts and reduce conflicting information and messages about mental health, a mental health communications working group should be established and comprised of all key stakeholders. This working group will use the mental health communication framework as a platform for planning and implementing relevant activities. The group will also develop mechanisms to coordinate activities to keep one another up-to-date, facilitate opportunities for collaboration, develop standard approaches and materials that can be used across various audiences, ensure program activities are linked for maximum impact (when appropriate), reduce programming gaps, and share high-impact practices and lessons learned. References

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