Rural Vs Urban Residence and Experience of Discrimination Among People with Severe Mental Illnesses in Ethiopia
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Forthal et al. BMC Psychiatry (2019) 19:340 https://doi.org/10.1186/s12888-019-2345-7 RESEARCH ARTICLE Open Access Rural vs urban residence and experience of discrimination among people with severe mental illnesses in Ethiopia Sarah Forthal1, Abebaw Fekadu2,3,4,5, Girmay Medhin6, Medhin Selamu3, Graham Thornicroft7 and Charlotte Hanlon7,3,2* Abstract Background: Few studies have addressed mental illness-related discrimination in low-income countries, where the mental health treatment gap is highest. We aimed to evaluate the experience of discrimination among persons with severe mental illnesses (SMI) in Ethiopia, a low-income, rapidly urbanizing African country, and hypothesised that experienced discrimination would be higher among those living in a rural compared to an urban setting. Methods: The study was a cross-sectional survey of a community-ascertained sample of people with SMI who underwent confirmatory diagnostic interview. Experienced discrimination was measured using the Discrimination and Stigma Scale (DISC-12). Zero-inflated negative binomial regression was used to estimate the effect of place of residence (rural vs. urban) on discrimination, adjusted for potential confounders. Results: Of the 300 study participants, 63.3% had experienced discrimination in the previous year, most commonly being avoided or shunned because of mental illness (38.5%). Urban residents were significantly more likely to have experienced unfair treatment from friends (χ2(1) = 4.80; p = 0.028), the police (χ2(1) =11.97; p = 0.001), in keeping a job (χ2(1) = 5.43; p = 0.020), and in safety (χ2(1) = 5.00; p = 0.025), and had a significantly higher DISC-12 score than those living in rural areas (adjusted risk ratio: 1.66; 95% CI: 1.18, 2.33). Conclusions: Persons with SMI living in urban settings report more experience of discrimination than their rural counterparts, which may reflect a downside of wider social opportunities in urban settings. Initiatives to expand access to mental health care should consider how social exclusion can be overcome in different settings. Keywords: Global mental health, Mental illness, Discrimination, Stigma, Psychotic disorders, Bipolar disorder, Urbanization Background resource-poor settings, where the percentage of people Stigma has been branded “the most basic cultural and who do not receive necessary mental health care is usually moral barrier” to ending the global burden of mental ill- greater than 75% [3]. Furthermore, as the world urbanizes, ness [1]. Discrimination is the behavioural consequence of with low-income nations doing so at the fastest rate [4], stigma, in which people are treated unfairly due to their there has been increasing interest in better understanding condition [2]. Perceived or experienced discrimination can the implications of urban versus rural living on overall negatively impact upon help-seeking, access to care, re- mental health and well-being [5]. covery, and overall well-being among those with mental Nevertheless, there have been very few studies of dis- illnesses [2]. This may be particularly important in crimination in low-resource settings [6, 7] in general, and in sub-Saharan Africa in particular [8, 9]. Existing * Correspondence: [email protected] studies have rarely compared rural and urban popula- 7King’s College London, Institute of Psychiatry, Psychology and Neuroscience, tions, despite evidence of high levels of health inequity Health Service and Population Research Department, Centre for Global by residence on the one hand [10] and the prevailing Mental Health, London, UK 3Department of Psychiatry, School of Medicine, College of Health Sciences, view that more traditional, rural communities may be Addis Ababa University, School of Medicine, Addis Ababa, Ethiopia more tolerant of people with mental health problems Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Forthal et al. BMC Psychiatry (2019) 19:340 Page 2 of 10 [11]. In population-based studies from Ethiopia, both of SMI. The key informant method is a sensitive case de- urban [12] and rural [13, 14] residence have been linked tection technique previously used in a neighbouring dis- with higher levels of stigma, but levels have not been trict. HEWs are women with at least a grade 10 compared in the same study. Rural residence was inde- education and 1 year of health care training in health pendently associated with internalised stigma in a study promotion and illness prevention activities. HEWs live carried out in a tertiary referral centre in the capital city, in the community they serve and visit each household in but this may be explained by selection bias [14]. In this their catchment area every month and therefore have study, we aimed to evaluate the experience of discrimin- close community ties [18]. The use of community-based ation among persons with severe mental illnesses (SMI) case ascertainment methods allowed us to recruit a more in Ethiopia. Given findings from the Ethiopia Butajira representative sample with minimal selection bias; this is population-based cohort studies showing excess mortal- particularly important in a setting such as Sodo District ity and low remission among those with severe mental where access to facility-based health care is low. Prob- illnesses (SMI; psychotic disorders and bipolar disorder) able cases of SMI were referred to local PHC services from a predominantly rural setting [15], we hypothesized and were then evaluated by nurses or health officers that, in the Ethiopian setting, rural residence would be who had been trained in use of the World Health associated with higher levels of experienced discrimin- Organization mental health Gap Action Programme ation in people with SMI. Intervention Guide (mhGAP-IG) to diagnose and treat people with psychosis or bipolar disorder [19]. A trained Methods psychiatric nurse confirmed the diagnoses using the Study design semi-structured OPerational CRITeria for research The study was a cross-sectional survey of community- (OPCRIT) interview [20]. ascertained people with SMI in an Ethiopian district as part People with confirmed SMI and their caregivers were of the Programme for Improving Mental health carE then recruited into the study if they met the following (PRIME) study [16]. PRIME was a consortium of mental criteria: health researchers, the World Health Organization, Minis- try of Health representatives and non-governmental organi- Aged 18 years or older, sations in five low and middle-income countries, including Planning to continue living in the district for the Ethiopia. In PRIME, participatory district level mental next 12 months, health care plans were developed in order to evaluate the Provided informed consent (evaluated by trained impact of task-shared mental health care on disability and psychiatric nurses) or, if lacked capacity to consent, symptom severity for people with priority disorders [17]. did not refuse and caregiver permission was The larger PRIME study includes participants with depres- obtained, and sion, alcohol use disorder, psychosis, and epilepsy; the Able to understand Amharic. current study only includes those with psychosis. Those diagnosed with a mental, neurological and sub- Setting stance use (MNS) disorder prior to the study were not The study took place in Sodo District, Gurage Zone, of excluded. the Southern Nations, Nationalities and Peoples’ Region (SNNPR), Ethiopia, between December 2014 and July Sample size and power calculation 2015. The district is located 100 km from the capital city, The sample size was powered for the primary objectives Addis Ababa. Reflecting Ethiopia as a whole, 90% of the of the PRIME study: detection of a 20% reduction in district inhabitants live rurally with the main sources of symptom severity after 12 months, with 90% power, two- livelihood being farming and animal husbandry. The of- sided significance level of 5%, and an assumed attrition ficial language is Amharic. At the time of the study, the rate of 20% [21]. The final analytic sample had 300 par- district had a population of approximately 165,000 with ticipants; this was the baseline psychosis cohort for the no mental health specialists. However, through PRIME, PRIME study. a district level mental health care plan was being imple- mented with the goal of expanding access to integrated Measures primary mental health care [18]. The primary outcome of the current study was discrim- ination experienced by people with SMI and the primary Participant selection exposure was residence. Potential confounders were Figure 1 shows a flow chart of the participant recruit- clinical diagnosis, symptom severity, disability, alcohol ment process. Health Extension Workers (HEWs) and use, social support, poverty, age, sex, marital status, and community key-informants first identified probable cases education level. All assessments were administered Forthal et al. BMC Psychiatry (2019)