Pioneering Work in Mental Health Outreaches in Rural, Southwestern Uganda

Byaruhanga et al.

Pioneering work in mental health outreaches in rural, southwestern Uganda

Elias Byaruhanga, Elizabeth Cantor-Graae, Samuel Maling & Jerome Kabakyenga

In Uganda, the ratesof mental illness are high due to Background poverty, high prevalence of HIV/AIDS and long- Uganda has a population of approximately term exposure to civil wars and armed rebellion. 26 million people (2002 census),89% reside The cost of mental health services in urban in ruralareas.Thecountryhas emerged from hospitals remains prohibitive for the rural poor who a period of political and bloody civil strife resort to traditional healers, and many mental lasting over 40 years. Most regions in health workers prefer working in urban areas. In Uganda have experienced armed con£ict response, a community outreach program has been since 1972, i.e. the killings of civilians during developed in rural, southwestern Uganda to deliver Idi Amin’s rule, the liberation war of 1979, e¡ective mental health care. The programme was the Luwero war of 1981^1986, and the prolonged war that has been raging in the aimed at improving access to psychiatric care by northern part of the country during the past taking services to communities where the majority 22 years. of the rural population live, yet where services were The Mbarara District, one of the 56 districts non-existent. Baseline information on the training ofUganda,islocatedinthesouthwesternpart needs was collected by interviewing health workers of the country about 260 kilometres from in rural health units, and the need for a mental the capital city Kampala. The district has a health service was assessed by interviewing land area of approximately 10 500 square members of the community and local leaders. kilometres and a population of about Records of local health units were also reviewed. 1.4 million people. The main economic The result of the programme has shown that activity in the district is agriculture, consist- marginalized and neglected people with mental ing primarily of cattle rearing and subsis- disorders have been able to access mental health tence farming. About 45% of the population care. Through increasing knowledge and access to is below the age of 15 years. psychiatric services in the community, mental During the liberation war of 1979, the health problems and psychological problems can be Mbarara district was particularly a¡ected managed e¡ectively with little need for referral to by widespread destruction of property and larger hospitals. lives. Subsequently, Mbarara became the temporary home of internally displaced Keywords: Mental health outreaches, people from Luwero, who are now living in mental illness, primary health care, Kanyaryeru. Mbarara is also the site of two community mental health care, con£ict, refugee camps, Oruchinga and Nakivale, Uganda serving refugees from Rwanda, Burundi,

117 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Pioneering work in mental health outreaches in rural, southwestern Uganda Intervention 2008, Volume 6, Number 2, Page 117 - 131

Democratic Republic of Congo (DRC), are regarded as part of the larger category Ethiopia and Somalia. The population of patients with neuropsychiatric disorders has been exposed to torture, maiming and and mental health issues. killing, various forms of sexual and gender- Mental illness in most parts of rural Uganda based harassment and violence, forced is often surrounded by stigma. The majority marriages, physical injuries from bullet of patients with mental illness and epilepsy wounds, landmines, robberyanddestruction in rural areas remain untreated due to lack of property, erosion of moral and social of knowledge and limited access to services, values, massive abductions of the youth, Those who do seek treatment in health care and the displacement of entire communities services have often been su¡ering for a long into camps. period, and if not ‘cured’, may be abandoned. The HIV/AIDS epidemic has also contri- Recent epidemiological surveys on rates of buted to extensive personal loss, family mental disorder in Uganda do not exist, but fragmentation, and the increased burden of highratesofmental illnesswouldbeexpected caringfor illrelativesandorphanedchildren. due to the impact of poverty, decades of Substance abuse is also common. Many of internal military con£icts, and the HIV/ these problems are inter-related, with for AIDS epidemic. An early prevalence study example, HIV/AIDShaving adverse psycho- carriedout intwovillages in Uganda showed logical e¡ects on infected individuals as well rates of mental disorder of 23.3% (Orley & as their partners and children. In Uganda, Wing,1979), while a more recent community therateofHIV/AIDSis5.3%inmales,and based study in western Uganda estimated 7.3% in females, with a national average of prevalence rates of mental disorder at 6.5%, (The Uganda Ministry of Health 30.7% in adults (Kasoro, Sebudde, ( MOH ), 20 05). Kabagambe-Rugamba, Ovuga & Board- man, 2002). Mental health problems in Mental illness is therefore considered com- Uganda mon in the sub-Saharan Africa, but only InUganda,mostpeopleareunawareofwhere those with severe behavioural disturbances they can get medical help for mental health are identi¢ed. Many forms of mental dis- disorders. Because of widespread cultural orders are likely to remain unrecognized, beliefs that mental illness is caused by witch- eventhoughmany peoplewith mental health craft, patients are often taken to traditional issues present themselves to the health care healers,orleftuntreated.Patientswithmental services, with surprisingly large numbers illness are regarded as an embarrassment to attending general outpatient services. A the family, and may be restrained with longitudinal study by the World Health shackles, chains or ropes, or subjected to Organization (WHO), conducted in 14 stoning and expulsion from the community. developing countries, found that almost Patients with epilepsy face many problems one-third of all patients presenting at similar to those of the mentally ill. Although primaryhealthcare services showeddiscern- epilepsy is a neurological condition, in ible evidence of mental health problems Uganda mental healthcare workers usually (Sartorius, Ustun, Costa de Silva, Goldberg, treat it. Other health workers perceive it as Lecrubier, Ormel, Von Kor¡ & Wittchen, a‘disease of the head’. In this article therefore, 1993). For example, a study in Zimbabwe for practical reasons, people with epilepsy found that 26% of patients attending

primary health care sites had mental health district capital. It has a capacity of 336 beds disorders (Reeler, Williams & Todd, 1993). and serves three districts in southwestern Recent research in Nigeria showed that Uganda, i.e. Mbarara, Bushenyi, and around 20% of child attendees at primary Ntungamo districts (with a population of carefacilitiesweresu¡eringfrompsychologi- approximately 3.2 million people). Within cal or psychiatric conditions, including the hospital is apsychiatric unit with 20 beds. depression, anxiety and conduct disorders The sta⁄ng level of the psychiatric unit (Gureje, Omigbodun, Gater, Acha, Ikuesan consists of, at present, one psychiatric & Morris,1994).The inadequate knowledge clinical o⁄cer, eight psychiatric nurses, two of general health workers in mental health occupational therapists, a counsellor, and a also contributes to this lack of recognition as recently posted psychiatrist. Although the mental health professionals are primarily sta⁄ng level for the psychiatric unit is located in urban areas and far too few adequate for in patient care, there is a need in number. for more sta¡ to provide better quality for Mental health isanunderdevelopedaspectof out patient services, both in the hospital health care in Uganda. Uganda has approxi- and in the community. On average, the mately 18 psychiatrists in total, with the hospital receives about 200 out patients each majority practicing in the capital city of week. Hospital sta¡ participation is needed Kampala. In addition, there are about in the community outreaches, which creates 40 psychiatric clinical o⁄cers, with half of a burden for the few sta¡ remaining at the thempracticing in regional hospitals in rural hospital. The average waiting time at the areas. hospital is between 2-6 hours. Decentralization of mental health services, The average distance to Mbarara regional with increasing emphasis on outreaches and hospital from other places in the district community based programmes therefore, is about 60 kilometres. Therefore, most represents an obvious strategy for accessing patients must travel long distances to access mental health care service for the majority the mental health services in the regional of the population.WHO advocates inclusion hospital. In some places, public transport is of mental health care as a part of primary quite di⁄cult and the quality of the infra- health care worldwide (World Health structureispoor. Somehavetowalk longdis- Organization, 1978). The need to train tances in order to get to a road where they primary health care workers and other may be able toboard avehicle.This is a di⁄- personneltoprovidebasic mental healthcare cultventure, especiallyifapatient isseverely is increasingly recognized (Acorn, 1993; disturbed or rather resistive and cannot Brooker,Tarrier,Barrowclough, Butterworth walk. & Goldberg,1992), and may be particularly Additionally, such a journey costs approxi- indicated in con£ict a¡ected countries mately 8000 Ugandan shillings (approxi- (Eisenman, Weine, Green, De Jong, Ray- mately 4 US $).In Uganda, the average daily burn,Ventevogel, Keller & Agani, 2006). income for a person is less than1$. Although it is government policy to o¡er free Health services in Mbarara treatment, hospital supplies of psychotropic A referral hospital attached to the medical medication are inadequate and erratic, school of Mbarara University of Science patients are often prescribed drugs that must and Technology (MUST) is located in the be purchased from pharmacies in urban

119 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Pioneering work in mental health outreaches in rural, southwestern Uganda Intervention 2008, Volume 6, Number 2, Page 117 - 131

areas and often cannot a¡ord it. As a result, mental health workers are included in the many remain in villages untreated. sta¡ on any of these levels. In addition to the referral hospital, there Rural health care is provided at primary are over 130 rural health units located health care units (i.e. HC II, III, and IV) throughout Mbarara district. The basic located in the district. If proper training structure of the primary health care system could be provided for primary health care in Uganda consists of four levels of health workers, the location of these care units care delivery that are outlined below. in community settings would make them Health Care Centre (HC) I ^ serves a village ideally accessible to most patients with men- of approximately 1000 people. Services tal disorders. provided at this level include community based preventive measures and promotion of Initiation of the mental health health services. No trained health sta¡ are outreach service (planning found at this level. The service is provided phase) by a village health committee, a cadre of In 2002, a programme was initiated to test elected representatives, who have been given the feasibility of providing mental health some basic instruction in health issues. In outreach services to populations in rural accordancewiththeMinistryof Health, units and remote areas in the Mbarara district. at this level are called‘‘health care centres’’. We chose 15 health units in the district and Health Centre II ^ serves a parish of approxi- also in a rural community of Rubindi mately 5000 people. Services provided sub-county, where a community oriented include preventive measures, promotion of sensitizationprogramwastobeimplemented health services and out patient curative in order to increase awareness of mental health services, as well as outreach care, with health issues. Four of the health units were sta⁄ng provided by general nurses. located at a distance of approximately Health Centre III ^ serves a sub-county of 40kilometres fromMbararaRegional hospi- approximately 20 000 people. Services tal, while 11 were located at a distance of provided include preventive measures and between 40 and 70 kilometres. All of these promotion of health services, in and out health units were rural in character. The patient curative services, maternity care, sub-county of Rubindi was also chosen and laboratory services. Sta⁄ng is provided because there was no functional government by a medical assistant (clinical o⁄cer), health unit, as opposed to a nongovernmen- general nurses, and a laboratory assistant. tal unit, e.g. sta¡ed by a nongovernmental Health Centre IV ^ serves a county of approxi- organization (NGO). During the planning mately 100000 people. Services provided phase, we obtained baseline data regarding include preventive measures, promotion of health workers’ attitudes to mental illness, health services, in and out patient curative the level of care currently available, and the services, maternity care, emergency surgery, numbers of patients visiting the health unit. blood transfusion, and laboratory services. We developed a questionnaire (see Box 1) to Medical doctors, clinical o⁄cers, nurses, a assess the training needs of health workers, health educator, a health inspector, dental e.g. their knowledge of mental health, com- assistant, laboratory technician, laboratory mon mental disorders, services available, etc. assistant, anaesthetic o⁄cer and a dispenser The questionnaire was administered to all provide sta⁄ng. It is worth noting that no quali¢ed health workers who agreed to

Box 1: Primary Health Workers Needs Assessment Questionnaire

MBARARA HOSPITAL. Mental Health Program. Name of Health unit Date Name of HealthWorker Qualification 1. Have you ever received any training in mental health? Yes/ No. 2. Do you receive/attend to patients with mental illness? Yes/ No. 3. On average how many patients with mental illness do you treat in a month? 4.What types of mental illness do you come across in the course of your work or do you know of? If any, what drug do you use for each condition? - 5.What are the common psychiatric drugs you stock in your health unit? - 6.What are the common drugs used for the treatment of epilepsy? - 7. Apart from the health unit, where else do patients with mental illness in this area seek help? - 8. Do you think that more mentally ill people could be seen and helped in the existing health units? - 9. What are the common attitudes and beliefs towards mental illness? - 10.What suggestions do you have that could help to improve the situation of, or the care of, persons with mental illness? -

Thank you

121 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Pioneering work in mental health outreaches in rural, southwestern Uganda Intervention 2008, Volume 6, Number 2, Page 117 - 131

participate and who were available at the disorder, substance abuse, schizophrenia, health unit. Atotal of 34 health workers were delirium, epilepsy and severe learning interviewed. We also reviewed medical disabilities. The intent was to provide a attendance records for the year before. course tailored to the needs of participants, Medical attendance records were available rather than an encyclopaedic curriculum or in all the health units. The health workers area overview (Ventevogel & Kortmann, on duty recorded the information contained 2004). The content included: introduction/ in the records. It is basic information de¢nition, etiology, symptomatology, and and includes names of patients and their management (drug management and other particulars, diagnosis and drugs prescribed, forms e.g. counselling and patient communi- whether admitted, treated as an outpatient, cation skills). Information regarding drug or referred. As a result of inadequatetraining treatment emphasized the most essential in mental health issues, the diagnosis com- drugs, e.g. chlorpromazine, haloperidol, monly used was ‘mental disorder’, and not benzhexol (for side e¡ects), imipramine or speci¢ed any further. amitriptyline, and phenobarbitone. The A focus group discussion was carried out in medication list was purposefully restricted one community.The group consisted of nine because we considered it more important members of the adult population (¢ve for primary care workers to know a lot about females and four males), with each person a few drugs than to know a little about given an opportunity to speak about many drugs. The training methods included issues concerning mental health in their lectures, brainstorming, group discussions, community. The members were selected in plenary sessions, and role play. Pre and post order to collect as diverse views as possible. training tests were conducted in order to The group consisted of a religious leader, a assess the participants’ level of knowledge. local leader, a traditional birth attendant, At the end of each training session, partici- two traditional healers, two elders/opinion pants received attendance certi¢cates issued leaders, a teacher, and a person with by the District Director of Health Services. adisability. Following the baseline data collection, a The mental health outreach training of health workers was planned, service consisting of three separate training sessions Following completion of the planning phase (one sessioneachyear),each lasting ¢ve days. (2001), the mental health outreach service The health workers trained included nurses has been in operation since 2002. A mental and medical assistants (clinical o⁄cers). health team at Mbarara regional hospital, During the training we used and followed a consisting of a psychiatrist, psychiatric training manual for operational health clinical o⁄cer, a nurse, and occupational workers developed by the mental health therapist, conducts the outreach and clinical section of the Ministry of Health. The skills supervision.The outreachteamgoesoutonce taught included interviewing and diagnostic a week, according to a preset program. skills, so that sta¡ workers could identify/ Medical students from Mbarara also partici- recognize and refer di⁄cult patients. The pate in these activities. Health care units training covered the following clinical (HC levels III, IV) are informed of the dates diagnoses: mania, depression, anxiety, forthevisitswellinadvance.Thisgivesample somatization disorder, post traumatic stress time for health workers to announce the date

for the clinic in public places, e.g. churches, patient register book as part of the Health schools, markets, etc. Three health units are Management Information System (HMIS). visited once every month because of the Thetrainingin mental healthprovidedtothe heavy patient load at these clinics.The other primary health workers in these health units seven health units are visited once every has resulted in an ongoing uptake of new three months. The community volunteers patients, prescription renewals, and the did an intensive mobilization and sensiti- referral of di⁄cult cases to clinic days zation programme in these areas. Com- during which a psychiatric clinical o⁄cer or munity volunteers encourage all identi¢ed psychiatrist reviews the patient with the patients to attend the clinic. Some patients health worker at the health unit. During are self-referred, while patients who have the training, the emphasis was on recog- improved or bene¢ted from the service nition of mental illness and the ability to encourage others. Functions of the mental categorize this as mania, depression, health team in the outreach include: patient schizophrenia, epilepsy, etc. After the train- diagnosis and initiation of treatment, men- ing, most health workers are able to give tal health education at the health unit, dis- speci¢c diagnoses, although adjustments cussion/response to social concerns of may be needed during clinical supervision patients and caretakers, on-the-job training by the mental health team. For example, it of health workers, case conferences has been fairly di⁄cult for primary health with patients, counselling to patients, and workers to di¡erentiatebetween depression, identifying and dealing with patients who anxiety, and somatic problems, thus need rehabilitation. Because of limited preferring combining all of these into one resources, only two members of the team diagnostic category. The health worker’s accompany the outreach each time. How- ability to make an accurate diagnosis is a ever, a psychiatric clinical o⁄cer goes on bonus and most trained primary health every visit with other members of the team. workers have generally shown improve- Only 10 health units out of the original ment in identifying major diagnostic 15 health units are currently visited, due categories. to ¢nancial limitations and the heavy work- load of the mental health team at the Awareness raising activities regional hospital. Sensitization meetings with community members During the visits, clinics are heldjointly with In Rubindi sub-county, with a population of the primary health workers present at the about 18000 people, community sensiti- health unit. At the clinic, the psychiatric zation meetings were carried out in clinical o⁄cer or a psychiatrist conducts the seven parishes. Over the course of one year, clinical interview, performs a mental state each parish had ¢ve sensitization meetings, examination, and collects information on with 30 participants attending each session. illness history with additional information Elders, religious leaders, teachers, local provided by relatives who accompany the leaders, traditional healers, traditional patient. The diagnosis is determined using birth attendants, and representatives of DSM-IVcriteria. Case notes are kept in the interest groups for women, youths and patients’notebooks, whichthe patientcarries disabled persons attended meetings. Sensiti- back and forth; as they form a good basis zation meetings focused on common mental for follow up. Patients seen are recorded in a illnesses, beliefsandattitudestowardsmental

123 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Pioneering work in mental health outreaches in rural, southwestern Uganda Intervention 2008, Volume 6, Number 2, Page 117 - 131

illness, approach/handling/care of persons community; encouragement of community with mental health problems in the social support especially to patients and community,the community’srole in promot- families; help in the resettlement of patients ing mental health, importance of early and their engagement in productive activi- identi¢cation and early referral of patients ties; and liaison work between the com- for medical treatment, as well as the resettle- munity and health unit. These volunteers ment of patients. are motivated young people who have basic literacy skills. They are also natives of the Development and printing of posters and lea£ets villages they serve, and live and work within Given the need for increased public aware- their villages/parishes. Although they do ness of mental disorder, we developed posters not demand payment for their service, they and lea£ets containing important and basic are provided an incentive in the form of a health messages for use in educational lunch allowance and bicycles to facilitate campaigns, and pre tested them in schools, movements within the villages. in adult community groups, with patients during health education talks, and with Medication supply health workers. These materials were then Medication supply by the government further adapted for printing. The printed healthunits/hospitals is inadequate andoften materials were distributed to patients, care- unreliable. As mentioned, it is government givers, schools, community leaders, and policy to provide free medication to patients, health workers. These materials served as although in most cases medications are useful stimulators of discussion during lacking and patients do not get the mental health education campaigns and prescribed treatment. Patients and care community sensitization meetings. givers appreciate the importance of medication, and therefore the absence of Community volunteers (village medication in health units is a source health workers) of frustration and greatly contributes to Duringcommunity sensitizations in Rubindi poor compliance. sub-county, it became apparent that com- In the light of this problem, patients and munity volunteers were needed to motivate caregivers resolved to contribute to the patients with regard to seeking treat- purchase of medications. During the discus- ment,compliance of treatment and to sionsleading uptothisdecision,thefollowing encourage caregivers to support patients in issues were considered: the distance travelled these e¡orts. Community members selected to a regional hospital, the waiting time, the volunteers to receive some basic training and the expenses involved in terms of instruction inthe areaof mental health. Each transport and purchase of the prescribed parish hasat leastonevolunteer.Community medications from private pharmacies in the volunteers have the following responsibil- event medications at the hospital were not ities: identi¢cation and referral of patients in stock. Support for the idea of contribution for treatment; home visits (follow up of to medication purchasing was partly due patients, assessment of home situation and to increased awareness of the dangers treatment compliance); provision of basic associated with lack of medication, e.g. that information to the community concerning patients with epilepsy have more frequent the care of mental health patients in the attacks and that those with mental disorders

experience symptomexacerbation. A patient Work in refugee camps pays3000 Ugandan shillings (approximately Services were extended to internally dis- US $1.50) £at rate at every visit to the mental placed people residing in the Kanyaryeru, health outreach unit. Nakivale and Oruchinga refugee camps. Thepaymentsystemworksbestinhealthunits Psychosocial problems are common among attached to churches. Those who are unable these internally displaced people and to pay are giventreatment, but asked to make refugees. Many people presented with up the payment in subsequent visits. In cases somatization, depression, anxiety disorders, where a chronic mentally ill patient has no post traumatic stress disorder (PTSD), sub- money whatsoever, the committee managing stance abuse, helplessness and loneliness. the fund meets to discuss the issue, and may In one meeting with the refugees, one male recommend that such a patient be exempt refugee said: ‘here as refugees there is no man; frompayment. In a few cases, the community Red Cross is the ‘‘man’’’. When asked to clarify, has helped patients who fail to pay. he said that as men, they have lost the power to take charge and provide for their families; Working with traditional all of them line up for handouts, a situation healers shared by all men in the meeting. In the course of our work, we realized that Support groups have been formed for nearly all mental health patients ¢rst sought traumatized persons.Women in Kanyaryeru help from traditional healers. Therefore, we with psychosocial problems bene¢ted from approached one prominent traditional the support groups and from praying healer who agreed to organize other healers togetherat leasttwiceaweek. Incon£ict-torn for meetings, with the aim of establishing areas where existing health services are collaboration. We have been in contact with inadequate, traumatized persons may rely 20 traditional healers who agreed to on religious coping mechanisms (Scholte, work with us, especially in the areas of refer- Ol¡,Ventevogel, deVries, Jansveld, Cardozo ral of patients, exchange visits and sharing & Crawford,2004).Testimonies couldbe seen of information. Thus far, traditional healers as contributing to create a bridge between have visited the health units and interacted the psychological and social processes of with the sta¡, and some health workers have recovery. More important than the testimo- had the opportunity to visit the shrines of nies in this process, was the opportunity pro- the traditional healers. Some traditional vided through bible study groups at the healers have referred patients to the health churches for members to create a new net- units, and patients and relatives who have work which facilitates bonding and social expressed an interest in consulting a cohesion (Tankink, 2007). Primary health traditional healer have not been discour- care systems need to be aware of the silent aged. Our methods are similar to a su¡ering of traumatized persons to ensure community mental health intervention in the development of appropriate intervention Sierra Leone, where collaboration was strategies. established with traditional healers, who allowed reciprocal visits to their healing Results consultations and who attended outpatient Table 1 shows the distribution of patient sessions and training workshops (de Jong attendanceathealthcareunitsduringthepast &Kleber,2007). three-year period. In total, 12957 patients

125 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Pioneering work in mental health outreaches in rural, southwestern Uganda Intervention 2008, Volume 6, Number 2, Page 117 - 131

(2621 new patients, 10336 re-attending epidemic has had an impact on mental patients) were seen at 10 outreaches (health health in the population, the identi¢cation care units).The total number of new patients of mental disorders associated with HIV/ seen by the mental health outreach pro- AIDS has thus far not been emphasized in gramme increased approximately four-fold the outreaches. during the three year period. Patients with Although for most diagnostic categories, the epilepsy (1563 new patients,8101re-attending numbers of new patients seen tended to patients)comprisedbyfarthelargestdiagnos- increase over the three years, the proportion tic group within the total patient sample of new patients within each of the main diag- (74.5%). nostic categories remained approximately The majority of the patients presented thesamefromyeartoyear,withtheexception with epilepsy, brief psychotic disorder, and of severe learning disabilities, where the depression. Very few patients present with number of new patients decreased slightly alcohol problems at the healthunits possibly over the three years (see Table 2), partly because in the community, alcohol is because we did not o¡er specialized services socially accepted. Drinking and getting to this category of patients. Due to the usual drunk are considered normal behaviours. di⁄culties involved in record keeping at Some patients do, however, present with a primary health centres, it has not been dual diagnosis of alcohol problems with possible to further stratify (e.g. gender, age) another diagnosis. Women have twice the information provided inTables 1and 2. the number of depressive disorders than The implementation of the project has men, as seen in numerous epidemiological resulted in improved mental health services surveys in low and high income country in the rural and remote communities in the settings (Rihmer & Augst, 2005). In district. The integration of mental health Uganda, men do not easily express their care with primary health care services has depressive feelings, while women do and provided better access to treatment for seek help. Finally, although the HIV/AIDS patients with mental disorders. Continuity

Table 1. Patients’attendance at health care units served by the mental health outreach during the years 2002^2004 Diagnosis by year 2002 2003 2004

Schizophrenia 95 128 174 Psychotic disorder 359 485 561 Depression/anxiety disorder 441 491 333 Bipolar a¡ective disorder 39 50 78 Epilepsy 2330 3614 3720 Severe learning disabiltiy 37 16 16 Total attendance by year New Re-attendence 2002 388 2913 2003 684 4100 2004 1549 3323

of care, with patients being managed at Therefore, continuity of medication supply nearby health units and/or in their homes, and associated care inputs must be assured has resulted in generally improved levels of if the service is to be meaningful to patients functioning. Indeed, as indicated in Table 1, and their families. Furthermore, it is often patient attendance has greatly increased. dangerous to abruptly discontinue an Patients that have been treated at Mbarara essential psychotropic medication or anti- regional hospital when discharged can be convulsant. Additionally, patients with followed up at the nearby health units, thus severe mental disorders without supportive decongesting the hospital. The involvement families maybe especially pronetotreatment of the community and the training of com- non-compliance, because no one encourages munity volunteers has helped in the early themto stay onthe medication.While a large identi¢cation and referral of patients to number of patients with epilepsy respond nearby health units, and also reduced the well to treatment, some continue to get level of stigmatization of mental health seizures despite the medication adminis- patients and those su¡ering from epilepsy tered, which causes considerable frustration (reduced hostility, isolation, exclusion and for patients and family members. Many discrimination of patients). communities that have been mobilized and Thus far, commitment to the outreach sensitized have then actively participated program is high among sta¡ members at in helping patients to access treatment. the local clinics. However, some health However, the importance of continuous workers have complained of extra work. pharmacological treatment has still notbeen Some improvement may be needed in the recognized in the more remote areas, and data collection process in the future, in order therefore some patients remain in villages to alleviate this problem. The increasing locked up/or held in chains without medical numbers of patients with mental health help, thereby increasing the risk of the disorders being seen and treated in the development of chronic illness and long outreach clinic certainly bears a risk of term social disability (social rejection, work increasing the burden for primary health handicap). workers. However, perhaps this will encourage the Ministry of Health to develop ap- Discussion propriate strategies in order to respond to In the context of community mental health, the mental health needs of the population. both the United States and the United King- Fortunately, the Ministry of Health is dom have been reducing psychiatric inpati- currently advocating for the integration of ent facilities over the last four decades, mental health intotheexistinggeneralhealth favouring instead non-institutional altern- services at all levels. We believe this gives atives (Raftery,1992).In developed countries the best guarantees for sustainability. such as the UK, mental health services are The lack of psychiatric and anti-epileptic well developed with good resources and drugs and supplies creates a danger for adequate sta⁄ng levels, and care is provided patients who seek treatment, but who must within a standardized health care delivery return home without having received system. Low income countries have never adequate medication. Such patients may lose hadthe opportunity to establish ‘decentralized’ con¢dence in the services and cease to seek institutional mental health care. Thus, medical help at the health unit in the future. moving in the direction of an outreach

127 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Pioneering work in mental health outreaches in rural, southwestern Uganda Intervention 2008, Volume 6, Number 2, Page 117 - 131

service is both a necessary step due to the ) n

( geographical remoteness of some regions,

Total lack of trained mental health professionals, and the limited number of institutional facilities. It is also a development that is well in line with current conceptualizations regarding the negative e¡ects of institutiona- lization. Traditional life styles that stress )% n ( social support constitute an advantage for the integration of mental health disability with primary health care systems, where Severe learning the involvement of family may be seen as an essential component of mental health care (Murthy,1998). )%

n Much of the success of the mental health out- reachisduetotheactivitiesofthecommunity volunteers.Their involvement in linking the community to health services, early identi¢- cation, referral of patients for treatment

)%( and follow up of patients in homes has been (37) 61.1% (954) 0.4% (6) 100.0% (1549) (17) 56.6% (387) 1.8% (12) 100.0% (684) n of major importance for improving the qual- h, by diagnostic group Bipolar disorder Epilepsy

1.6% (6) 57.2% (222) 5.7% (22)ity of life 100.0% (388) of the mentally ill. This compares well with the work done by family welfare educators of Botswana. Family welfare educators help in preventive aspects of health )%(

n care, and encourage all identi¢ed patients to attend outreach clinics (Ben-Tovim,1983). anxiety

Depression/ The results of our mental health outreach show that with the help of special training, nized, catatonic schizophrenia). primary health care workers can improve hizophreniform disorder, Psychotic disorder (N.O.S). their knowledge and skills regarding mental )%( n

( illness. Consequently, the majority of patients with mental health disorders may disorder Psychotic be managed at the lower health care units. Community based health care for mental illness has several advantages. Patients may be more motivated for treatment when )% n treatment is delivered in a familiar and sup-

%( portive environment, without disruption of family, social and community networks. Schizophrenia Community based treatment in rural areas also eliminates the need for costly travel and thus improves patient compliance and 200220032004 4.6% (18) 6.1% (42) 3.1% (48) 9.8% (38) 13.7% (94) 13.4% (208) 21.1% (82) 19.3% (132) 19.1% (296) 2.5% 2.4% Table 2. Proportion of new patients seen by mental health outreac Note: Schizophrenia (commonly seen types include disorga Year Psychotic disorders include Brief psychotic disorders, Sc treatment follow up. Patients are able to walk

to the treatment units, where they are seen recognize culturally relevant ways of coping, quickly by health workers who are familiar e.g. prayers or rituals at times of di⁄culty to them and who have a receptive attitude (Inter-Agency Standing Committee (IASC), towards patients. Community mental health 2007).Prayers give social support and relaxa- services are thus more ‘u se r ’ friendly than tion, help to diminish trauma, and provide a distant regional hospitals. form of emotional ventilation through testi- Refugees, especially men, ¢ndthemselves ina monies. This type of interpersonal sharing situation where they have no power or may have considerable therapeutic bene¢ts. authority over their families since agencies The long term impact of con£ict on mental take over control and provide thebasic neces- health necessitates the establishment of a sities.Yearsof refugee life seems to have pro- comprehensive mental health care service moted a ‘learned helplessness’ where people feel that can competently address the psychologi- little power to control or in£uence their own cal problems experienced by the community. lives (Seligman,1975).War results in extreme The government of Uganda through the su¡eringofthecivilianpopulation, especially Ministry of Health recognizes this need.The women and children. There is little question Health Sector strategic Plan II (MOH, 2005) that emotional distress and psychosocial pro- provides a framework for special approaches blems can be directly related to being a survi- fordeliveryofhealth services incon£ictareas, vor of violence and displacement (Marsella, especially in the north. The Ministry of Bornemann, Ekblad & Orley,1994). Psycho- Health is increasing its support to the train- logical intervention is therefore important in ing of health workers and mental health out- emergency situations, as well as in long term reaches and psychiatrists receive ¢nancial rehabilitation, by providing psychological support from the government to do clinical support and prevention of complications. supervision in upcountry hospitals. Moreover, the HIV/AIDS pandemic that has caused severe loss of life, increased caring of Challenges ill relatives and orphaned children, family Despite considerable service improvement, a fragmentation, domestic violence and other numberofongoingchallengeswarrantfurther common forms of abuse, has undoubtedly attention.Theseincludetheinadequatesupply also had adverse psychological e¡ects on the of drugs, the stigma associated with mental majority of the population. Therefore, it is illness, the tendency among some health important to educate the general population care workers to view mental illness as less that most forms of su¡ering may cause psy- important than other illnesses, and the di⁄- chological problems and/or mental health culties associated with the management of problems, and that they are treatable. mental illness, especially schizophrenia, While dealing with communities, it is also where treatment compliance is poor. There important to determine which coping are still many people with psychosocial pro- methods may be most appropriate in that blems who do not seek help. Finally and most particularculturalsetting,suchasthetrauma- seriously, the long term sustainability of the tized women in Kanyaryeru who responded outreach program remains uncertain. well to prayers. In developing appropriate materials, it is important to identify the Recommendations range of expected individual and community Based on our accumulated experience, we reactions to severe stressors (e.g. rape) and to suggest that mental health services be easily

129 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Pioneering work in mental health outreaches in rural, southwestern Uganda Intervention 2008, Volume 6, Number 2, Page 117 - 131

accessible, especially to the rural poor, and Ben-Tovim (1983). A Psychiatric Service to the that basic drugs should be made available Remote Areas of Botswana. British Journal of without unnecessary interruption. The Psychiatry, 142,199-203. IASC guidelines on mental health and psychosocial support should be made available Brooker, C., Tarrier, N., Barrowclough, C., But- to primary health care workers. Nongovern- terworth, A. & Goldberg, D. (1992).Training mental organizations should be encouraged communitypsychiatricnursesforpsychosocial to enter the area of mental health, ande¡orts intervention. British Journal of Psychiatry, 160, should be made to promote public awareness 836-844. of mental health issues. De Jong, K. & Kleber, R. J. (2007). Emergency con£ict-related psychosocial interventions in Conclusion Sierra Leone and Uganda: Lessons from By increasing knowledge and access to Me¤decins Sans Frontie' res. Journal of Health treatment within the community, mental Psychology,12,485-497. disorders and psychological problems can be managed very e¡ectively, rarely requiring Eisenman, D., Weine, S., Green, B., DeJong, J., referral to larger hospitals. Such decentra- Rayburn, N., Ventevogel, P., Keller, A. & lization need not be costly. Through the Agani, F. (2006).The ISTSS/Rand guidelines support of continued training of primary on mental health training of primary health- health care workers, community volunteers, care providers for trauma-exposed popu- and increased community awareness, many lations in con£ict-a¡ected countries. Journal more patients couldreceive quality treatment ofTraumatic Stress, 19,5-17. closer to their homes. While improving the health and productivity of the rural popu- Gureje, O., Omigbodun, O. O. Gater, R., Acha, lation,italsoencouragespatientstoseektreat- R.A.Ikuesan,B.A.&Morris,J.(1994).Psy- mentearlier,reducingtheburdenofadvanced chiatric disorders in paediatric primary care cases at the regional hospital. clinic. BritishJournal of Psychiatry,165, 527-530.

Inter-Agency Standing Committee (IASC) Funding (2007). Inter-AgencyStandingCommitteeGuidelines This project was supported by the Sir Halley on Mental Health and Psychosocial Supportin Emer- Stewart Trust, a charity organization in the gency settings. Geneva: IASC. UK throughTropical Health and Education Trust (THET) UK.The Red Cross and more Kasoro, S., Sebudde, S., Kabagambe-Rugamba, recently, the GermanTechnical Cooperation G., Ovuga, E. & Boardman, A. (2002).Mental (GTZ) supported the mental health work in illness in one district of Uganda. International the refugee camps. Journal of Social Psychiatry,48(1), 29 -37.

Marsella, A. J., Bornemann, T., Ekblad, S. & References Orley, J. (Eds.). (1994). Amidst peril and pain: Acorn, S. (1993). Use of the Brief Psychiatric The mental health and well-being of the world’srefu- Rating Scale by nurses. Journal of Psychosocial gees.Washington, DC: American Psychological Nursing and Mental Health Services, 31,9-12. Association.

Ministry Of Health (MOH) (2000). Health Sector Seligman, M. E. P.(1975). Helplessness: on depression, Strategic Plan 2000/01^2004/05. Kampala, Min- development and death. San Francisco:W H Free- istry of Health, Uganda. man.

Ministry Of Health (MOH) (2005). Health Sector Scholte,W.F. Ollf, M., Ventevogel, P., deVries, G.- Strategic Plan II, 2005/06^2009/2010). Kampala, J., Jansveld, E., Cardozo, B. L. & Crawford, Ministry of Health. C. A. G. (2004). Mental health symptoms following war and repression in eastern Afghani- Ministry Of Health (MOH) (2006). Uganda HIV/ stan. JAMA, 2 92(5),585-593. AIDS sero-behavioural Survey 2004-2005.Kam- pala, Ministry of Health. Tankink, M. (2007).‘The moment I become born- again the pain disappeared’: The healing of Murthy, R. S. (1998).Rural psychiatry in develop- devastating war memories in born-again ing countries. Psychiatric Services, 49,967-969. churches in Mbarara District, Southwest Uganda.Transcultural Psychiatry,44, 203-231. Orley,J.& Wing,J.K.(1979).Psychiatricdisorders in two African villages. Archives of General Psy- Ventevogel, P. & Kortmann, F. (2004). Develop- chiatry, 3,513-520. ing basic mental health modules for health workers in Afghanstan. Intervention, 2(1), 43- Raftery, J. (1992). Mental health services in tran- 54. sition: the United States and United Kingdom. BritishJournal of Psychiatry, 161, 589-593. World Health Organization (WHO) (1978).Alma Ata: Primary Health Care Report. Geneva: Reeler, A. P. Williams, H. & Todd, C. H. (1993). World Health Organization. Psychopathology in primary care patients: a four year study in rural and urban settings in Zimbabwe. Central African Journal of Medicine, Elias Byaruhanga is a principal psychiatric 39(1), 1-7. clinical o⁄cer in the Department of Psychiatry of Mbarara University Teaching Hospital, Rihmer, Z. & Augst, J. (2005). Mood disorders: Mbarara, Uganda. email: eliashanga@ epidemiology.In: B. J.Kaplan, & V.A. Sadock yahoo.com (Eds.), Kaplan and Sadock’sComprehensiveTextbook Elizabeth Cantor-Graae is associate professor of Psychiatry (8th edition, pp. 1578^1579). New in psychiatric epidemiology, at the Division York: LippincottWilliams & Wilkins. of Social Medicine and Global Health, at Lund University, Sweden. email: Elizabeth. Sartorius, N., Ustun, T. B. Costa de Silva, J. A. [email protected] Goldberg, D., Lecrubier, Y., Ormel, J., Von Samuel Maling is a psychiatrist. He is with the Kor¡, M. & Wittchen, H. U. (1993). An inter- department of Psychiatry, Mbarara University national study of psychological problems in of Science and Technology, Mbarara, Uganda. primary care. Preliminary report from the email: [email protected] World Health Organization Collaborative Jerome Kabakyenga is a public health specialist Project on‘Psychological Problems in General at the Faculty of Medicine, Mbarara University Health Care’. Archives of General Psychiatry, of Science and Technology, Mbarara, Uganda. 50(10), 819 - 823. email: [email protected]