Socio-Economic Factors Associated with Mental Health Disorders in Fort Portal, Western Uganda

South African Journal of Psychiatry ISSN: (Online) 2078-6786, (Print) 1608-9685 Page 1 of 8 Original Research Socio-economic factors associated with mental health disorders in Fort Portal, western Uganda Authors: Background: Mental health disorders, which are interlinked with social issues such as poverty 1 Charlotte Hawkins and stigma, present a significant burden in Uganda. John M. Bwanika2 Martin Ibanda3 Aim: This article explores perceptions about and experiences of mental health disorders in western Uganda, particularly as they pertain to the socio-economic context. Affiliations: 1 Department of Setting: The research was conducted in the mental health unit at the Fort Portal Regional Anthropology, University College London, London, Referral Hospital, Kabarole District, Uganda. United Kingdom Method: This article is based on qualitative anthropological research conducted from January 2The Medical Concierge to March 2017, including 49 semi-structured interviews about ideas and determinants of Group Limited, Kampala, mental health, with health workers, former mental health service users, their relatives and Uganda influential community members. 3Mental Health Unit, Fort Results: Many interviewees felt that mental health disorders are an increasing problem in their Portal Regional Referral community. Economic challenges, such as poverty, unemployment and financial stress, are Hospital, Fort Portal, Uganda seen as both a cause and a consequence of mental illness. Mental health challenges can be exacerbated by shortages in mental healthcare, which are shown to be complexly interrelated Corresponding author: Charlotte Hawkins, with stigma. charlotte.hawkins.17@ucl. ac.uk Conclusion: This article provides an insight into mental health experiences in Fort Portal based on the perspectives of various interviewees. Further funding and research are Dates: recommended to inform contextually appropriate services. Received: 01 Mar. 2019 Accepted: 11 Nov. 2019 Keywords: mental health; mental health services; stigma; economic stress; outreach; Uganda. Published: 07 July 2020 How to cite this article: Hawkins C, Bwanika JM, Introduction Ibanda M. Socio-economic According to the 2010 global burden of disease survey, mental, neurological and substance use factors associated with mental health disorders in (MNS) disorders are leading causes of the disease burden, responsible for 10.4% of ‘Disability- Fort Portal, western Uganda. Adjusted Life Years’ (DALYs).1 The World Health Organization (WHO) recognises an ‘escalating S Afr J Psychiat. 2020;26(0), a1391. https://doi.org/10. burden of mental disorders’ around the world, which are determined by both individual attributes 4102/sajpsychiatry. and broader contextual issues.2 v26i0.1391 Socio-economic factors are particularly influential in determining both mental health disorders Copyright: © 2020. The Authors. and the effectiveness of mental health policies and services. The mental health burden is therefore Licensee: AOSIS. This work disproportionately felt in low-income countries, where poverty is prevalent, and psychiatric is licensed under the Creative Commons specialists, medicines and responsive community-based services are lacking, as stated by the Attribution License. WHO.3 Accessible and cost-effective mental health interventions need to respond to an evidence base of contextual considerations. Whilst there have been no systematic reviews on the prevalence of mental health problems in Uganda to date,4 and there is limited reliable data on hospital utilisation,5 the WHO has estimated that there are a total of 2.2 million people affected by MNS disorders in Uganda, with only 9% of them able to access care.6 According to 2017 data, there are 0.08 psychiatrists for every 100 000 people, as well as 2.24 mental health nurses and 0.5 ‘other paid mental health workers’.7 In the Read online: Scan this QR Kabarole district where this study was based, a 2002 survey of 384 households identified 130 code with your individuals with a mental health disorder in the previous year, leading them to estimate that 31 smart phone or % mobile device of the population experience mental health disorders.8 Whilst the sample is limited, it suggests to read online. that mental health problems are endemic in the district. http://www.sajpsychiatry.org Open Access Page 2 of 8 Original Research Uganda has a high population growth of 3.2%, with a 2018 district, western Uganda. The hospital serves the seven IndexMundi estimate showing that 69% of the population is surrounding districts, including part of eastern Democratic under the age of 25.9 Uganda is classed by the World Bank as Republic of Congo (DRC), comprising 2.2 million people over a low-income country,10 and their assessment notes that whilst an area of 11 000 km2 (Figure 1). Patients are referred to the poverty rates have decreased from 57% in 1993 to 20% in 2013, regional hospital from all health service levels, including inequality is rising and ‘even after two decades of progress, general hospitals, primary healthcare centres and village poverty is still widespread’.11 Epidemiology often determines health teams.1 The mental health unit has a bed capacity of 45 that poverty correlates with higher rates of disease,12 and in-patients and a busy outpatient clinic, which at the time of WHO cites various studies that confirm this relationship the study in 2017 was frequented by approximately 930 people between poverty and mental illness.13 A 2019 study in six low- seeking treatment each month. As it was founded in 2005, the and middle-income countries, including Uganda, found that staff strength, led by the PCO in-charge, has increased from 2 households with a member with an MNS disorder had lower to 24, and patient intake continues to increase. income and higher healthcare expenditure, leading the researchers to conclude that households that have a member with an MNS disorder are ‘susceptible to chronic poverty’.14 Study population and sampling Psychologists have defined poverty-induced breakdown as Interviewees were recruited using a judgement sampling chronic stress or ‘toxic shock’, a response to ‘strong, frequent, approach, selecting respondents most appropriate to the and/or prolonged adversity’,15 which damages ‘brain research interests,18 based on the experience and the network architecture’ and future health. Furthermore, theorists note of the PCO in-charge and the research assistant, an that mental illness and poverty also often exist in a cyclical occupational therapist. This included their colleagues at the relationship with stigma,16 notably so in Uganda.17 This hospital, service users or peer support workers, existing suggests that systemic issues can impact individuals’ mental patient’s attendant relatives and key influential members of health, supporting the relevance of the current study, which is the community, including religious leaders. Chosen sample an exploration of the experiences of mental health disorders in categories were additionally informed by Weiss’ framework relation to the social and economic context in Fort Portal, from for researching health concepts and interventions.22 This the perspective of health workers, former service users and included their colleagues, service users or peer support their relatives. workers, existing patient’s attendant relatives and key influential members of the community, including religious Research methods and design leaders. Interviewees by population, age and gender are outlined in Table 1. This qualitative study used face-to-face, informal, in-depth interviews to collect responses from 49 participants chosen on a judgement basis, or selecting respondents most Data collection 18 appropriate to the research interests. In-depth, semi-structured interviews lasting 1 h on average were conducted in an informal manner to allow for Health workers, mental health service users and their relatives participants’ interpretation of the questions and to elucidate were interviewed by the principal investigator for their views free opinions.18 Interviews mostly took place in an office in the and experiences of mental health problems in the context of the mental health unit. Questions were developed after 2 weeks of Kabarole District. Service users interviewed were formerly in- participant observation in the mental health unit and adapted patients at the hospital and act as peer support workers to assist with feedback from hospital workers. They explored the the hospital with community-based care. Given the subjectivity following areas of particular relevance in this setting: stories and complexity of research interests, holistic qualitative and experiences of mental health disorders; perceptions of methods such as open-ended interview questions were causality; treatment and health education preferences; particularly relevant.19 Research design and implementation attitudes towards medicine; family and community responses; was supported by the psychiatric clinical officer (PCO) in- stigma, exclusion and labelling; self-perceptions; the mental charge at the hospital, who facilitated the research in the mental health system in the region; influence of communicable health unit and assisted with the recruitment of interviewees. A research assistant who works in the mental health unit as an diseases such as human immunodeficiency virus (HIV); and occupational therapist supported data collection with interview perceptions of neurological disorders such as epilepsy. question design and translation into Rutooro.

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