PERCEPTIONS OF MENTAL ILLNESS IN SOUTH- EASTERN NIGERIA: CAUSAL BELIEFS, ATTITUDES, HELP-SEEKING PATHWAYS AND PERCEIVED BARRIERS TO HELP-SEEKING UGO IKWUKA BA, BSc, MA June 2016 A thesis submitted in partial fulfilment of the requirements of the University of Wolverhampton for the degree of Doctor of Philosophy The exploratory studies of three of the four chapters of this work have been published in peer reviewed journals. SAGE granted an automatic ‘gratis reuse’ for the first publication on causal beliefs that allows for the work to be posted in the repository of the author’s institution. Copyright licence (no. 3883120494543) was obtained from John Wiley and Sons to republish the second paper on attitudes towards mental illness in this dissertation. Copyright licence (no. 3883131164423) was obtained from the John Hopkins University Press to republish the third paper on barriers to accessing formal mental healthcare in this dissertation. The exploratory study on Pathways to Mental Healthcare has been accepted for publication in Transcultural Psychiatry with the proviso that it is part of a doctoral dissertation. Save for any express acknowledgments, references and/or bibliographies cited in the work, I confirm that the intellectual content of the work is the result of my own efforts and of no other person. The right of Ugo Ikwuka to be identified as author of this work is asserted in accordance with ss.77 and 78 of the Copyright, Designs and Patents Act 1988. At this date copyright is owned by the author. Signature……………………………………….. Date…………………………………………….. Acknowledgments I share the communitarian worldview that ‘a tree cannot make a forest’ which was clearly demonstrated in the collective support that made this research possible. The Igbo people and the Judeo-Christian tradition which I also share furthermore believe that ‘the forest’ is made up of the seen and the unseen. I am therefore very grateful to God and to all who contributed directly or indirectly to the realisation of this initiative. Dr. Lovemore Nyatanga who supervised my BSc project in Applied Psychology (University of Derby) guided me with pragmatic precision on what I wanted to do at the time but lacked the clarity of thought and methodology. I am grateful to him and Dr. Abiodun Adewuya of Lagos State University (Nigeria) whose work he recommended which enlightened me at those early stages and heightened my motivation to further research in mental health in sub-Saharan Africa. Dr. Adewuya generously obliged me his research instruments when I eventually contacted him. Prof. Ken Manktelow kindly facilitated my admission for the doctoral programme. He was instrumental in my getting the studentship for this research. He helped with mapping out the framework for the research and was also instrumental in placing me in the hands of a dream supervisory team which included himself, Dr. Jo Chen-Wilson and Dr. Niall Galbraith who led the team. Ken also read and revised the drafts of all the emergent publications from the research. Dr. Jo demonstrated genuine interest in my work and kept supplying me with relevant bits and pieces of information till the end. She also facilitated the invaluable seminar series of the Department that enlightened and equipped me with the skills for the tasks ahead. Dr. Niall Galbraith my Director of Studies provided the support that made this project realisable. He was instrumental in my getting the studentship for the research and was personally involved from the beginning to the end. He provided the template and schedule for the research which we meticulously followed and which set the research in seeming auto- cruise. Niall was available and provided guidance at every step of the process. He was re- assuring on the many occasions when I had doubts. It was also his idea that we engage the services of external advisors in the field who are conversant with the target population. This proved a masterstroke as it led to our engagement of Prof. Femi Oyebode, Head of Psychiatry in the University of Birmingham and Dr. Rosemary Muomah of the Department of Psychological Medicine, University of Nigeria Teaching Hospital, Enugu. Prof. Oyebode’s interventions ensured that the project addressed pertinent questions while Dr. Muomah who resides in Nigeria ensured that it was well grounded in the Igbo context. Both also revised the drafts of the emergent publications and made very critical interventions. i Dr. Anulika Igboaka, a young Nigerian-British psychiatrist with Northwick Park hospital, London, proof-read emergent manuscripts from the study and also made critical observations. I equally benefitted from the insights and constructive criticisms of the many anonymous reviewers of the emergent publications from the research. The staff of the Department of Psychology and fellow doctoral students across faculties demonstrated supportive interest in the research process. While it lasted, Prof. Chike Oduoza of the Faculty of Science and Engineering remained a ‘big brother’ and Danielle Joyce a sister away from home. I dedicate this work with gratitude to friends whose goodwill and financial support made it possible: Fidel and Oby Eneh, Emma and Mary Ogagarue, Gabriel and Tonia Pidomson, Steve and Ify Ekwelibe, Emeka and Nkiru Onuora, Paul B. and Ijeoma Enidom, Bob and Aku Odinkemelu, Vin and Rosebells Uviovo, Johnny and Oby Arachie, Mike and Edith Ezenduka, Chinelo Nwosu, Ozioma Agu, Pet Tabansi, Pat Muoghalu, Austin Odili, Ikenna and Esther Okafor, Ken and UK Agbiriogu, Jude and Beatrice Nabie, Ikenna Chigbo, Stella Muoneke and a host of others. Teachers, students, friends and relatives both in Nigeria and in the UK were practically conscripted and trained to administer the questionnaires for this research. These worked hard as the foot soldiers in the exhaustive field work. I am grateful to Chiamaka Uzoh, Ukamaka Onwuneme, Oby Ewulu, Mike Alakwe, Chika Uche (nee Anyigbo), Oge Ilo, Uju Emelife, Ngozi Ogboji, Onyeka Igboaka, Keren Osunkwo, Uju Oti, Adaobi Okwuora, Uju Onuigbo, Oge Ogunanobi, Ngozi Oguanobi, Nnedi Chukwunwike, Concilia Odimegwu, Concilia Esiaka and many others. I am also grateful to the many institutions and establishments that accepted my application to survey their members. I am most grateful to the over 2,500 participants who were surveyed in the course of the research. This work would not have been possible without their availability. I thank friends, colleagues, my secretary Patricia and her assistants Mary and Maureen who directly bore the psychological brunt of this research. As we hopefully come to the end of a cycle, I pray and hope that I have retained their friendship still. Finally, my mum could not wait to see the end of the tortuous process. I could count on her genuine concern for me to get the job done with and get a life. Thank you ma. I hope we’ll all soon heave a sigh of relief. Ugo Summer, 2016 ii Abstract To provide empirical basis for mental health interventions in the deprived sub-Saharan African region, this study explored the perspectives of the Igbo people of south-eastern Nigeria on four dimensions of mental illness: causal beliefs, attitudes towards sufferers, preferred treatment pathways and perceived barriers to accessing formal psychiatric care. Mixed sampling methods were used to select participants who completed quantitative questionnaires. The number of participants varied between 200 and 706 in the exploratory studies but remained constant (n = 1127) in the confirmatory studies. The study found mixed endorsements of the supernatural, biological and psychosocial causal explanations with supernatural causations being significantly more endorsed. The study also found mixed treatment preferences with formal psychiatric care being significantly more preferred to the spiritual pathway which was in turn significantly more preferred to the traditional pathway. Significant negative attitudes and desire for social distance from persons with mental illness were observed across groups. Barriers to accessing mental healthcare were also significantly perceived with ideological barriers being significantly more perceived than instrumental barriers. Systematic associations were found between causal beliefs and treatment preferences: supernatural causal belief predicted preference for the spiritual and traditional treatment pathways while psychosocial causal belief predicted preference for both formal psychiatric care and the traditional treatment pathway. Mixed causal attributions and treatment preferences reflect holistic view of health and healing and calls for the evolution of complementary model of care that would incorporate people’s spiritual and cultural needs. The prospect is supported in psychosocial causal beliefs being associated with preference for the traditional treatment pathway. Significant negative attitude is a contradiction in the traditionally communitarian and predominantly Christian culture, and is deserving of intervention in the context where the solidarity of the social network should compensate for the inadequate mental healthcare. Significantly more ideological than instrumental barriers have crucial policy implication; improved conceptualizations of mental illness should precede improvement of facilities and services or else these could be underused. Demographic correlates of causal beliefs, negative attitudes, pathway preferences and barriers to accessing formal mental healthcare care were determined for targeted interventions. iii Table of Contents 1. Abstract .................................................................................................................................ii.