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Exploring Pathways to Care in the Zimbabwean Mental Health Sector

Exploring Pathways to Care in the Zimbabwean Mental Health Sector

Mlambo Nefasi

Professional Counsellor

DOI: https://dx.doi.org/10.47772/IJRISS.2024.802175

Received: 05 February 2024 Accepted: 08 February 2024; Published: 26 March 2024

ABSTRACT

This study investigated pathways to care in mental health treatment in Zimbabwe. Survey method was used to gather data through interviews and focus group discussions. For a period spanning over one year, the researcher randomly interviewed service providers, clinic staff, patients, caregivers/parents and community leaders. 20 Patients and 40 parents/caregivers were randomly selected as they seek services while 80 urban clinic staff, 50 from farm clinics, 50 from peri-urban clinics. 20 major referral hospital staff and 10 ATR practitioners, 30 FBO practitioners were purposively sampled making a total number of 300 participants.  Results from these   encounters revealed that people seeking mental health services use more than one treatment mode. Others use two while the majority use all three. There are varying factors contributing to their choice of pathway to care. Some notable factors revealed were that demographic and socioeconomic characteristics as well as health status shape how one enters mental health care and the subsequent perceptions of the effectiveness of that chosen path. additionally, the pathway to mental health care is associated with perceptions about the effectiveness of treatment. Additionally, severity of a mental illness has a strong bearing on the choice of pathway to treatment.  Findings also revealed that only the medical pathway is used during daylight while half consulted faith based healers during daytime. For ATR the majority visit clandestinely after consulting hospitals during the day. It was concluded that mental health service in Zimbabwe is provided by three means which constitute pathways to care. These are the medical model, the traditional healers and the faith based practitioners. Results were inconclusive as to the efficacy of these pathways to care since some are concurrently used. From the above conclusions, the following recommendations are proposed: multi sectoral collaboration should be encouraged, evidence based practices to be enforced and further research into FBOs and ATR efficacy as well as the correlation between these pathways to care.

INTRODUCTION

Whilst it is not a widely accepted view on the existence of mental illness and its prevalence, there exists more clinical and research implications in Zimbabwe. An estimated 25% of the population experience a mental health issue annually in the country. While there have been considerable research documenting causes of mental illness, symptoms, efficacy of antipsychotics and related phenomena, not much has been done to explore pathways to care in the Zimbabwean Mental Health sector. Most of the research has always focused on mental health treatment in specific settings and efficacy certain interventions. Nothing much has been said or done with regard to factors determining what other or why people use some alternatives for mental health issues. Some go to hospitals, (Medical model) some use traditional healers (ATR) some use religious sectors (FBOs) or both sometimes all the three. These are what constitute pathways to care in this paper and justify the rationale for this research.

METHODOLOGY

The study sought to explore pathways to care in the Zimbabwean Mental Health sector.  it was based on the… design. 300 participants were involved in this research. These were randomly and purposively drawn from  recovered patients, parents/guardians/caregivers, faith based practitioners, traditional practitioners and health officials. Data was collected using interview guides and discussions. It was later presented using narrations

LITERATURE REVIEW

Mental health is a concept that refers to a human individual’s emotional and psychological well-being. The Merriam-Webster dictionary defines Mental Health as “a state of emotional and psychological well-being in which an individual is able to use his or her cognitive and emotional capabilities, function in society, and meet the ordinary demands of everyday life.”

On the other hand, WHO (World Health Organization) Mental Health can be defined as: “A state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”.

The WHO dimension proposes that mental health is not merely an absence of disease or infirmity, but includes having sufficient money to live on, having a job and enjoying relationships and friendships. It is dependent on an individual having a sense of meaning for their life and having control over their life.

So, Mental health has been defined variously by scholars from different cultures. mental health include either subjective well-being, perceived self efficacy, autonomy, competence, or inter generational dependence, and self actualization of one’s intellectual and emotional potential, among others”.

Thus, Mental Health is the balance between all aspects of life – social, physical, spiritual and emotional. It impacts on how we manage our surroundings and make choices in our lives – clearly it is an integral part of our overall health. Despite these different definitions, mental health interventions are still plagued by various, natural and man made challenges.

Mental health and mental illness run along a continuum. When there is no balance between aspects of life or our personal balance is off, either repeatedly or for long periods, we may eventually find ourselves moving closer along the continuum towards mental illness.

Vanhaecht et al. [2000] interchangeably defined the terms ‘care pathway’ or ‘pathway’ as:

“A care pathway is a complex intervention for the mutual decision-making and organisation of care processes for a well-defined group of patients during a well-defined period. The defining characteristics of care pathways include, but not limited to the following:

  • an explicit statement of the goals and key elements of care based on evidence, best practice, and patients’ expectations and their characteristics;
  • the facilitation of the communication among the team members and with patients and families;
  • the coordination of the care process by coordinating the roles and sequencing the activities of the multidisciplinary care team, the patients and their relatives;
  • the documentation, monitoring, and evaluation of variances and outcomes, and
  • the identification of the appropriate resources.

The aim of a care pathway is to enhance the quality of care across the continuum by improving risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources.”

RESULTS/FINDINGS

Whilst under the medical model, the following aspects are covered:

  • explicit statement of the goals and key elements of care based on evidence, best practice, and patients’ expectations and their characteristics;
  • the facilitation of the communication among the team members and with patients and families;
  • the coordination of the care process by coordinating the roles and sequencing the activities of the multidisciplinary care team, the patients and their relatives;
  • the documentation, monitoring, and evaluation of variances and outcomes, and
  • the identification of the appropriate resources.

ATR

  • patients’ expectations
  • communication with patients and families;

FBO

  • patients’ expectations and their characteristics;
  • the facilitation of the communication among the team members and with patients and families;
  • the coordination of the care process and sequencing the activities of the care team, the patients and their relatives;

No documentation, monitoring, and evaluation of variances and outcomes

Much of the research into mental health care is motivated by the findings that most people with mental health problems do not receive treatment in a given year, and although many eventually enter care, it is often after long delays (Walker etal. 2015; Wang, Berglund, etal. 2005; Wang, Lane, etal. 2005). This often results in prolonged periods of untreated psychosis, herein referred to as duration of untreated (DUP). its effects are….

Unmet need for mental health care is framed as a significant public health problem, and there has been enormous research and policy attention to the issue in other nations. Much of this attention is predicated on the assumption that if we can change attitudes about treatment and reduce structural barriers, people will seek help sooner and ultimately, outcomes will improve (Mojtabai, Eaton, and Maulik 2012). This is despite the fact that not all persons receiving mental health care make independent decisions to seek care. It is widely known that most mental health clients rely on forced or coerced interventions by relatives, friends and caregivers.

Rosenfield (1984) Socioeconomically advantaged groups are likely to seek mental health care from the hospital than their counterparts. Some factors influencing the choice of treatment options include predisposing resources such as good jobs, education, knowledge of health systems and services, as well as enabling resources such as access to the available resources centres.

In addition, entry into care involves processes occurring over time and multilevel interactions between individuals, their social networks, and a host of institutions that create and enact policies around mental health services, including involuntary commitment statutes

This is due to perceived effectiveness of treatment and severity of symptoms

Perceived effectiveness of treatment is typically conceptualized as a health belief that motivates or predisposes individuals to enter treatment. Perceived effectiveness may also be considered an outcome in its own right. We know that simply getting services is not enough to ensure full access. In later models, ABM was expanded to include patient perceptions of their health care experiences as important outcomes (Andersen 1995). Patients’ perceptions of the care they receive has long been recognized as an important marker of quality (Donabedian 1988), and understanding patients’ expectations and experiences with health care has become even more important as the health system shifts toward patient-centered care (Davis, Schoenbam, and Audet 2005; Sofaer and Firminger 2005). However, how patients make judgements of their care is complex. Patient preferences and expectations, their social characteristics, along with actual changes in symptoms and well-being will impact patients’ evaluations (Sofaer and Firminger 2005). Most importantly, however, such evaluations also shape outcomes of care.

Among persons who have received treatment, perceived effectiveness of mental health care is a subjective evaluation of whether one thought the treatment helped or worked. Research about perceived effectiveness of mental health treatment indicates that it matters for health outcomes for several reasons. First, perceived effectiveness of mental health treatment is an important predictor of adherence to and future use of mental health services among patients and people in their social networks (Croghan etal. 2003; Edlund etal. 2002; Lippens and Mackenzie 2011). Second, the belief that treatment is effective is associated with greater likelihood of recovery from mental illness (Ojala and Wheeler 2012). It is from this recovery that the same person or relative will use to determine the rightful treatment option in the near future and influenc the pathway to care. Third, it is an indicator of satisfaction with services and may be associated with poor quality (Druss, Rosenheck, and Stolar 1999). Fourth, perceived effectiveness of treatment influences support for policies that aim to improve psychiatric care (Barry etal. 2014). Therefore, understanding perceived effectiveness of treatment among people using mental health services could help inform the delivery of care and ultimately improve service use and outcomes of care.

Perceptions of medical care are influenced by one’s demographic characteristics. Persons from minority racial and ethnic groups and those who are socioeconomically disadvantaged express less trust in doctors and less satisfaction with health care (Boulware etal. 2003; Haviland etal. 2005). These perceptions of care are shaped by differences in expectations of and past experiences with the health care system. While there is less work on differences in views of the effectiveness of medical treatment, it seems reasonable that patterns would be similar. However, in mental health research, the impact of race/ethnicity on attitudes toward treatment has yielded someone mixed findings. On the one hand, in general population studies, African Americans are more likely to believe in the effectiveness of medical treatment for severe mental illness compared to whites (Anglin etal. 2008). On the other hand, among African Americans who have had contact with mental health systems, attitudes toward treatment are more negative (Cai and Robst 2016; Cooper etal. 2003; Diala etal. 2000), perhaps reflecting prior negative experiences.

Perceptions and subsequent choice of care pathway may be influenced by whether one enters care by choice. Studies mainly done in the inpatient context suggest that perceived coercion interferes with therapeutic alliance (Sheehan and Burns 2011). Moreover, coercive mental health treatment is linked to feelings of helpless and disempowerment (Abderhalden etal. 2006), which might be expected to influence how well patients believe the treatment worked. If individuals perceive that their symptoms are severe or their need is evaluated to be serious by professionals, whether and how they enter into care might be linked to their views about the effectiveness or benefits of psychiatric treatment. Given enabling resources such as health insurance and the timely availability of mental health professionals, those who seek mental health services on their own might be more likely to believe that the treatment will work.

The goal of mental health providers and policymakers should be to improve positive expectations of treatment.

Others also join the medical model as a last resort and it is upon realization of good outcomes that they will continue with the new found model. Otherwise they might continue with their old practices. It should also be noted that these people will not be completely weaned off their original practices. Seeking services is also dependent on belief system strengths and social or traditional orientation. Social factors play a pivotal role in determining pathways to care.

CONCLUSIONS

Mental health care is associated stigma or fear of harm to self or other. Seeking help is sometimes limited by symptoms and severity.it was also noted that sociodemo graphic characteristics are closely associated with pathways to mental health care. These factors highly contributes to the nature of pathway to care.

This set of findings linking demographic, socioeconomic, and health status characteristics with pathways to care and treatment effectiveness contributes to the body of research that seeks to understand how clients make a choice among the three pathways to mental health care.

RECOMMENDATIONS

  • Multi sectoral collaboration should be encouraged
  • Evidence based practices to be enforced
  • Further research into FBOs and ATR efficacy
  • It is also important to make government to ensure that resources that help people seek mental health care are uniformly distributed:
  • Education around the location and benefits of services, employment of people with mental health problems, access to and affordability of care
  • Responsible authorities to avail resources which facilitate self-entry into mental health care.
  • Put in place measures to curb discrimination, maltreatment, and mistrust in the mental health system

REFERENCES

  1. Alang, S. M., & McAlpine, D. D. (2019). Pathways to Mental Health Services and Perceptions about the Effectiveness of Treatment. Society and Mental Health, 9(3), 388–407. https://www.jstor.org/stable/48683951
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  3. Druss, B. G., Rosenheck, R. A., & Stolar, M. (1999). Patient satisfaction and administrative measures as indicators of the quality of mental health care. Psychiatric Services, 50(8), 1053–1058. https://doi.org/10.1176/ps.50.8.1053
  4. Mojtabai, R., Eaton, W. W., & Maulik, P. K. (2012). Pathways to Care: Need, Attitudes, Barriers. In Public Mental Health Oxford University Press. https://doi.org/10.1093/acprof:oso/9780195390445.003.0015
  5. Rosenfield, S. (1984). Race differences in involuntary hospitalization: Psychiatric vs. labeling perspectives. Journal of Health and Social Behavior, 25(1), 14–23. https://doi.org/10.2307/2136701
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  7. Sofaer, S., & Firminger, K. (2005). Patient perceptions of the quality of health services. Annual Review of Public Health, 26, 513–559. https://doi.org/10.1146/annurev.publhealth.25.050503.153958
  8. Vanhaecht, Kris, et al. “Clinical pathway audit tools: a systematic review.” Journal of nursing management 14.7 (2006): 529-537.
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