Impact of Socio-Cultural Factors on Early Intervention in Psychosis: Goromonzi, Mashonaland East Province, Zimbabwe.

Impact of Socio-Cultural Factors on Early Intervention in Psychosis: Goromonzi, Mashonaland East Province, Zimbabwe.

Mlambo N

Zimbabwe Open University

DOI: https://dx.doi.org/10.47772/IJRISS.2024.804092

Received: 15 November 2023; Revised: 03 December 2023; Accepted: 08 December 2023; Published: 09 May 2024

ABSTRACT

This paper discusses Socio-cultural factors and their impact on early intervention in psychosis in Zimbabwe. It is an analysis paper which draws from literature as well as being informed by work done. This work involved dramas, interviews, FGDs and unobtrusive observations, as well as ethnography and was done in rural   Mashonaland east Province. 300 Participants were drawn from the entire community, and these included 8 local clinic staff, 7 headmen, 5 Government officials, 20 traditional and faith-based practitioners and 260 mental health patients and caregivers. These were purposively sampled. Findings revealed that social factors have both a negative and positive impact on mental health issues. It argues that, through social and cultural practices compounded by economic hardships, gains from early interventions are compromised. The paper acknowledges that these two factors have a larger bearing in mental health interventions both negative and positive and is always evolving, yet national policy seems to be silent on its contribution to this vulnerable population. The state machinery has been unable to adequately provide the necessary care and support for mental illness because of financial and or political constraints. This write-up has proved that there is both negative and positive impact of social and cultural factors in early intervention in psychosis.  It has been noted that they both contribute to help seeking and treatment pathways. It concludes by recommending that the Government should embrace faith based organisations (FBOs) African Tradition Religions (ATR) and the conventional medical models (Hospitals) collaboration. It further recommended that these collaboration be linked with formal community based support structures in order to strengthen the psychosis intervention matrix.

Keywords: socio-cultural, intervention, psychosis, impact.

BACKGROUND

There has been a tremendous improvement in the treatment of mental illness in the world including Zimbabwe. However there are challenges in the intervention process ranging from health-seeking behaviour, medication compliance to lack of resources. Erratic adherence may call for poor outcome or unexpected contingencies. In a study carried out on Community perceptions and factors influencing utilization of health services in Uganda, it was noted that social and cultural factors have an effect on health matters Bakeera et al; (2009). Some studies have established that in every state there exists a social gradient in relation to health, ie a person’s socio-economic status in society vis a vis the income gap has an impact on his/her health, U.S. Department of Health and Human Services (USDHHS, (1999). The differential patterning of social resources may exacerbate or contribute to the persisting inequities in health care utilization, Bakeera et al; (2009) Along every rung of the socioeconomic ladder we have a different health status; as the higher you go, the better the status. This has a large bearing on how, where and when to seek health services. Another author, Michael et al. (2010) stated that economic deprivation has limitations to accessibility of facilities offering diagnostic and therapeutic services at convenient periods.

Cultural attributes of causality vary widely across various societies and have an impact in the treatment dimension of psychosis. Mental ill-health has several causes ranging from biological to spiritual; regardless of the case, optimum mental healthcare is compromised. Early intervention in psychosis seeks to close the gap emanating from the above shortcomings in the quest to advance mental health intervention. During the course of early intervention in psychosis, there are social and cultural factors that have both a negative and positive effect on the process. Within this dimension, this paper seeks to examine the impact of socio-cultural factors on early intervention in psychosis. Since some can be mitigatory while some can be exacerbating a proper examination is key to the development of mental health services that are more responsive to the cultural and social contexts of racial and ethnic clientele base.

Context and Discussion

It has been noted that clinicians working with individuals with serious mental illnesses such as schizophrenia and related psychotic disorders will undoubtedly recognise the importance of the family in initial treatment-seeking, on-going assistance with adherence and the social support that is a vital aspect of the treatment plan and recovery process, Skinner, D., Correa, V., Skinner, M., & Bailey, D. (2001). The same goes on to say that family member commonly provide far-reaching and sustained psychosocial support, emotional and tangible assistance i.e. during the early course and throughout the long trajectory of such disorders. It is the same family that is plagued by social and cultural factors which either promote or negate the quality of psychosis treatment outcome. However this does not mean that culture and society are the only determinants in mental health.

Importance of family members is often an underappreciated aspect of mental health despite the family being a major cog in the system. This is also despite the fact that the discovery of a psychotic dimension in a family has a negative social and economic impact within the family as an entity and community as a whole.

Social-cultural factors

Culture can be best described as the values, beliefs language, rituals traditions and other behaviours that are passed from generation to generations within any social group, Helms & Cook (1999). It affects how individuals sanction societal practices and responses to situations. Thus it also shapes individual and familial beliefs about specific illnesses and disability in general. These impacts on family’s perceptions of a condition, its diagnosis and subsequent interventions. This will therefore have a ripple effect on the outcome of interventions as well as the quality of life of individuals in this society.

Cultures also vary with respect to the meaning they impart to illness, their way of making sense of the subjective experience of illness and distress, Kleinman (1988). The meaning of an illness refers to deep-seated attitudes and beliefs a culture holds about whether an illness is “real” or “imagined,” whether it is of the body or the mind (or both), whether it warrants sympathy, how much stigma surrounds it, what might cause it, and what type of person might succumb to it.

Kleinman, (1988) further supports this by saying cultural meanings of illness have real consequences in terms of whether people are motivated to seek treatment, how they cope with symptoms, how supportive their families and communities are, where they seek help (mental health specialist, primary care provider, clergy, or traditional healer), the pathways they take to get services and how well they fare in treatment. Many features of family life have a bearing on mental health and mental illness although it varies across ethnic groups. Family factors can protect against or contribute to the risk of developing mental illness, for example supportive families and good sibling relationships can protect against the onset of illness whilst family episodes marked by several marital discord can contribute to the onset of mental illness.

• Causes of psychosis

Cultural and social factors contribute to the causation of mental illness but vary with disorder, USDHHS, (1999). The role of each can be weaker or stronger depending on the disorder. What people think or believe as causes will definitely affect the treatment modality. If relatives or patient believes it’s a curse , then treatment will be to deal with the curse or “return to sender”  likewise if one thinks it’s  witchcraft he/she will also seek to be ‘unwitched’ or exorcised etc. All these are likely to cause a delay in seeking early treatment from health centres.

Some people attribute mental illness to avenging spirits (ngozi in Shona)… thus if someone kills a human being one is supposed to appease the dead person’s spirit through payment of a stipulated token failure upon the dead person will haunt the killer or torment any of the relatives. While there are others who believe that evil spirits are responsible (mamhepo) (demons). Thinking along these lines will call for them to consult traditional practitioners for cleansing while some might consult faith-based healers for divine intervention. EIP reports, (2017)

Some actually think it’s a family protective spirit, ancestral (mudzimu). In this case, people believe that departed elders want to communicate with alive family members through an identified member so will exhibit mysterious signs to draw attention, therefore there is need for rituals, EIP reports (2016). Thus instead of seeking early interventions, they allocate resources towards the cultural practice. During these activities the duration of untreated psychosis (DUP) is also prolonged.

One way in which culture affects mental illness is through how patients describe (or present) their symptoms to their clinicians. There are some well recognized differences in symptom presentation across cultures.  This finding supports the view that patients in different cultures tend to selectively express or present symptoms in culturally acceptable ways, Kleimman, (1988)

Other reviews on current knowledge about the role of socio-economic and cultural factors in early detection and subsequent interventions, it was noted that socio-economic and cultural factors may be important in two ways: first, they may play a role in detection and progression to acute psychosis, and second, they may lead to greater differentials in barriers to detection and successful treatment. Both have implications for successful detection and intervention programmes. Differentials in social and economic roles and activities may lead to different preferences for health-seeking behaviours therefore have an impact on early detection and subsequent outcomes. The general mental health interventions on persons affect their rate of disease progression and outcomes. In areas where someone’s mental health is deeply culturally defined, it’s highly possible that responses to illness are bound to be enmeshed with barriers to early detection and treatment of psychosis.

All the above have an impact on early intervention as they either help in early seeking of help or delay. For example those who think that the cause is avenging spirits might meander in the spiritual wilderness trying to get the best services at the same time delaying appropriate medical attention. Whatever people believed to be the cause of the illness will determine where to seek help. If it is believed that it’s due to curse, bewitching or evil spirits, they will not seek treatment from hospitals. At the other end if they believe in conventional medical interventions, then help will be sought earlier at hospitals.

• Interventions

The way one react to psychosis is dependent on what one think or assumes is the cause or origin of the condition. Cultural meanings of illness have real consequences in terms of whether people are motivated to seek treatment, how they cope with their symptoms, how supportive their families and communities are, where they seek help (mental health specialist, primary care provider, clergy, and/or traditional healer), the pathways they take to get services, and how well they fare in treatment. US DHHS (1999), the consequences can be grave – extreme distress, disability, and possibly, suicide when people with severe mental illness do not receive appropriate treatment. Research indicates that some minority groups are more likely than whites to delay seeking treatment until symptoms are more severe , Borowsky, S. J., Rubenstein, L. V., Meredith, L. S., Camp, P., Jackson-Triche, M., & Wells, K B. (2000)

• Response at onset of psychosis

There is also the aspect of aetiology of psychosis. As previously mentioned, what guardians believe is the cause(s) of a condition will definitely determine health seeking behaviuor. Treatment-seeking denotes the pathways taken to reach treatment and the types of treatments sought, Rogler & Cortes (2009). The pathways are the sequence of contacts and their duration once someone (or their family) recognizes their distress as a health problem.

Cultural and social factors contribute to the causation of mental illness, and this contribution varies by disorder. Mental illness is considered the product of a complex interaction among biological, psychological, social, and cultural factors. The role of any one of these major factors can be stronger or weaker depending on the disorder, US DHHS(1999).

In Zimbabwe and most African states with similar contexts, it is common practice that fathers are usually not around the house for prolonged periods. This will mean that most onset of psychosis is likely to occur in their absence. Even if the women or mothers want to take the concerned person to the hospital, the final decision rests with the father due to patriarchal set-up, that power is vested in father as household heads. These to a higher extend impact on early intervention in psychosis as traditionally, fathers or husbands should sanction treatment especially of a psychotic nature since belief system impact on help seeking behaviour. Also some people would feel confused with the circumstances and are likely to conceal the anomaly from neighbours thereby depriving themselves from ideas from some who might be knowledgeable.

BELIEF SYSTEMS

Traditional practitioners (n’anga)

People who have a very strong believe in traditional healers will always rush to these practitioners for almost every concern, likewise even with psychosis, they will do the same. This can have either negative or positive impact. It might delay early intervention if the healers fail to deal with the condition or might be beneficial if successful.

Faith-based practitioners

1. Traditional churches have various and different ways of handling actions or behaviours deemed out of synch with reality. Some do not want to hear of anything to do with medication so the probability of their members getting early or even delayed medical attention is next to zero. Some church practices acupuncture which involves the repetitive pricking of pressure points with a sharp needle, eg ZCC, some hypnotise through vigorous shaking of the head (kushreka), some burning incense or hot stones (Kufukira). All is done in the name of dealing with psychosis though it is given various names and various causes being attributed to it.
2. There are also emerging churches, charismatic: famous for using ‘anointed’ tokens like water, pens, maize cobs, umbrellas, sewer etc. They claim that whatever ailment or misfortune will be instantly cured through the use of those ‘anointed’ articles. In some instances, when people exhibit abnormal behaviours they are said to be manifesting therefore the Apostle would be consulted to lead in the spiritual ascendancy yet signs of psychosis are being misinterpreted and delaying in early intervention of psychosis. Effects of this are prolonged delays in seeking early professional help.

RESOURCES

Prioritising resources is a common phenomenon and a known factor that most government offer less than 6% of the health budget to mental health. This seems to have cascaded to household levels as many families do not prioritise funding for mental health issues.  E.g. one community member upon being asked she said, ‘ndingatambisamariyechikafukurapisamupengo?’ literally meaning one cannot waste resources meant for food treating a mad man (psychotic).  This is also linked to what can be described as disease-related outcomes wherein parents apply the cost-benefits analysis of the interventions to be undertaken. Some considered that channelling resources to ‘mad’ person is tantamount to throwing them down the drain as they don’t anticipate full recovery especially after witnessing previous experiences with unsuccessful interventions from other service providers.

Other studies have linked the economic structure of society to the health of its citizens, OECD, (2011). The same went further to say that economic realities affect the material conditions at people’s disposal that enable them to achieve health. In another study the writer later lamented that, “Despite good evidence from a range of contexts that family interventions are key components in packages of care for schizophrenia, mental health practitioners struggle to integrate family sessions into their caseload” Leff, (2000). The same went on, “this is however sometimes hindered further by logistical difficulties; for example, family member resources may face competing care demands and transport difficulties, and may have problems applying for leave from their jobs” Additionally,  “These challenges may well be exacerbated in low-income contexts Kritzinger, Swartz, Mall &Asmal, (2011). Possibly because of these challenges, many African institutions, Zimbabwe included, end up offering half-baked services without involving family members. In Zimbabwe currently available services involve the provision of medication, hospitalisation, limited occupational therapy and limited psychotherapy and psychosocial support, Mlambo, N. (2010).

This is more of a reflection of what is happening in the Zimbabwean context. From baseline surveys done through questionnaires in both rural and urban clusters most respondents listed pathways to care, in order of preferences as follows; traditional healers, prophets and church counsellors ahead of hospitals. EIP Reports, (2018) On further probing they indicated that given the choice and with resources, they would go for hospitals.

Some actually indicated that it is cheaper to consult n’angas than doctors hence they are forced to visit faith-based and traditional healers due to the nature of their pricing policies which are flexible, negotiable and therefore cheaper as compared to fixed non-negotiable hospital fees, EIP (2016). They indicated that they can easily travel to traditional healers or prophets where they can pay for services through barter trade, exchanging goats, chicken, cows or other livestock. Access to traditional and faith-based healers is sometimes within reach so they are tempted to use the readily and easily accessible services with flexible payment options.

Religions across different cultural groups sometimes help emotionally and socially as it plays a role in parents’ coping mechanism whilst offering alternatives to interventions. Some can actually be in the form of early interventions. For example the Jewish community who turn to medical community for treatment then go to Rabbi for counselling, Pitten (2008). This is not very much different from Zimbabwe where there is a cultural milieu that is a cocktail of various cultural practices at play. Some churches encourage early health seeking from hospitals so their impact is positive in early intervention in psychosis.

Family relations have powerful impact on health outcomes and not health professionals only. The family can also be a potential haven for covering up cases of abuse in the home .In some families, where there have been cases of psychosis, deliberate choices are made to conceal the scourge in order to protect the family name. In one study it was established that children who had been orphaned and moved in with extended families often reported being verbally abused, neglected, forced to undertake exploitative work, and not allowed to attend school. Mandell, D. & Novak, M. (2005).

Given this background, the role of family has been that of negating the benefits of EIP. Some orphaned children preferred to stay together as a family group in familiar surroundings (schools, friends, neighbourhood etc.) rather than be split up or “parcelled out” amongst various relatives. This could be the same scenario with sufferers of psychosis so people should also take note of this possibility to avoid mishaps in mental health. However, this alone should not dampen the spirit of valuing the role of family in mental health as it is the hub of both social and cultural values which have a tremendous impact in early intervention in psychosis.

CONCLUSION

Culture influences many aspects of mental illness, including how patients from a given culture express and manifest their symptoms, their style of coping, their family and community supports, and their willingness to seek treatment. Likewise, the cultures of the clinician and the service system influence diagnosis, treatment, and service delivery. However, they are not the only determinants of mental illness and patterns of service utilization, but they do play important roles. Cultures alter the types of mental health services use. Cultural misunderstandings or communication problems between patients and clinicians may deter people from using services and receiving appropriate care. Mental disorders are highly prevalent across all populations, regardless of race or ethnicity. Cultural and social factors contribute to the causation of mental illness, yet that contribution varies by disorder. Mental illness is considered the product of a complex interaction among biological, psychological, social, and cultural factors. The role of any one of these major factors can be stronger or weaker depending on the specific disorder. These have both a single and combinatory impact on early intervention in psychosis so mental health practitioners should have a better understanding of this matrix. This understanding is key to developing mental health services that are more responsive to the cultural and social contexts of racial and ethnic minorities. Regardless of controversy in aetiology, early intervention with evidence-based treatments is the most effective way to assist people with psychosis. This will increase treatment outcome, reduce hospitalisation and imminent suicides whilst minimising trauma and disruption of family lives. Therefore there is need for motivation to seek health services from established health centres by professionals.

RECOMMENDATIONS

Concerted efforts in awareness campaigns in communities.

Encouraging and supporting medical staff in embracing socio-cultural diversity.

Design and implement a curriculum for cultural diversity training for health care professionals to embrace cultural and religious issues for appropriate practices.

There is also need for formulation of a policy that emphasises collaboration between practitioners from both traditional and conventional backgrounds.

Embrace a Multi sectoral approach from community levels

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