Use of participatory, action and research methods in enhancing awareness of mental disorders in Kariobangi, Kenya.

Worldwide, mental disorders affect 450 million people and account for 15% of the overall burden of diseases from all causes (World Health Organization, 2001). Two-thirds of those affected do not receive adequate care owing to stigma, discrimination, neglect and poverty. The World Health Organization (2001) found that only 1% of the total health expenditure went to mental health in most countries.

In Kenya, service provision is further impeded by limited facilities and lack of mental health workers. Milder forms of psychiatric disorder (especially those affecting children, who comprise a large part of the population) are not adequately identified (Kiima et al, 2004). Plans to increase access to mental health services mainly use the top-down approach, instead of involving community members in planning. The First Kenya National Mental Health Programme of Action, in 1996, emphasised the need for the development of infrastructure and the training of mental health workers but gave little detail on community involvement, although it recognised the need to improve community services. This paper describes an attempt to involve community members and primary health workers in identifying and working out solutions to mental health problems in a socio-economically disadvantaged area in Nairobi, Kenya, using participatory, reflection and action (PRA) methods. PRA methods empower people to share, analyse, enhance their knowledge and plan further actions after evaluation and reflection (Wadsworth, 1998). Although the methods have been used successfully in other areas of rural development, their use in relation to psychiatric services has not been reported in Kenya.

Method

Over a 6-month period, in 2007, 30 community members from Kariobangi and community mental health workers based at Mathari Hospital were selected and engaged in a PRA process to identify mental health challenges and to enhance the community’s problem-solving capacity. During the first meeting, a baseline questionnaire was administered to assess the participants’ perception of mental health and the stigma associated with it, and the role of families and social organisations in promoting mental health. Thereafter, concepts of mental health were discussed using health pictures. Through brainstorming and group discussions, the mental health problems were ranked and scored on charts by the participants. Working in groups, they drew up lists of stakeholders in the community and a community map. The relationships between the various institutions were shown in Venn (chapatti) diagrams and possible entry points were identified. They further identified important areas, which they later visited during a walk in the community (transect walk), and important people, whom they interviewed. Using the information gathered and the insights gained, the participants discussed and agreed on what could be done to reduce mental health problems in the community. The actions were ranked using beans arranged on paper to help them visualise the process. After a period of intervention, the actions were assessed by the participants using a wheel chart. This is a quick, qualitative method of measuring progress, using lines drawn in a circle (Loewenson et al, 2006).

Results

The baseline survey showed that the mental health workers’ knowledge of mental disorders was moderate, while those from the community thought they had poor knowledge. However, the scores of the two groups did not differ significantly. Over 80% of the participants thought that mental illness in the community was extremely common. The majority attributed mental illness to afflictions of the mind and poverty. They identified stress and depression followed by alcohol and substance use and epilepsy as major problems in the community. Childhood psychiatric disorders, apart from intellectual disability, ranked lower. Obstacles identified included lack of support from the local administration, inadequate medication, high cost of drugs, stigma, long distance to the referral hospital and inappropriate clinic timing.

A social map of the area revealed several organisations dealing with children, youths, widows, orphans, the elderly, and those with HIV/AIDS. In addition, there were privately run schools that provided free meals. They felt that apart from the health institutions, other organisations offered little help to people who are mentally ill.

Key people interviewed included the chief, church leader, community clinic workers, and teacher. Their views on common mental disorders were similar to those described above. They agreed that more collaboration was needed and that tighter controls on alcohol and drug use were necessary. Children with an intellectual disability and orphaned children in the community needed more support. The participants felt that the administrative and security officers were very important, as they had a big role to play in regulating drugs in the community and licensing outlets to sell alcohol.

Reflecting on the findings, the group agreed that, with the available resources, they could increase awareness of mental health problems through public education, establish an additional community clinic, provide adequate drugs at the existing clinics, advocate tighter controls on the sale of alcohol, and provide sheltered workshops and day care centres for people with an intellectual disability. The participants suggested that they should start a mental health promotion and support group within the community. The family members of those with mental illness would organise themselves into groups with the help of the health staff. These groups would identify available resources and coordinate mental health programmes within the community. The participants could not agree on how to alleviate poverty, although they regarded it as a major cause of mental ill health. Options considered included starting income-generating small-scale businesses and strengthening self-help groups with the resource of invited experts. At the meeting, individuals volunteered for the various actions.

Follow-up meeting

A feedback meeting was held 6 months after the initial assessment. The community members’ perception of mental illness had changed and they believed the burden of mental illness was greater than they had initially thought. They had increased awareness of mental illnesses and their causes.

Some of the specific targets identified earlier had been met. Hospital psychiatrists had given talks on mental health to the local school and church. A community health nurse had been invited to the local chiefs’ meeting and mental health personnel had participated in meetings of local social groups. An occupational therapist from Mathari Hospital had started working with children with intellectual disabilities in one of the community organisations. A request had been made to the Ministry of Health for adequate supplies of antidepressants and anti-epileptic drugs for the clinics.

Discussion

The results show the three phases of the PRA process – participation in identifying problems, reflection on possible solutions using local resources, and action. The community members welcomed the project and were more confident in discussing mental health disorders and possible interventions at follow-up. Initially, the participants had high expectations of outside aid. Being unfamiliar with PRA methods, they were at first surprised that they were expected to come up with solutions to their problems but, after explanation, this was overcome. The PRA methods used, such as ranking, scoring, drawing and the group discussions, were easily implemented, unlike reflective discussions. Most of the participants expected the facilitators to give them the solutions while they played a more passive role. They were repeatedly reminded that the community affected had better knowledge of the problems and could offer useful solutions.

Lack of coordination and poor communication between the various social groups in the community resulted in poor care for people who are mentally ill. Community members are willing to work with mental health workers to improve healthcare in the community but need to be given support.

Conclusions

Further interventions and evaluation of the impact of the PRA methods as a means of giving the community a voice in mental health issues are needed. The next phase of the project will focus on substance use in the community.