INCORPORATION OF MENTAL HEALTH INTO PRIMARY HEALTH CARE: PROBLEMS OF

CROSS-CULTURAL ADAPTATION OF TECHNOLOGY

Author(s): J. S. NEKI
Source: International Journal of Mental Health , Fall 1983, Vol. 12, No. 3, Mental Health
Care in Developing Countries (Fall 1983), pp. 1-15
Published by: Taylor & Francis, Ltd.

Stable URL: https://www.jstor.org/stable/41344327

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Int. J. Ment. Health, Vol. 12, No. 3, pp. 1-15
M. E. Sharpe, Inc., 1984

INCORPORATION OF MENTAL HEALTH

INTO PRIMARY HEALTH CARE:
PROBLEMS OF CROSS-CULTURAL
ADAPTATION OF TECHNOLOGY

J. S. NEKI

In the Declaration of Alma-Ata [1], primary health care was

defined as "essential health care based on practical, scientifically
sound and socially acceptable methods and technology made uni-
versally accessible to individuals and families in the community
through their full participation and at a cost that the community
and country can afford to maintain at every stage of their develop-
ment in the spirit of self-reliance and self-determination. It forms
an integral part both of the country's health system, of which it is
the central function and main focus, and of the overall social and
economic development of the community. ..." At the same
international conference at which this declaration was made,
health was reaffirmed as "a state of physical, mental and social
well-being" and was further described as "a fundamental human
right." Mental health was thus envisaged as an integral part of
primary health care. This, however, implied utilizing the health
care system as the major vehicle for catering to the people's
mental health, and therefore adoption of the medical model as the
basic model for mental health care- though it did permit social,
educational, and other approaches insofar as they fit into the basic
medical model.
There seems to be a special reason for adopting the medical

Dr. Neki is WHO Consultant to the National Mental Health Programme

of Tanzania, P.O. Box 6529B, Dar-es-Salaam, Tanzania. He was formerly
Director, Post-graduate Institute of Medical Education and Research, Chan-
digarh, India.

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 J. S. NEKI

model. Epidemiological studies that have followed reliable case-

detection techniques [2] seem to show that nonpsychotic mental
illness is one of the most common reasons for which doctors are
consulted. Studies by Giel & Van Luijk [3], Mbafeno [4], Har-
ding [5], and Ndetei & Muhangi [6] have also indicated that the
rate of mental disorders seen in primary health care in facilities in
both developing and developed countries is amost the same.
These observations are supported by studies of mental disorder at
the second echelon of health care [7-10], and further support
comes from a World Health Organization (WHO) collaborative
study in four countries- Colombia, India, the Philippines, and
the Sudan [11]. Since people with emotional disorders tend to
consult doctors very frequently, the health care system must nec-
essarily cater to their needs.
On the strength of studies such as those cited, it seems also to
have been concluded that [12]:

Psychological ill-health is known to be widely prevalent in

quite varied cultures; only a few of its manifestations are cul-
ture specific. Mental health problems are strikingly similar
across cultures, and there is now sufficient evidence to show
that their management along similar lines helps patients re-
gardless of culture. It requires knowledge and skills that can be
learned by various categories of health staff; and the rules for
action, from first contact to diagnosis and managment, can be
operationalized to a considerable degree so that health auxil-
iaries can apply them. (Emphasis added.)

Such statements suggest that the technology for incorporating

mental health into primary health care is totally culture free and
that no special problems will be encountered in transferring this
technology across cultures. This may not be a fully tenable con-
clusion, however. It is the aim of this communication to point out
some of the problems that may be encountered in cross-cultural
adaptation of the technology for incorporating mental health into
primary health care.

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 MENTAL HEALTH AND PRIMARY HEALTH CARE

Determining objectives, priorities,

and tasks

Even before any health technology is applied, one has essentially

to determine the objectives, priorities, and tasks for which such a
technology must be utilized. The objectives of a mental health
program have to be determined within the particular culture and
the particular country. It has been suggested that the general
principles and criteria that need to be taken into account are the
following [13]:

(1) Needs should be considered in terms of both the preva-

lence and the consequences of various mental disorders. The
consequences can be assessed from various points of view, for
example, social and health consequences, and the impact on
welfare and health services. The public should not be passive
recipients but should participate actively in planning health
services. . . .
(2) In selecting objectives, a major consideration should be
whether effective means of modifying the course of a particular
mental disorder are available.
(3) The available resources, which will necessarily be
limited, must also be taken into account. . .
(4) . . .Forecasting of future needs and resources
is ... an integral part of planning. (Emphasis added.)

In spite of these agreed-upon criteria and principles, the specif-

ic target problems that would actually be included in the priority
list and how they would be dealt with operationally would differ
from culture to culture.
Although prevalence rate is one of the important criteria for
selecting target conditions, a significant factor, which often over-
rides the prevalence rate and consequences of a particular disor-
der, is how the community perceives it. If drug addiction finds
itself among the target conditions in the mental health program in
Indonesia, it is as much because of public concern as of its

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 J. S. NEKI

prevalence. On the other hand, if, in spite of considerable preva-

lence of alcohol consumption and related problems in Tanzania,
this condition does not find itself among the target conditions in
that country's national mental health program, it is probably in
part because of lack of much public concern about it.
Moreover, which disorders will be taken for care to whom- to
a doctor, a traditional healer, the police, or a priest- will general-
ly depend on cultural attitudes and social prejudices. A person
who attempts suicide, for example, may be taken to a medical
specialist if the cause is considered to be an illness, to a tradition-
al healer if it is considered the consequence of witchcraft, to the
police if it is deemed a culpable offense, or to a priest if it is
considered a sinful act.
Cultural beliefs and attitudes also determine the acceptability
of a treatment modality. Epilepsy in most parts of East Africa is
considered an "African disease" treatable only by an African
mganga. European doctors and their system of modern medicine
are prejudicially considered to be "ignorant" about its causation
and ineffective insofar as the treatment of this disease is con-
cerned. This is in spite of the European doctors' having available
effective therapeutic technology for this condition. Although, by
virtue of better therapeutic results, modern medicine is able to
conquer this prejudice inch by inch in some places, in most other
places it tends to persist tenaciously. Tomov (personal communi-
cation, 1983) has reported that the practice of traditional healing
for mental disorders seems to be on the increase in Tanzania. This
indicates not only a growing public concern with mental health
but also, possibly, the preferred consultative agency.
The selection of target conditions is contingent on the level of
the professional training and background of the primary care
personnel available. The prevalance rate of neurotic conditions is
more than considerable almost everywhere, and psychotic disor-
ders are relatively much rarer [6,14-16]. In fact, so few psycho-
tics are encountered in the surveys that it has sometimes been
impossible to draw conclusions about the health workers' ability
to diagnose such patients [11]. In Africa the rarity of psychotics
in community surveys has led to interesting suggestions concern-

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 MENTAL HEALTH AND PRIMARY HEALTH CARE

ing reasons for their absence. Giel & Van Luijk [3], for example,
explain the low figures for psychosis as being due to psychotics'
being excluded from the community or banished to the bush, or
removed by death from neglect or starvation.
In spite of the low prevalence of psychoses and the relative
preponderance of neurotic conditions, it is the former that almost
invariably find their way into the list of target mental disorders for
primary care programs, while the latter are generally disregard-
ed. This is because even the second-echelon worker in the devel-
oping world is often a person on the lowest professional rung,
with only brief exposure to mental health technology. He or she
has generally not received much training in the variegated, intri-
cate, and individualized therapy for neurotic disorders, but has
certainly been trained in providing the more prototypical and
mechanistic treatment for certain psychotic conditions. On the
other hand, in places where a doctor is available to provide the
second-echelon care, not only have neurotic conditions but even
the emotional aspects of physical disorders been included in the
target conditions [7] .
Thus, the emphasis on selection of priorities according to
clearly established criteria [13, 18] becomes more academic. In
practice, it is the cultural and developmental factors in a commu-
nity and the perceptual focus and expectations of people that to a
large extent determine the selection of target conditions.

Policy, manpower, and other

resources

Specifying the scope and complexity of mental health

given at different levels depends on the national po
specific country, its geographic position and transp
(which determine commutability), and its policy rel
distribution of health personnel and of drugs.
Enormous differences may be encountered from one
another in the sensitivity of health workers to mental
lems, their readiness to accept them as relevant con
their motivation and enthusiasm for dealing with th

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 J. S. NEKI

In some countries, territories are huge, distances are enor-

mous, transport is unreliable, and peripheral areas may be sea-
sonally cut off altogether from any metropolis. In other countries,
distances may be relatively manageable, transport reliable, and
all areas uniformly accessible. The favored service strategies in
these two kinds of settings will be different. In the former, a
centripetal strategy- i.e. , peripheral self-sufficiency and peri-
odic links with the center for the exchange of information and
supplies- tends usually to be preferred. In the latter, on the other
hand, a centrifugal strategy- i.e., a strong center continually
monitoring the needs of the periphery and catering to them, su-
pervising and directing its functioning, and having an efficient
referral system- is more often preferred. The two are distinctive
service strategies and have distinctive relevance.
Another important factor to be taken into account is at what
point in time an attempt should be made to incorporate mental
health into primary health care. If mental health is included in
primary care from the very beginning, i.e., as the latter is being
introduced, there is little problem. But if incorporation of mental
health lags behind, considerable resistance is experienced against
its introduction at a later stage. The health worker has by then
learned to reckon without it. He or she has already adapted to the
medley of tasks he or she is expected to perform. Anything new
that is introduced is considered an "additional burden." In this
situation, the strategies for motivating the health workers to as-
sume mental health functions would obviously be very different.
In any consideration of primary health care, one cannot disre-
gard the traditional healer. The role he will play in mental health
care will depend on various factors. These include the kind of
patients that tend to consult him, the relative benefit/harm his
treatment methods produce in the conditions for which his help is
sought, the availability/nonavailability of competitive modern
methods in primary health care, and so on. Attitudes toward
collaboration with traditional healers vary from "We can ill af-
ford to be a party to sending our patients to the bedlams of
traditional medicine' ' to ' 'The traditional healer is our co-partner
in the care of the sick; we must develop active strategies of

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 MENTAL HEALTH AND PRIMARY HEALTH CARE

collaborating with him." The form such strategies take will de-
pend on whether the traditional healers are an organized group
(as, for instance, in India) or an unorganized group (as, for
instance, in Tanzania).
These, then, are a few of the varied factors that determine the
exact strategy adopted and the precise technology selected for
incorporating mental health into primary health care.

The pathogenic, pathoplastic

role of culture

Another relevant point to consider is how culture affects psycho-

pathology. Whether the particular culture is merely pathoplastic,
i.e., shapes pathology, oř is even pathogenic, i.e., causes pathol-
ogy, is a key question. The predominant view in comparative
psychiatry has been that cultural factors have a pathoplastic rath-
er than a pathogenic role. However, instances of a pathogenic
influence of culture must not be ignored. Jilek [19] has enumer-
ated quite a few examples of such instances from his experience:
1 . Culturally prescribed patterns of breeding may enhance the
risk of neuropsychiatrie illness by disadvantageous gene distribu-
tion. Among the Wapogoro of Tanzania, a culturally preferred
pattern of mating between cross-cousins and between members of
epileptic families has been observed, and this mating pattern
appears responsible for the high prevalence (2%) and family
incidence of a seizure disorder often associated with psycho-
pathology [20].
2. Culturally prescribed obstetric practices, such as those
among the tribal populations in East Africa, may lead to perinatal
brain damage with neuropsychiatrie seqelae [21].
3. Culturally conditioned dietary habits may cause neuropsy-
chiatrie pathology through mineral or vitamin deficiencies. For
example, pibloktoq among the polar Eskimos is caused by cultur-
ally conditioned diet preferences (pathogenic effect), but its
symptom formation is shaped by social learning (pathoplastic
effect).
4. Culturally or subculturally sanctioned use and abuse of
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 J. S. NEKI

noxious substances such as alcohol, narcotics, and psychedelics

have both psychopathogenic and psychopathoplastic effects. Cul-
turally sanctioned abstinence, on the other hand, is the main
factor in the prevention of alcohol-associated mental conditions.
The pathogenic factors have special relevance to the technol-
ogy to be adopted for primary prevention of mental disorders.
It has been repeatedly stated that mental disorders are charac-
terized by considerable somatization in the developing countries.
It may be stated with equal, if not greater, justification that such
disorders are characterized by considerable "psychologization"
in Western cultures. The near absence among African popula-
tions of obsessive-compulsive, phobic, ruminative states, the rel-
ative infrequency and amorphous nature of guilt feelings, the
rather rare occurrence of such phenomena as thought insertion,
thought withdrawal, thought interference, and such, and the great
paucity of what are called "pseudohallucinations" are evidence
of the absence of much "psychologization" in African people.
Devereux [22] calls even schizophrenia an "ethnic psychosis"
characteristic of modern Western society. Chronic process
schizophrenia does appear to be less prevalent in tradition-direct-
ed societies without Westernizing culture change [23, 24]. The
International follow-up study of schizophrenia [25] has shown
that in the developing countries, significantly more of the pro-
bands improved than in the developed countries. Murphy & Ra-
man [26], in their Mauritius study, have hypothesized that the
Western patient "may be trapped within an established sick-role
by the superficial rationality of his society's view of his sickness,
whereas the Mauritian patient, with a range of what one would
call superstitious explanations for his initial disorder, may more
easily find a way of escape."
Much of modern psychiatry is in need of being divested of
ethnocentricity, and this factor needs to be borne prominently in
mind in extending any kind of mental health care.
Although the Western patient may be trapped within his ration-
ality, the "primitive" mind may equally well be trapped within
its peculiar belief systems. Fear of black magic, bewitchment,
and the evil eye or of possession by an evil spirit, for example,

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 MENTAL HEALTH AND PRIMARY HEALTH CARE

may result in frenzied anxiety [27]. This is an acute anxiety

reaction resembling hysterical twilight states, on the one hand,
and (by virtue of paranoid delusions of bewitchment, catatonic
symptoms, and perplexity) schizophrenia, on the other. Lambo
[28] equated this with the bouffée délirante diagnosed by Franco-
phone African psychiatrists. He stated, "These reactions would
seem much more to be related to culture than to infection" [29].
Those at risk are the "marginal" Africans, the semi- Western-
ized, detribalized, newly urbanized people who have lost their
roots in the old culture, but have not yet established any in the
new. In reactive psychoses of this kind, anxiety can become
extremely malignant if the patient's delusion of bewitchment or
of magical retaliation is shared by his people. This may well lead
to what has been called "voodoo death" [30], "psychogenic
death" [31], or mort psychosomatique [32]. In spite of a superfi-
cial resemblance to hysteria and to schizophrenia, these transient,
acute, psychotic reactions must be distinguished from these con-
cepts, and French psychiatry does so by assigning them an inde-
pendent diagnostic rubric [33] . Their management involves con-
sideration of cultural factors.
Ritualized possession and trance states, which are culturally
sanctioned and often institutionalized, are sometimes defined as
abnormal by some experts. In attaching pathology levels to such
behavior, the Western-trained expert commits a eurocentric falla-
cy, and perhaps also a positivistic fallacy insofar as it considers
behavior abnormal because it does not fit into the framework of
the logico-experimental explanatory theories of positive science
[19]. It is therefore important to guard against these fallacies
whenever an attempt is made to adapt models of health care from
the West to the developing world.

The importance of social networks

One of the mental health responsibilities almost invariably dele-

gated to the primary health worker is the aftercare and rehabilita-
tion of chronic mental patients. For this he or she often has to
intervene in the existing social networks of the community. Social

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 J. S. NEKI

networks are known to act as social support systems that can

buffer psychological stress and promote mental health; any men-
tal health care system must, of necessity, fall back on them for
support. Speck & Attneave [34] have described social networks
as all human relationships that have a lasting impact on a person's
life. These networks mobilize the person's resources, enable him
to bear his emotional burdens, provide him with resources and
skills, and buttress his coping and problem-solving capabilities.
They meet some of humankind's most basic needs. The Task
Panel on Community Support Systems of the U.S. President's
Commission on Mental Health [35] concluded, after reviewing
over two hundred studies, that a necessary goal of the community
mental health movement should be to "recognize and strengthen
the natural networks to which people belong and on which they
depend. ..."
These networks differ from culture to culture. Caste, clan, and
club are three of the outstanding organizational prototypes of
these networks. It has been amply confirmed that the type of
support available depends on the structure of the person's net-
work and the quality of the relationships [36]. It is the quality
rather than the mere existence of an intimate relationship that is
important [37, 38]. Since mentally ill and mentally "normal"
people have been found to have quite different social networks,
both quantitatively and qualitatively, restructuring of the net-
works of the mentally ill should tend to improve the course and
outcome of treatment.
In order to be able to intervene in social networks, it would be
important to know:
1 . What are the strengths and liabilities of the common social
networks in a culture in terms of mental health?
2. In what way(s) do the social networks of the mentally ill
differ from those of the "normal" people in the particular
culture?
3. In what way is it possible to structure institutional environ-
ments for mental patients so that social contact among patients,
between patients and their relatives, and between patients and
staff are maximized?

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 MENTAL HEALTH AND PRIMARY HEALTH CARE

Some of the social network intervention strategies for the reha-

bilitation of former mental patients are halfway houses [39-41],
community support by hospital personnel to ex-patients living
independently in rooms or homes [42] , and housing of patients
with surrogate families [43] or in foster homes, as in Gheel,
Belgium, as members of a collective used for therapeutic pur-
poses, as in the USSR [44], or in a therapeutic village, as in
Nigeria [45].
Within the African setting, two models of rehabilitation vil-
lages have been developed that meet the specific local cultural
needs.
The first one, pioneered by Lambo [45], the village of Aro, is
in western Nigeria. This village has a day hospital, and is sur-
rounded by four small villages. In the program a patient, accom-
panied by a relative, is placed in a home in one of the villages
while continuing outpatient treatment at the hospital. Members of
the community in these villages have been carefully trained to
understand the problems of the patients who are temporarily
lodged in their midst. The patients thus remain in a social envi-
ronment to which they are accustomed. They do not have to stay
in a hospital ward, which to them is almost invariably a strange
and disturbing place; but the therapeutic facilities of a psychiatric
hospital are available to them. The social and human resources of
the community, which are conducive to the promotion of mental
health, are also available to them. "Among these resources are
the natural flexibility and tolerance of village communities, the
therapeutic value of traditional cults, and the confessional dances
and rituals that play so large a part in peasant life. Acting togeth-
er, they all provide strong natural psychotherapy" [45].
The other African model is the rehabilitation village scheme in
Tanzania, which originated as a means of relieving the over-
crowded conditions in the mental hospital. These villages fit
logically into the national scheme of djamaa (cooperative) vil-
lages. Built by patients, these villages are made with local, low-
cost materials. Each patient works either in the shamba (extended
garden) or raises chickens, goats, pigs, or cattle. The goal of each
village is self-sufficiency insofar as food production is con-

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 J. S. NERI

cerned. A village houses 40-50 patients. Two or three auxiliary

health workers provide supervision, guidance, and health care.
Periodic visits are made by medical and nursing staff from the
psychiatric unit of the related general hospital.
Such a village provides a normal living situation for a patient
who is able to leave the hospital, but is not yet ready to return to
his home community. For the few patients who have no family,
the village serves as a longer-term home. The acceptance by
surrounding villages of this kind of artificial village has been
quite salutary. They have assisted in the construction of the vil-
lage and joined the convalescent patients in community festivi-
ties, ritual dances, and evening recreation activities. This interac-
tion with neighboring villages and the presence of some resi-
dential staff and their families in the village promote almost nor-
mal life for the ex-patients. Such a village is a more efficient ther-
apeutic milieu for convalescing patients than a hospital ward and,
at the same time, has the advantages of natural community life.
The village in Nigeria caters primarily for patients who are still
under active care; the one in Tanzania, for those who are conva-
lescent. The former requires considerable ongoing staff supervi-
sion; the latter, minimal supervision. The former is an extended
therapeutic community; the latter, an extended halfway house.
The former is a natural village into which patients are absorbed.
The latter is an artificial village built and run largely by patients;
it is less costly and "has the unique benefits derived from its very
emphasis on djamaa and self reliance" [46]. The two models
have distinctive profiles because they fulfill distinctive needs in
the care of mental patients specifically perceived in distinctive
cultural settings.

Conclusion

The incorporation of mental health into primary health care ap-

pears to be almost inescapable, at least for the developing world.
The dictates of the system compel us to adopt a model centered on
traditional healers. Yet social networks and folk concepts and
practices are extremely relevant to the technology for primary

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 MENTAL HEALTH AND PRIMARY HEALTH CARE

care in mental health; to ignore them would be to deprive the

primary care mental health programs of their optimal impact.
Every culture has its particular problems and demands appropri-
ate solutions.
In spite of the seeming availability of what appears to be uni-
versally applicable technology, considerable modification is re-
quired to adapt it to the specific cultural demands of each commu-
nity. Experiences the world over have repeatedly called on human
resourcefulness for this task. It is a task of even greater relevance
where there is culture change, for there, such factors as anomie,
unfulfilled expectations, and cultural confusion compound the
difficulties. And this is the situation that prevails in most of the
developing countries today.

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