Sociocultural and Economic Factors and Mental

Health Disorders and Caregiving

Socioeconomic condition vs. pre-existing biological problems
• Do poor socioeconomic conditions predispose
people to mental disability? Or
• Do pre-existing, biologically based mental
illnesses result in the drift of individuals into poor
socioeconomic circumstances?
• Are there particular types of conditions—whether
unemployment, little family support, noisome
work conditions or lack of autonomy—that
mediate this effect?
 Gender
• Do you think women’s experience of living in the
community with sever MI is different from that of men?
How about the care extended by the families and friends or
health care providers?
As Chernomas and colleagues (2000) indicated the
experiences of women with severe MI described:
“multiple loses, social stigma, limited interpersonal
contact, poverty, and feeling out of the information loop [that
result] in leading marginalized, deprived lives in the
pervasive shadow of their illness … losing custody of
children conveyed living with deep sense of grief… It is
important to note what the women did not talk about.”
 Macro and Micro Factors that affect MH Caregiving
• The rate of severe mental illness is relatively the same both
in developing and developed world (e.g., 2.6 in USA).
• Majority of the people with severe mental illness receive
primary care from their family members.
• Delegation of increased care giving responsibilities to the
family-based services have both positive and negative
impacts.
• When we consider deinstitutionalization, we need to make
sure resources (education and services) are available to
help the caregivers.
• Based on the perspective that shape the contexts in which
caregivers provide care to their MI relatives and friends,
and experiences of everyday caregiving encounters,
influence on the family-based caregiving can be divided in
to:
A. Macro Influences
B. Micro Influences
Macro Influences on the Caregiving
Sociocultural factors—ethnicity, gender, age, education, and
income
• Do you think these factors can affect the caregivers’ social
position, and their ability and perception in caregiving
duties of the MI? How? How about the perspectives of the
MIP?
• Why these factors are important for social workers?
Social Workers need to examine and understand the
contextual factors that affect the care, and provide culturally
appropriate and context specific services and support to the
caregivers as well as the consumers, which help to maximize
the effectiveness and positive response of the
deinstitutionalized care.
Interpersonal factors
• Sense of obligation and duty to care for MI depend on the
closeness of kinship ties—relationship with the MIP,
residence status, and marital status of the caregivers.
• E.g., parents and spouses, and married individuals
may feel stronger obligation or more strained to care
than siblings/children and unmarried, respectively.
• As social work professionals, considering
interpersonal factors in the caregiving experience is
crucial.
Structural factors
 Factors that affect the everyday experiences of
caregivers are principally related with health care
operation system and its financing schemes. The
following are the major factors:
• The availability of range of services
• The type of relationship health service providers have
with caregivers and MIP
• The responsiveness of the system to caregivers’ issues
 
Clinical factors
 Clinical status of the MIP is another influencing factor
that impact the care extended to MIP.
• Those who manifest less symptoms may be able to care
of themselves and the involvement of the caregiver is
less compared to those with many symptoms. Thus, the
caregivers experience less burden or stress.
 Micro Influences on Caregiving
• These influences are related with the caregivers’ everyday
experiences or burden.
Can be divided as: objective and subjective burden.
 Objective burden: “observable, concrete, costs to the
family resulting from the MI”—instrumental assistance,
everyday disruption in the household, and financial
expenditure.  
 Subjective burden: “individuals’ personal appraisals of
the caregiving situation and the extent to which people
perceive they are carrying burden”—reaction to and
perception of the relationship with the MIP and
psychological impact their caregiving experiences.
• Caregivers often express a sense of burden and worry in
caring for the MIP, expended instrumental care and
financial support to the MIP—these directly or
indirectly incur emotional/psychological strain or
challenges.
• In spite of the challenges that the caregivers experience,
caregiving roles can produce a sense of satisfaction and
gratification.
• Therefore, understanding the macro and micro factors
that affect the caregiving services and the contextual
experiences of the caregivers is mandatory in family or
community-based care, especially in multicultural
settings like Ethiopia.
 Overview of Mental Health Issues in Ethiopia

Introduction 
• The prevalence of mental health problems and their disabling
impinge on individuals’ and the country’s social development
and economic growth.
• Mental health problems supplemented by different factors in
Ethiopia is hastening.

• WHO recognized mental health care as one of the priorities

and its inclusion in primary health care program—
transformation from isolation to integration, in general
medical care—de- institutionalization (to general hospitals and
clinics, and to community care
 Mental Health Problems in Ethiopia 
• “Modern” psychiatric nomenclature vs. identifying syndromes
of mental illnesses in traditional Ethiopian societies
• Syndromes are given different names in different ethnic
languages and inconsistently assigned criteria for the degree of
illness. For example,
• "Cherqun yetale" (Amharic) or "maraattu" (oromifa)
denotes a severely mentally ill person unfit for any
responsibility.
• "Wofeffe" or "nik" (Amharic)—a person is not too reliable,
has inconsistent behavior and unusual changes in ones inter-
personal communication.
• "Abbsho "—an individual who had taken some psycho-active
drug (herb) at some earlier period in one’s life, show some
psychotic-like behavior whenever taking some alcoholic drink.
 Prevalence of mental illness in Ethiopia
 
• The prevalence rates of MI found to be similar to findings
in other parts of Africa and developing countries elsewhere.
The figures could be higher for Ethiopia considering the current
global and local stressful situations and the study population size.

• 12% of Ethiopians suffer from mental illnesses (i.e., 9.6

million/80 million population)
• 2% of the total population (1.6 million/80 million population) is
suffering from the severest form of mental illness or psychosis
• 10% (8 million/80 million populations) are suffering from milder
disorders or neurotic condition
 Determinants of Mental Health
1. Traditional Notion: Determinants
• Supernatural powers vs. controlling the wellbeing of the
individual's mind.
 
Assumptions related to etiology of mental illnesses:
a) Commission or omission sins;
b) Doing the forbidden; or
c) Enmity vs. favoritism by supernatural force
d) Minds are dwelt in or possessed by spirit(s) of evil
supernatural force(s)
Assumptions related to why/when a person may be possessed by evil spirit(s):
• “Walking alone in the woods”
• “Having sex in the open place
• “Falling asleep in the meadow”
• “walking along the river-side around noon-time”
• “Walking in a grave yard”
• “Getting into a long-closed room without blessing self” etc
Incantation, sorcery, enchantment, and rituals: Magical power used by certain
individuals (e.g., offerings are given to them so that they may drive one's
enemy mad or protect one from going mad)
• "Debtera",
• "Kalicha",
• "Tenquai"
• "Tila Wogi”
• Buda” (evil eye)—by looking at a person with evil eyes (when eating
in front of others or if the victim is child, adolescent and woman,
especially the attractive ones) with very acute onset the victim
becomes restless, aggressive, and destructive and shouts incoherently.

• “Danqara”/”Metet”: Used by adversaries against each other.

"Denqara" is an item (i.e., the bodies of a dead mouse, chicken, cat, or
food/grain) with the incantation of a magician ("debtara" or "tanquai
")—put on the roof, door, at the gate or in the compound of a person's
home or across the path of that person).
 
• Poisoning through food and drink: During exorcism at holy water
or church healing rituals, one can hear the mentally ill talk, whilst in a
trance state, about having been made ill by being poisoned via food or
drink.
• 2. Mental disorders vs. physical/psychological
(personal)/familial/social and other environmental factors:
Determinants
• Association between stressors and psychiatric symptoms:
malnutrition, chronic illnesses, separation, migration, natural
disasters, unstable social situations, overpopulation, etc
• chronic illnesses like hypertension, diabetes, epilepsy and
chronic liver disease and higher prevalence of psychiatric
disorders.
• War, remarkable environmental changes, associated famine,
and political torture.
• Famine, poverty, migration, displacement (resettlement) and
parental loss 
• The use of the psych stimulant substancee
 Services can be
• Traditional
• Modern health Services
Traditional
a) Wearing amulets: Writings or inscriptions on goat skin or a piece of paper
strip (folded into a tiny bundle) and is worn by the patient. Some healers also
give herbs, pieces of hyena skin, lip, palpebral or skin.
b) Holy Water: mainly used by Coptic followers --Bathing in, drinking,
sprinkling holy water on the walls and floor of one's home
c) Herbal prescriptions
d) Performing rituals: e.g. slaying a cock of particular texture (as prescribed
by the healer),
e) Moving the carcass round oneself a particular number of times, and then
throwing it towards a particular (prescribed) direction.
f) Exorcism by prayer
g) Exorcism by fumigation (e.g., for "buda")
Modern (Western) mental health care
a. Psychiatric centers: few in number and poorly staffed
b. Services available: outpatient and in-patient service.
• Basic occupational therapy
• Counseling and simple psychotherapy
• A drug and alcohol treatment unit
• Other sub-specialty services: Child and adolescent units, and forensic
units
• Day care centers, rehabilitative services, occupational and other
therapeutic services are limited due to limited of trained staff and
materials in the various specialties.
C. Training in Mental Health is very limited
 Strategies for Developing Mental Health Care Systems in
Ethiopia

• Need to focus on preventive and curative aspects and

rehabilitative strategies. Thus, the health care system and its
structure should strategically work on the following:
1. Address stigma associated with MI at micro, meso and macro
level
2. Availability and accessibility of service centers (scarcity).
3. Increase knowledge and awareness of the spectrum of mental
disorders: severe and mild
4. De-centralization of mental health services to clinics or
hospitals
5. Pre and post-training on various basic clinical,
psychosocial, and other specialty areas
6. Integration of preventive, curative and rehabilitative
services
7. Put in place proper planning, monitoring and
evaluation
8. Develop MIS and basic statistics on the prevalence
of major mental health problems and
Care giving
9. Availability and accessibility of essential drugs
10. Develop and effectively implement national mental health
policy to:
• Recognize mental illnesses as early as possible.
• Determine priorities of services and effective ways of working
on them.
• Enhance family or community-based mental health care to the
mentally ill
• Involve the community in the preventive, therapeutic and
rehabilitative programs
• Doing various researches in various areas of psychiatric
problems and care-giving and found the mental health care on the
contextualized experience