Economic vulnerabilities, mental health, and coping strategies among Tanzanian youth during COVID-19.

BACKGROUND: The COVID-19 pandemic has exacerbated struggles for youth living in poor households. Youth in rural Tanzania are particularly vulnerable given widespread poverty, lack of formal sector employment opportunities, and health risks. We examine influences of the pandemic on economic insecurity and mental health and explore the coping strategies employed by youth and their households. METHODS: We conducted mixed-method data collection with youth (N = 760 quantitative and N = 44 qualitative interviews) and households (n = 542) via mobile phone among a sub-set of a cohort from an on-going longitudinal sample in two rural regions in Tanzania. In addition to phone interviews, we collected data bi-weekly via SMS messaging. We present mixed-methods, descriptive analysis of the outcomes and longitudinally compare quantitative outcomes pre- and post-COVID-19, within the same individuals. RESULTS: Adverse economic impacts were most salient, and to cope, youth engaged in more labor and domestic chores. Compared to prior the COVID-19 pandemic, youth reported spending more time caring for elderly or sick household members and gathering firewood or nuts. CONCLUSIONS: These findings underscore the potential opportunity to promote policies and programs which address risks youth face. Recommended measures include expansion and adaptation of social protection policies, strengthened food and nutrition surveillance and referral systems, and scaling up community-based mental health programming.

'You are looked upon as a luxury tool': Young Tanzanian women's perception of community norms supporting partner violence during transactional sex (kudanga).

This paper explores the definition of, and perceived community attitudes, toward kudanga, a Swahili street term for a type of transactional sex practised in Dar es Salaam, Tanzania. Rooted in economic and gender disparity, transactional sex increases adolescent girls' and young women's vulnerability to HIV and gender-based violence. We sought to understand perceived community attitudes about kudanga, and how the internalisation of norms surrounding gender-based violence relate to the experiences of young women who practise kudanga. Using qualitative data from focus group discussions with 37 young women, we found that community perceptions of kudanga were largely negative, and those who engaged in it were looked down upon and despised. Violence and lack of sexual agency were normalised when doing kudanga. However, young women understood kudanga to often be their best option to obtain economic stability and felt strongly that those who practised kudanga should not be stigmatised. Our research provides further evidence that transactional sex exists on a continuum and highlights the importance of reducing community stigma surrounding transactional sex as a means of decreasing risk of HIV and gender-based violence for young women. To our knowledge, this article is the first to explore kudanga.

Reaching Out-of-school Adolescent Girls and Young Women at Risk for HIV Through Their Social Networks.

Out-of-school adolescent girls/young women (AGYW) in Africa are at increased risk for HIV and are underserved by HIV prevention interventions. Identifying social networks of out-of-school AGYW may be a strategic approach for reaching them. A sequential mixed methods study design was used. The PLACE (Priorities for Local AIDS Control Efforts) methodology, implemented in one ward of Dar es Salaam, Tanzania, identified 69 networks of AGYW. We randomly selected 28 networks and conducted surveys and network assessments with 80.9% (n = 310) of the members. On average, the networks consisted of 13.7 members, and had a density of 0.65 and a transitivity of 0.80, indicating high cohesion. The networks were mostly female (92%). On average, 67% of network membership were AGYW aged 15-24 years, of whom 70% were out-of-school and 67% were sexually active. Among sexually active AGYW aged 15-24, self-reported HIV seropositivity was 12.2%. We then conducted focus group discussions with 6 purposively selected networks. AGYW described their networks as sources of support and advice. Social norms supported AGYW engaging in transactional sex to alleviate life's hardships; it was the easiest way to earn income without "sweating". AGYW discussed IPV as a common experience, and social norms stigmatized AGYWs' use of condoms. AGYW were largely unaware of pre-exposure prophylaxis. The self-reported HIV prevalence rates of this cohort were higher than national averages, suggesting we tapped into high-risk networks. Social norms promoted transactional and unprotected sex. Social networks are an acceptable channel for HIV prevention intervention delivery to out-of-school AGYW.

Effects of Adolescent-Focused Integrated Social Protection on Depression: A Pragmatic Cluster-Randomized Controlled Trial of Tanzania's Cash Plus Intervention.

We assessed the impacts of Tanzania's adolescent-focused Cash Plus intervention on depression. In this pragmatic cluster-randomized controlled trial, 130 villages were randomly allocated to an intervention or control arm (1:1). Youth aged 14-19 years living in households receiving governmental cash transfers were invited to participate. The intervention included an intensive period (a 12-session course) and an aftercare period (9 months of mentoring, productive grants, and strengthened health services). We examined intervention impacts on a depressive symptoms scale (10-item Center for Epidemiologic Studies Depression Scale score (range, 0-30)) and rates of depressive symptomatology (score ≥10 points on the scale), recorded at study baseline (April-June 2017), midline (May-July 2018), and endline (June-August 2019). Using intention-to-treat methodology, we employed logistic and generalized linear models to estimate effects for binary and continuous outcomes, respectively. Quantile regression was used to estimate effects across the scale. From 2,458 baseline participants, 941 intervention and 992 control adolescents were reinterviewed at both follow-ups. At endline, the intervention reduced the odds of depressive symptomatology (adjusted odds ratio = 0.67, 95% confidence interval: 0.52, 0.86), with an undetectable mean scale difference (risk difference = -0.36, 95% confidence interval: -0.84, 0.11). Quantile regression results demonstrated an intervention effect along the upper distribution of the scale. Integration of multisectoral initiatives within existing social protection systems shows potential to improve mental health among youth in low-resource settings.

The Intersection of Intimate Partner Violence Perpetration and Sexual Risk Behavior Among Young Men in Tanzania: A Latent Class Analysis of Patterns and Outcomes.

Few studies of intimate partner violence (IPV) perpetration and sexual risk behavior among men have examined how multiple dimensions of these behaviors intersect in ways that may uniquely elevate health risks. The current study used latent class analysis to: (1) identify distinct patterns of IPV and sexual risk behavior in a sample of Tanzanian men (n = 985) and (2) examine associations between identified patterns and health outcomes. Four classes were identified: normative (64% of the sample), IPV only (14%), sexual risk only (13%), and comorbid IPV/sexual risk (5%). Compared to men in the normative subgroup, men in the comorbid group had significantly higher odds of STI infection, higher perceived HIV risk, and greater odds of substance use. Findings provide evidence that engaging in IPV and multiple sexual partnerships (i.e., a comorbid pattern) denotes elevated health risks across a range of indicators, suggesting the importance of targeted treatment and prevention efforts for men in this subgroup.

RESUMEN: Pocos estudios sobre la violencia infligida por la pareja (IPV) y las conductas sexuales de riesgo entre los hombres han examinado como las múltiples dimensiones de estas conductas pueden combinarse para elevar los riesgos de estas conductas para la salud. El estudio actual utilizó el análisis de clases latentes para: (1) identificar patrones (o clases) distintos de IPV y conductas sexuales de riesgo en una muestra de hombres de Tanzania (n = 985) y (2) examinar asociaciones entre los patrones identificados y indicadores de salud. Se identificaron cuatro clases: normativa (64% de la muestra), IPV solo (14%), riesgo sexual solo (13%) y riesgo sexual / IPV comórbido (5%). En comparación con los hombres del subgrupo normativo, los hombres del grupo comórbido tenían probabilidades significativamente más altas de infección de transmisión sexual, mayor riesgo percibido de VIH, y mayores probabilidades de consumo de sustancias (alcohol y marijuana). Los hallazgos proporcionan evidencia de que ser perpetrador de violencia en pareja y tener múltiples parejas sexuales (un patrón comórbido) es asociado con múltiples riesgos para la salud, lo que sugiere la importancia del tratamiento dirigido y los esfuerzos de prevención para los hombres en este subgrupo.

Effects of Government-Implemented Cash Plus Model on Violence Experiences and Perpetration Among Adolescents in Tanzania, 2018‒2019.

Objectives. To examine the impacts of a government-implemented cash plus program on violence experiences and perpetration among Tanzanian adolescents. Methods. We used data from a cluster randomized controlled trial (n = 130 communities) conducted in the Mbeya and Iringa regions of Tanzania to isolate impacts of the "plus" components of the cash plus intervention. The panel sample comprised 904 adolescents aged 14 to 19 years living in households receiving a government cash transfer. We estimated intent-to-treat impacts on violence experiences, violence perpetration, and pathways of impact. Results. The plus intervention reduced female participants' experiences of sexual violence by 5 percentage points and male participants' perpetration of physical violence by 6 percentage points. There were no intervention impacts on emotional violence, physical violence, or help seeking. Examining pathways, we found positive impacts on self-esteem and participation in livestock tending and, among female participants, a positive impact on sexual debut delays and a negative effect on school attendance. Conclusions. By addressing poverty and multidimensional vulnerability, integrated social protection can reduce violence. Public Health Implications. There is high potential for scale-up and sustainability, and this program reaches some of the most vulnerable and marginalized adolescents. (Am J Public Health. 2021;111(12):2227-2238. https://doi.org/10.2105/AJPH.2021.306509).

Examining determinants of gender attitudes: evidence among Tanzanian adolescents.

BACKGROUND: The shaping of gender beliefs and attitudes in early adolescence affects the way young people internalize and self-enforce prevalent notions of masculinity and femininity, with lifelong consequences for sexual and reproductive health. This cross-sectional study examines determinants of gender attitudes among some of the poorest and most vulnerable adolescents in Tanzania using an ecological model. METHODS: Data come from baseline interviews with 2458 males and females aged 14-19 years conducted as part of a larger impact evaluation. Structural equation models are used to examine how factors at the community-, household-, and individual-levels influence gender attitudes in the four domains measured by the Gender Equitable Men (GEM) Scale (i.e. violence, sexual relationships, reproductive health and disease prevention, and domestic chores and daily life). RESULTS: A structural equation model of the four latent domains of the GEM scale regressed on individual, social-interactional and structural level characteristics indicated that secondary school attendance was associated with more equitable gender attitudes, while females held less equitable attitudes than males in the sample. Having had sexual intercourse was associated with more gender equitable attitudes among females, but the reverse was true among males. CONCLUSIONS: Addressing gender inequity requires understanding gender socialisation at the socio-interactional level. As females had more inequitable gender attitudes than males in the study, a special emphasis on highlighting the rights of women to girls should be considered. This study will inform future analysis of programme impacts on gender attitudes and sexual and reproductive health.

Sexual and Social Network Correlates of Willingness to Self-Test for HIV Among Ever-Tested and Never-Tested Men: Implications for the Tanzania STEP Project.

We examined factors associated with HIV self-testing (HIVST) willingness among male ever-testers and never-testers who participated in a midpoint survey of a cluster randomized controlled HIV prevention trial in Dar es Salaam. Linear mixed binary logistic regression models were constructed to examine factors (demographic, HIV risk behavior, and sexual/social network) associated with willingness to self-test. Sixtyseven percent of 301 never-testers were willing to self-test for HIV compared to 72% 577 of ever-testers. Among never-testers, having discussed testing for HIV with a sexual partner was the only factor associated with HIVST willingness (2.36, 95% CI: 1.35-4.15). For evertesters, younger men were less willing to self-test than older men while men with higher education were more willing to self-test than less educated men. Having a moderate/great HIV risk perception decreased the odds of HIVST willingness relative to no risk perception (0.40, 95% CI 0.23-0.70) for ever-testers. Discussing HIV testing with a sexual partner and having been encouraged to test for HIV by a friend were associated with higher odds of being willing to self-test (2.22, 2.23; 95% CI 1.34-3.67, 1.14-4.39, respectively) among ever-testers. These findings suggest that HIVST willingness is highly acceptable among both male ever-testers and never-testers.

How Alcohol, Space, and Time Influence Young People's Sexual Encounters in Tanzania: A Qualitative Analysis.

A significant under-addressed issue in the global adolescent health agenda is the interaction between alcohol use and sexual encounters among adolescent boys and girls in sub-Saharan Africa. The aim of this study was to explore the structural and environmental factors influencing young people's access to and use of alcohol, and subsequent engagement in safe or unsafe sexual behaviors in such contexts, from the perspective of young people themselves. We used qualitative and participatory methodologies to explore the experiences and perspectives of 177 adolescent girls and boys in and out of school in four sites across Dar es Salaam, Tanzania. Findings suggest that alcohol use intersects with a spatial dimension in relation to where youths are consuming alcohol and subsequently engaging in sex. This in turn influences young people's likelihood of using condoms and practicing safer sex. The spatial dimension was found to be influenced by time, gender, age, economics, and social norms around the carrying of and use of condoms. Interventions are needed that both address the gendered and social sanctioning of youth carrying condoms in Tanzania and that increase the availability of condoms where alcohol is sold and consumed.

Structural Network Position and Performance of Health Leaders Within an HIV Prevention Trial.

The effectiveness of peer leaders in promoting health may depend on the position they occupy within their social networks. Using sociocentric (whole network) and behavioral data from the intervention arm of a cluster-randomized HIV prevention trial in Dar es Salaam, Tanzania, we used generalized linear models with standardized predictors to examine the association between heath leaders' baseline structural network position (i.e., in-degree and betweenness centrality) and their 12-month self-reported (1) confidence in educating network members about HIV and gender-based violence (GBV) and (2) number of past-week conversations about HIV and GBV. As in-degree centrality increased, leaders reported fewer HIV-related conversations. As betweenness centrality increased, leaders reported greater number of conversations about GBV. Network position was not significantly associated with confidence in discussing either topic. Our results suggest that peer leaders who occupy spaces between sub-groups of network members may be more effective in engaging their peers in sensitive or controversial topics like GBV than more popular peer leaders.

Changes in Anxiety and Depression Symptoms Predict Sexual Risk Behaviors Among Young Men Living in Dar es Salaam, Tanzania.

Young men are important targets in HIV prevention in Tanzania and throughout sub-Saharan Africa. Anxiety and depression are common among youth and may be important predictors of HIV risk behaviors; evidence of these relationships in high-risk populations is needed. Using baseline and 1 year follow-up assessments from an HIV prevention trial we assessed the association between changes in symptoms of anxiety and depression and follow-up sexual risk behaviors (condom use and sexual partner concurrency) controlling for baseline sexual risk behaviors among 1113 male members of social groups known as "camps" in Dar es Salaam, Tanzania. Anxiety and depression were measured using the HSCL-25 and condom use and sexual partner concurrency were assessed through self-report. In separate models, increases in anxiety and depression were associated with sexual partner concurrency and with lower levels of condom use. In a combined model, both anxiety and depression appeared to independently affect concurrency but only depression was independently associated with condom use, with the association between anxiety and condom use being likely attributable to covariance with depression symptoms. The results of this study indicate the importance of screening and providing treatment for depression and anxiety disorders in high HIV-prevalence contexts, and the need to develop effective HIV prevention interventions targeting young men living with anxiety and depression.

Peer network influence on intimate partner violence perpetration among urban Tanzanian men.

Male perpetration of intimate partner violence (IPV) against women in Tanzania is widespread. Theory and empirical evidence suggest peer networks may play an important role in shaping IPV perpetration, although research on this topic in sub-Saharan Africa is limited. Grounded in social learning theory, social influence theory, and the theory of gender and power, the purpose of this study was to examine whether and how peer networks influence men's perpetration of IPV in Dar es Salaam, Tanzania. We conducted in-depth interviews (n = 40) with a sub-sample of 20 men enrolled in the control condition of an ongoing cluster-randomised controlled trial. We purposively sampled participants who previously reported perpetrating physical IPV. To analyse the data, we generated narrative summaries and conducted thematic and interpretative coding. We saw no evidence that men self-selected into peer networks with certain values or behaviours. Rather, men described several mechanisms through which their peers influenced the perpetration of IPV, including: (1) the internalisation of peer network norms, (2) pressure to conform to peer network norms and (3) the direct involvement of peers in shaping couple power dynamics. Our findings suggest that peer networks influence men's perpetration of IPV and should be targeted in future programmes and interventions.

Associations Between Peer Network Gender Norms and the Perpetration of Intimate Partner Violence Among Urban Tanzanian Men: a Multilevel Analysis.

Male perpetration of intimate partner violence (IPV) against women in sub-Saharan Africa is widespread. Theory and empirical evidence suggest peer networks may play an important role in shaping IPV perpetration, though research on this topic in the region is limited. We assessed the degree to which peer network gender norms are associated with Tanzanian men's perpetration of IPV and examined whether the social cohesion of peer networks moderates this relationship. Using baseline data from sexually active men (n = 1103) nested within 59 peer networks enrolled in an on-going cluster-randomized HIV and IPV prevention trial, we fit multilevel logistic regression models to examine peer network-level factors associated with past-year physical IPV perpetration. Peer network gender norms were significantly associated with men's risk of perpetrating IPV, even after adjusting for their own attitudes toward gender roles (OR = 1.53 , p = . 04). Peer network social cohesion moderated this relationship (OR = 1.50 , p = . 04); the positive relationship between increasingly inequitable (i.e., traditional) peer network gender norms and men's risk of perpetrating IPV became stronger, as peer network social cohesion increased. Characteristics of the peer network context are associated with men's IPV perpetration and should be targeted in future interventions. While many IPV prevention interventions focus on changing individual attitudes, our findings support a unique approach, focused on transforming the peer context.

Social Network Influence on HIV Testing Among Urban Men in Tanzania.

Men in sub-Saharan Africa have low HIV testing rates. Social networks exert an important influence on men's HIV-related behavior. We examined associations between network factors and HIV testing among men in Dar es Salaam, Tanzania. Data are from the baseline assessment of an HIV prevention trial with 48 primarily male networks. Among 923 sexually active men, 52 % had ever tested for HIV. In a random effects logistic regression model, men in the network core were 1.50 times more likely (p < .05) to test than those in the periphery. Percentage of women in the network was associated with men's increased HIV testing (AOR 4.24, p < .05). Perception of network HIV stigma was negatively associated with HIV testing (AOR 0.92, p < .01). Thinking at least one close friend tested for HIV was associated with increased testing (AOR 2.66, p < .001). Social network interventions are a promising approach for scaling up men's HIV testing.

Anxiety and depression strongly associated with sexual risk behaviors among networks of young men in Dar es Salaam, Tanzania.

This study tested the association between mental health scores and sexual risk behaviors among male members of social groups known as "camps" in Dar es Salaam, Tanzania. Anxiety and depression were measured using the HSCL-25 and condom use and sexual partner concurrency were assessed through self-report. A total of 1113 sexually active men with an average age of 27 years were included in the analyses. Higher anxiety and depression scores were significantly associated with both condom use (Anxiety AOR = 0.58, 95% CI: 0.44, 0.77; Depression AOR = 0.60, 95% CI: 0.47, 0.77) and concurrency (Anxiety AOR = 2.32, 95% CI: 1.73, 3.12; Depression AOR = 2.08, 95% CI: 1.60, 2.70). The results of this study provide information salient to the development of effective HIV prevention interventions targeting populations with high burdens of anxiety and depression. The feasibility and effect of integrating mental health promotion activities into HIV prevention interventions should be explored.

Effect of the PREPARE intervention on sexual initiation and condom use among adolescents aged 12-14: a cluster randomised controlled trial in Dar es Salaam, Tanzania.

BACKGROUND: Unsafe sexual practices continue to put adolescents at risk for a number of negative health outcomes in Tanzania. While there are some effective theory-based intervention packages with positive impact on important mediators of sexual behaviours, a context specific and tested intervention is urgently needed in Tanzania. PURPOSE: To develop and evaluate an intervention that will have a significant effect in reducing sexual initiation and promoting condom use among adolescents aged 12-14 in Dar es Salaam, Tanzania. DESIGN: A school-based Cluster Randomised Controlled Trial was conducted during 2011-2014 in Kinondoni Municipality. METHODS: A total of 38 public primary schools were randomly selected, of which half were assigned to the intervention and half to the control group based on their size and geographic location. Participants were interviewed using a self-administered questionnaire at baseline before the PREPARE intervention and then, 6 and 12 months following intervention. The primary outcomes were self-reported sex initiation and condom use during the past 6 months. Data analysis was done using Generalized Estimating Equation (GEE) modelling controlling for repeated measures and clustering of students within schools. RESULTS: A total of 5091 students were recruited at baseline, and interviewed again at 6 (n = 4783) and 12 months (n = 4370). Mean age of participants at baseline was 12.4 years. Baseline sociodemographic, psychometric and behavioural characteristics did not significantly differ between the two study arms. The GEE analysis indicated that the intervention had a significant effect on sexual initiation in both sexes after controlling for clustering and correlated repeated measures. A significantly higher level of action planning to use condoms was reported among female adolescent in the intervention arm than those in the control arm (p = 0.042). An effect on condom use behaviour was observed among male adolescent (p = 0.004), but not among female (p = 0.463). CONCLUSIONS: The PREPARE intervention had an effect in delaying self-reported sexual initiation among adolescents aged 12-14 in Dar es Salaam Tanzania. The intervention positively influenced action planning to use condoms for both sexes and increased actual condom use among male adolescents only. Future interventions addressing adolescent sexual and reproductive health should focus on impacting mediators of behaviour change. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12613000900718 , registered on 13 August, 2013.

Young Men's Social Network Characteristics and Associations with Sexual Partnership Concurrency in Tanzania.

Social network influence on young people's sexual behavior is understudied in sub-Saharan Africa. Previous research identified networks of mostly young men in Dar es Salaam who socialize in "camps". This study describes network characteristics within camps and their relationship to young men's concurrent sexual partnerships. We conducted surveys with a nearly complete census of ten camp networks (490 men and 160 women). Surveys included name generators to identify camp-based networks. Fifty seven percent of sexually active men (n = 471) reported past year concurrency, measured using the UNAIDS method. In a multivariable model, men's individual concurrency was associated with being a member of a closer knit camp in which concurrency was the normative behavior. Younger men who had older members in their networks were more likely to engage in concurrency. Respondent concurrency was also associated with inequitable personal gender norms. Our findings suggest strategies for leveraging social networks for HIV prevention among young men.

Comparing Perceptions with Actual Reports of Close Friend's HIV Testing Behavior Among Urban Tanzanian Men.

Men have lower rates of HIV testing and higher rates of AIDS-related mortality compared to women in sub-Saharan Africa. To assess whether there is an opportunity to increase men's uptake of testing by correcting misperceptions about testing norms, we compare men's perceptions of their closest friend's HIV testing behaviors with the friend's actual testing self-report using a unique dataset of men sampled within their social networks (n = 59) in Dar es Salaam, Tanzania. We examine the accuracy and bias of perceptions among men who have tested for HIV (n = 391) and compare them to the perceptions among men who never tested (n = 432). We found that testers and non-testers did not differ in the accuracy of their perceptions, though non-testers were strongly biased towards assuming that their closest friends had not tested. Our results lend support to social norms approaches designed to correct the biased misperceptions of non-testers to promote men's HIV testing.

Parenting practices and styles associated with adolescent sexual health in Dar es Salaam, Tanzania.

Parenting styles and practices are suggested to be important predictors of adolescent sexual health, mostly in Europe and North America. Limited research has been conducted on these processes in Sub-Saharan Africa, which has different patterns of adolescent sexual behavior and family traditions. This study qualitatively explored parenting practices and styles associated with adolescent sexual health in Tanzania, with 12 adolescents and 12 parents of adolescents. The themes we identified from the data included parental monitoring, preventive, and punitive behaviors. Parents were reported to use mostly punitive behaviors to correct or prohibit sexual behavior; parents also set clear rules about appropriate sexual behavior (e.g., modesty and abstinence). Parents were also reported to closely monitor their adolescent children's friendships and sexual behavior to minimize sexual behavior. However, some parents also engaged in positive preventive practices aimed at protecting their adolescent children.

The psychosocial problems of families caring for relatives with mental illnesses and their coping strategies: a qualitative urban based study in Dar es Salaam, Tanzania.

BACKGROUND: Mental illness may cause a variety of psychosocial problems such as decreased quality of life of the patient's family members as well as increased social distance for the patient and the family caring for the patient. Psychosocial challenges are enhanced by the stigma attached to mental illness, which is a problem affecting not only the patient but also the family as a whole. Coping mechanisms for dealing with mentally ill patients differ from one family to another for a variety of reasons. The aim of the study was to determine the psychosocial problems of mental illness on the family including the coping strategies utilized by family members caring for a person with mental illness. METHOD: A qualitative study was conducted, involving four focus group discussions and 2 in-depth interviews of family members who were caring for patient with mental illness at Temeke Municipality, Dar es Salaam. Purposive sampling procedure was used to select participants for the study. Audio-recorded interviews in Swahili were conducted with all study participants. The recorded interview was transcribed and qualitative content thematic analysis was used to analyse the data. RESULTS: Financial constraints, lack of social support, disruption of family functioning, stigma, discrimination, and patients' disruptive behaviour emerged as the main themes in this study. Acceptance and religious practice emerged as the major coping strategies used by family members. CONCLUSION: Familial care for a person with mental illness has its advantages, yet it has multiple social and psychological challenges. Coping strategies and skills are important for the well-being of the caregiver and the patient. Addressing these psychosocial challenges requires a collaborative approach between the health care providers and government so that the needs of the family caregivers and those of the patients can be addressed accordingly.