Victimisation in the life of persons with severe mental illness in Uganda: a pluralistic qualitative study.

INTRODUCTION: Victimisation of persons with severe mental illness is recognised as an urgent global concern, with literature pointing to higher rates of violent victimisation of persons with severe mental illness than those of the general population. Yet, for low income countries, there is a huge gap in the literature on the risk, character and victims' in-depth experiences of victimisation of persons with severe mental illness. We explore the lived experiences and meanings of victimisation of persons with severe mental illness in Uganda, and discuss their implications for care of the mentally ill. METHODS: A pluralistic qualitative study was undertaken to explore victimisation among patients with severe mental illness. Patients who had suffered victimisation were purposively sampled from Butabika National Referral Mental Clinic and Masaka Regional Referral Hospital, following confirmation of symptom remission. In-depth interviews were held with 18 participants, comprising 13 females and 5 males from low to moderate socioeconomic status. Interpretative phenomenological analysis and thematic content analysis were conducted. RESULTS: Victimisation was exhibited in three main forms: (a) psychological, expressed in attitudes towards mentally ill family members as valueless and dispensable, and stigmatisation, (b) physical, as manifested in beatings, indoor confinement and tethering mostly by family members and (c) sexual victimisation, particularly rape. Also observed were victim's various responses that pointed to the negative impact of victimisation, including a heightened risk of suicide, social withdrawal, a sense of hatefulness and a predisposition to more victimisation. CONCLUSION: The family environment plays a predominant role in perpetrating victimisation of the mentally ill in some sub-Saharan African contexts such as Uganda. We propose a holistic framework for mental health interventions, incorporating biomedical but notably also social determinants of mental health, and targeted at improving familial relationships, social support and a sense of belongingness both within the family and the broader community.

Epistemological differences in the discussion of the interpersonal theory of suicide: A reply to the response.

This paper is a reply to Smith and colleagues' response to our critique of the interpersonal theory of suicide (IPTS). They believe that we mischaracterize and misinterpret aspects of the IPTS. Here, we argue that the problem rather seems to be that we are discussing the IPTS from two different epistemological "planets."

To die or not to die: a qualitative study of men's suicidality in Norway.

BACKGROUND: Previous research has shown that men who adhere to traditional beliefs about masculinity have increased health risks compared to those who do not. Single marital status, unemployment, retirement, and physical illness are commonly known risk factors for male suicidal behavior. Most men struggling with these risk factors are, however, not suicidal. To find out more about what makes some men vulnerable to suicidal behavior, risk factors must be analyzed in light of men's life history as well as the social context where they live their masculinity. METHOD: We conducted semi-structured qualitative in-depth interviews with 15 men (20-76 years old) who were admitted to hospital after a suicidal act. We analyzed the data by means of qualitative content analysis with a directed approach. The analysis was directed by the participants' reports on whether they had wanted to die or not at the time of the suicidal act. On this basis, they were divided into two groups: a "to die" and a "not to die" group. We then analyzed each group separately before comparing them. RESULTS: In both groups, the main reason or trigger for the suicidal act were problems in intimate relationships. These problems were complex and connected to the men's lived masculinity, ranging from shame, or tainted masculine honor, to taking responsibility as a man for the wife. Some men pointed to pain and ennui as reasons or triggers for their suicidal act. Only one in the "not to die" group took full responsibility for the suicidal act, whereas all but one did the same in the "to die" group. The men not taking responsibility described the suicidal act as involuntary because of either alcohol or a kind of "black-out". Not taking responsibility for the act may be a way of preserving masculine identity. CONCLUSION: Relationship problems are the main reason or trigger of the suicidal act for most participants, but in very different ways, mirroring lived masculinity. The most striking finding is the uniqueness of each story, questioning the utility of standardized suicide prevention efforts.

Suicide among men in Ghana: The burden of masculinity.

In Ghana, some studies have reported a high rate for both fatal and non-fatal suicidal behaviors among men. The current study aimed at understanding the psychosocial circumstances involved in male suicides. We interviewed between two to seven close relations of each of 12 men who died by suicide. Interpretative phenomenological analysis of data indicates that experiences of shame related to loss of economic control, breach of patriarchal norms, and threats to sexual competence contributed to the suicides. Addressing socioeconomic issues, creating opportunities for men to disclose their emotions, and identifying sources of these emotions may help prevent suicide among men.

The Coping Mechanisms and Strategies of Hypertension Patients in Ghana: The Role of Religious Faith, Beliefs and Practices.

This qualitative study explored the role of religious faith, belief and practice systems in the coping mechanisms and strategies of essential hypertension patients in Accra, Ghana. Six participants were recruited for participation, of which five were Christians and one was a Muslim. Interviews were conducted and interpretative phenomenological analysis was used to analyze the data. Results showed that participants used their religious faith, beliefs and practices as coping resources. Participants used a deferring-collaborative style of religious coping, which seemed to have provided them with an avoidance strategy that protected the participants from conscious confrontation with their illness. Religious faith and beliefs also afforded the participants a sense of coherence that enabled the participants to manage their stress, reflect on their external and internal resources to promote effective coping and adaptive functioning in a health promoting manner. Implications of a deferring-collaborative style of religious coping and religious re-appraisal are discussed.

The experiences of caregivers of children living with HIV and AIDS in Uganda: a qualitative study.

BACKGROUND: Home-based care for HIV patients is popular in contexts severely affected by the epidemic and exacts a heavy toll on caregivers. This study aimed at understanding the experiences of caregivers and their survival strategies. METHODS: A total of 18 caregivers (3 males and 15 females) were interviewed using a semi-structured interview guide, and thematic analysis was used to analyse the data. RESULTS: Analysis suggests that the caregivers are burdened with insecure provisions for food and difficulties in accessing health care. They however survived these strains through managing their relationships, sharing burden with care-recipients, social networks and instrumental spirituality. These findings are discussed under two major themes: 1). Labour of caregiving and 2). Survivalism. CONCLUSIONS: Home-based care presents huge opportunities for community response to the HIV/AIDS epidemic in African settings. It is however burdensome and thus should not be left for families alone to shoulder. There is therefore an urgent need for protecting home-based care for HIV children in Uganda. Implications for improving and strengthening social interventions in home-based care of HIV/AIDS in the Ugandan context are addressed.

Connecting with suicidal patients in psychiatric wards: Therapist challenges.

In this qualitative interview study, the authors investigated how therapists experience and view treatment and care for suicidal patients in psychiatric wards. The focus is on aspects that may contribute toward shaping and possibly constraining therapists' connections with suicidal individuals. They conducted semistructured interviews of 4 psychiatrists and 4 psychologists and analyzed the data by means of thematic analysis. The findings suggest that high emphasis on diagnostics and standardized suicide risk assessments, limited direct care of suicidal patients, and fragmented mental health services may challenge therapists' connections with suicidal patients.

Mental Health Nurses' Experiences of Caring for Suicidal Patients in Psychiatric Wards: An Emotional Endeavor.

The purpose of the study is to investigate mental health nurses' experiences of recognizing and responding to suicidal behavior/self-harm and dealing with the emotional challenges in the care of potentially suicidal inpatients. Interview data of eight mental health nurses were analyzed by systematic text condensation. The participants reported alertness to patients' suicidal cues, relieving psychological pain and inspiring hope. Various emotions are evoked by suicidal behavior. Mental health nurses seem to regulate their emotions and emotional expressions, and balance involvement and distance to provide good care of patients and themselves. Mental health nurses have an important role and should receive sufficient formal support.

Relational Principles in the Care of Suicidal Inpatients: Experiences of Therapists and Mental Health Nurses.

This study explored and compared therapists' and mental health nurses' experiences of caring for suicidal inpatients in light of ethics of care and ethics of justice. Analysis of interview data from eight therapists and eight mental health nurses indicates two approaches: "connection and care" and "duty and control," reflecting aspects of both ethical perspectives. There are some differences between the two professional groups, and sometimes there might be conflicts between the two approaches and ethical perspectives. Clinical practice is increasingly shaped by standardization and guidelines, and it is important to promote professionals' efforts to provide relational-emotional care for suicidal patients.

Mental health workers' views on the criminalization of suicidal behaviour in Uganda.

Attempted suicide is still criminalized in Uganda. However, the Ministry of Health has asked the psychiatric community to help in the work to abolish this law. The purpose of this study was to investigate how Ugandan mental health workers view this law. We conducted a qualitative interview study of 30 mental health workers (psychiatrists, psychologists, psychiatric clinical officers and psychiatric nurses). We found that two-thirds of this sample wanted the law abolished, mainly because they view suicidal behaviour as a mental health issue. Some, however, wanted to keep the law because they viewed it as a suicide prevention in that it would deter people from killing themselves. A few were ambivalent. The findings indicate a need for increased awareness of the negative consequences of the law as well as educating mental health workers in understanding of suicidal behaviour and suicidal people.

UK ethnic minority healthcare workers' perspectives on COVID-19 vaccine hesitancy in the UK ethnic minority community: A qualitative study.

Background: The experiences of UK ethnic minority (UKEM) healthcare workers are crucial to ameliorating the disproportionate COVID-19 infection rate and outcomes in the UKEM community. We conducted a qualitative study on UKEM healthcare workers' perspectives on COVID-19 vaccine hesitancy (CVH) in the UKEM community. Methods: Participants were 15 UKEM healthcare workers (11 females; age range: 26-58 [43.3 ± 9.4] years). Data were collected using individual and joint interviews, and a focus group, and analyzed using thematic analysis. Results: We generated three themes: heterogeneity (two subthemes), mistrust (six subthemes), and mitigating (six subthemes). Therein, participants distinguished CVH in the UKEM community in educational attainment and ethnicity. They pointed to the role of mistrust in CVH in the UKEM community. They opined that the mistrust underlying CVH in the UKEM community is rooted in history and religion, conspiracy theories, the speedy development and novelty of the vaccines, post-vaccination complications/side effects, false positive test results, and social media and social support/influence. Participants recommended that interventions targeted at mitigating CVH in the UKEM community need to, in a non-judgmental way, tackle dis/misinformation and provide education, and incorporate UKEM healthcare worker endorsement. They also suggested such interventions be community-oriented, enhance the convenience of vaccination centers and the possibility of vaccine choice, and appreciate that overcoming CVH and accepting vaccination is a gradual process involving personal assessment of risks and benefits. Conclusion: CVH in the UKEM community is a multifaceted phenomenon requiring multicomponent interventions.

"Time to Try Something New" - Professionals' Experiences and Reflections on Suicide Prevention in Norway.

Background: The suicide rate in Norway has remained relatively stable despite 25 years of government-funded suicide prevention efforts. Aim: We aimed to gather experiences of the professionals responsible for implementing suicide prevention action plans and guidelines and/or involved in relevant research. Method: We conducted semistructured interviews with 22 professionals about their reflections on the priorities and work done so far as well as where to go next. Data were analyzed by means of thematic analysis. Results: The participants described conflicting understandings and a monopolization of "the truth" within the suicide prevention community. They perceived the dominant biomedical understanding of suicidality and appurtenant approach to suicide prevention as too narrow. Thus, they found the suicide prevention work and collaboration challenging and recommend that it is time to try something new. Limitations: This study was conducted in a Norwegian context. A biomedical approach to suicide prevention is, however, common internationally. Conclusion: Participants described several challenges in the suicide prevention work. The contemporary "regime of truth" limits how suicide is understood and studied, as well as how suicide prevention is approached. A more open approach to suicide prevention, emphasizing the importance of relationships, context, and collaboration between sectors, is recommended.

A Struggle for Survival: Meaning of Late Life in a Rural District in Uganda: A Qualitative Study.

Background: Between 2015 and 2050, the aging population of Uganda (aged 50 years and older) will be nearly doubled. Therefore, later-life problems have become an area of increasing research and policy interest. This study aimed at exploring how aging people living in extreme poverty in a low-income country experience their everyday life and what kind of meaning systems employed by them to understand and cope with their living conditions. Methods: We conducted a qualitative interview with 14 participants in the Buikwe district. In this interview, 11 women and 3 men were included, and a thematic analysis was employed for data processing and analysis. Results: Unanimously, all participants reported their condition as extreme poverty. The key informants (KIs) emphasized respect from descendants and the community as a foundation for a meaningful later life. In contrast, this aspect has been ever mentioned by no caregivers but by only one care-receiver. The willingness/ability of children to support the elderly who are in need of support formed a major part of the reflections of care-receivers, which would be decisive for their position in the society and the respect they would receive. In addition, both Christianity and traditional beliefs as well as beliefs in witchcraft and ancestral spirits were employed as a basis for actions and reflections. Discussion: The question arises whether life in extreme poverty conditions can be perceived as meaningful. Respect was mentioned as fundamental by the KIs, thereby giving priority to social relations as the most meaningful factor for living a meaningful life. The ability and willingness of the possible descendants for support as the focus of care-receivers might be a more down-to-earth description of this aspect but without using the same level of abstraction. For the majority, due to their belief system did not serve as a source of consolation their main focus was on social relationships for support. To improve the wellbeing of the old people, their sense of meaning must be restored through a system, guaranteeing the coverage of basic needs and measures to restore dignity through a reintegration in both community and congregations. Social service agencies who are targeting the elderly people need to work toward this objective.

Religion as Meaning-Making Resource in Understanding Suicidal Behavior in Ghana and Uganda.

Suicidal behavior is condemned by religions and tradition, and suicide attempts are criminalized by law in several African countries, including Ghana and Uganda. Suicide and suicide attempts may have severe consequences for both the entire family and the community. Religion is known to act as a protective coping force that helps people to make meaning and find comfort when dealing with stressful life events or situations like suicide. In this article, we focus on the cultural interpretations of the dominating religion in Ghana and Uganda, Christianity, and whether these affect attitudes toward suicidal behavior, meaning making, and coping possibilities for people who have attempted suicide or are bereaved by suicide. This article is based on data material from previous studies on the mentioned topics by the authors.

Societal Reactions to Suicide in Ghana.

Background: Condemnatory reactions toward suicide are prevalent in Africa, yet no study has examined how society reacts to suicides from the perspective of suicide-bereaved persons. Aims: This qualitative study explored societal reactions to suicides so as to further our understanding of the problem in Ghana. Method: Using a semi-structured interview guide, we interviewed 45 close relations of 14 men who took their lives. Results: The reactions followed ontological questions of what suicide means (construing the act), its impact (consequences), why it happened and who to blame (attributions and allocation of responsibility), and how to remedy perceived damages (damage control). Limitations: Focusing on suicides of only men might have limited the range of societal reactions to suicide in general. Conclusion: Reparative and retributive societal reactions to suicides were influenced predominantly by views that suicide is an extraordinary moral evil in the setting. Increased culturally focused suicide education can improve people's understanding and enhance responsive suicide prevention and postvention.

Health care professionals' perspectives on barriers to treatment seeking for formal health services among orphan children and adolescents with HIV/AIDS and mental distress in a rural district in central, Uganda.

BACKGROUND: Little/no research has been conducted in Uganda in particular and sub-Saharan Africa in general on the health professional's perspectives on barriers to treatment seeking for formal health services among orphan children and adolescents with a double burden of HIV/AIDS and mental distress. AIM: To explore health professionals' perspectives on barriers to treatment seeking for formal health services among orphan children and adolescents with HIV/AIDS and mental distress in Masaka, Uganda. METHOD: Qualitative research design using key informant interviews with health service managers and staff in agencies working with children and adolescents with HIV/AIDS in Masaka district, Uganda. RESULTS: Barriers to treatment seeking reported by health care professionals were quite enormous and are summarized under: family, individual, community and health systems level barriers. The crosscutting finding here is that the societal informal and formal systems of care had been affected by the HIV/AIDs epidemic, and, mental distress aggravates this challenge for the individuals afflicted and families affected by mental distress. CONCLUSION: Children and adolescents with both HIV/AIDS and mental distress are vulnerable due to constraints at family, community and health systems levels. Effective public health interventions to address the double burden of HIV/AIDS and mental distress will be vital in the study communities addressing the constraints at family, community and institutional level. Public health interventions should aim at increased access and effective utilization of services for both HIV/AIDS and mental health services. Stigma reduction strategies at individual, family and community levels are also recommended.