"Trust in God, but tie your donkey": Holy water priest healers' views on collaboration with biomedical mental health services in Addis Ababa, Ethiopia.

This exploratory qualitative study examines holy water priest healers' explanatory models and general treatment approaches toward mental illness, and their views and reflections on a collaborative project between them and biomedical practitioners. The study took place at two holy water treatment sites in Addis Ababa, Ethiopia. Twelve semi-structured interviews with holy water priest healers found eight notable themes: they held multiple explanatory models of illness, dominated by religious and spiritual understanding; they emphasized spiritual healing and empathic understanding in treatment, and also embraced biomedicine as part of an eclectic healing model; they perceived biomedical practitioners' humility and respect as key to their positive views on the collaboration; they valued recognition of their current role and contribution in providing mental healthcare; they recognized and appreciated the biomedical clinic's effectiveness in treating violent and aggressive patients; they endorsed the collaboration and helped to overcome patient and family reluctance to the use of biomedicine; they lamented the lack of spiritual healing in biomedical treatment; and they had a number of dissatisfactions and concerns, particularly the one-way referral from religious healers to the biomedical clinic. The study results show diversity in the religious healers' etiological understanding, treatment approaches and generally positive attitude and views on the collaboration. We present insights and explorations of factors affecting this rare, but much needed collaboration between traditional healers and biomedical services, and potential ways to improve it are discussed.

Perceptions of readiness for interprofessional learning among Ethiopian medical residents at Addis Ababa University: a mixed methods study.

BACKGROUND: Interprofessional learning is an important approach to preparing residents for collaborative practice. Limited knowledge and readiness of residents for interprofessional learning is considered one of the barriers and challenges for applying Interprofessional learning. We aimed to assess the perceptions of readiness of medical residents for interprofessional learning in Ethiopia. METHODS: We conducted a parallel mixed-methods study design to assess the perceptions of readiness for interprofessional learning among internal medicine and neurology residents of Tikur Anbessa Specialized Teaching Hospital in Addis Ababa, Ethiopia, from May 1 to June 30, 2021. One hundred one residents were included in the quantitative arm of the study, using the Readiness for Interprofessional Learning Scale (RIPLS) tool. All internal medicine and neurology residents who consented and were available during the study period were included. SPSS/PC version 25 software packages for statistical analysis (SPSS) was used for statistical analysis. Descriptive statistics were summarized as mean and standard deviation for continuous data as well as frequencies and percentages to describe categorical variables. Data were presented in tables. In addition, qualitative interviews were undertaken with six residents to further explore residents' knowledge and readiness for IPL. Data were analyzed using a six-step thematic analysis. RESULTS: Of the 101 residents surveyed, the majority of the study participants were male (74.3%). The total mean score of RIPLS was 96.7 ± 8.9. The teamwork and collaboration plus patient-centeredness sub-category of RIPLS got a higher score (total mean score: 59.3 ± 6.6 and 23.5 ± 2.5 respectively), whereas the professional identity sub-category got the lowest score (total mean score: 13.8 ± 4.7). Medical residents' perceptions of readiness for interprofessional learning did not appear to be significantly influenced by their gender, age, year of professional experience before the postgraduate study, and department. Additionally, the qualitative interviews also revealed that interprofessional learning is generally understood as a relevant platform of learning by neurology and internal medicine residents. CONCLUSIONS: We found high scores on RIPLS for internal medicine and neurology postgraduate residents, and interprofessional learning is generally accepted as an appropriate platform for learning by the participants, which both suggest readiness for interprofessional learning. This may facilitate the implementation of interprofessional learning in the postgraduate medical curriculum in our setting. We recommend medical education developers in Ethiopia consider incorporating interprofessional learning models into future curriculum design.

Assessment Practices of Learning Outcomes of Postgraduate Students in Biomedical and Pharmaceutical Sciences at College of Health Sciences at Addis Ababa University: Student and Faculty Perspectives.

Introduction: Higher education institutions are under increasing pressure to respond to societal needs which has in turn led to changes in the type of knowledge, competencies, and skills required from learners. Assessment of student learning outcomes is the most powerful educational tool for guiding effective learning. In Ethiopia, studies are scarce on assessment practices of learning outcomes of postgraduate students in biomedical and pharmaceutical sciences. Objective: This study investigated the assessment practices of learning outcomes of postgraduate students pursuing studies in biomedical and pharmaceutical sciences at the College of Health Sciences of Addis Ababa University. Methods: A quantitative cross-sectional study was conducted using structured questionnaires administered to postgraduate students and teaching faculty members in 13 MSc programs in biomedical and pharmaceutical sciences at the College of Health Sciences of Addis Ababa University. About 300 postgraduate and teaching faculty members were recruited with purposive sampling. The data collected included assessment methods, types of test items, and student preferences on assessment formats. Data were analyzed using quantitative approaches, descriptive statistics, and parametric tests. Results: The study indicated that several assessment strategies and test items were practiced without a significant difference across fields of study. Regular attendance, oral questioning, quiz, group and individual assignments, seminar presentations, mid-term tests, and final written examination were commonly practiced assessment formats, while short question and long question essays were the most commonly used test items. However, students were not commonly assessed for skills and attitude. The students indicated they mostly preferred short essay questions, followed by practical-based examinations, long essay questions, and oral examination. The study identified several challenges to continuous assessment. Conclusion: Practice of assessing students' learning outcomes involves multiple methods focusing on assessing mainly knowledge; however, the assessment of skills appears inadequate, and several challenges appear to be hindering implementation of continuous assessment.

Transformative learning in the setting of religious healers: A case study of consultative mental health workshops with religious healers, Ethiopia.

Objective: Psychiatric interventions that consider the socio-cultural and spiritual traditions of patients are needed to address stigma and improve access to mental health services. Productive collaboration between traditional healers and biomedical practitioners hold promise in such efforts, and applying tenets of transformative learning hold potential for mitigating an overemphasis on biomedical models in such collaboration. We present a framework for how to engage in health system reform to enhance mental health services in communities that are distrustful of, or unfamiliar with biomedical approaches. Our research question was how to bridge two seemingly opposing paradigms of mental health care, and we sought to understand how the theory of transformational learning (TLT) can be applied to learning among Religious healers and biomedical practitioners in culturally appropriate ways to improve collaboration. Methods: TLT informed the development, implementation, and evaluation of an educational intervention in Addis Ababa, Ethiopia that aimed to improve delivery of mental health services at two Holy water sites. The initiative involved both psychiatrists and religious healers with extensive experience providing care to mentally ill patients. Using a focused ethnographic approach that incorporates document analysis methodology, this qualitative study examined recordings and minutes of stakeholder meetings, workshops and informal interviews with participants, analyzed for evidence of Mezirow's 11 stages of transformative learning. A participatory action approach was used to encourage practice change. Results: All participants exhibited a high degree of engagement with the of the collaborative project and described experiencing "disorienting dilemmas" by Mezirow's classic description. Opportunities to reflect separately and in large groups encouraged a re-examination of attitudes previously contributing to siloed approaches to care and led to instrumental changes in mental health care delivery and a higher degree of coordination and collaboration between psychiatrists and traditional healers. Conclusion: Our study demonstrates the utility of TLT in both the design and evaluation of initiatives aiming to bridge cross-cultural and cross-professional divides. The learning process was further enhanced by a collaborative participatory action model adjusted to accommodate Ethiopian socio-political and cultural relations.

The effect of interpersonal psychotherapy on quality of life among breast cancer patients with common mental health disorder: a randomized control trial at Tikur Anbessa Specialized Hospital.

PURPOSE: To determine the effect of interpersonal psychotherapy on anxiety, depression, and quality of life among breast cancer patients with mental health disorders at Tikur Anbessa Specialized Hospital, Ethiopia. METHODS: A two-arm parallel randomized controlled trial study was conducted among 114 (n = 57 intervention, and n = 57 control group) breast cancer patients with common mental health disorder at the oncology center of Tikur Anbessa Specialized Hospital. The hospital anxiety and depression measurement scale was used to assess depression and anxiety disorder and a 30-item quality of life questionnaire was used to assess the quality of life. General linear model analysis was done, confounding factors were controlled, and p < 0.05 was used to declare statistical significance. RESULTS: Patients in the intervention group showed a significant improvement in the anxiety (coefficient - 3.68; 95% CI - 5.67, - 1.69; p < 0.001), depression (coefficient - 3.22; 95% CI - 4.7, - 1.69; p < 0.001), physical functioning (coefficient 10.55; 95% CI 3.13, 17.98; p = 0.006), health-related quality of life (coefficient 21.85; 95% CI 14.1, 29.59; p < 0.001), insomnia (coefficient - 19.56; 95% CI - 31.87, - 7.25; p = 0.002), and fatigue (coefficient - 11.37; 95% CI - 21.49, - 1.24; p = 0.028) respectively. CONCLUSIONS: The adapted Ethiopian version of interpersonal psychotherapy had improved anxiety, depression, and some domains of health-related quality of life. Hence, health programmers should consider incorporating it as a treatment option in oncology centers. TRIAL REGISTRATION NUMBER: PACTR202011629348967 granted on 20 November 2020 which was retrospectively registered.

"Medical treatments are also part of God's gift": Holy water attendants' perspectives on a collaboration between spiritual and psychiatric treatment for mental illness in Ethiopia.

In Ethiopia, traditional and spiritual treatments, such as holy water, are used by people with mental disorders instead of, or alongside, psychiatric services. Collaborations between traditional and psychiatric providers may increase access to evidence-based treatments and address human rights abuses. This study aimed to explore the perspectives of holy water attendants on a novel collaboration between holy water and psychiatric care, at St Mary's Clinic, Entoto, Ethiopia, and to characterize the users of this service. Semi-structured interviews were conducted with 14 holy water attendants, who run group houses for holy water residents and are paid by family members. A thematic analysis was conducted. Socio-demographic and clinical data were extracted from the records of all service users who had attended the clinic. A total of 174 individuals have attended the clinic in the three years since it opened. The majority were diagnosed with schizophrenia. Holy water attendants provide a partial gatekeeping role to psychiatric care, selecting which of their clients they think will benefit and, for these individuals, facilitating attendance to the clinic and antipsychotic medication adherence. Psychiatric care was felt to be compatible with holy water by some, but not all, attendants. However, family members often had the "final say" in individuals attending the clinic, in some cases putting up strong resistance to using psychiatric care. A novel collaboration is acceptable to some holy water attendants and may increase access to psychiatric care amongst people with mental illness living at a holy water site in Ethiopia.

Holy water and biomedicine: a descriptive study of active collaboration between religious traditional healers and biomedical psychiatry in Ethiopia.

BACKGROUND: Religious and traditional healers remain the main providers of mental healthcare in much of Africa. Collaboration between biomedical and traditional treatment modalities is an underutilised approach, with potential to scale up mental healthcare. AIMS: To report the process and feasibility of establishing a collaboration between religious healers and psychiatrists in Addis Ababa, Ethiopia. To gain insight into the collaboration through studies of patient demographics, help-seeking patterns, nature of illness and receptivity of the project. METHOD: This case study describes the process and challenges in establishing a collaborative psychiatric clinic for patients who are simultaneously receiving treatment with holy water, including an examination of basic clinical records of 1888 patients over a 7-year period. RESULTS: The collaboration is feasible and has been successfully implemented for 8 years. A majority (54%) of the clinic's patients were seeing biomedical services for the first time. Patients were brought in largely by families (54%); 26% were referred directly by priest healers. Most patients had severe mental illness, including schizophrenia (40%), substance misuse (24%) and mood disorders (30%). A vast majority (92.2%) of patients reported comfort in receiving treatment with holy water and prayers simultaneously with medication, and 73.6% believed their illness was caused by evil spirit possession. CONCLUSIONS: A cross-system collaborative model is a feasible and potentially valuable model to address biomedical resource limitations. Provider collaboration and mutual learning are ultimately beneficial to patients with severe mental illness. Open-minded acceptance of cultural benefits and strengths of traditional healing is a prerequisite. Further study on outcomes and implementation are warranted.

Toronto Addis Ababa Academic Collaboration: A Relational, Partnership Model for Building Educational Capacity Between a High- and Low-Income University.

Educational partnerships between academic health sciences centers in high- and low-resource settings are often formed as attempts to address health care disparities. In this Perspective, the authors describe the Toronto Addis Ababa Academic Collaboration (TAAAC), an educational partnership between the University of Toronto and Addis Ababa University. The TAAAC model was designed to help address an urgent need for increased university faculty to teach in the massive expansion of universities in Ethiopia. As TAAAC has developed and expanded, faculty at both institutions have recognized that the need to understand contextual factors and to have clarity about funding, ownership, expertise, and control are essential elements of these types of collaborative initiatives. In describing the TAAAC model, the authors aim to contribute to wider conversations and deeper theoretical understandings about these issues.

The International Partner as Invited Guest: Beyond Colonial and Import-Export Models of Medical Education.

The dominant model of international collaboration in medical education, both currently and in the past two centuries, is one of foreign (i.e., Euro-American) ownership and control. In this Invited Commentary, the authors provide a brief selected history of such international partnerships. They then focus on recent partnership models that have alternative structures. One of these is the collaborative partnership between Addis Ababa University (AAU) and the University of Toronto. This partnership is known as the Toronto Addis Ababa Academic Collaboration (TAAAC). From the inception of this partnership, the TAAAC has aimed to be relational and has firmly placed ownership of the codeveloped curriculum at AAU. Other explicit aims of the TAAAC are to help AAU develop culturally appropriate programming that is sustainable with local resources and to develop capacity-building, coteaching models. In seeking potential precedents to the TAAAC, the authors have explored archives in Ethiopia, Canada, and the United Kingdom. They found that invited foreign guests have played a role in the development of educational systems in Ethiopia since the 1940s. The authors believe that by paying close attention to the language used to describe the nature of a relationship, medical educators may be able to move toward more collaborative, capacity-building international partnerships.

Stigma, explanatory models and unmet needs of caregivers of children with developmental disorders in a low-income African country: a cross-sectional facility-based survey.

BACKGROUND: Understanding the perspectives of caregivers of children with developmental disorders living in low-income countries is important to inform intervention programmes. The purpose of this study was to examine the stigma experiences, explanatory models, unmet needs, preferred interventions and coping mechanisms of caregivers of children with developmental disorders in Ethiopia. METHODS: Participants comprised caregivers (n = 102) of children with developmental disorders attending two child mental health clinics in Addis Ababa. The majority (66.7%; n = 68) had a diagnosis of intellectual disability (ID); 34 children (33.3%) had autism spectrum disorder (ASD) as their primary diagnosis. All caregivers were administered a structured questionnaire via a face-to-face interview, which included an adaptation of the Family Interview Schedule, closed questions about socio-demographic characteristics, explanatory models of illness, type of interventions used or desired and coping strategies, and an open ended question regarding the family's unmet needs. RESULTS: Most caregivers reported experience of stigma: 43.1% worried about being treated differently, 45.1% felt ashamed about their child's condition and 26.7% made an effort to keep their child's condition secret. Stigma did not depend on the type of developmental disorder, the child's age or gender, or on the age or level of education of the caregiver (all p > 0.05). Reported stigma was significantly higher in caregivers who had sought traditional help (p < 0.01), provided supernatural explanations for their child's condition (p = .02) and in caregivers of Orthodox Christian faith (p = .03). Caregivers gave a mixture of biomedical explanations (e.g. head injury (30.4%) or birth complications (25.5%)) and supernatural explanations (e.g. spirit possession (40.2%) or sinful act (27.5%)) for their child's condition. The biggest reported unmet need was educational provision for their child (74.5%), followed by treatment by a health professional (47.1%), financial support (30.4%) and expert help to support their child's development (27.5%). Most caregivers reported that talking to health professionals (86.3%) and family (85.3%) helped them to cope. Many caregivers also used support from friends (76.5%) and prayer (57.8%) as coping mechanisms. CONCLUSIONS: This study highlights the stigma experienced by families caring for a child with a developmental disorder. Designing interventions appropriate for low-income settings that improve awareness about developmental disorders, decrease stigma, improve access to appropriate education and strengthen caregivers' support are needed.

Child and adolescent mental health in sub-Saharan Africa: a perspective from clinicians and researchers.

There is a widening mental health treatment gap for children and adolescents in sub-Saharan Africa. The region has few economic or human resources dedicated to the mental health of children and young people. The World Health Organization's Mental Health Gap Action Plan and the push for mental health to be included in the Millennium Development Goals have raised the profile of child mental health but comparatively few studies have estimated prevalence rates or assessed needs or tested interventions in African countries. In most countries there is no clear pathway to access treatment, especially in-patient facilities. This article considers these issues from clinical, educational and research perspectives.

Burden of mental disorders and unmet needs among street homeless people in Addis Ababa, Ethiopia.

BACKGROUND: The impact of mental disorders among homeless people is likely to be substantial in low income countries because of underdeveloped social welfare and health systems. As a first step towards advocacy and provision of care, we conducted a study to determine the burden of psychotic disorders and associated unmet needs, as well as the prevalence of mental distress, suicidality, and alcohol use disorder among homeless people in Addis Ababa, the capital of Ethiopia. METHODS: A cross-sectional survey was conducted among street homeless adults. Trained community nurses screened for potential psychosis and administered standardized measures of mental distress, alcohol use disorder and suicidality. Psychiatric nurses then carried out confirmatory diagnostic interviews of psychosis and administered a locally adapted version of the Camberwell Assessment of Needs Short Appraisal Schedule. RESULTS: We assessed 217 street homeless adults, about 90% of whom had experienced some form of mental or alcohol use disorder: 41.0% had psychosis, 60.0% had hazardous or dependent alcohol use, and 14.8% reported attempting suicide in the previous month. Homeless people with psychosis had extensive unmet needs with 80% to 100% reporting unmet needs across 26 domains. Nearly 30% had physical disability (visual and sensory impairment and impaired mobility). Only 10.0% of those with psychosis had ever received treatment for their illness. Most had lived on the streets for over 2 years, and alcohol use disorder was positively associated with chronicity of homelessness. CONCLUSION: Psychoses and other mental and behavioural disorders affect most people who are street homeless in Addis Ababa. Any programme to improve the condition of homeless people should include treatment for mental and alcohol use disorders. The findings have significant implications for advocacy and intervention programmes, particularly in similar low income settings.

Psychotherapy Knowledge Translation and Interpersonal Psychotherapy: Using Best-Education Practices to Transform Mental Health Care in Canada and Ethiopia.

Psychotherapies, such as Interpersonal Psychotherapy (IPT), that have proven effective for treating mental disorders mostly lie dormant in consensus-treatment guidelines. Broadly disseminating these psychotherapies by training trainers and front-line health workers could close the gap between mental health needs and access to care. Research in continuing medical education and knowledge translation can inform the design of educational interventions to build capacity for providing psychotherapy to those who need it. This paper summarizes psychotherapy training recommendations that: adapt treatments to cultural and health organizational contexts; consider implementation barriers, including opportunity costs and mental health stigma; and engage local opinion leaders to use longitudinal, interactive, case-based teaching with reflection, skills-coaching, simulations, auditing and feedback. Community-based training projects in Northern Ontario, Canada and Ethiopia illustrate how best-education practices can be implemented to disseminate evidence-supported psychotherapies, such as IPT, to expand the therapeutic repertoire of health care workers and improve their patients' clinical outcomes.

A comparison of levels and predictors of emotional problems among preadolescent Ethiopians in Addis Ababa, Ethiopia, and Toronto, Canada.

According to a literature of theory and advocacy, immigration and resettlement jeopardize the mental health of children and youth, largely because of factors such as intergenerational tensions arising from conflicts about the retention of traditional values, and experiences of prejudice and discrimination. The current study examines the specificity of these putative mental health risks to the immigration experience. The level and predictors of emotional problems among preadolescent Ethiopians living in immigrant families in Toronto, Canada, were compared with a matched sample of Ethiopian youngsters in Addis Ababa, Ethiopia. Data came from structured interviews with the person most knowledgeable about the family (usually a parent), as well as from the children themselves. Youth reported higher levels of emotional problems (EP) than their parents. Predictors differed for parent and child ratings. In both the Toronto and Addis Ababa samples, parental mental health predicted parent-rated, but not self-rated EP. Contrary to immigration stress theory, parental perceptions of prejudice predicted EP in Addis Ababa, but not Toronto, and parent-child discordance regarding ethnic adherence were predictors of self-rated emotional problems in Ethiopia, but not in Canada. Perceived discrimination was a significant predictor of self-rated emotional problems in both settings. Implications for theory and further research are discussed.

Foreign body in the vagina (FBV) in women of two different age groups.

We are presenting two case series of vaginal foreign body (VFB) in patients belonging to two different age groups. The literature review, summary of the two cases, and, the corresponding discussions will be presented.

Maternal common mental disorders and infant development in Ethiopia: the P-MaMiE Birth Cohort.

BACKGROUND: Chronicity and severity of early exposure to maternal common mental disorders (CMD) has been associated with poorer infant development in high-income countries. In low- and middle-income countries (LAMICs), perinatal CMD is inconsistently associated with infant development, but the impact of severity and persistence has not been examined. METHODS: A nested population-based cohort of 258 pregnant women was identified from the Perinatal Maternal Mental Disorder in Ethiopia (P-MaMiE) study, and 194 (75.2%) were successfully followed up until the infants were 12 months of age. Maternal CMD was measured in pregnancy and at two and 12 months postnatal using the WHO Self-Reporting Questionnaire, validated for use in this setting. Infant outcomes were evaluated using the Bayley Scales of Infant Development. RESULTS: Antenatal maternal CMD symptoms were associated with poorer infant motor development (ß^ -0.20; 95% CI: -0.37 to -0.03), but this became non-significant after adjusting for confounders. Postnatal CMD symptoms were not associated with any domain of infant development. There was evidence of a dose-response relationship between the number of time-points at which the mother had high levels of CMD symptoms (SRQ ≥ 6) and impaired infant motor development (ß^ = -0.80; 95%CI -2.24, 0.65 for ante- or postnatal CMD only, ß^ = -4.19; 95%CI -8.60, 0.21 for ante- and postnatal CMD, compared to no CMD; test-for-trend χ(2)13.08(1), p < 0.001). Although this association became non-significant in the fully adjusted model, the ß^ coefficients were unchanged indicating that the relationship was not confounded. In multivariable analyses, lower socio-economic status and lower infant weight-for-age were associated with significantly lower scores on both motor and cognitive developmental scales. Maternal experience of physical violence was significantly associated with impaired cognitive development. CONCLUSIONS: The study supports the hypothesis that it is the accumulation of risk exposures across time rather than early exposure to maternal CMD per se that is more likely to affect child development. Further investigation of the impact of chronicity of maternal CMD upon child development in LAMICs is indicated. In the Ethiopian setting, poverty, interpersonal violence and infant undernutrition should be targets for interventions to reduce the loss of child developmental potential.

Measuring common mental disorders in women in Ethiopia: reliability and construct validity of the comprehensive psychopathological rating scale.

BACKGROUND: There is a dearth of methodological studies critically evaluating reliability, validity and feasibility of measures of common mental disorders (CMD) in low-income countries. METHODS: Test-retest and inter-rater reliability of categorisation of CMD caseness, according to locally agreed criteria using the Comprehensive Psychopathological Rating Scale (CPRS), was measured in 99 women from out-patient clinics (inter-rater) and 99 women from a primary healthcare centre (test-retest) in Ethiopia. The construct validity of CMD as measured with CPRS was assessed with exploratory factor analysis using maximum likelihood with varimax rotation. RESULTS: Test-retest reliability was fair (kappa = 0.29). Subsequent assessment of inter-rater reliability found excellent agreement (kappa = 0.82). The construct of CMD appeared unidimensional, combining depressive, anxiety and somatic symptoms. CONCLUSIONS: Detection of socioculturally meaningful cases of CMD in Ethiopia can be reliably achieved with local psychiatrist assessment using CPRS, although thorough training is essential.