"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.

Reimagining global mental health in Africa.

In 2001, the WHO launched The World Health Report most specifically addressing low-income and middle-income countries (LAMICs). It highlighted the importance of mental health (MH), identifying the severe public health impacts of mental ill health and made 10 recommendations. In 2022, the WHO launched another world MH report and reaffirmed the 10 recommendations, while concluding that 'business as usual for MH will simply not do' without higher infusions of money. This paper suggests the reason for so little change over the last 20 years is due to the importation and imposition of Western MH models and frameworks of training, service development and research on the assumption they are relevant and acceptable to Africans in LAMICs. This ignores the fact that most mental and physical primary care occurs within local non-Western traditions of healthcare that are dismissed and assumed irrelevant by Western frameworks. These trusted local institutions of healthcare that operate in homes and spiritual spaces are in tune with the lives and culture of local people. We propose that Western foundations of MH knowledge are not universal nor are their assumptions of society globally applicable. Real change in the MH of LAMICs requires reimagining. Local idioms of distress and healing, and explanatory models of suffering within particular populations, are needed to guide the development of training curricula, research and services. An integration of Western frameworks into these more successful approaches are more likely to contribute to the betterment of MH for peoples in LAMICs.

Reconsidering a Global Agency for Medical Education: Back to the Drawing Board?

Issue: The World Federation for Medical Education (WFME) was established in 1972 and in the five decades that followed, has been the de facto global agency for medical education. Despite this apparently formidable remit, it has received little analysis in the academic literature. Evidence: In this article, we examine the historical context at the time WFME was established and summarize the key decisions it has taken in its history to date, highlighting particularly how it has adopted positions and programmes that have seemingly given precedence to the values and priorities of countries in the Global North. In doing so, we challenge the inevitability of the path that it has taken and consider other possible avenues that such a global agency in medical education could have taken, including to advocate for, and to develop policies that would support countries in the Global South. Implications: This article proposes a more democratic and equitable means by which a global organization for medical education might choose its priority areas, and a more inclusive method by which it could engage the medical education community worldwide. It concludes by hypothesizing about the future of global representation and priority-setting, and outlines a series of principles that could form the basis for a reimagined agency that would have the potential to become a force for empowerment and global justice in medical education.

Faster, higher, stronger - together? A bibliometric analysis of author distribution in top medical education journals.

INTRODUCTION: Medical education and medical education research are growing industries that have become increasingly globalised. Recognition of the colonial foundations of medical education has led to a growing focus on issues of equity, absence and marginalisation. One area of absence that has been underexplored is that of published voices from low-income and middle-income countries. We undertook a bibliometric analysis of five top medical education journals to determine which countries were absent and which countries were represented in prestigious first and last authorship positions. METHODS: Web of Science was searched for all articles and reviews published between 2012 and 2021 within Academic Medicine, Medical Education, Advances in Health Sciences Education, Medical Teacher, and BMC Medical Education. Country of origin was identified for first and last author of each publication, and the number of publications originating from each country was counted. RESULTS: Our analysis revealed a dominance of first and last authors from five countries: USA, Canada, UK, Netherlands and Australia. Authors from these five countries had first or last authored 70% of publications. Of the 195 countries in the world, 43% (approximately 83) were not represented by a single publication. There was an increase in the percentage of publications from outside of these five countries from 23% in 2012 to 40% in 2021. CONCLUSION: The dominance of wealthy nations within spaces that claim to be international is a finding that requires attention. We draw on analogies from modern Olympic sport and our own collaborative research process to show how academic publishing continues to be a colonised space that advantages those from wealthy and English-speaking countries.

Caring for a child with retinoblastoma: Experience of Ethiopian parents.

OBJECTIVE: This study explored the lived experience of parents of children with retinoblastoma. DESIGN AND METHOD: A phenomenological qualitative study design was used, and a purposive sampling technique to recruit parents of children with retinoblastoma. Semi-structured interviews were conducted to document the lived experience of participants, who were asked to narrate their experiences caring for a child with retinoblastoma, thinking back to the day they learned about their child's condition, as well as their thoughts about the future. The interviews were conducted in Amharic and Oromo language, and audio recordings were transcribed and translated to English. Data were analyzed using thematic analysis. RESULTS: Thirteen parents (seven mothers, six fathers) participated in the study. Collectively, the children of the participants represented all the stages of the retinoblastoma journey (i.e., diagnosis, treatment, remission, and recurrence). Five major themes emerged from the thematic data analysis: (a) reactions when learning the child's condition; (b) receiving health care; (c) costs of caregiving; (d) support; and (e) uncertainties. CONCLUSION: The lived experiences of parents of children with retinoblastoma revealed a significant mental health and psychosocial burden. The sources of mental distress were found to be complex and varied. Holistic care for retinoblastoma should include programs that address the biopsychosocial needs of caregivers.

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.

Breaking Borders: How Barriers to Global Mobility Hinder International Partnerships in Academic Medicine.

This article describes the authors' personal experiences of collaborating across international borders in academic research. International collaboration in academic medicine is one of the most important ways by which research and innovation develop globally. However, the intersections among colonialism, academic medicine, and global health research have created a neocolonial narrative that perpetuates inequalities in global health partnerships. The authors critically examine the visa process as an example of a racist practice to show how the challenges of blocked mobility increase inequality and thwart research endeavors. Visas are used to limit mobility across certain borders, and this limitation hinders international collaborations in academic medicine. The authors discuss the concept of social closure and how limits to global mobility for scholars from low- and middle-income countries perpetuate a cycle of dependence on scholars who have virtually barrier-free global mobility-these scholars being mainly from high-income countries. Given the current sociopolitical milieu of increasing border controls and fears of illegal immigration, the authors' experiences expose what is at stake for academic medicine when the political sphere, focused on tightening border security, and the medical realm, striving to build international research collaborations, intersect. Creating more equitable global partnerships in research requires a shift from the current paradigm that dominates most international partnerships and causes injury to African scholars.

Explanatory Models for Mental Distress Among University Students in Ethiopia: A Qualitative Study.

BACKGROUND: Socio-culturally determined processes account for how individuals give meanings to health, illness, causal attributions, expectations from treatment, and related outcomes. There is limited evidence of explanatory models for mental distress among higher education institutions in Ethiopia. The objective of this study was to explore the explanatory models for mental distress among Wolaita Sodo University. METHODS: The current study used a phenomenological research approach, and we collected data from 21 students. The participants were purposively recruited based on eligibility criteria. Semi-structured interviews were conducted from December 2017 to January 2018 using the Short Explanatory Models Interview. The interviews were audio-recorded, transcribed into the Amharic language and translated into English. Data were analyzed using framework analysis with the assistance of open code software 4.02. RESULTS: Most students experienced symptoms of being anxious, fatigue, headaches and feelings of hopelessness. They labeled these symptoms like anxiety or stress. The most commonly reported causal explanations were psychosocial factors. Students perceived that their anxiety or stress was severe that mainly affected their mind, which in turn impacted their interactions with others, academic result, emotions and motivation to study. Almost all the students received care from informal sources, although they wanted to receive care from mental health professionals. They managed their mental distress using positive as well as negative coping strategies. CONCLUSION: The policy implication of our findings is that mental health interventions in higher education institutions in Ethiopia should take into account the explanatory models of students' psychological distress.

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.

Feasibility and acceptability of brief individual interpersonal psychotherapy among university students with mental distress in Ethiopia.

BACKGROUND: The prevalence of mental distress among university students in low- and middle-income countries (LMICs) is increasing; however, the majority do not receive evidence-based psychological intervention. This calls for the provision of culturally adapted psychological therapy in higher education institutions in LMICs. The aim of this pilot study is to evaluate the feasibility and acceptability of Interpersonal Psychotherapy adapted for Ethiopia (IPT-E) among Wolaita Sodo University students and to assess the preliminary outcomes of IPT-E in reducing symptoms of mental distress and in improving functioning. METHODS: We used a quasi-experimental single-group pre-post-test study design. As indicators of feasibility of IPT-E, we used consent, treatment completion and attrition. We used Client Satisfaction Questionnaire and semi-structured interview to measure the acceptability of the intervention, self-reporting IPT-E checklist to assess treatment adherence and World Health Organization Disability Assessment and Self-Reporting Questionnaire-20 tools to assess functional impairment and mental distress, respectively. We used percentage, frequency, mean and standard deviation to summarize the demographic variables, feasibility and acceptability of IPT-E. We analyzed changes from pre- to post-tests of mental distress and functioning results using paired t-test and Wilcoxon signed-rank tests. Independent sample t-test and one way-ANOVA used to assess the difference in mean score of in demographic variables at baseline and eight weeks. The qualitative data was analyzed with the support of open code 4.02. RESULTS: IPT-E was feasible (consent rate = 100%; completion rate = 92.31%; attrition rate = 7.69%; mean score of the sessions = 8 and mode of the session = 8). The total mean score of treatment satisfaction was 27.83 (SD = 4.47). After the delivery of IPT-E, symptoms of mental distress were decreased, functioning was improved and therapist adherence to the treatment model was 100% (i.e. treatment delivered according to the IPT-E guideline). CONCLUSION: IPT-E was feasible and acceptable to treat university students with mental distress in low-income country setting. The preliminary results also suggest promising viability of IPT-E in higher education institutions of low-income country setting for students with symptoms of anxiety and depression.

Understanding the key processes of excellence as a prerequisite to establishing academic centres of excellence in Africa.

BACKGROUND: Africa's economic transformation relies on a radical transformation of its higher education institutions. The establishment of regional higher education Centres of Excellence (CoE) across Africa through a World Bank support aims to stimulate the needed transformation in education and research. However, excellence is a vague, and often indiscriminately used concept in academic circles. More importantly, the manner in which aspiring institutions can achieve academic excellence is described inadequately. The main objective of this paper is to describe the core processes of excellence as a prerequisite to establishing academic CoE in Africa. METHODS: The paper relies on our collaborative discussions and real-world insight into the pursuit of academic excellence, a narrative review using Pubmed search for a contextual understanding of CoEs in Africa supplemented by a Google search for definitions of CoEs in academic contexts. RESULTS: We identified three key, synergistic processes of excellence central to institutionalizing academic CoEs: participatory leadership, knowledge management, and inter-disciplinary collaboration. (1) Participatory leadership encourages innovations to originate from the different parts of the organization, and facilitates ownership as well as a culture of excellence. (2) Centers of Excellence are future-oriented in that they are constantly seeking to achieve best practices, informed by the most up-to-date and cutting-edge research and information available. As such, the process by which centres facilitate the flow of knowledge within and outside the organization, or knowledge management, is critical to their success. (3) Such centres also rely on expertise from different disciplines and 'engaged' scholarship. This multidisciplinarity leads to improved research productivity and enhances the production of problem-solving innovations. CONCLUSION: Participatory leadership, knowledge management, and inter-disciplinary collaborations are prerequisites to establishing academic CoEs in Africa. Future studies need to extend our findings to understand the processes key to productivity, competitiveness, institutionalization, and sustainability of academic CoEs in Africa.

Perinatal mental distress in a rural Ethiopian community: a critical examination of psychiatric labels.

BACKGROUND: Perinatal mental distress poses a heavy burden in low- and middle-income countries (LMICs). This study investigated perceptions and experiences of perinatal mental distress among women in a rural Ethiopian community, in an effort to advance understanding of cross-cultural experiences of perinatal mental distress. METHODS: We employed a sequential explanatory study design. From a population-based cohort study of 1065 perinatal women in the Butajira Health and Demographic Surveillance Site, we purposively selected 22 women according to their scores on a culturally validated assessment of perinatal mental distress (the Self-Reporting Questionnaire). We examined concordance and discordance between qualitative semi-structured interview data ('emic' perspective) and the layperson-administered fully-structured questionnaire data ('etic' perspective) of perinatal mental distress. We analysed the questionnaire data using summary statistics and we carried out a thematic analysis of the qualitative data. RESULTS: Most women in this setting recognised the existence of perinatal mental distress states, but did not typically label such distress as a discrete illness. Instead, perinatal mental distress states were mostly seen as non-pathological reactions to difficult circumstances. The dominant explanatory model of perinatal mental distress was as a response to poverty, associated with inadequate food, isolation, and hopelessness. Support from family and friends, both emotional and instrumental support, was regarded as vital in protecting against mental distress. Although some women considered their distress amenable to biomedical solution, many thought medical help-seeking was inappropriate. Integration of perspectives from the questionnaire and semi-structured interviews highlighted the important role of somatic symptoms and nutritional status. It also demonstrated the differential likelihood of endorsement of symptoms when screening tools versus in-depth interviews are used. CONCLUSIONS: This study highlights the importance of the wider social context within which mental health problems are situated, specificially the inseparability of mental health from gender disadvantage, physical health and poverty. This implies that public health prevention strategies, assessments and interventions for perinatal distress should be developed from the bottom-up, taking account of local contexts and explanatory frameworks.