Mental health disparity and family involvement in the care of people living with mental health disorders in Nigeria – the UPTH care mode. By Dr. Frances Nkechi Adiukwu and Mrs. Ibiye Soingo George

Healthcare disparity exists in the context of mental health care in Nigeria and Africa as a continent. This disparity is present in mental health care service availability, human resources, and access to mental health care treatment 1. The situation is further exacerbated by the economic disparity among individuals influencing who can have access to the available mental health services. This disparity in mental health care leads to huge treatment gaps and inequity in terms of mental health access and provision within the country and when comparing Nigeria, a low-middle-income country with other high-income countries.  It is estimated that for every 10 people requiring mental health care in Nigeria, only 2-3 would gain access to adequate mental health care. This figure is estimated to be lower with the current mass migration of healthcare workers out of Nigeria (our current brain drain crisis) worsening shortage of mental health professionals, thus access to mental health care. Socio-cultural factors have a significant role to play in the access to mental health care in Nigeria. Socio-cultural factors, including cultural beliefs and stigma surrounding mental illness, play a substantial role in shaping access to mental health care. In a 1995 study in Nigeria on the pathway to mental health care, 90% of people with mental health disorders first access mental health care through religious and spiritual healers 2. While this figure has decreased with more people opting for biomedical treatment, the majority of people in Nigeria still attribute spiritual causation to mental illness 3. Acknowledging the prevailing cultural beliefs and practices is crucial for making mental health care accessible and acceptable to society.

The family (nuclear and extended) is an important part of the Nigerian culture and plays an important role in the care of people with mental illness from outpatient care to in-patient admission and follow-up care. Family involvement is the process of identifying, enrolling, and retaining families in treatment services. Adherence to treatment and management plans is usually a reflection of the family dynamics of the patient, with perceived social support being significantly associated with adherence 4. Every individual is influenced tremendously by the family of origin. From the time of birth and the formation of early attachments to family members that continue throughout our lifespan5. Our families shape us by influencing our development and modeling our behavior, habits, and culture.

Family Involvement in the Care of Patients with Mental Health Disorders

With the deinstitutionalization of mental health services over the past five decades, families are becoming the primary carers of patients with mental illness and have a more significant role to play in mental health outcomes. The World Psychiatric Association (WPA), in its task force on best practices in working with service users and family members, has recommended that clinical mental health care of any person in acute or rehabilitation situations should be done in collaboration among the user, family, and the health care providers. Family involvement in mental health care defined as the process of identifying, enrolling, and retaining families in treatment services 6 has become an essential part of the care of patients in the Department of Neuropsychiatry at the University of Port Harcourt Teaching Hospital (UPTH). This model of care is promoted and maintained by mental health nurses of the department.

Nurse-Family Relationship in Mental Health Care the UPTH Care Model      

Nurses are an essential part of the mental health care service delivery team. Their establishment of a strong relationship with families and caregivers of people accessing mental health care is central to our establishment of high level of service delivery and has become fully integrated into our model of care delivery. The nurse-family relationship starts with the family’s first access to the psychiatric care environment for in-patient care or outpatient clinic appointments. Cooperative and collaborative therapeutic relationships require negotiation and must consider the needs of all stakeholders involved. Barriers need to be overcome before psychiatric care and nurse-family relationships can develop. Possible barriers include limited time, dysfunctional response styles, perceptions that families are stressors and premature judgments. At the Department of Neuropsychiatry, family members are encouraged to be active in the care plan of their loved ones. They are allowed overnight stay-in in the wards until the patient feels comfortable in their new environment. Following this, family members are not restricted by visitation times and are involved in every step of the management plan of the patient. This ranges from medication choice to laboratory investigations, and psychotherapy. Their concerns are brought to the management team and addressed as soon as they are raised. Where the family support is noticed to be inadequate, a family meeting is held with all stakeholders to address any areas that could make achieving treatment goals a problem. These family meetings are essential prior to discharge from in-patient care for proper reintegration of the patient into their socio-cultural environment and during the outpatient follow-up to promote adherence to the care plan. While this is an oversimplification of the model, the benefits of this model have been enormous.

 Benefits of Family Involvement in the Care of Patients with Mental Illness

From experience, the benefits that people with mental health disorders get from family involvement have far-reaching positive consequences on the overall effectiveness of treatment. From our model, we found that the chances of recovery are highly increased, the rates of hospitalization and chances of relapse decrease in addition to this, and the adherence and compliance to the choices of treatment are readily enhanced. This model saves a lot of financial resources as family support often leads to an improvement in conditions within a short space of time. Whereas, without family support, the treatment is prolonged and chances of relapse are increased. The involvement of family also serves as an educational platform to the general public as it helps demystify and destigmatize mental illness. Ultimately, this model is estimated to decrease the mental health gap, and time to access treatment and improve the pathway to care.

REFERENCES

  1. Ngui EM, Khasakhala L, Ndetei D, et al. Mental disorders, health inequalities and ethics: A global perspective. International Review of Psychiatry 2010; 22: 235–244.
  2. Abiodun OA. Pathways to mental health care in Nigeria. Psychiatr Serv 1995; 46: 823–826.
  3. Ikwuka U, Galbraith N, Manktelow K, et al. Pathways to mental healthcare in south-eastern Nigeria. Transcult Psychiatry 2016; 53: 574–594.
  4. Afolabi BA, Afolabi MO, Afolabi AA, et al. Roles of family dynamics on adherence to highly active antiretroviral therapy among people living with HIV/AIDS at a tertiary hospital in Osogbo, south-west Nigeria. Afr Health Sci 2013; 13: 920–926.
  5. Andershed B, Ternestedt BM. Development of a theoretical framework describing relatives’ involvement in palliative care. J Adv Nurs 2001; 34: 554–562.
  6. Veltman A, Cameron JI, Stewart DE. The experience of providing care to relatives with chronic mental illness. J Nerv Ment Dis 2002; 190: 108–114.

Authors

Dr Frances Nkechi Adiukwu

Dr Frances Nkechi Adiukwu

Dr Frances Nkechi Adiukwu is a consultant psychiatrist practicing in the Department of Neuropsychiatry of the University of Port Harcourt Teaching Hospital and a Lecturer at the University of Port Harcourt in Rivers State, Nigeria. She is a fellow of the West African College of Physicians (faculty of Psychiatry). She is the Chair of the early career psychiatry section of the Association of Psychiatrists in Nigeria. She is currently a member of the ECP section and genetics in psychiatry section of the World Psychiatry Association.  Her current areas of research include Bipolar Disorder, global mental health, biomarkers for mood disorders, and the genetics of severe mental illnesses.  She is currently the Head of Department, Department of Neuropsychiatry, University of Port Harcourt Teaching Hospital, Rivers state.

Mrs Ibiye Soingo George

Mrs Ibiye Soingo George

Mrs Ibiye Soingo George is a native of Asari- Toru LGA of River State, Nigeria. She is a trained psychiatric nurse and has an MSc from the prestigious University of Nigeria, Nsukka in 2016. She joined the University of Port Harcourt Teaching Hospital in 2001 and joined the Department of Psychiatry soon after where she currently is the Deputy Director of Nursing in charge of the department. She is involved in the education of nurses in the Nursing Council of Nigeria and on-site training of nursing students during their psychiatry rotations. She is a mental health advocate, working to decrease the stigma attached to mental health disorders in Nigeria. Mrs. Ibiye Sonigo George is married with 4 children.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None

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