Worldwide, mental illness touches the lives of nearly everyone – often through family members, friends, neighbors, co-workers or community institutions. According to the World Health Organization (WHO), 13 percent of the world’s population is affected by mental health and substance use disorders. In Tanzania, although very few prevalence studies of mental disorders have been done in primary care settings, some research suggests that the percentage of those affected by at least one incident of general or major mental illness may be closer to 25 percent. Until 2021, Global Volunteers’ Reaching Children’s Potential Program (RCP) focused solely on the physical health of participating families. That changed in the summer of 2021 when the RCP Mental Wellness Initiative launched with the goal of integrating mental health into primary care in the Ukwega Ward.
In the latter half of 2021, Global Volunteers and Ipalamwa General Clinic staff cultivated working relationships with mental health professionals in the Iringa District to broaden families’ access to care and information. In January, 2022, two Tanzanian doctors and five psychology students from Iringa and Ilula hospitals collaborated with Global Volunteers on a two-week mental wellness education and training program for staff and villagers participating in Global Volunteers’ Reaching Children’s Potential Program (RCP). Building on workshops and practices developed over the previous year, the mental health team presented daily education sessions and visited homes, schools and churches to raise awareness of available resources. The team also offered group therapy and individual consultations in various areas of mental health.
Mental Health Workshops
The professionals used RCP’s basic mental health workshops on general depression, peri-natal depression, alcohol abuse and stress reduction as reference points for daily sessions with village leaders, parents and staff in the Mohamed Kassim Learning Center on the RCP campus. More than 140 parents and village leaders from Mkalanga, Lulindi, Ukwega and Ipalamwa attended the workshops.
Dr. Petro Lusasi reported that families in the Ukwega Ward may have a higher prevalence of mental and substance use disorders than the urban population referred to him at Lulindi Lutheran Hospital. Dr. Yusto Kinyoa from Iringa Referral Hospital concurred. “From our observation in home visits and therapy sessions, we can say the burden of mental illness is high compared to other populations,” said Dr. Lusasi. “Often, one person’s condition will deeply affect family members, and that results in emotional and economic suffering.” He cited depression, anxiety and alcohol abuse as the most prevalent conditions in the community.
Therefore, widespread community education can provide a higher level of support for families who struggle. Trauma, poverty and loss can quickly lead to depression and anxiety, which form a cycle of loss and more emotional strain. The RCP Program is committed to strengthening family bonds and community understanding to help break this cycle. The workshops address how to recognize depression and anxiety in yourself and others – how to intercept the beginnings of a cycle, when to consult a professional, and why to avoid alcohol and other substances to self-medicate. Families have responded well to the material and have requested continuing education in these areas. Global Volunteers recruits volunteers with mental health and social work expertise to present workshops on these topics, and professionals to offer sessions on stress reduction and alcohol dependency. Volunteers are also encouraged to share their personal journey with mental illness and addiction during workshops to provide a wide perspective to participants.
Interventions at Home Visits
On several days, the mental health team observed how RCP Caregivers use a mental health self-assessment tool at family home visits to help parents identify their own symptoms of mental stress. The Beck Depression Inventory is a multiple-choice questionnaire which can quickly reflect the intensity or severity of a given symptom, which then provides insight to a treating physician. Caregivers refer family members to the Ipalamwa General Clinic (IGC) for follow up when the inventory suggests the need for intervention. Dr. Lusasi said that in his practice, “many families start treatment with traditional healers before coming to hospital when the condition worsens.” Caregivers can objectively assess parents’ self-care and learn how individuals are dealing with their psychological concerns. “I feel comfortable knowing different the ways of facing my challenges,” reported one RCP mom.
“There is no physical health without mental health, and no child health without the mother’s health,” says Dr. Lusasi. Therefore, mental health interventions will have the greatest benefit when focused on pregnant women and mothers. The RCP Program focuses on the first 1,000 days of a child’s life – in utero through the second year.
Community Mental Health Education
Dr. Lusasi also led the students in a mental health awareness session with teachers at Mkalanga and Fikano Primary Schools on childhood mental disorders such as autism, attention deficit disorder, depression and anxiety, and speech, language and communication disorders. Often in crowded classrooms, students who live with mental disorders are classified as “trouble makers” and may be punished or shamed instead of accepted and/or re-directed. In Tanzania, while corporal punishment in schools has been formally discouraged for over a decade, recent administrations have tolerated and even endorsed the practice of caning students. Studies show violence has long-term negative effects on children’s development. Children who are beaten, caned, assaulted, or insulted are more likely to develop learning problems, and participate less in class. Teachers from both schools were eager to learn positive discipline strategies and how to spot potential mental disorders early so they can create learning environments that work for all students.
Meanwhile, Dr. Kinyoa led students in a meeting with local pastors on signs of mental illness, and the role that church leaders can play in fighting stigma and stereotypes. “The greatest need is for on-going education,” said Dr. Kinyoa. “Villagers insist that better understanding is necessary to improve conditions so people can feel open about their (mental health) needs.” Pastors can become a “first line of defense” against discrimination and mistreatment of those who live with psychological disorders, he said. The students gave examples of intolerant, insensitive behavior, and offered suggestions for supporting parishioners who reveal their struggles with mental health.
Group and Individual Therapy
Dr. Kinyoa and three students conducted group therapy sessions with RCP mothers who shared issues with depression, child care, alcohol use, family conflict and domestic abuse. In their discussion, they examined the causes for these conditions and options for mitigating and ending harm to themselves and other community members.
Participants who expressed serious issues in group sessions were referred to individual therapy with Dr. Lusasi and IGC doctor Silas Mosha. While not trained in psychotherapy, IGC doctors prescribe anti-depressant and anti-psychotic medicines in a limited way, owing to a shortage of such pharmaceuticals. As a rural health care provider, Dr. Mosha is exceptionally dedicated, and multi-skilled, and supports greater integration of mental health care into the primary care system. The WHO Mental Health Gap Intervention Guide for Non-Specialized Health Settings and other WHO publications enable the medical staff and RCP caregivers to confidently enlarge mental wellness resources on the village level. He said that to date, most of his mental health patients have been mothers.
“Non-pharmacological treatment, or talk therapy strategies, are useful for women with mild to moderate depressive symptoms. The talk therapy may include individual or group psychotherapy – cognitive-behavioral and interpersonal therapy. All these are effective for mild to moderate symptoms that do not interfere with a mother’s ability to function and care for her child,” Dr. Mosha explained. “The handshake of pharmacological and talk therapies is more difficult with cases of moderate to severe symptoms causing marked impairment of function. Either way, we can treat these patients and refer to inpatient hospitalization where necessary.”
The psychology students met with individuals for counseling on a wide range of mental health concerns. For most parents, it was the first time they had met with a mental health professional. “The individual counseling was so therapeutic for the parents,” said RCP Caregiver and Mental Health Education Manager Regina Mhagama. “The doctors reported that clients opened up a lot and allowed them to come up with good treatment plans for each of them. It was a complete success.”
The doctors and students also conducted mental health training sessions for RCP and IGC staff using WHO manuals supplied by RCP. Time was set aside for caregivers to identify families of concern whose cases were identified during home visits. Together, the caregivers and doctors developed management plans for follow up at IGC consultations. Consistency of care is a goal, said Dr. Lusasi, in building a strong mental wellness component for the RCP Program. He recommended additional mental health training for IGC staff, a consultation room for individual therapy, and access to pharmaceuticals to treat a wider range of disorders. Both doctors pledged long-term collaboration with RCP to continue community education and therapy, and referrals from IGC at their respective hospitals. “We promise we will work with Global Volunteers to bring excellent service to the people of the Ukwega Ward. With such an effective start with the good vision and hard work of Global Volunteers, we promise to complete a program of mental wellness for the villagers who have been so willing and cooperative,” Dr. Lusasi asserted.
Volunteers serving in 2022 and beyond will have the opportunity to share their professional expertise as well as their learned experience in workshops, parents meetings, community informational sessions and home visits to advance the outreach and breadth of the RCP Mental Wellness Initiative.