Skip to main content Accessibility help

‘Restoring the person's life’: a qualitative study to inform development of care for people with severe mental disorders in rural Ethiopia

  • S. Mall (a1), M. Hailemariam (a2), M. Selamu (a2), A. Fekadu (a2) (a3), C. Lund (a1) (a4), V. Patel (a5) (a6) (a7), I. Petersen (a8) and C. Hanlon (a2) (a4)...



In low-income countries, care for people with severe mental disorders (SMDs) who manage to access treatment is usually emergency-based, intermittent or narrowly biomedical. The aim of this study was to inform development of a scalable district-level mental health care plan to meet the long-term care needs of people with SMD in rural Ethiopia.


The present study was carried out as formative work for the Programme for Improving Mental health CarE which seeks to develop, implement and evaluate a district level model of integrating mental health care into primary care. Six focus group discussions and 25 in-depth interviews were conducted with service planners, primary care providers, traditional and religious healers, mental health service users, caregivers and community representatives. Framework analysis was used, with findings mapped onto the domains of the Innovative Care for Chronic Conditions (ICCC) framework.


Three main themes were identified. (1) Focused on ‘Restoring the person's life’, including the need for interventions to address basic needs for food, shelter and livelihoods, as well as spiritual recovery and reintegration into society. All respondents considered this to be important, but service users gave particular emphasis to this aspect of care. (2) Engaging with families, addressed the essential role of families, their need for practical and emotional support, and the importance of equipping families to provide a therapeutic environment. (3) Delivering collaborative, long-term care, focused on enhancing accessibility to biomedical mental health care, utilising community-based health workers and volunteers as an untapped resource to support adherence and engagement with services, learning from experience of service models for chronic communicable diseases (HIV and tuberculosis) and integrating the role of traditional and religious healers alongside biomedical care. Biomedical approaches were more strongly endorsed by health workers, with traditional healers, religious leaders and service users more inclined to see medication as but one component of care. The salience of poverty to service planning was cross-cutting.


Stakeholders prioritised interventions to meet basic needs for survival and endorsed a multi-faceted approach to promoting recovery from SMD, including social recovery. However, sole reliance on this over-stretched community to mobilise the necessary resources may not be feasible. An adapted form of the ICCC framework appeared highly applicable to planning an acceptable, feasible and sustainable model of care.


Corresponding author

*Address for correspondence: C Hanlon, Department for Psychiatry and Mental Health, University of Cape Town, Alan J. Flisher Centre for Public Mental Health, 46 Sawkins Road, Rondebosch, 7700, South Africa. (Email:


Hide All
Alem, A, Jacobsson, L, Araya, M, Kebede, D, Kullgren, G (1999). How are mental disorders seen and where is help sought in a rural Ethiopian community? A key informant study in Butajira, Ethiopia. Acta Psychiatrica Scandinavica (Supplementum) 397, 4047.
ATLAS.ti. Version 5.0 (2003). Scientific Software Development GmbH: Berlin.
Au, JT, Kayitenkore, K, Shutes, E, Karita, E, Peters, PJ, Tichacek, A, Allen, SA (2006). Access to adequate nutrition is a major potential obstacle to antiretroviral adherence among HIV-infected individuals in Rwanda. AIDS 20, 21162117.
Barbui, C, Dua, T, van Ommeren, M, Yasamy, MT, Fleischmann, A, Clark, N, Thornicroft, G, Hill, S, Saxena, S (2010). Challenges in developing evidence-based recommendations using the GRADE approach: the case of mental, neurological, and substance use disorders. PLoS Medicine 7, e1000322.
Brown, GW, Birley, JLT, Wing, JK (1972). Influence of family life on the course of schizophrenic disorders: a replication. British Journal of Psychiatry 121, 241258.
Central Statistical Authority (CSA) (2008). Summary and Statistical Report of the 2007 Population and Housing Census. Population Size by Age and Sex. Population Census Commission, Federal Democratic Republic of Ethiopia: Addis Ababa.
Cohen, A, Raja, S, Underhill, C, Yaro, BP, Dokurugu, AY, De Silva, M, Patel, V (2012). Sitting with others: mental health self-help groups in northern Ghana. International Journal of Mental Health Systems 6. doi: 10.1186/1752-4458-1186-1181.
De Silva, M, Rathod, S, Hanlon, C, Breuer, E, Chisholm, D, Fekadu, A, Jordans, M, Peterson, I, Prince, M, Shidhaye, R, Thornicroft, G, Kigozi, F, Tomlinson, M, Lund, C, Patel, V (2015). Cross country methods to evaluate the coverage and effectiveness of district mental health care plans in 5 low and middle income countries. British Journal of Psychiatry (Supplement). DOI: 10.1192/bjp.bp.1114.153676.
Donnelley, J (2011). Ethiopia gears up for more major health reforms. Lancet 377, 19071908.
Epping-Jordan, JE, Pruitt, SD, Bengoa, R, Wagner, EH (2004). Improving the quality of health care for chronic conditions. Quality and Safety in Health Care 13, 299305.
Farooq, S, Nazar, Z, Irfan, M, Akhter, J, Gul, E, Irfan, U, Naeem, F (2011). Schizophrenia medication adherence in a resource-poor setting: randomised controlled trial of supervised treatment in out-patients for schizophrenia (STOPS). British Journal of Psychiatry 199, 467472.
Gureje, O, Nortje, G, Makanjuola, V, Oladeji, BD, Seedat, S, Jenkins, R (2015). The role of global traditional and complementary systems of medicine in the treatment of mental health disorders. Lancet Psychiatry 2, 168177.
Hanlon, C, Wondimagegn, D, Alem, A (2010). Lessons learned in developing community mental health care in Africa. World Psychiatry 9, 185189.
Hardon, AP, Akurut, D, Comoro, C, Ekezie, C, Irunde, HF, Gerrits, T, Kglatwane, J, Kinsman, J, Kwasa, R, Maridadi, J, Moroka, TM, Moyo, S, Nakiyemba, A, Nsimba, S, Ogenyi, R, Oyabba, T, Temu, F, Laing, R (2007). Hunger, waiting time and transport costs: time to confront challenges to ART adherence in Africa. AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV 19, 658665.
Kebede, D, Alem, A, Shibre, T, Negash, A, Deyassa, N, Beyero, T (2004). The sociodemographic correlates of schizophrenia in Butajira, rural Ethiopia. Schizophrenia Research 69, 133141.
Kebede, D, Alem, A, Shibre, T, Deyassa, N, Negash, A, Beyero, T, Medhin, G, Fekadu, A (2006). Symptomatic and functional outcome of bipolar disorder in Butajira, Ethiopia. Journal of Affective Disorders 90, 239249.
Krueger, RA, Casey, MA (2009). Focus Groups: A Practical Guide for Applied Research, 4th Edition. SAGE Publications: Los Angeles.
Lambert, SD, Loiselle, CG (2008). Combining individual interviews and focus groups to enhance data richness. Journal of Advanced Nursing 62, 228237.
Leff, J, Wig, NN, Ghosh, A, Bedi, H, Menon, K, Kuipers, L, Korten, A, Ernberg, G, Day, R, Sartorius, N (1987). Influence of relatives’ expressed emotion on the course of schizophrenia in Chandigarh. British Journal of Psychiatry 151, 166173.
Lehtinen, V, Taipale, V (2001). Integrating mental health services: the Finnish experience. International Journal of Integrated Care 1, 3.
Lijalem, M, Tesfaye, F, Alem, A, Kumie, A, Kebede, D (2003). Nutrition Status of Cases of Schizophrenia and Bipolar Disorders in Butajira, Rural Ethiopia. Addis Ababa University: Addis Ababa.
Lund, C, De Silva, M, Plagerson, S, Cooper, S, Chisholm, D, Das, J, Knapp, M, Patel, V (2011). Poverty and mental disorders: breaking the cycle in low-income and middle-income countries. The Lancet. DOI: 10.1016/S0140-6736(1011)60754-X.
Lund, C, Tomlinson, T, De Silva, M, Fekadu, A, Shidhaye, R, Jordans, M, Petersen, I, Bhana, A, Kigozi, F, Prince, M, Thornicroft, G, Hanlon, C, Kakuma, R, McDaid, D, Saxena, S, Chisholm, D, Raja, S, Kippen-Wood, S, Honikman, S, Fairall, L, Patel, V (2012). PRIME: A programme to reduce the treatment gap for mental disorders in five low- and middle-income countries. PLoS Medicine 9, e1001359.
Mall, S, Sibeko, G, Temmingh, H, Stein, D, Milligan, P, Lund, C (2013). Using a treatment partner and text messaging to improve adherence to psychotropic medication: a qualitative formative study of service users and caregivers in Cape Town, South Africa. African Journal of Psychiatry 16, 364370.
Mogga, S, Prince, M, Alem, A, Kebede, D, Stewart, R, Glozier, N, Hotopf, M (2006). Outcome of major depression in Ethiopia: population-based study. British Journal of Psychiatry 189, 241246.
NVivo qualitative data analysis software. Version 9 (2010). QSR International Pty Ltd.
Patel, V (2015). Universal health care for schizophrenia: a global mental health priority (Editorial). Schizophrenia Bulletin. doi: 10.1093/schbul/sbv1107.
Patel, V, Belkin, GS, Chockalingam, A, Cooper, J, Saxena, S, Unützer, J (2013). Grand challenges: integrating mental health services into priority health care platforms. PLoS Medicine 10, e1001448.
Pfammatter, M, Junghan, UM, Brenner, HD (2006). Efficacy of psychological therapy in schizophrenia: conclusions from meta-analyses. Schizophrenia Bulletin 32, S64S80.
Selamu, M, Asher, L, Hanlon, C, Medhin, G, Hailemariam, M, Patel, V, Thornicroft, G, Fekadu, A (2015). Beyond the biomedical: community resources for mental health care in rural Ethiopia the role of resource mapping in developing a mental health care plan in a low-income setting. PLoS ONE 10(15), e0126666.
Shibre, T, Negash, A, Kullgren, G, Kebede, D, Alem, A, Fekadu, A, Fekadu, D, Medhin, G, Jacobsson, L (2001). Perception of stigma among family members of individuals with schizophrenia and major affective disorders in rural Ethiopia. Social Psychiatry and Psychiatric Epidemiology 36, 299303.
Shibre, T, Kebede, D, Alem, A, Negash, A, Deyassa, N, Fekadu, A, Fekadu, D, Jacobsson, L, Kullgren, G (2003). Schizophrenia: illness impact on family members in a traditional society – rural Ethiopia. Social Psychiatry and Psychiatric Epidemiology 38, 2734.
Shibre, T, Medhin, G, Teferra, S, Wakwoya, A, Berhanu, E, Abdulahi, A, Alem, A, Fekadu, A (2012). Predictors of carer burden in schizophrenia: a five year follow-up study in Butajira, Ethiopia. Ethiopian Medical Journal 50, 125133.
Smith, J, Firth, J (2011). Qualitative data analysis: the framework approach. Nurse Researcher 18, 5262.
Teferra, S, Shibre, T, Fekadu, A, Medhin, G, Wakwoya, A, Alem, A, Kullgren, G, Jacobsson, L (2011). Five-year mortality in a cohort of people with schizophrenia in Ethiopia. BMC Psychiatry 11, doi: 10.1186/1471-1244X-1111-1165.
Teferra, S, Hanlon, C, Beyero, T, Jacobsson, L, Shibre, T (2013). Perspectives on reasons for non-adherence to medication in persons with schizophrenia in Ethiopia: a qualitative study of patients, caregivers and health workers. BMC Psychiatry 13, 168.
Thara, R, Padmavati, R, Aynkran, JR, John, S (2008). Community mental health in India: a rethink. International Journal of Mental Health Systems 2. doi: 10.1186/1752-4458-1182-1111.
Thornicroft, G (2006). Shunned: Discrimination Against People with Mental Illness. Oxford University press: Oxford.
Wagner, EH, Austin, BT, Von Korff, M (1996). Organizing care for patients with chronic illness. Milbank Quarterly 74, 511544.
Wig, NN, Suleiman, MA, Routledge, R, Srinivasa Murthy, R, Ladrido-Ignacio, L, Ibrahim, HHA, Harding, TW (1980). Community reactions to mental illness. A key informant study in three developing countries. Acta Psychiatrica Scandinavica 61, 111126.
World Health Organization (2008). Mental Health Gap Action Programme (mhGAP): Scaling up Care for Mental, Neurological, and Substance use Disorders. WHO: Geneva.
World Health Organization (2010). Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) for Mental, Neurological and Substance use Disorders in Non-Specialized Health Settings. WHO: Geneva.
Zergaw, A, Hailemariam, D, Alem, A, Kebede, D (2008). A longitudinal comparative analysis of economic and family caregiver burden due to bipolar disorder. African Journal of Psychiatry 11, 191198.


Type Description Title
Supplementary materials

Mall supplementary material
Mall supplementary material

 Word (63 KB)
63 KB

‘Restoring the person's life’: a qualitative study to inform development of care for people with severe mental disorders in rural Ethiopia

  • S. Mall (a1), M. Hailemariam (a2), M. Selamu (a2), A. Fekadu (a2) (a3), C. Lund (a1) (a4), V. Patel (a5) (a6) (a7), I. Petersen (a8) and C. Hanlon (a2) (a4)...


Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed