Culture and Context: Lessons from a Sub-Saharan African Experience Rachel Hingst, OTR, CPRP.
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Transcript of Culture and Context: Lessons from a Sub-Saharan African Experience Rachel Hingst, OTR, CPRP.
![Page 1: Culture and Context: Lessons from a Sub-Saharan African Experience Rachel Hingst, OTR, CPRP.](https://reader030.fdocuments.in/reader030/viewer/2022032605/56649e765503460f94b77e5e/html5/thumbnails/1.jpg)
Culture and Context: Lessons from a Sub-Saharan African
Experience
Rachel Hingst, OTR, CPRP
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Learning Objectives:
Attendees will be able to: Describe cultural values which are reflected in the
principles and practice of psychiatric rehabilitation in the United States
Explain some of the specific challenges faced by both individuals with mental illness and service providers in developing countries
Recognize their responsibility as global citizens to advocate for mental health to be prioritized on the international health agenda
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Session Outline:
Introduction to Sub-Saharan Africa American cultural values, norms, and
assumptions Small group work Presentations of group work Challenges Examples of practices Questions/discussion
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“Developing countries”
Developing/developed Least Developed Countries (LDC) Less Economically Developed Country (LEDC) Non-industrialized/industrialized Third world/first world Global south/global north Majority World
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If the world was a village...
If the world's population was reduced to 100 people: 60 Asians, 14 Africans, 12 Europeans, 8 Latin Americans, 5 from the USA
and Canada, and 1 from the South Pacific
67 would be unable to read
50 would be malnourished and 1 dying of starvation
24 would not have any electricity (And of the 76 that do have electricity, most would only use it for light at night.)
1 would have a college education
5 would control 32% of the entire world's wealth; all 5 would be US citizens
33 would be receiving --and attempting to live on-- only 3% of the income of "the village"
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Global Mental Health:
WHO estimates 450 million people worldwide experience mental health problems: 154 million: depression 25 million: schizophrenia 91 million: alcohol use disorders
Spending in developing countries: Most middle and low-income countries devote less than 1% of their health expenditure to mental health.
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Sub-Saharan Africa:
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Sub-Saharan Africa:
What words come to mind?
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Sub-saharan Africa
Population of over 800 million Diversity:
1000 different languages Shared experiences
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Resources: Ivory and slaves Copper, cotton, rubber, diamonds, tea, tin Oil, gold, platinum, uranium, coltan
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The Scramble for Africa:
End of 19th century Colonization: artificial boundaries Minority governments Apartheid
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Independence: Decolonization Some challenges with independence: human
resource and infrastructure...
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Conflicts:
Country Time Estimated deaths
Nigeria 1967-1970 200,000-1 million+
Mozambique 1977-1992 900,000
Angola 1975-2002 500,000+
Sierra Leon 1991-2002 75,000-150,000
Rwanda April 1994-July 1994 500,000-1 million
Congo 1998-2003 3 million+
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Politics:
Dictatorships One-party states
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Economics:
Average GDP per capital in Sub-Saharan Africa: approximately $1,800 (compared to about $46,000 for USA)
Almost half of people live on less than $1 a day (extreme poverty)
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HIV/AIDS:
Accounts for 67% of HIV infections worldwide (about 22 million people)
Disrupted communities and families 14 million children are orphans Human resources: loss of productive
citizens Stress/grief: psychosocial burden
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Psychiatric Rehab?
Worked for 2 ½ years in Malawi
First in government psychiatric hospital then for NGO providing mental health services
Programs included: inpatient hospital, outpatient clinic, community outreach clinics, day rehabilitation program, vocational training school, food security program, street children's program, college for training psychiatric nurses and clinical officers, and programs for children with special needs
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Where is Malawi?
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Examining American norms, values, and assumptions:
“Psychiatric rehabilitation has its origins in a Western humanistic worldview, based predominantly on United States and British culture.”-from USPRA Multicultural Principles
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Multicultural Principles:
Understanding own culture:
“The essence of multiculturalism is the study of one’s own culture and ethnicity as the basis for understanding and identifying with those from others. Interpersonal encounters are not “objective” or “value-free” even when these encounters occur in a therapeutic or rehabilitation relationship.” (from Principle 2)
Recognizing Worldview of Others:
“Psychiatric rehabilitation practitioners recognize that thought patterns and behaviors are influenced by a person’s worldview, ethnicity and culture of which there are many.” (from Principle 4)
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Value: Individual
American value: “Rugged individualism” Independence valued over interdependence
“...appreciating cultural preferences that value relationships and interdependence, in addition to individuality and independence.” (Principle 7)
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Value: Work and Achievement
From USPRA Vision:
“It promotes a world in which individuals with mental illnesses can recover to achieve successful and satisfying lives in the working, learning and social environments of their choice.”
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Value: Work and Achievement
Do all cultures highly value work and achievement? “Psychiatric rehabilitation practitioners show respect towards
others by accepting cultural values and beliefs that emphasize process or product, as well as harmony or achievement.” (Principle 7)
“Most mental health service systems in the U.S. place a great deal of emphasis on outcomes, especially achievement of independence and success in role functioning, such as competitive employment. Psychiatric rehabilitation practitioners recognize that people who use psychiatric rehabilitation services will have a variety of definitions of what constitutes success, satisfaction, and recovery.”
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Value: Future Orientation
Emphasis on planning and progress: Life goals, short-term and long-term goals, strategic planning, etc.
Is this something all cultures can relate to? Importance of the past
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Value: Control
American dream: we control our own destinies; have the ability to bring prosperity to ourselves
Tradition of democracy Automony Not everyone has choices: influenced by
political, social, and economic factors Role of fate and the supernatural
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Assumption: Infrastructure
Roads/transportation Communication: phone, mail, internet Water/sanitation Electricity
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Assumption: Healthcare/social service system:
Functional structure Human resource Other basic resources: medication, soap, lab
tests, etc. Social security/welfare system: housing options,
disability benefits, etc.
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Assumption: Economic opportunities
Employment: diverse economy with various sectors
Loans accessible: business, education, housing, etc.
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Small Group Work:
Each group will be given one principle or practice of psychiatric rehabilitation or a characteristic of recovery-focused services
Discuss the challenges and opportunities you anticipate in applying this principle/practice in the context of a developing country
Consider the cultural differences, social and political factors, and economic disparities
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Challenges in implementing psychiatric rehab services:
Based on personal experiences in Malawi In addition to day to day challenges Economic Available support
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Traditional Beliefs:
Causes of mental illness Witchcraft Traditional healers Locus of control Challenges: adherence to medication/treatment
poor; active role in illness management difficult
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Stigma
Disability in general seen as burden
Enormous public stigma
Open discrimination by leaders, public figures, and health workers
Staff working in mental health also stigmatized
Challenges: mental health is relegated to background; no resources allocated; even with good skills clients struggle to have satisfying lives due to public stigma
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Donor culture
International development sector: controversy
Allowances for workshops: “allowance culture”: created by donors
Volunteering as a job
Donors have the power
Challenges: difficult to find committed employees and volunteers; resources spent on trainings with questionable outcomes; Western standards/expectations imposed which may not be needed/realistic/sensible in the context
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Evidence
Digital divide: how many people in this world have internet access?
Imported evidence
Validity of tools: cultural bias
Capacity for research
Outside researchers
Challenges: Difficulty measuring outcomes—building an evidence base; relying on imported evidence; alienation of our colleagues across the digital divide
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What works?
Examples of practices...
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Sensitization
Employers Police and prison workers Churches Traditional/community leaders Community-level
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Relationships with Traditional Healers
Early identification of problems Using as part of the team
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Skills training
Adapting to language and culture Examples: conflict management, problem
solving, stress management
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Food Security Program
“Supported farming” Involves family and community Gives client status/fights stigma Links with housing
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Vocational training
Various trades for self-employment or community employment
Educational support
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Business/supported employment
“supported employment”--not same as US model
Business raises money for service Gives clients work experience Fights stigma
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Community-Based Rehabilitation CBR Model for rehabilitation and social integration for
people with disabilities See WHO references in handout
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Plea for Advocacy:
Remember the Majority World Be an advocate for making mental health a
global priority “No health without mental health.” Celebrate World Mental Health Day on October
10.