Free List Data
Free list results were reviewed by the investigation team, consisting of three individuals with diverse advanced degrees (i.e., clinical psychology, public health, and international development), and were collapsed into summary lists that consisted of 42 women’s problems, 36 children’s problems, and 32 problems of women that affect their children. Summary lists of child questions contained 11 problems of children and 14 problems of parents that affect children.
Six of the 42 problems identified by women were classified as potential psychological issues (). Of these, domestic violence occurred most frequently (72%), and three of these six dealt with spousal interpersonal relationship.
Mental Health Issues Identified From Free Listing Interviews of 25 HIV-Infected Women in Lusaka, Zambia
The problems of children in the community that women identified are listed in , 10 of which were identified as potential mental health issues. Among these problems, 52% of women identified orphanhood, with many women noting that orphaned children adopted by other family members are treated as second class citizens. Defilement or sexual abuse of children was also reported as a problem by 40% of women. Many mental health issues of children concerned neglect, abuse, or the lack of parental guidance.
Ten of the 32 problems of adults that affect children were identified as mental health issues (), and 68% noted that parental illness/sickness was a problem that affected their children. HIV/AIDS was noted specifically by 12% of the women and 40% described the impact of violence or violence between parents in the presence of children as an issue.
Of the 28 problems on the free list identified by children, 10 were potential mental health issues (). Thirty percent identified defilement as a problem. Disease/sickness, orphan hood, and being beaten at home or school were noted as significant problems for children. Children’s responses typically revolved around child-adult relationship problems, with half of the responses characterizing a form of violence.
Mental Health Issues Identified From Free Listing Interviews of 20 HIV-Affected Children in Lusaka, Zambia
Children’s estimation of the problems of adults that affect children included 42 problems, nine of which were potential mental health issues (). Forty-five percent of children cited parental fighting as poorly affecting the children and community, and 15% specifically said interpersonal violence (man beating his wife) was a problem for children. Forty percent of the children said dying parents and mourning are difficult, and 25% said that adult alcohol abuse was a big problem for them. Domestic violence was a prominent common theme connecting many of the problems cited by children and women.
Participants were obtained from the free lists with 22 community members deemed knowledgeable of the reported mental health issues. Three identified KIs were employed by the ZEBS project and were aware of its aims, and thus were interviewed only once to request names of other possible KIs, resulting in an additional four names. All KIs were asked for others knowledgeable of mental health issues, generating eight more names. The final set of 21 KIs interviewed included marriage counselors, pastors, traditional healers, chairpersons of neighborhood watch programs, members of the Police Department’s Victim Support Unit, headmasters and teachers in schools, and nurses.
Key informant interviews were more directed than free listing, lasted approximately 60 minutes, and focused on the mental health issues identified during free list exercises. These interviews were intended to corroborate and expand the problems that emerged from the free lists, and to elicit other problems not captured in the free lists. KI interviews were open-ended with a question such as, “Tell me about_____” (a mental health problem identified from free listing), or a description of a hypothetical person with symptoms described in the free lists. All KIs were interviewed twice, with most completing three 60-minute interviews. Each interview was summarized and assessed by both the interviewers and the investigation team at the end of each day. Interviewers were instructed to probe potentially related topics on follow-up interviews. Interviewers were coached to return until the respondent stated that they had no new information.
Domain analysis techniques were used to explore the KI data. This consists of identifying patterns of cover terms (terms that describe a group of concepts, such as the name of a syndrome) and included terms (terms that are included under a cover term, such as symptoms). Patterns of cover and included terms that emerged from the interviews with one informant were compared with those from other KIs and from the free list interview results. These patterns were also compared with the local mental problems independently described by the interviewers and by one of the authors (AH), who is a local psychiatrist in Lusaka.
Key Informant Results for Women
Three major mental health issues of HIV-affected women were repeatedly discussed and described by KIs: DV, a depression-like syndrome, and alcohol abuse.
Domestic violence was commonly referred to as a husband beating his wife. KIs described women who experienced DV as “not looking happy,” “looking thin and losing appetite,” “being lonely,” “having disturbed minds,” “feeling unloved,” “looking confused,” “quiet,” “feeling grief,” and “sometimes killing themselves.” One informant stated:
“When the women fight every time with the husband she always has grief—She has a lot of thinking and even when you are greeting her sometimes she can’t hear what you are saying. You can think she is ignoring you and yet she isn’t. Her mind is disturbed and she loses appetite as a result she becomes thin… She stops doing housework, this person doesn’t know what is right to do—thinks all she does is not appreciated. Kill themselves as all problems are piled on them has no solution or anyone to advise her so dying is the solution… Mind disturbed—this person cannot bathe, can’t see friends or talk to friends… Looks confused—her thoughts are scattered, house is dirty, doesn’t want people around her. At times she will result in sleeping all the time.” (KI)
Key informants identified three main causes for domestic violence: (1) when the man comes home drunk, (2) when a woman comes home and tells him she is infected, and (3) when the woman will not have sex with her husband. KIs stated:
“Beer causes problems in a marriage, there’s always conflict.”
“Men get annoyed if his wife tells him he HIV-positive. Confusion in the house which may lead to divorce and domestic violence.”
“You start fighting with your wife, saying you have infected me with the disease.”
“Many women are beaten because they refuse to have sex with their husband.”
Key informants described depression-like symptoms in women consisting of “worries,” “losing sleep,” “thinking too much,” “losing appetite,” “withdrawal,” “loneliness,” “difficulty concentrating,” “crying,” “looking sad,” “suffering inside,” “feeling hopeless,” “feeling unloved,” and “wanting to commit suicide.” No acceptable overall term was found that encompassed all these symptoms. These symptoms related to domestic violence or conflict and HIV:
“When a person has been found with HIV she becomes so sad, thinking maybe she’s going to die soon.”
“They feel bad inside and start wishing they were dead. They also wish they were not born.”
“You begin to do things out of frustration like having sex with different kinds of people so that you infect others too saying you can’t die alone.”
Drinking was identified as a severe problem, describing alcohol abusing men as “staggering,” “having impaired speech,” “not reasoning,” “insulting,” “behaving rudely,” “not caring for kids,” “sexually weak,” “having no respect,” “bringing conflict in the home,” “defiling others,” and “stealing.” Binge and high intake drinking is the norm in Zambia (Haworth, 2004
). Some KIs stated:
“There are so many beer breweries. Men stop bringing money home and telling the truth to their wives. Alcoholics’ appearances are so bad and dirty, they look like they are mad. There are always wrangles and fights in the community. Their wives live in fear all the time. Children grow up with a certain fear of their fathers.”
“If a person takes a lot of alcohol he loses self control and ends up having sex with anyone; that’s why the rate of HIV has risen.”
Key Informant Results: Children
Key informant interviews cited three main domains of child-related symptoms: (1) the effects of defilement, (2) the effects of violence or conflict in the home, and (3) behavior problems.
Key informants described children who had been defiled as “crying,” “thinking too much,” “alone and withdrawn,” “fearful that it will happen again,” “feeling used,” “looking confused,” “damaged psychologically,” “feeling rejected,” “shy,” “difficulty concentrating,” “feeling uneasy and surprised,” and “having an unsettled mind—thinking about what has happened.” KIs corroborated the free list results that closely linked defilement to DV, alcohol abuse, and HIV. Example responses include the following:
“They are not free with their families thinking maybe they’re against them or blaming them.”
“She’s psychologically disturbed. She’s confused, she runs away from home out of fear, frustration and self-stigma. She thinks it’s a taboo because they say if an HIV-infected man sleeps with a young girl he gets cured and infects the young girl.”
“You force yourself into a young girl who’s not even matured, she doesn’t even know anything, she becomes confused, her sex organs damaged and affected. The girl will be left in pain.
“There was a 32-year-old woman who had sex with an 8-year-old boy. The boy’s penis was bruised and infected the boy with syphilis. The children don’t grow up well; even their private parts don’t grow as expected because they are damaged. The child is infected with diseases such as syphilis/HIV. Even psychologically the child gets affected.
“In this community men drink a lot and when they get drunk, they start feeling a desire of sleeping with a woman and if they find a young girl near, they just force themselves into her and rape her.”
Key informants described children exposed to domestic violence as “not growing up peacefully,” “feeling lonely,” “imitating bad language,” “looking unhappy and miserable,” and “looking confused.” KIs stated:
“They do not even go to school because of no cooperation between parents.”
“The child thinks that my father does not want me, they feel unloved, they hate their father and love their mother.”
A second local syndrome commonly described by the KIs included externalizing symptoms, or behavior problems that others can outwardly see. Drinking beer was the most common, which was accompanied by “stealing,” “having no respect,” “being out of control,” “raping others,” “looking scruffy,” “not attending school,” “disturbed thinking,” and “smoking dagga” (marijuana). A common causal theme was lack of control and discipline from the parents, and the death of one or more family members. KIs stated:
“When the child starts drinking beer he loses respect, he insults the elders, he smokes dagga, he stops going to school, he starts stealing, he gets out of control. You’ll just hear that he’s raped someone. He’s uncontrollable. You can’t just talk to him.”
“It’s because of this deadly disease HIV/AIDS; it has stricken many families and children are left with no one to look after them. He develops bad characters like stealing, drinking beer and fighting.”