This qualitative study explored views held by prominent men and women from the Borana semi-nomadic community in Southern Ethiopia with regards to their belief about causes of severe mental disturbances and their preferred intervention modalities when someone in their community developed mental disturbance. It provides a unique opportunity to understand the belief systems and intervention in mental health related issues in this relatively isolated and underserved community.
According to Kleinman [26
], culture is an important factor affecting how people perceive severe mental disturbance. There is a general belief that people from western countries and non-western countries have different views regarding the causes of mental disturbances, the former being more biologically-oriented with the latter tending to emphasize religious-magical views. Studies done in western countries about public views regarding causes of mental illnesses reported the predominantly held beliefs to be biological, such as genetics or infections, and social factors such as stressful life events, traumatic experiences, family problems, and social disadvantage[1
The predominant views held in this study population regarding causes of mental disturbance incorporated both religious/magical and biopsychosocial. Among the religious/magical views, possession by evil spirits was commonly held as the main cause of mental disturbance. Bewitchment/witchcraft was another magical view that was reported as a common reason for developing mental disturbance. But besides the religious/magical views, there were prominent biopsychosocial causes reported: biological causes such as malaria, traumatic brain injury, epilepsy, and alcohol and khat abuse; psychosocial stressors such as loss (of property or family member), the experience of child birth, severe psychological stress (such as fear, war) and ‘thinking too much’ were reported time and again by the participants as major causes of mental disturbance. ‘Thinking too much’, which was repeatedly mentioned across the groups as cause of mental disturbance, is a finding consistent with reports from Zimbabwe by Abas et al [27
] and Uganda by Okello & Ekblad [28
] which found a similar attribution style referring to less severe forms of mental distress such as the non psychotic conditions referred to as ‘worry’.
Mental disturbances following the experience of child birth which was associated with ‘exposure to wind before the woman becomes clean’ was a common view held by the participants which is consistent with a finding from a study in a rural setting in Butajira, Ethiopia. The women participants reported pregnancy to be a time of high risk for evil spirit attack. To protect the woman from attack by evil spirit, they keep the woman in hiding behind curtain and close every hole or window until she becomes clean [29
]. Mental illnesses were reported to be heritable by a small number of the participants. Although we put it under biological, it was not very clear from their description whether heritable meant inheriting through genes or spirits. It is good to bear in mind that the Borana people believe in the influence of ancestral spirits descending on subsequent generations.
Several reports from other non-western countries also showed the diversity of opinion held by people living in non-western countries. For instance, a study done in Nigeria involving a large community survey found that as many as one third of the respondents suggested that possession by evil spirits could be a cause of mental illness, but in this same study the majority held the biopsychosocial causes such as drug and alcohol misuse, traumatic event/shock, stress, physical abuse and genetic inheritance as the causes of mental illness [30
]. Another study done among adults in a rural community in 250 adults residing in Karfi village in northern Nigeria reported that one third of the respondents reported drugs of abuse as causes of major mental illness and another third reported divine wrath or spirit possession as the cause[16
]. In a cross-sectional survey done in Pakistan involving 404 people at the outpatient departments of Aga Khan University Hospital Karachi, reported that more than half of the respondents held spiritual or magical causes for psychosis, less than half of the participants reported loneliness or unemployment as a cause for psychotic symptoms [31
More recent studies from Ethiopia showed inclusion of biological and psychosocial factors as causes of mental disturbances in addition to the age old spiritual and magical views. For instance, a study done in western Ethiopia before the 1974 communist revolution on traditional perception and treatment of mental disorders reported that traditional and religious views were the predominant views as causes of mental illnesses. These were disturbances in relationships between people and divinity, possession by evil spirits or punishment by God to the unfaithful [32
]. But a recent survey in a nearby area, a small town in western Ethiopia, reported biopsychosocial problems such as poverty, stress and drug abuse were believed to be important problems for mental illness besides religious/magical views such as God’s will or attack by evil spirit [6
]. Mulatu also reported a similar finding of predominantly psychosocial and supernatural retribution as causes of mental than physical illnesses in North-western Ethiopia challenging the earlier report that lay Ethiopians exclusively believe in spiritual factors as causes of mental illnesses [6
The findings in this study regarding preferred interventions for mental illness were mainly indigenous, although modern health care was also mentioned as important. The overwhelming majority reported preference for consulting the Borana wise men and indigenous healers, but they also reported their belief in other interventions such as modern mental health care delivered in health centers in their area or going to bigger towns to get more specialized care as a last resort. According to their report the care delivered in modern health facility was expensive and inaccessible. To go to a hospital one has to sell his property and take the patient to the capital city, Addis Ababa, which is very far from the place they live. This shows that the people do not necessarily have a special preference of one over the other; rather, it all depends on the availability of the services, financial capacity and severity of the problem as demonstrated by the pragmatic nature of their approach to seeking help, although the role of belief system in dictating preference is acknowledged. According to reports from Nigeria and India, belief system had a direct effect on the preferred treatment. In these countries, the prevailing attribution styles were reported to be mainly supernatural and the preferred treatments were mainly alternative i.e. traditional and religious [34
]. But other reports showed a significant majority of people preferred modern health care despite their attribution styles. For instance, in the study done in rural Northern Nigeria, nearly half of the respondents preferred orthodox medical care for the mentally sick while a third were more inclined to spiritual healing [16
]. In the study done in Pakistan, again nearly half of the respondents reported psychiatric consultation to be the single most important management step [31
]. This shows people living in non-western countries endorse modern western medical care for mental health problems in addition to the existing indigenous methods. They tended to be more pragmatic and pluralistic in their approach and were will willing to try anything that would help the sick. Their views tend to be more dynamic and amenable to change as the situation demands which is similar to other findings from non-western countries [13