Breaking chains of discrimination

Mental illness in Nigeria

In Nigeria stigma towards those with mental illness is a strong barrier to inclusion and a challenge for communities. At a local level, there is little known about mental illness. As a result views of mental illness are often fuelled by myths. In many Nigerian communities it is believed mental illness is caused by witchcraft or is the result of divine punishment. Consequently communities have been known to chain people with mental illness or hide family members affected by mental illness as a result of the stigma [1].

The Mental Health Awareness Program’s approach to disability inclusive development

The Amaudo Community Mental Health Program is the only community based mental health service in south eastern Nigeria. The project provides accessible, affordable and professional care to people with mental illness through a network of clinics and directly to homes. The project found educating communities and challenging traditional beliefs about mental illness is an essential part of supporting people with mental illness.

As part of the program, the Mental Health Awareness Program (MHAP) was developed to educate community workers and families and provide them with the tools and knowledge to support people with mental illness in their community. MHAP is a five- year program delivered to the four states where the Community Mental Health Program operates.

How is MHAP implemented?

Recognising that access to good health care is an important first step towards community inclusion, the project arranges training for community psychiatric nurses and other government health professionals. Once trained, they deliver awareness and education programs about mental illness and human rights to village health workers who directly support people affected by mental illness in their communities. In each area the government recruits 15 voluntary village health workers to support approximately 200,000 people. The village health workers learn positive messages about mental health and advice on how to identify, refer and support people with a mental illness in the community. In raising awareness about mental illness and encouraging those with mental health problems to attend CMHP clinics, the village health workers are helping to change community beliefs and prevent discrimination. 

What is most effective?

In the six months leading up to the project’s start in a new area, communities are heavily involved in the development of the project. This means meeting with influential community members and government officials to share the importance of mental health. By the time the project officially launches in each community, the community psychiatric nurses, other government health staff and 15 village health workers have already attended training, key community members are supportive of the project and there is a strong sense of community ownership.

Mr Omo is a village health worker for the MHAP. In his spare time he visits the traditional leaders in local villages to explain his role and provide information about mental illness, support services and the importance of community inclusion. Each village health worker maintains a close relationship with a psychiatric nurse, and Mr Omo is no exception. He has a strong relationship with the community psychiatric nurse, who supports him, and he requests their support when he has any questions.

Mr Omo found that as more people access mental health care the community has become more supportive as they can see the results for themselves. People are now starting to approach Mr Omo from other communities because they have heard about his work and are hopeful that mental health problems can be treated. This is an important first step in starting to change community attitudes and increase participation of people with mental illness in the community.

Village health workers do much more than provide referral services; they also help people with mental illness take part in community life. They encourage family reconciliation and visit schools and workplaces where people with mental illness are no longer able to attend. In these homes, schools and workplaces they teach people about the challenges of mental illness and the importance of disability inclusive practices. This component of the project is a vital step towards reintegrating people with disabilities who have experienced discrimination.

The MHAP monitoring processes are integrated into the existing Community Mental Health Program’s monitoring where possible. A monitoring and evaluation team is established at the beginning of each period of village health worker training with the aim of reviewing attendance, content and the quality of training. This team conducts pre- and post-training tests to assess the change in attitude and knowledge of the village health workers. Information, including the number of referrals made to clinics and awareness raising activities in the community, is also collected by community psychiatric nurses from each village health worker.

Inclusive development in practice

The Amaudo MHAP highlights two key factors for effective inclusive development:

1. Advocacy to build awareness of and support for disability inclusion - Before working in new local government areas, project staff spend six months building awareness and support for the project. This includes meeting with government officials, the primary health care director, local chiefs and religious groups to share the importance of the project. This helps each community understand mental health and feel part of the project. It is also a crucial step to ensure community psychiatric nurses, village health workers and other government health staff are trained and ready to start work when the project launches in their community.
    
2. Working together with government and other service providers for coordinated, sustainable projects - The MHAP works closely with the government in two ways: it is linked with existing government services and is supported by government staff. The MHAP works to strengthen existing services the government is already committed to providing. This approach helps to build the longevity of the services offered for people with mental illness. In terms of staff, rather than employing new project staff the project utilises existing government staff such as community psychiatric nurses to implement the project. Government systems are used to recruit, train and supervise village health workers. By building the project into the government health structure, the services for people with mental illness remain the responsibility of the government, are not dependent on donor funding and have a greater likelihood of continuing beyond the time frame of the project.