Contrasting Concepts of Depression in Uganda: Implications for Service Delivery in a Multicultural...

Amencan Journal of Onhopsychiatry 2009. Vol. 79, No 2, 275-289

0 2009 American Psychological Association 0002-9432/09/$12.00 DOI: I0.1037/a0015818

Contrasting Concepts of Depression in Uganda: Implications for Service Delivery in a Multicultural Context

Laura R. Johnson University of Mississippi

Med Kajumba Mayanja, Paul Bangirana, and Simon Kizito

Makerere University, Kampala, Uganda

Depression is a rising public health concern worldwide. Understanding how people conceptualize depression within and across cultures is crucial to effective treatment in a global environment. In this article, we highlight the importance of considering both lay and professional perspectives when developing a culturally competent and contextually relevant model for service delivery. We conducted interviews with 246 Ugandan adults to elicit their explanatory belief models (EMS) about the nature of depression, its causes, social meanings, effects, help seeking, and treatment. Interviews were transcribed, content analyzed, and coded. We compared EMS of community members (n = 135) to those of professional practitioners (n = 11 I), whom we further categorized into traditional healers, primary care providers, and mental health professionals. We found significant differences between lay and professional EMS and between 3 types of professionals. Contrary to our expectations, lay concepts did not overlap more with traditional healers than with other professional EMS. We discuss the diverse concepts of depression in Uganda, the nature of group differences, and implications for service delivery and treatment.

Keywords: depression, Uganda, explanatory model, traditional healing, service delivery

Depression is a growing concern worldwide, negatively impact- ing the lives of individuals, families, and communities around the globe. By 2020, depression will be the second leading contributor to the “global burden of illness” based on its relatively high contribution to disability and death as measured in disability- adjusted life years (World Health Organization [WHO], 2001). Exploring depression across cultural contexts is crucial to treating depression on a global, multicultural scale (Kleinman, 2004; Stevens & Gielen, 2007). Despite international rhetoric about its rising negative impact, we know little about how depression is conceptualized and best treated in many parts of the world. African perspectives, in particular, are frequently underrepresented in psychological research (Stevens, 2007). Despite increasing concern about depression globally, psychological research and practice

Laura R. Johnson, Department of Psychology, University of Missis- sippi; Med Kajumba Mayanja and Simon Kizito, Department of Mental Health and Community Psychology, Makerere University, Kampala, Ugan- da; Paul Bangirana, Department of Psychiatry, Makerere University Med- ical School, Kampala, Uganda.

We thank the J. W. Fulbright Foundation for supporting this research and Joseph F. Aponte, Emilio Ovuga, and Janet Nambi for their advice, support, and critiques. Seggane Musisi and Joshua Tugumisirize provided helpful feedback, and Elialilia Okello assisted with the development of the vignette. We appreciate the assistance of the Department of Psychiatry at Makerere University, the Ugandan Ministry of Health, the staff at Mulago and Butabika Hospitals, and members of the research team. A special note of thanks is offered to Kiggo Livingstone, of the Mukono District Healer’s Association, for his trust, openness, and collaborative spirit.

For reprints and correspondence: Laura R. Johnson, Department of Psychology, Peabody Building, Room 207, University of Mississippi, University, MS, 38677. E-mail: Ijohnson@ olemiss.edu

remains a largely insular endeavor focused on European and North American populations (Arnett, 2008). Few studies have examined current conceptualizations of depression and related systems of care on the African continent.

In Africa, depression is increasing and currently accounts for 1.2% of the overall illness burden (Ustun, Ayuso-Mateos, Chat- terji, Mathers, & Murray, 2004). Socioeconomic shifts resulting in poverty, the breakup of traditional family structures, population mobility, political upheaval, civil conflict, famine, disease, and rapid cultural changes are contributing factors (WHO, 2006). Older and more recent epidemiological studies in Uganda have shown strikingly high rates of depression compared with regional and Western standards (Bolton et al., 2003; Bolton, Wilks, & Ndogoni, 2004; Cox, 1979; Orley, 1972; Orley, Blitt, & Wing, 1979; Ovuga, Boardman, & Wasserman, 2005). Although referred to as “the pearl of Africa” by Winston Churchill, Uganda is commonly associated with the tyrannical rule of Idi Amin, the AIDS epidemic, and the 21-year-old war in the North, which has been characterized by massive killings, maiming, and the abduc- tion of children forced to join rebel fighters. Such stressful events, combined with high rates of poverty and communicable illnesses, have contributed to the high prevalence of depression (from 14% to 22% in most studies [e.g., Bolton et al., 2003; Ovuga et al., 20011 and as high as 44.5% in the war-affected North [e.g., Vinck, Pham, Stover, & Weinstein, 20071).

Depression is increasingly recognized as a public health concern in Uganda, yet the majority of Ugandans do not get treatment. Many are unfamiliar with the Western concept of depression and are unlikely to seek out professional services. Traditional beliefs about spiritual causes, such as witchcraft, and other cultural factors, such as social stigma may interfere with help seeking and treatment. Indeed, in focus groups conducted among the Baganda

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in Uganda, psychotic depression was thought to be caused by neglect of traditional rituals, breaking of taboos, or mixing of African and Western belief systems (Okello & Musisi, 2006). Others may have a somatic conceptualization of depression and seek help from health clinics. With depression accounting for as much as 30% of primary care service utilization, health clinics in Uganda are unprepared and underresourced for meeting this need (Muhwezi, Agren, & Musisi, 2007; Okello & Neema, 2007; Ovuga et al., 2001). Moreover, depression in collectivist cultures may be masked in presentation, lacking in self-focused features such as sadness or guilt (Corin & Bibeau, 1980; Ovuga, 1986). An absence of these core features can further impede effective diagnosis and service provision within the health and mental health service sectors (Kleinman, 2004).

There is agreement that it is neither appropriate nor effective to simply transport Westem-based methods of conceptualizing and treating mental illness to African countries. The WHO and other nongovernmental organizations (NGOs) have initiated attempts to work with traditional healers and primary care providers to incor- porate traditional beliefs and practices into modem services (WHO, 2001; WHO Africa Regional Office, 2008; World Health Assembly, 1998). There has also been a call to work within the established primary care system. Government agencies are also recognizing and responding to the problem. Uganda’s health policy recognizes important roles for traditional beliefs and healing systems, as well as primary care services, in the provision of mental health services. However, little progress has been made toward an integrated system of care (Ovuga et al., 2001).

Parallel Systems for Treating Depression

The Westem-based psychological approach to treating mental illness in Uganda arose in the 1950s from a need to protect the public from dangerous patients (Baingana, 1990). Early treatments largely followed a biomedical model and focused on symptom reduction through medication, electroconvulsive shock therapy, and removal of patients from their home environments (Ovuga et al., 2001). Under the repressive regimes of Amin and Milton Obote, mental health services suffered dramatically as many professionals were targeted, tortured, killed, or forced to flee the country. Despite major efforts to rebuild and decentralize mental health services, Uganda still faces limited resources, poor infrastructure, and a lack of trained clinicians. There is a severe short- age of mental health services, with only 12 psychiatrists in 2002 for a population of nearly 25 million people (Ndyanabangi, Basangwa, Lutakome, & Mubiru, 2004).

In contrast, traditional healers play a major role in the delivery of mental health services in Uganda. Although often disregarded by other professionals, healers exist in 80% of Ugandan communities and thus carry the burden of dealing with most mental and physical ailments (Baingana, 1990; Ovuga et al., 2001). Lack of attention to, and misunderstanding of, traditional healers’ roles and approaches to mental illness have contributed to their subsidiary status in many countries. Traditional healers encompass a diverse group including herbalists, spiritualists, diviners, sheiks, and those who identify with a specialty such as midwifery, “madness,” or AIDS treatment (Ovuga, Boardman, & Oluka, 1999). Many healers use a range of diagnostic and treatment methods. Herbal medications are among the most common. Others include coun-

seling, conflict resolution, spiritual or cultural rituals, monetary assistance, and community intervention. Traditional healers often offer a holistic form of treatment focusing on patient-environment interactions, interpersonal relationships, spiritualkultural health, and community well-being (Clark, 1982; Corin & Bibeau, 1980; Johnson, Bastien, & Hirschel, 2009).

Given the limited resources, Ugandans may be more likely to seek help from whatever source is available, be it traditional healers, health clinic nurses, psychiatric officers, community leaders or family members. Multiple sources may be sought simulta- neously or sequentially. Ugandans with mental illness, such as depression, may first seek out the services of a healer, eventually resorting to modem mental health services if they fail to improve (Ndyanabangi et al., 2004). Unfortunately, the different systems operate in a parallel, nonintegrated fashion that can have deleteri- ous effects on patient well-being and treatment success. For example, traditional and modem systems may have different ways of conceptualizing and treating depression, leaving patients and families feeling caught between the opposing systems (E. Kizito, personal communication, August 12, 2003). Confusion and a lack of faith in the approach of one or both systems may result in early attrition, treatment nonadherence, or poor treatment outcomes.

Explanatory Belief Models (EMS) and Mental Health Service Utilization

One approach to developing a more integrated treatment for depression is to explore and describe variations in concepts of depression and associated treatment expectations. Phenomenolog- ical investigations of EMS of illness have been a central feature of research in medical anthropology and may be particularly useful when designing and implementing mental health services in medically pluralistic countries such as Uganda, where a range of beliefs and treatment options exist.

EMS are beliefs about an illness that give meaning to the illness and convey how it is understood by individuals and systems (Kleinman, 1977, 1980, 2004). EMS include personal, social, and cultural beliefs about the nature and cause of depression, its severity and course, impact, fears, and treatment. These components, taken together. present a picture of how depression is viewed from inception to eventual outcomes (Weiss & Kleinman, 1988). Studies in Uganda indicate that, when individuals hold a cultural or spiritual conceptualization of the problem, they are more likely to seek traditional healing services (Baingana, 1990). Focus-group studies among the Baganda have suggested that depression is largely viewed as a biomedical phenomenon, resulting from social conflict, or the breaking of cultural taboos. Unipolar depression has been associated with an “illness of thoughts,” whereas psychotic depression has been conceptualized as a clan illness, (eByekike). Modem medications were not seen as being necessary to treat either condition (Okello, 2006), indicating that professional help for depression will not often be sought.

It is insufficient to look only at patient EMS, as EMS are held by families, other laypersons, and by health and mental health practitioners. When professional treatment is sought, differences in EMS between patients and their practitioners may n’egatively affect the treatment process and outcomes. Thus, it is important to examine the EMS of health care practitioners (Chrisman & John- son, 1996). Studies suggest that the EMS of laypersons and patients

CONCEPTS OF DEPRESSION IN UGANDA 277

frequently differ from professional EMS (e.g., Cohen, Tripp- Reimner, Smith, Sorofman, & Lively, 1994; Gray, 1995; Gregg & Curry, 1994). Disparate beliefs, left unexplored, may result in poor patient-practitioner communication and lead to misdiagnosis, in- appropriate treatment, treatment nonadherence, early attrition, and poor treatment outcomes (Chrisman & Johnson, 1996; Kleinman, 1980). Exploring patient-practitioner variation in EMS may be helpful in understanding help seeking, service utilization patterns, and treatment outcomes (Patel, 1995; Weiss & Kleinman, 1988).

The Present Study

Exploring EMS of depression can capture cultural and contextual information with important implications for help-seeking and treatment. To inform service delivery and treatment of depression in Uganda, we sought to explore beliefs about depression held among the lay community and three types of professionals likely to encounter depressed patients. In Uganda, these include traditional healers, primary care professionals, and mental health professionals. Our questions were: Is depression, as recognized by Western psychology, a relevant concept in Uganda? What is the perceived nature of depressive illness, its cause, its social meaning, and its impact? What sources of help or types of treatment would depressed Ugandans seek? Equally important, how do mental health professionals, traditional healers, and primary care providers, view depression and appropriate treatment? Are there differences between lay people and professionals in their concepts of depression and treatment beliefs? Are there differences between types of professionals? What implications does this have for the organization of mental health services and for our understanding of depression? The specific study aims were to (a) provide a description of the diverse concepts of depression in Uganda, (b) examine differences in concepts of depression and views on treatment, and (c) discuss implications for effectively treating depression in the context of cultural diversity and medical pluralism in Uganda and elsewhere. We examined the following hypotheses: Lay community members and professional practitioners will differ in their concepts of depression (Hypothesis 1); the three types of professional practitioners will differ in their concepts of depression (Hypothesis 2); and lay community concepts will be closer to concepts held by traditional healers than to those held by primary care and mental health professionals (Hypothesis 3). In addition to our focus on lay and professional views, we explored EM differences based on several sociodemographic factors, including income, education, age, gender, and language (Hypothesis 4).

Method

Study Design

Because Uganda is a medically pluralistic and multicultural setting for research, we chose a combined qualitative and quanti- tative approach to data gathering and analysis that would allow us to capture emic (i.e., culture-specific or contextually related) aspects of depression, such as local idioms, as well as etic, or universal, aspects of depression (Jenkins, Kleinman, & Good, 1996; Pelto & Pelto, 1996). The study is both discovery oriented and confirmatory. Qualitative data from open-ended interviews elucidates personal, social, and cultural beliefs about depression

for each component of the EM. Content analysis and coding of interview transcripts set parameters on interview data that allowed us to test for group differences with implications for help seeking and treatment.

Research Team

Our study benefitted from a diverse research and consultative team that aided in the conceptualization of the design, the development and translation of the interview, and the data collection and interpretation. Three primary researchers, authors on this article, conducted interviews and transcribed and analyzed the data. They were Ugandan male graduate students in a clinical psychology program at Makerere University. Researchers were trained to conduct the interviews first in English and then in Luganda. The first several interviews were transcribed and reviewed for accuracy before additional interviews were conducted. Audiotaping and additional observations allowed for continued monitoring throughout the data collection process. Laura R. Johnson, a U.S. psychologist, recruited survey sites by securing letters of support from healers’ associations, ministries of health, and clinic directors and, as appropriate in the context, personally invited and interviewed several traditional healers and other professionals.

Participant Recruitment

Participants were 246 Ugandan adults selected to represent diverse lay and professional perspectives on depression. We used purposive sampling to ensure the inclusion of perspectives from specific groups. Professional practitioners (n = 111) were recruited from health service settings, mental health service settings, and traditional healing clinics, all portals of entry for persons with depression. We strove for approximately one third from each service setting resulting in psychiatrichental health providers (n = 33), primary care providers (n = 42), and traditional healers (n = 36). We selected lay community members ( n = 135) to represent a diverse range of “potential patients,” whom we recruited from the same service settings, as well as community locations, such as shops and businesses. All recruitment sites were in urban and semi-urban sites in Kampala or in the surrounding districts of Mukono, Mpigi, and Wakiso. With potential access to inpatient and outpatient mental health facilities, as well as to health centers and traditional clinics, these areas had the most developed infrastructure and services for treating depression, as well as the most exposure to psychology and psychological nomenclature.

Participant Characteristics

The majority of participants (61%) were between 18 and 29 years of age, 62% were women, and 49% were married. Roughly half of participants (52%) were Baganda, which was not unexpected, given that Baganda is the dominant tribe in the research district and the most populous in the country. Among the other tribes represented were Nyankole, Soga, Toro, Kiga, Nyoro, and Lugbara. Reflective of the massive urban migration occurring in Uganda, many regions of the country were represented, with a total of 44 home districts. The largest percentage came from the Mpigi district (1 l.4%), followed by Kampala (8.2%), Masaka (7.4%), and Mukono (5.2%). Others came from districts as far as Nebbi


and Gulu in the north, Fort Portal in the west, and Kabale in the southwest. On indicators of socioeconomic status, 32% of participants had finished some high school education, and another 41 % had some postsecondary education. Most participants (67%) reported working full time. Monthly incomes ranged between $6 and $180 U.S. dollars. Although the majority reported having electric- ity in their homes, over 50% did not have running water, and 39% lived in a single-room dwelling. In terms of religious affiliation, 38% of participants reported affiliation with the Church of Uganda, an Anglican church, followed by Catholic (28%), Moslem (21%), and other or none (8%).

Interview Procedures

Ugandan researchers, nurses, and/or other health service staff invited individuals to participate in the study. The majority of interviews took place in primary care settings (40%), followed by other community settings (21 %), traditional healers’ clinics (20%), and mental clinicshospitals (19%). No incentives were given for participation. Researchers invited individuals to participate and obtained consent. Selection of the English or Lugandan version of the interview was based on the participant’s choice. Researchers read the case vignette of depression twice, followed by open-ended questions to elicit the participant’s EM. Interviews were audio- taped and transcribed.

Instrumentation

Depression vignette. A case vignette depicting a single episode of unipolar depression (see Appendix) was developed simi- larly to other studies with nonclinical samples (Patel, Musara, Butau, Maramba, & Fuyane, 1995; Ying, 1990). The vignette met the criteria of the International Classification of Mental and Be- havioral Disorders, 10th revision, for a major depressive episode. On the basis of cultural consultation with Ugandan psychiatrists and a medical sociologist, we selected specific idioms that are meaningful in Uganda (e.g., lack of energy, loss of appetite, and sleep problems) for inclusion, whereas others (e.g., crying) were omitted because of associated stigma. The resulting vignette included both etic and emic aspects. Similar versions of this vignette were developed concurrently and have been used in recent studies in Uganda (Okello, 2006).

A semistructured open-ended interview based on Kleinman’s (1980) questions was designed to elicit qualitative descriptions of EMS, including the name of the condition, perceived causes, effect on one’s life, seriousness, and the need for treatment. Additional questions targeted beliefs about social stigma, first-hand experience with depression, participants’ own past help seeking, or their ideas about what type of help they would seek if they had depression (see Appendix). Several studies have used similar questions as the basis for open-ended EM interviews (Gray, 1995; Gregg & Curry, 1994; Patel, 1995; Weiss & Kleinman, 1988; Ying, 1990). Sociodemographic information included age, gender, income, education, language, tribe, and home district.

The vignette and interview questions were translated into Luganda, back-translated, and cross-evaluated for conceptual equivalence and cultural appropriateness by a mul- tilingual, multicultural team of researchers and clinicians (Butcher,

Explanatory model interview.

Translation procedures.

Nezami, & Exner, 1998; Van de Vijver & Leung, 1997). A psychology graduate student and a medical sociologist performed the translation and back-translations. Three psychology graduate students, a medical anthropologist, a psychiatrist from the United Kingdom, and the first author, evaluated the vignette and interview for conceptual equivalence and cultural appropriateness. Areas of discrepancy were identified, suggestions for revisions were dis- cussed, and any changes made were based on consensus opinion.

Data Reduction and Analysis

Explication of coding system and procedures. Audiotapes were transcribed verbatim and content analyzed. Transcripts were reviewed in their entirety by Laura R. Johnson and Med Kajumba Mayanja. Research assistants identified meaningful chunks of data, such as phrases, sentences, or paragraphs that were grouped together under each EM component (cause, impact, type of help needed, etc.). The research team examined these to identify content themes and develop a coding scheme. Many coding categories were chosen a priori on the basis of previous studies of EMS in sub-Saharan Africa, but they were expanded, collapsed, and further elaborated to account for the data (Miles & Huberman, 1994; Ratner, 1997). For example, poverty was added under the EM component “cause” because of its frequency, suiciddsuicide attempt was added under “impact” because of its frequency and the failure of existing categories to account for this important effect of depression. After a final set of categories was defined, a coding sheet was constructed to aid the process. For example, under the “cause” category of illness/biomedical, a list followed that included malaria, AIDS, fever, pregnancy, and genetic problems Because of the open-ended nature of the questions, participants often gave several responses. Multiple responses were allowed (up to 4), but the most salienthmportant response was identified and coded for use in statistical analyses. Statistical analyses for nonparametric data (e.g., Fisher’s exact tests and chi-square analyses) were used to test hypotheses of group differences.

After training with the coding system, researchers began coding interviews. The first several interviews were coded independently by two researchers and reviewed together. Preliminary assessments of interrater reliability (using the kappa statistic to correct for chance agree- ments) indicated acceptable rates of agreement for name (0.87), cause (1 .OO), impact (1 .OO), location of helpltreatment ( 1 .OO), type of helpltreatment (1.00), and treatment benefit (0.86). To provide a measure of internal consistency (Miles & Huberman, 1994), we selected several interviews from each researcher to be recoded a few days later. Measures of intrarater reliability, on the basis of percentage agreement for the overall interview, were 100% for each coder. Over the course of the study, 51 interviews (20%) were randomly selected for double coding by more than one researcher. Interrater agreement for EM aspects, based on Cohen’s kappa, were as follows: name (0.88), cause (0.98), impact (0.95), seriousness (0.79), persohal view (0.88), community view (0.88), location of helpltreatment (0.86), type of help sought by acquaintance (0.95), type sought by self (1.00), and treatment benefit (0.81).

Reliability among raters.


Results and Discussion

In this section, we first present an overview of the conceptualization of depression collapsed across groups to provide a big picture of the explanatory model for this diverse group of Ugandans. Next, we report the results for Hypotheses 1-3, predicting group differences between lay community EMS and professional EMS (Hypothesis 1); group differences between the three types of professional EMS (Hy- pothesis 2); and greater agreement between lay views and those of traditional healers, compared with other types of professionals (Hy- pothesis 3). After the tests of our major hypotheses, we present details of each EM component, including its contextual relevance in Uganda, namefiabels, cause/etiology, impact and social meanings, help seeking, and treatment. Under each section, we provide percentages for each group and qualitative details about the nature of responses and direction of differences between groups. By combining the results and discussion under each EM component, we are able to ground our study findings within their cultural and geographic contexts. Last, we present results for Hypothesis 4, predicting EM differences based on sociodemographic variables, followed by a discussion of implications.

Overall Conceptualization

Overall, the picture of depression presented by this diverse group of Ugandans is multifaceted and variable in nature. Although similar to the Western psychological conceptualization, important sociocultural components emerged, including the role of poverty, illnesses such as AIDS, and important social aspects such as stigma and the reliance on social support. In Table 1, we present the EM collapsed across laypersons and professionals to give an overall view of how depression is conceived. Qualitative content is included in parentheses to elucidate the quality of responses.

Group Differences in EMS

Although laypeople and professionals agreed on some aspects of the EM, major areas of disagreement emerged, supporting Hypothesis 1. Tests for nonparametric data (Fisher’s exact test) revealed lay and professional differences in the following EM components: name (13.36, p < .05), cause (15.09, p < .01), impact of the condition (14.79, p < .05), source of help (18.90, p < .Ol), and type of treatment needed (20.41, p < .O1). We also compared the three groups of professional practitioners, including traditional healers, mental health professionals, and primary care staff. Supporting Hypothesis 2, Fisher’s exact test revealed differences for nameAabe1 (19.45, p < .0l), causation (22 .33 ,~ < .Ol), community viewktigma ( 1 0 . 5 1 , ~ < .05), where to get help (55.32, p < .001), and type of treatment needed (72.51, p < .001).

Next, we explored the amount of agreement between the lay community EM and the EMS of each type of professional (traditional, primary care and psychiatric/mental). The percent agreement between the lay community EM and different professional EMS failed to support Hypothesis 3, which predicted a closer association between lay and traditional healer EMS than between lay and other professional EMS. Contrary to our expectations, the greatest overlap between EMS as a whole was between lay community members and primary care practitioners, with a 78% percent agreement, compared with 70% for mental health practitioners and 68% agreement with

Table 1 Overall Explanatory Model of Depression Collapsed Across Groups ( N = 246)

EM domain and category

Labelhame of condition Psychological (sad, depressed, worried, unhappy, distress) Biomedical (HIV, AIDS, malaria, pregnancy, sickness) Other (don’t know, hardship) Poverty Social (loneliness) CulturaVreligious (bewitching)

Biomedical (AIDS, illness, fever, pregnancy, malaria,

Social (deatMoss, isolation, marital or familial problems) Financial (debt, poverty, job loss, unemployment) Psychological (worry, over thinking) Spiritual (spirits, bewitching) Other (don’t know, problem in environment)

Physical health (weight loss, high blood pressure, illness,

Psychological (depression, negative mood, worrying, thinking

Suicide (ideation or attempts) Social (marital problems, isolatiodwithdrawal, relational

Performance deficits (work, school, household duties) Other (stealing, drug abuse, prostitution, financial problems)

Health clinic or hospital Mental health services (ward, mental clinic) Social support (friends, family) Nongovernmental organization Traditional clinic or healer Elderskommunity leaders Religious sources (church, God)

Medical (medicine, tablets, antidepressants) Therapykounseling (professional guidance, advice) Social support (talk with family and friends) Financial (money, vocational help) Herbal remedies (smoke pipe) Spiritual or religious rituals

Cause of condition

heredity)

Impact

ulcers)

too much)

problems)

Sources of treatment

Type of treatment

% -

53 24 14 3 3 2

28 24 23 17 6 6

35

17 23

1 1 8 6

37 15 13 13 11 8 4

30 30 14 11 7 4

Note. EM = explanatory belief model.

traditional healers. Perhaps the most interesting finding here is not of total EM agreement but that community EMS overlapped differen- tially with professional EMS depending on the particular EM component being assessed (see Figure 1 ) . For example, laypersons agreed most with mental health professionals about the cause of depression, whereas they agreed most with traditional healers about the impact of depression. Details about the nature and direction of differences and illustrations given later depicting group differences are provided under each domain of the EM.

Contextual Relevance of Depression

Depression was recognized by 98% of participants as commonly occurring and by 95% of participants as a serious problem with numerous negative effects such as ill health, mood and mental problems, suicide or suicide attempts, and social ramifications. Nearly all participants (98%) reporting knowing at least one acquaintance with


100 i

Name’ Cause’ Impact Source of Treatment’ Overall

Explanatory Model Domain

Help’

Figure 1. of professionals. Significant differences found between EMS of all groups are indicated with an asterisk.

Amount of overlap between explanatory belief models (EMS) of the lay community and three types

the disorder, and nearly half of the participants (46%) endorsed a personal history of depressive symptoms. This is consistent with research indicating high rates of depression in Uganda (Bolton et al., 2003; Ovuga et al., 2001). These findings also lend support to the overall relevance and utility of the construct in Uganda.

Labeling and Conceptualization

Participants provided a diverse array of labels for the condition in the vignette. As illustrated in Table 1, psychological conceptualizations (e.g., sadness, worry) were the most common (53%) overall, followed by biomedical or illness-related conceptualizations (24%) such as HIV, illness, and pregnancy. External stressors (e.g., poverty, social conflict) were also common, whereas culturalkpiritual labels, such as bewitching, were infrequent. Despite recognizing the condition, a number of participants (14%) lacked knowledge about depression and were not able to provide a name, responding with “don’t know.” Some tried but could not find the right word for this emotional state, simply responding “many problems” or “hardships.” This is concurrent with prevalent views suggesting a significant lack of awareness of common mental health problems among most Ugandans (Wendo, 2001).

In Table 2, we provide a more detailed elaboration of the specific names used to describe depression and present percentages in each grouping to contrast the quality of lay and professional views. Educated community members and modem practitioners predominantly labeled the problem as psychological in nature, using terms such as depression, sadness, worry, and too many thoughts. Although use of the term depression was some- what unexpected, this may illustrate the growing influence of Western educational and sociocultural perspectives. Lugandan words such as bunakuwavu (sadness), myike (excessive sadness or sorrow), and kiwubalo (loneliness) were used to describe the condition, congruent with recent literature suggesting that sadness

is a salient feature in present-day African depression, although not always spontaneously reported (Ovuga, 1986).

Many participants also used terms related to anxiety, such as worry, overthinking, and Lugandan terms such as birowoozo (thoughts) and kwelalikilira (worrying). In fact, worry was a common theme throughout the entire EM of laypersons and professionals. It was provided as a name, a cause, and an effect of depression, whereas reduced worries and relared thinking were cited as treatment benefits. This is similar to a recent qualitative study linking unipolar depression to an “illness of thoughts” by the Baganda (Okello & Ekblad, 2006). Although unlike in that study, we also found ample evidence of mood-related aspects to the conceptualization of depression. In fact, our participants as a whole were more likely to use terms commonly associated with depression than those related to worry, although they were both prominent features in the EM. This is consistent with previous observations of clinical presentation in Sub-Saharan Africa and in Western primary care settings, suggesting the utility of a mixed anxiety-depressive category. It also highlights the point that symptoms of depression and anxiety may be fused among the lay community or persons from different sociocultural groups (Good & Good, 1986).

Reflective of the Ugandan context was the frequency with which depression was labeled as AIDS. Uganda was among the first hard-hit countries, and by the end of 1992, the national prevalence rate was estimated at 18.3%, with some centers regis- tering rates above 30% (Uganda AIDS Commission, 2006). In some parts of the country, one in four adults suffer from AIDS, with high comorbidity of depression (e.g., 47% among those with AIDS; Kaharuza et al., 2006). Although Uganda was heralded as successful in reducing rates dramatically through public education and prevention, early gains were overstated by> a government benefitting from an influx of international aid dollars for HIV programming. Moreover, it is argued that reduction trends have reversed concurrently with a U.S. funding policy (i.e., President’s

CONCEPTS OF DEPRESSION IN UGANDA 28 1

Table 2 Words Used to Describe Depression by Laypersons and Professionals and Percentages Within Different Categories

% Laypersons % Professionals Cateeorv of name (n = 135) ( n = 111)

14 14

15 17

Depressive type 18 35 Depression, depressed, general depression, bipolar depression, depressed mind, affective disorder

in depressive phase Unhappy, unhappiness, not happy, sadness, kuwavu (sad), myike (excessive sadness), despairing,

hopeless, can’t enjoy life, disappointment with life Lazy, lack of energy, lack of self esteem, broken heart Anxiety Worry, kwelalikilira (worrying) over worrying, worrying condition, womed about . . . wars, AIDS,

Thoughts, bad thoughts, birowozo (thoughts), thinking too much General psychological Stress, tension, pressure, distress, frustration Suffering, suffering mentally and emotionally, not a good condition, feeling uneasy Mentally sick, mental illness, mentally disturbed, mental disorganization, problem with mind,

psychological problem, psychiatric condition, problem with head, schizophrenia, neurosis, mental retardation, mania, restlessness, hysteria, wants to run mad, not understanding oneself, insomnia depersonalization

illness, dying, money

Biomedical 30 19 AIDS, HIV, sick with AIDS, sexually transmitted disease Illness, sickness, pregnancy, malaria, fever, sleeping sickness, poor feeding, dehydration, anemia Problems with sexual power Epilepsy, body defect, cerebral palsy Don’t know 11 12 Don’t know, can’t find a name, hard to name, cannot name it, uncertain, must see to diagnose Siruaiional 7 4 Poverty, poor, has nothing Many hardships, intolerable hardships, many problems, when your life is not better, bad conditions Sociocultural 3 6 Loneliness, kiwubalo (loneliness), problem with relationship, friends, left by lover Ancestral spirits, bewitching, spiritual thing, spirits on his head, possessed

Note. Names within each section are loosely grouped and presented in order of frequency.

Emergency Plan for AIDS Relief) that has been tied to abstinence- only education.

The frequency of terms such as sickness, disease, and malaria are reflective of the high burden of communicable diseases in Uganda, as well as a cultural tendency to express psychological symptoms somatically (Boardman & Ovuga, 1997). Among the biomedical names given for depression, pregnancy was specifi- cally mentioned several times, possibly suggesting a link between depression and pregnancy in Uganda. In fact, a previous study of psychiatric morbidity in pregnant Buganda women found that 10.7% of pregnant women met “certain diagnosis” of a depressive disorder (Cox, 1979). However, this finding may also represent an artifact of sampling at antenatal clinics. Those that used biomedical labels did not necessarily view depression as having biological underpinnings but seemed to find difficulty differentiating between the physical and mental phenomena. They had a sense of emotional distress but referred to the condition as AIDS, sickness, illness, pregnancy, or malaria.

In Figure 2, we illustrate conceptualizations provided by lay participants and each type of professional. Overall, modem mental health practitioners were most likely to have a psychological conceptualization, whereas a biomedical conceptualization was common to lay community members and primary care practitioners. Traditional healers and some community members displayed a financial, social, or spiritual conceptualization and did not seem

to make a clear distinction between cause and effect. Labels related to external stressors such as poverty, relational problems, and “many problems” were used to refer to depression.

Etiology

Overall, biomedical conditions (e.g., AIDS, disease, pregnancy, and malaria) accounted for 28% of causes, social problems (e.g., loddeath, marital problems, loneliness, and family conflicts) accounted for 24%, and financial (e.g., poverty, debts, and lack/loss of job) accounted for 23% (see Figure 3). Psychological causes for the condition (e.g., worry and overthinking), other causes (e.g., don’t know, poor environmental conditions) and spiritual causes (e.g., bewitching) each accounted for 6% of responses. The onset of depression was attributed to external stressors such as health problems, family conflicts, and poverty. Most mental health practitioners cited biomedical and social causes, as did primary care practitioners. It is interesting that depression was labeled broken heart a few times and associated with stress, and high blood pressure, suggesting a link between depression and stress-related diseases such as cardiac problems or hypertension. Traditional healers cited a combination of financial, cultural, and social causes.

Although lay community members emphasized health problems, such as AIDS, few cited cultural or religious causes. This


HLay Community .Mental Health

BTraditional

. ”” 90

80

70

60

50

40

30

20

10

0 Psych Biomedical Other Poverty Social Cultural or

Relgious

Category of NameILabel

Figure 2. practitioners providing different categories of namesflabels for depression.

Percentage of lay community, mental health practitioners, traditional healers, and primary care

was surprising, given previous studies (e.g., Baingana, 1990; Okello, 2006) and the notion that searching for an “ultimate cause” of mental symptoms (i.e., “why me?’ and “why now?’) is considered important among Africans generally (Seape, 1997). Al- though many gave illnesses or external stressors, it is possible that these answers reflect direct, more immediate causes rather than beliefs about an ultimate cause, which could be spiritual or cultural in nature. For example, poverty or AIDS may have caused the depression, but whom or what caused poverty or AIDS to occur? Additional probing may have revealed more responses of a spiritual nature (Patel, 1995).

In giving causes for the condition, most mental health practitioners cited biomedical (38%) and social causes (28%), as did primary care staff (with 46% biomedical and 30% social causes). Traditional healers were more likely to cite financial (30%), traditionaVcultural (20%), and social causes (20%). It is notable that several traditional healers refused to give a cause, saying that it was impossible to determine without seeing the patient. They noted that symptom presentation alone was inadequate for assessing etiology. To determine the cause, these healers would use traditional diagnostic techniques such as observation, patient and family report, divining with cowrie shells, and direct spirit inquiry through entering a trance and commu-

.Mental Health MTraditional

100

90

70 8o 1 30

20

10

0 Biomedical Social Financial Psych Sptntual Other

Category of Causation

Figure 3. practitioners providing different types of causes for depression.

Percentage of lay community, mental health practitioners. traditional healers. and primary care


nicating with spirits. Often, the prescription for treatment was revealed in the same manner. Direct spirit inquiry typically involved the healer bathing, wearing bark cloth, inhaling or smoking herbs, and entering the shrine of a particular spirit. After this, the healer would go into a trance, which allowed himself to be used as a medium for spiritual communications that would reveal the ultimate cause. In describing this, one healer stated in a puzzled fashion, “When I am in a trance, I am unaware of what is happening . . . someone else is taking notes about what is happening [i.e., what is being revealed as the diagnosis] and so, I wonder what you Western doctors do in such a case.” This highlights the fact that differences in conceptualizations occur at multiple levels and may be so profound that questions designed from a Western perspective are either irrelevant to the Ugandan context or at least inadequate for fully exploring the phenomena.

Impact and Social Meanings

We asked participants how the condition might affect a person’s life. About one third of the responses referred to ill health. The largest percentage (29.7%) cited ill health or problems of a physical nature. Common responses included weight loss/loss of appetite, illness/disease/fall sick, lose energy/become weak, high blood pressure, ulcers, and bad appearance. Problems of a psychological nature (i.e., related to mood and mental status) accounted for the next highest percentage of responses ( 1 8.5%). Most negative effects were symptoms commonly associated with depression (e.g., not happyhad, will feel worthless, will become irritable, will lose interest in things), anxiety (e.g., worrying, thinking too much), or going madlrunning mad. Suicide or suicide attempts and social problems such as maritalkelational problems, social isolation, and withdrawal accounted for 14.1% of responses each. Additional negative effects included performance deficits in work, studies, or household duties (12.3%) and other negative effects such as financial problems, stealing, and drug abuse (1 1 %).

The case of depression was primarily viewed as a problem related to external stressors and was thus distinguished from “true mental illness,” which may be viewed as resulting from spiritual possession and, thus, greater stigma. Nonetheless, the majority of respondents (65%) stated that a depressed person would feel

embarrassed or ashamed and face a negative response in the community, especially if he or she failed to meet responsibilities. When asked how the community would view KizitoNamaganda, the largest percentage (37%) said that he or she would be viewed negatively (see Figure 4). Examples of what people in the community might do, think, or say included: laugh at himher; not associate with himher; think ill of himher; say that he or she is bewitchedlpossessed; and talk or gossip, saying he or she is a coward, an enemy, or a lazy person. However, a similar percentage (36%) said the community would respond positively with sympa- thy, advice, and offers of help and support. Despite this, or maybe because of it, many Ugandans said they would rely on community and social supports if they needed help for depression. These results demonstrate the social embeddedness of depression and point to the importance of mobilizing family, community, and traditional supports.

The remaining participants (26.8%) believed that community views would be mixed, or they gave responses that were not necessarily linked to negative or positive attitudes. A frequent response in this category was that KizitoDlamaganda was suffering from AIDS or some other illness. Although it is true that AIDS and other illnesses may be associated with negative attitudes, this is not necessarily the case and, thus, these answers were coded as otherhixed views.

Help Seeking fo r Depression

Nearly all participants (95%) said that the condition was serious and that treatment was needed (98%), mentioning a range of help sources. Mental clinics or outpatienthpatient psychiatric facilities accounted for 15% of responses, as did traditional and religious sources such as traditional clinics, church, and God (15%). Other sources of help were family or friends (13%), NGOs (13%), and village elderskommunity leaders (8%). Despite agreement about the relevance and need for help, laypersons and different professionals disagreed on where help should be sought, as illustrated in Figure 5. Community members and professional practitioners (ex- cept healers) were likely to identify health clinics or hospitals as appropriate sources of treatment. This finding reflects the overall development, availability, and awareness of health, as opposed to

100 1 -- I I

- m e t

Negative Self-stigma Negative Community Mixed Community View Stigma

Type of Social Impact

Figure 4. Percentage of total sample indicating negative self and social stigma for depression.


=Mental Health

c 0 E n

I00

60

50

40

30

20

10

0

Health Clinic Mental Health Social NGO, other Traditional Elders/ support Clinic Leaders

Sources of Help

Figure 5. practitioners suggesting different sources of help for depression.


mental health clinics in Uganda. It may also reflect a cultural tendency toward a somatic conceptualization. This biomedical conceptualization of depression may explain why over 30% of patients seeking medical treatment at primary health care centers in Uganda were found to have depression (Muhwezi et al., 2007).

Traditional clinics and other sources, such as NGOs, were cited as appropriate sources of help by traditional healers who were less likely to suggest mental health clinics (O%), as contrasted by 28% of mental health practitioners and 14% of primary care staff. Lay community members and traditional healers tended to suggest help from informal sources. Among Ugandans, mental clinics and hospitals are believed to be appropriate only for madness or violent, uncontrollable behavior, (eddalu; Baingana, 1990). What actually brings depressed Ugandans to treatment likely depends on both the severity of the illness and, as Kleinman suggested, the specific meanings assigned to each particular episode of illness (Kleinman, 1977). In Uganda, formal help seeking from professional sources is most likely when symptoms cause significant disruption or embarrassment; for example, running naked or criminal behavior (which would be more likely with psychotic or bipolar depression). Professional help for unipolar depression may only be sought after a suicide attempt or after the burden related to lost productivity begins to severely affect family functioning.

For the 46% of participants who reported experiencing depressive symptoms in their own lives, we asked them what type of help or treatment, if any, they had sought in the past. Informal social support was most common (27%), followed by spiritual help (e.g., rituals and prayer) and financial help (e.g., money), which each accounted for 1 1 %. Last, traditional herbal medicine and psychotherapy accounted for 8% each. Thus, with the many alternative forms of intervention available, the patients who receive professional mental health services of any kind are few, compared with the number of depressed individuals in the community.

For those reporting no history of depression, we asked them what type of help or treatment they would seek if they were to develop depression. Thirty-eight percent indicated that they would seek modem medical treatment (e.g., medicine, “tablets”), followed by social help (20%), counseling (20%), spiritual help or herbal medicine (9%) and financial assistance (6%). Despite the fact that traditional healers are readily accessible, and based on observation, usually full of depressed patients, a smaller percentage of participants recommended seeking help from traditional clinics than expected. This could reflect true preferences related to Westernization or effects related to social desirability or expect- ancy bias. With the spread of Christianity, many Ugandans have been pressured to reject traditional customs and approaches to healing, with many churches maligning traditional approaches.

Type of Treatment

Types of treatment for depression varied, and this question garnered the most responses, with participants suggesting multiple treatments. Modem medicines, financial help, social support, counseling, herbal medicine, and religious/spiritual help were all suggested. The majority of participants (60%) recommended treatment at a medical hospital or health clinic. This finding is in contrast to that of Okello (2006), who reported that Bugandan participants in a focus group did not view modem medications as necessary to treat either unipolar or psychotic depression.

It is interesting that all groups endorsed counseling or therapy as an appropriate treatment with primary care staff (52%) more often than mental health clinicians (31%) and healers (23%). Despite this, treatment recommendations accounted for the greatest areas of EM incongruence between all groups, as seen in Figure 6. Although lay community members, primary care, and mental health practitioners believed that modem medications were best


.Mental Health

70 1 1

Traditional Medicine Counseling Social Financial

Types of Treatment

Figure 6. practitioners recommending different types of treatment for depression.


for treating depression, traditional healers cited the importance of herbal remedies (37% vs. 0% for other practitioners), financial aid (20% vs. 0% for other practitioners), and assistance from organizations. Community members were less likely to recommend getting help from a traditional healer, although they were more likely to agree with healers in recommending help from other sources, such as financial and social organizations. After medical treatment, counseling was the next treatment that participants said they would seek out if they developed depression themselves. However, among those who reported past help seeking for depression, only a small percentage had received formal counseling or psychotherapy.

It is interesting that 23% of healers recommended counseling or therapy. In a related study among traditional healers in Uganda, talking to the patient individually or to patients as a group was mentioned as the treatment of depression (Okello, 2006) In fact, traditional healers interviewed here most often used an eclectic approach that relied heavily on counseling techniques. One healer said that counseling, comforting, and prayer were the best treatments for depressed patients. He reported working with a patient’s thoughts, giving herbs as placebos to address her thought of being bewitched. Many traditional healers recommended methods similar to Western behavioral techniques for depression, such as ac- tivity scheduling, problem solving, or conflict resolution. Al- though the practice or content may be different (e.g., ritualized bathing, communicating with ancestors, service work, and cultural rituals such as smoking pipes or animal sacrifice), the activities are designed to activate clients and to provide them with purpose and direction. Other similarities between Western psychotherapy and traditional African healing (e.g., a common desire to help others, training or special helping skills, and status in the community) may be key to increased collaboration between traditional and modem practitioners (Clark, 1982; Johnson et al., 2009).

Treatment Expectations

Overall, participants expected treatment to yield positive psychological benefits such as improved mood, regaining happiness

and hope, and decreased womes (35%), general results such as “feel better” (32%), and relief of physical symptoms, such as improved appetite and sleep (17%). Improved work performance and social benefits, such as not feeling isolated, accounted for 9% each. Most psychological benefits stated were cognitive in nature, such as reduced worries, not overthinking, thinking positively, cessation of suicidal ideation, improved concentration, and a set- tledpeaceful mind.

The emphasis on negative cognitions (as a cause and a target for treatment) combined with openness toward counseling/psychotherapy suggests that cognitive-behavioral treatment strategies may be useful for treating depression in Uganda. Group approaches or those that integrate social support and interaction into treatment also hold promise. Recent randomized clinical trials demonstrated efficacy of interpersonal psychotherapy for a group of Ugandans experiencing depression and social dysfunction (Bolton et al., 2003). Resources on the use of cognitive-behavioral treatment, interpersonal psychotherapy, forms of brief therapy, and cross-cultural and family models are needed.

Differences Based on Social Characteristics

In addition to looking at EM differences based on lay and professional status, we examined EM differences based on several sociodemographic variables, including education, income, gender, and language of the interview. Significant differences in conceptualizations were found that were primarily based on education and language rather than on gender or income. Differences based on educational status were found for the name of the condition, ~ ’ ( 4 , N = 244) = 34.36, p < .01; impact of the condition, ~ ’ ( 6 , N = 244) = 14.49, p < .05; where to seek help, ~ ’ ( 6 , N = 233) = 19.12, p < .OO; and type of help that should be sought, ~ ’ ( 6 , N = 240) = 48.01, p < .OO.

When naming the condition, participants who had attended university or college were less likely to cite biological names and nearly twice as likely to provide psychological names; that is, 73% versus 31.9% for those at or below primary seven

Education.

286 JOHNSON, MAYANJA, BANGIRANA. AND KIZITO

(P7), and 43.3% for those between standard one and six (Sl-S6). Those with little education (P7 or below) were more likely to say that they did not know the name of the problem and to provide names of a traditional, financial, or social nature. Regarding the impact of the condition, those with a universitykollege education cited more social/relational effects and fewer physical effects than those with less education. In terms of where to go for help, those with a universitykollege education were more likely to recommend getting help from a mental health clinichospital (21.4% vs. 4.8% for below P7 and 7.5% for Sl-S6). In fact, mental health clinics were the second most common source of help cited by the highest educated individuals (after health/medical clinics), whereas for those with less education, it was the least frequently cited. In responding to the type of help or treatment needed for the condition, responses of the most educated group again seem to stand apart from the others’ responses. Universitykollege- educated participants were more likely to suggest formal therapy or counseling (50% vs. 18.2% for below P7 and 20.8% for Sl-S6). They were also less likely to suggest traditional herballspiritual remedies (4% vs. 18.2% for below P7 and 15.6% for Sl-S6) and otherhnformal sources of help, such as financial assistance and social support (5% vs. 29.5% for below P7 and 34.4% for S 1-S6).

On the basis of income status, a significant difference was found for where help should be sought, ~ ’ ( 9 , N = 213) = 19.41, p < .05. No other differences were found. Participants in the midrange category appeared more likely to suggest seeking help from a health clinic. They also appeared less likely to suggest informal sources, such as family, community, or NGOs. It is interesting that those with the highest incomes were the least likely to suggest formal health and mental health services and the most likely to suggest help from informal sources and from traditional healers. This may be due to the fact that traditional healers were among those in the highest income brackets and were also the most likely to recommend traditional clinics.

In previous studies, Uganda has stood out, compared with the United States and European countries, in its high rates of depression, as well as in a lack of, or mixed findings for, gender effects in depression (Bolton, Wilks, & Ndogni, 2004; Culbertson, 1997; Orley, Blitt, & Wing, 1979). Our results are consistent with those findings. A strikingly large percentage of both men and women (35.7% and 47.4%, respectively) reported that they had experienced a problem like the one in the vignette. Few differences were found on the basis of gender, with men and women agreeing in nearly all aspects of the EM, including its relevance, seriousness, cause, impact, stigma, need for treatment, and type of treatment. Gender differences were found for the names used to label depression, with more women providing biomedical or health- related names (28.9% for women vs. 17% for men) and men providing more names of a psychological nature (68.8% for men vs. 46.7% for women), ~ ’ ( 2 , N = 246) = 7.28, p < .02. The second and only other significant difference based on gender was found for the type of help they would seek if experiencing depression, ~ ‘ ( 4 , N = 113) = 11.42, p < .05, with women more likely to suggest modem medicine (51.3% vs. 26.4%) and less likely to rely on social support (16.3%), compared with men (32.1%).

Differences based on the language of the interview were found across the EM, including name, ~’ (4 , N = 236) = 18.3 1, p < .00; cause, ~’ (3 , N = 236) = 8.65, p < .03; where to get help, ~’ (4 , N = 232) = 42.03, p < .oO; and the type of help suggested,

Income.

Gender.

Language.

~ ’ ( 3 , N = 232) = 45.56, p < ,001. Those completing the interview in English were more likely to provide a psychological label (64.1%) than those completing it in Lugandan (43.6%). Lugandan speakers were more likely than English speakers to label depression as an external situation, such as a social, relational, or general problem (14.3% vs. 2.9%, respectively) and also more likely to say “I don’t know” (13.5% vs. 7.8%, respectively). Lugandan-speaking interviewees were also more likely to indicate external causes, such as poverty, than English-speaking participants. As a rough approximation of acculturation toward a more Westernized perspective, formal therapy or counseling and modem medicine were more often suggested by English-speaking interviewees, whereas traditional healing, financial help or other sorts of help were much more likely to be suggested among Lugandan-speaking interviewees (35.7% vs. 4.9%). No differences were found based on where one would seek treatment, with roughly equal percentages indicating a combination of modem medicine, social support, counseling, and other help, such as financial support.

Implications

This study revealed similarities and differences in concepts of depression, with important implications for service delivery and treatment. Although depression was largely construed in a similar fashion to the Westem-based psychological view of depression, important cultural and contextual features emerged that were reflective of the Ugandan context. Some of these were the role of poverty, the strong association with HIV/AIDS, reliance on social supports, stigmatiza- tion, and the use of traditional and herbal medicines in treatment. We also identified important differences between lay views and those held by all three types of professionals.

Because many Ugandans rely on informal help, social and community support systems must be strengthened through community awareness and reducing the social stigma associated with depression. On a broader scale, it is important to look at contextual factors such as poverty. rates of illness, and social upheaval that contribute to the onset of depression and play a role in weakening social and community supports available for people with depression. This suggests a role for Ugandan government agencies and NGOs.

Because primary care clinics may be the point of first contact for Ugandans seeking help for depression, primary care staff should be prepared to meet these needs (Allwood & Gagiano, 1997). In this study, many primary care staff were unable to identify depression. As such, they should be educated and trained in simple screening, treatment, and referral. In addition, the Ugandan government has recognized the role of traditional healers in meeting the mental health needs of Ugandans. The establishment of traditional healer’s associations and freedom for healers to conduct their practice is evidence of this commitment. In addition to serving many depressed patients, healers are currently able to provide a wider range of services than professionals in the formal mental health sector. In doing so, they address a patient’s physical, mental, financial, social, and spiritual needs. One psychiatrist, describing the importance of healers, stated, “it is the healing component of their work, with its associations to the meanings of sickness, that is important.”

It has also been noted that the high levels of confidence among healers and the respect they are given may lead to better outcomes. However, there is a need to examine the effectiveness of traditional


approaches (Ovuga et al., 1999; Wendo, 2001). Improving mental health services in Uganda will depend on improved collaboration and better integration of services (Ovuga et al., 2001). Models of collaboration should be piloted to determine workable methods. Given the unique positioning of traditional healers to address depression, we suggest that mental health practitioners reach out to traditional healers. However, information often flows in one direction, emphasizing the Western approach. Effective collabora- tions will require respect for African culture and the shedding of negative stereotypes about African traditional healers. Indeed, we have much to learn from our traditional counterparts.

This study highlighted the fact that professional practitioners and prospective patients varied significantly in their EMS of depression. Keeping the incongruence between patient EMS and therapeutic interventions to a minimum may be essential for improving existing services Given the diversity of EMS and potential disagreements that can occur, professionals in Uganda and elsewhere should be educated about the range of cultural conceptions. Treatment outcomes may be enhanced if patient and family EMS are explored and a mutually agreeable approach to treatment is developed (Aponte & Johnson, 2000; Wohl & Aponte, 2000). Laypersons in Uganda desired a multipronged approach to treatment; thus, practitioners should offer a range of therapeutic services, including modem antidepressants and brief forms of therapy such as cognitive, behavioral, solution-focused, and group approaches that address interpersonal and social aspects of depression (Verdelli et al. 2003). Strengthened natural supports, such as family support, and traditional or religious beliefs are recommended (Johnson & Sandhu, in press).

Although specific to Uganda, several themes emerged here that are relevant more broadly in Africa. Contextual factors such as poverty and biomedical conceptualizations related to high rates of communicable disease are applicable across the continent. Moreover, with increasing cultural diversification occurring at a global level, many parallels can be drawn between concepts of depression held in Uganda and those held in other parts of the world (Aponte &Johnson, 2000, Wohl & Aponte, 2000). Ethnic and cultural minorities in the United States and Europe, for example, may also emphasize somatic and social aspects of depression, recognize the role of contextual factors, and tend to seek informal help from family, spiritual, or religious sources in addition to primary care (Brown, Abe-Kim & Banio, 2003; Karasz, 2005).

Although traditional healing is commonplace in Uganda, traditional, spiritual, and indigenous approaches are drawing new attention from mental health professionals as they strive to fmd culturally relevant ways of meeting the mental health needs of their diverse societies, which include refugees, immigrants, and ethnic minority populations (Koss-Chioino, 2000). Improved coordination with primary health service providers and mobilization of community supports is another similarity considered key to effective treatment of depression among ethnic and cultural minorities living in the United States and elsewhere (e.g., Brown et al., 2003). Additionally, there is a need for a contextual-ecological approach that addresses social and environmental problems (e.g., poverty, poor health, community vio- lence, and racism) while drawing on cultural strengths and resources (Aponte & Bracco, 2000; Johnson et al., 2009).

In this study, the Western psychologically based concept of depression was viewed as common and relevant to Ugandans. However, it is unknown to what extent an alternative, emic-based description may

have been more salient. Responses to open-ended questions may have been biased due to social desirability or expectancies, with participants less inclined to report spiritual or cultural models. The data collection sites, all around Kampala, and a self-selection bias may have further restricted the range of responses, with those participating being more acculturated to Western beliefs. Future studies should be conducted across diverse cultural groups and disorders so that we may continue to gain a broader and more representative view of the concepts of mental illness held around the world.

Summary and Conclusion

Our results reaffirm the importance of considering contextual factors and multiple viewpoints when developing effective treatments for depression. Our results also confirm the notion that concepts of depression held among patients and their healers are likely to differ. Despite some shared beliefs about depression, H1 was supported, as lay people and professionals had significant disagreements in their conceptualizations, especially when it came to where to get help and what type of help was needed. Differences were also found between beliefs held by the three types of professional practitioners, showing support for H2. The study failed to support H3, which predicted a closer association between lay and traditional beliefs about depression than between lay views and other professionals. Showing partial support for H4, we found significant sociodemographic differences based on education, age, and language, but less so for income and gender.

If we are to treat depression effectively in today’s service delivery context, we must recognize the diversity of explanatory beliefs and behaviors related to depression (Draguns, 2000). Over- all, the model of depression in Uganda shares much in common with Western psychological conceptualizations of depression. Al- though the results do not reveal an entirely new perspective, they reaffirm the importance of cultural and contextual factors and highlight differences in lay and professional views. Our results suggest that effective service provision for depression in Uganda and elsewhere, demands an integrated approach that recognizes the diversity of explanatory models and involves collaboration among multiple systems of healing.

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Appendix

Explanatory Model Interview for Vignette (Form A)

First I am going to read to you a short story about “Namaganda.” After that, I will ask you a few questions about the story.

Namaganda is a 25-year-old woman. For the past 8 weeks, she has been feeling very unhappy and sad. She has lost interest in previously enjoyed activities. Namaganda has difficulty concen- trating. She has trouble falling asleep, has lost her appetite, and complains of having a lack of energy. She says life is not worth living. (Read the story twice and repeat if needed.)

Now, I am going ask you a few questions about Namaganda’s condition. There are no right or wrong answers. We just want to know your own thoughts and opinions.

1. What do you think the name of this condition is; what do people call it?

What do you think could be the cause of the condition? (Identify the most important cause.)

How could the condition affect Namaganda’s life? What are the main problems it causes for her? (Probe for effects on daily life. If more than one, identify which effect is most important.)

Does Namaganda’s condition cause much concern or worry? Is it serious?

Do you think Namaganda feels embarrassed or ashamed about her condition?

2.

3.

4.

5.

6.

7.

8.

9.

10.

1 1 .

12.

13.

14.

How do people in the community view the condition? What do they think or say about her?

Does Narnaganda need any kind of help or treatment for her condition?

If so, where do you think Namaganda should go for this helpkreatment?

What kind of help or treatment do you think Namaganda needs?

What benefit or change should Namaganda expect from the helpkreatment?

Is this condition common? Does it occur frequently?

Have you ever known anyone who has this condition? If so, what did he or she do about it?

Have you ever had a condition like Namaganda’s? If so, what did you do about it?

If not, supposing you had this kind of condition, what type of help would you get? Why?

Received June 5, 2008 Revision received March 2, 2009

Accepted March 1 1 , 2009

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