transcultural psychiatry - CiteSeerX

Lay Concepts of Depression among the Baganda ofUganda: A Pilot Study

ELIALILIA S. OKELLO

Makerere University

SOLVIG EKBLAD

Karolinska Institutet

Abstract The literature indicates that although depression is highlyprevalent, it is rarely recognized as such. The aim was to test the use of casevignettes in exploring the explanatory models of various subtypes ofdepression, in six individual interviews, and four focus-group discussions.Depressive symptoms presented in these vignettes seem to be conceptual-ized as a problem related to cognition (thinking too much) rather thanemotion (sadness) and the resulting condition is referred to as ‘illness ofthoughts.’ Worrisome thoughts resulting from various socioeconomicproblems are seen as important aetiological factors for the illness of thoughtsand require no medication as it is believed that there is no medication forthoughts. There are culturally accepted ways of dealing with and healing thecondition. Once illness becomes recurrent or chronic, other explanationsabout causes and a different course of action have to be considered. Furtherexploration of the relationship between thoughts and emotions among theBaganda may be an important avenue for further research.

Key words case vignette • explanatory models • illness of thoughts •depression • Uganda

Vol 43(2): 287–313 DOI: 10.1177/1363461506064871 www.sagepublications.comCopyright © 2006 McGill University

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During the l950s depression was reported to be rare in nonwesternsocieties (Carothers, 1953; Lambo, 1956; Savage & Prince, 1963). However,these studies have been criticized for limited samples, poor controls andsuperficial evaluation of patients (Beiser, 1985; Kim, 1977, 1992; Sartoriuset al., 1983). Studies since the 1970s have shown that depression iscommon in other parts of the world (German, 1987; Hollifield, Katon,Spain, & Pule, 1990; Orley & Wing, 1979). Kleinman, Marsella and othershave commented on the rise in depression across both rich and poorerregions citing reasons such as increased economic difficulties, urbaniza-tion and breakdown of traditional family structure (Kleinman, 1991;Marsella, Sartorius, Jablensky, & Fenton, 1985).

In Uganda, the prevalence of major depression in the general popu-lation has been estimated at 10–25% (German, 1987; Orley & Wing, 1979).Uganda’s violent political history and other recent changes, including theemergence of HIV/AIDS and reemergence of diseases like tuberculosishave contributed to an increased prevalence of mental health problems,including depression (Musisi, Kinyanda, Liebling, & Mayengo-Kiziri,2000). Civil wars, HIV/AIDS and other chronic illnesses have been associ-ated with higher rates of psychological disorders, including depression(Nakasujja, 2002).

Depression is said to contribute significantly to the problems broughtto primary health care centres in Uganda (Muhwezi, 2004). Availableliterature and clinical observations in Uganda suggest that althoughdepression is one of the most common psychiatric disorders presented togeneral practitioners, it is rarely recognized as such (Musisi et al., 2000;Nakasujja, 2002). Depressive disorders not only differ in symptoms bysubtype and dimension (American Psychiatric Association [APA], 2000),but also have significant cultural variation in clinical presentation(Kirmayer, 2001; Kleinman, 1988). These variations may reflect differencesin cultural modes of expressing depressed mood, culturally learned illnessbehaviour, value systems, linguistic symbols and characteristics of healthservices (Kim, 1992; Kirmayer, 2001; Kleinman, 1988). An understandingof lay explanations of the causes, effects, and appropriate sources of helpfor illness has been recognized as important in improving the communi-cation between care providers and patients (Cohen, Tripp-Reimer, Smith,Sorofman, & Lively, 1994; Gray, 1995; Gregg & Curry, 1994; Kleinman,1980). Relatively little has been documented regarding lay persons’explanatory models for mental health and illness in Uganda (Orley, 1970;Patel, 1995a). In particular, there is a lack of specific information regard-ing depression that could inform the development of culturally appropri-ate intervention programs for people affected by depression.

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Objectives

This pilot study was conducted in order to pre-test the instruments andtechniques for a larger study of the lay explanations of causes, effects andhelp-seeking behaviour for depression among the Ganda, the largestcultural group in central Uganda.

Studies of explanatory models often have confined themselves toexploring explanatory models of mental illness among patients and theirpractitioners in a clinical setting without considering the community fromwhich these patients come (e.g. Patel, Gwanzura, Simunyu, Lloyd, &Mann, 1995; Weiss et al., 1986; Ying, 1990). Yet, it is well documented thathelp-seeking behaviour is partly determined by one’s social network(Cockerham, 1989; Janzen, 1978). The social network acts to suggest,advise or even coerce an individual into taking or not taking a particularcourse of action regarding health care. It also has been estimated that 70%– 90% of self-recognized episodes of sickness are managed exclusivelyoutside the perimeters of the formal health care system (Hollifield et al.,1990; Kleinman, Eisenberg, & Good, 1978).

Accordingly, the current study drew its sample from the members of thegeneral population; including middle-aged women, middle-aged men,youths, faith healers and traditional healers using herbal remedies. Thespecific objectives of this pilot study were to assess the feasibility of usingcase vignettes to explore local explanatory models for various subtypes ofdepressive illness, including etiological factors, perceived effects ofdepressive symptoms, and appropriate forms of help. The study adopteda cross-sectional exploratory design, using qualitative methods of datacollection including key informant interviews, focus group discussions,and indepth interviews centred on the case vignettes designed to exploreexplanatory models of depression.

Method

Background and Setting

The pilot study was conducted in Bajjo, a small village in Mukono, one ofthe Buganda administrative districts, about 23 kilometres from the capitalof Kampala and about 3 kilometres from the Kampala-Jinja highway. Bajjowas selected because it is semirural and hence provides an appropriatesetting to pre-test an instrument that is to be used for both urban and ruralpopulation groups. Economic activities in Bajjo include small-scale agri-culture mainly worked by women, and brick making carried out by men.Some members of the village are teachers in the nearby primary andsecondary schools.

Okello & Ekblad: Concepts of Depression among the Baganda

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The people of Buganda are referred to as Baganda (the singular form isMuganda), their language is called Luganda, a Bantu dialect that usesprefixes, infixes and suffixes in classifying both living and nonliving things.Human beings are classified under the ‘Mu-ba’ class hence the people arecalled ‘Muganda and Baganda’ for singular and plural forms respectively(Muliira, 1967). They refer to their customs as Kiganda customs. Some-times the generic term Ganda is used for all of the above.

The clan system is central to Buganda culture. No Muganda isadequately described except in terms of his patrilineal descent. A clanrepresents a group of people who can trace their lineage to a commonancestor in some distant past. The clan essentially forms a large extendedfamily and all members of a given clan regard each other as brothers andsisters regardless of how far removed they are from one another in termsof actual blood ties. The clans are not known by the clan founder but bytotems. Each clan has a main totem (omuziro) and secondary totem(akabbiro). The Baganda take great care to trace their ancestry through thisclan structure. A formal introduction of a Muganda includes his ownnames, the names of his father and paternal grandfather, as well as adescription of the family’s lineage within the clan to which it belongs. Theclan has a hierarchical structure with the clan leader at the top (owaka-solya), followed by successive subdivisions called the ssiga, mutuba,lunyiriri and, finally, at the bottom the individual family unit (enju).

The Baganda believe in superhuman spirits in the form of mizimu,Misambwa, and Balubaale (sing. Lubaale). The Baganda, like many otherethnic groups in Africa (Good & Kimani, 1980; Patel, 1995a), believe thatthe body dies and decomposes but the soul still exists as omuzimu (singularof mizimu). Mizimu are the ghosts of dead people. Such ghosts are believedto operate at a family level to haunt anyone the dead person may have hada grudge against. If the mizimu enter natural objects they are believed tobecome misambwa. Balubaale (sing. Lubaale) are believed to have beenmen whose exceptional attributes in life were carried over into death. Thesesuprahuman entities are commonly referred to by locals as byekika –literally translated as ‘the clan things’ (Nzita & Mbaga-Niwampa, 1998).

Spirits are regarded as an important influence on health and illness(Bennett, 1963; Orley & Wing, 1979). There are two main categories ofspirits including family and community ancestors, alien and evil spirits.Family and community ancestors are usually involved in the maintenanceof good health, although, if they are upset they may cause illness andmisfortune. It is the alien and evil spirits that are more likely to causeillness maliciously.

Orley (1970), points out that the Baganda think of their illnesses interms of the part of the body affected; thus a cough may be referred to asekifuba (chest). Depression is seen as an illness of thoughts (ebirowoozo/


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okweralikirira) and, since it is believed that both the heart and the brainthink, depression is referred to those bodily regions. Baganda also distin-guish two groups of illnesses, the ‘kiganda illnesses’ and the ‘nonkigandaillness’ (Orley, 1970). Both kiganda and nonkiganda illnesses can furtherbe categorized into: (a) Endwadde, which refers to simple ailments/afflic-tions treatable preferably by lay remedies or traditional healers; (b) obul-waddde, serious but less fatal illnesses treatable by both traditional andwestern medicine; and (c) olumbe, which refer to illnesses that are untreat-able and fatal. These distinctions have implications for help-seekingbehaviour. If a person is ill and s/he and her/his significant others considerit to be a kiganda illness, s/he will be encouraged seek help from atraditional healer. If the illness is a nonkiganda illness s/he will most likelyseek help from a western-type medical facility.

Sample

The purpose of sampling was to identify specific groups of people whoeither possess characteristics or live in circumstances relevant to thesocial phenomena being studied (Mays & Pope, 1995). The main charac-teristics that were relevant to the study included belonging to the Gandaculture and the age group of interest to the study. Sample size was small,subjects being initially selected because they could illuminate thephenomena being studied. The continued selection of subjects wasrelated to the findings that emerged in the course of the study (Sande-lowski, 1986). Selection of traditional healers and religious leaders, forexample, was based on the initial finding of the focus groups that indi-cated that traditional healers deal with mental illness that was attributedto spiritual/cultural causes. Although the selection of participants inqualitative research usually ends when there is saturation and no newinformation is forthcoming, because the purpose of this preliminarystudy was to pre-test the methods, no effort was made to attain satura-tion. The participants for individual interviews included three traditionalhealers and one faith healer from a Pentecostal sect: 3 men and 1 woman.The participant with least experience had been in practice for 10 yearswhereas the one with the longest experience had been in practice for over30 years.

Procedure

Five vignettes were prepared depicting five types of depressive illnessaccording to DSM-IV: Depression without psychotic features, depressionwith psychotic features, manic illness, adjustment disorder withdepressed mood and dysthymia. A senior consultant psychiatrist helped in


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reviewing all the vignettes with the aim of ensuring that they met theDSM-IV diagnostic criteria (APA, 2000). To ensure the conceptual equiv-alence (Brislin, 1986; Manson, 1997), both the vignettes and the interviewand focus-group discussion guides were translated into Luganda, the locallanguage spoken in Buganda, and blindly back-translated into English andreviewed by two independent bilingual speakers.

During the translation process an effort was made to ensure that theitems in the instrument satisfied the four criteria identified and recom-mended by Manson (1997), that is, comprehensibility, acceptability,relevance, and completeness. The process recommended by Brislin (1986)was followed, which involved: (a) Translation, (b) blind back-translationand, (c) examination of the originals, the translations, and the blind back-translations.

The following bodies approved the protocol for the pilot study: Facultyof Medicine Research and Ethics Committee, the Uganda NationalCouncil for Science and Technology, the Karolinska Institutet RegionalEthics Committee (Karolinska Institutets regionala forskningsetikkom-mitté) reference number KI Dnr 03-118, the office of the Resident DistrictCommissioner (Mukono district), and local leaders in Bajjo village.Informed consent was also sought from every participant and, again withthe participants’ consent the discussions and the interviews were tape-recorded.

The traditional healers who participated in the interviews werecontacted individually through the help of the District cultural officer andasked to participate in the interview after being given information aboutthe general purpose of the study. Focus-group participants were mobilizedwith the help of the village authority for the village participants, and theschool authority for secondary school students and primary schoolteachers.

Efforts were made to ensure that the variables that may influenceperception, such as age, gender and level of education were consideredwhile organizing the focus groups. Both interview and focus-group guidesincluded six broad themes covering the general discussion about commonmental illnesses known to the participants, as well as the five specificdepression vignettes. The discussion of each of the themes started with thepresentation of a case vignette. All the vignettes were presented inLuganda, the local language.

The moderator (first author) read each vignette slowly for everyone tohear clearly, and clarified anything that was unclear before starting thediscussion. This was done in order to ensure the uniformity and clarity ofthe symptoms presented in the vignette and also to allow the participantswho could not read the material to participate in the study. The procedurewas repeated until the five vignettes were completed.


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Twenty-five people participated in the focus group discussions and fiveparticipated in individual interviews. Thirteen of the 30 participants werewomen.

Four focus-group discussions were conducted as follows: Group 1comprised secondary school girls in Senior 6. This is the final year ofsecondary school education in Uganda (mean age 18.8 years). Group 2comprised women (village women, mainly housewives) with a mean ageof 35 years, most of whom had at least primary education. Group 3consisted of village men (mean age 38.3 years). Group 4 comprisedprimary school teachers; this was the only gender-mixed group with amean age of 34.5 years. The mixed group was included following thesuggestion by Goss and Leinbach (1996) that mixed groups in terms ofgender bring together different knowledge, experience and perspectivesthat may become important points of discussion.

Six participants per group were thought to be adequate to provide alarge enough group to conduct a discussion but not become unwieldy(Merton, Fiske, & Kendall, 1990). However, to avoid the possibility of lowattendance more than 6 participants were recruited (Morgan, 1988).

Data Analysis

Charmaz’s (2000) constructivist version of grounded theory (Glaser &Strauss, 1968) was used as the frame of analysis (Charmaz, 2000). Accord-ing to the constructivist version of Grounded Theory, our understandingof respondents’ meanings emerges from a particular viewpoint. Theresearcher’s disciplinary and theoretical proclivities, relationships andinteractions with respondents all shape the collection, content, andanalysis of data (Charmaz & Mitchell, 1996). Grounded theory analysisallows concepts, categories, and themes to be developed while the study isbeing conducted. In grounded theory analysis, concepts are related inorder to form abstract categories. The relationship between thesecategories is then identified in order to develop a formal theory (Glaser &Strauss, 1968). The findings reported in this article comprise the initialeffort in this process.

The collected information was managed as follows: Answers to explana-tory interviews and focus-group discussions were transcribed and literallytranslated from Luganda to English by a bilingual speaker. After transcrip-tion, the investigator read the transcripts several times and first groupedthe transcripts according to themes used in the interview guide for thefocus-group discussion. The transcripts were formatted and exported to theNVivo programme. Meanings and practices discussed by participants wereused as units of analysis. The analysis started with open coding using the‘constant comparative method’ (Glaser, 1967). This entails comparing


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various themes within the same interview/focus group and betweendifferent interviews/focus groups. This served as an attempt to check thefindings for bias by comparing and contrasting the data from focus groupswith interviews, described as within-method triangulation (Denzin, 1989).

FINDINGS

Identity Given to Symptoms According to the Type of Depression

Case 1: A 28-year-old Man/Woman with Symptoms of Major DepressionWithout Psychotic Features

Namubiru/Nsubuga is a 28 year-old woman/man. For the past 4 weeksshe/he has been feeling unhappy and no longer enjoys her/his usual activi-ties. She/he says that her/his mind is closed and she/he describesherself/himself as feeling ‘empty.’ Also, he/she has difficulty sleeping and hasnot been eating well. She/he complains of a lack of energy. She/he no longerenjoys sex. He has even failed to have erections. She/he says life is not worthliving. Her/his thoughts are always wondering and distant. She/he thinksabout death and wishes to die or even kill herself/himself.

All the participants were able to associate these symptoms either withsomeone they knew or their own experience. Most participants thoughtthe label that suited the symptoms was ‘too many worrisome thoughts.’ Aparticipant in the girls’ focus group made the following comment: ‘Okwer-aliikirira is when you have a lot of worrisome thoughts . . . You feel likeyou don’t want to do anything, not even bathing and you want to be alone.Sometimes you even think of killing yourself.’

It was also believed that a person should have some control over his orher thoughts. One of the participants in the older women focus group said:

Me, I take it that she has a lot of thoughts, very many worrisome thoughts,she thinks a lot . . .

. . . Yah! Those are thoughts. They disturb you . . . (Focus-groupdiscussion [FGD], women)

Another participant added:

In fact, even I agree that those are thoughts and she needs to avoid them.You see we always move with thoughts but we have to control them. If youdon’t control them . . . You feel you don’t fit anywhere; wherever you areseated you think of this and that. You keep on worrying . . . And what makespeople fail to sleep in many cases are thoughts. You find that you arethinking day and night . . . (FGD, women).

Depression attributed to individual weakness, as in this case lack of abilityto control one’s thoughts, is well documented in the literature (Schreiber& Hartrick, 2002; Schreiber, Stern, & Wilson, 1998, 2000). The symptoms


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presented in the vignette above were regarded by the majority of respon-dents as a form of mental disturbance or sickness of the soul. However,the respondents noted that the symptoms do not constitute ‘madness’ assuch.

One participant observed: ‘I think she has some kind of mental distur-bance . . . s/he is not mad as such . . . the soul is sick’ (FGD, girls). Theconcept of madness in this case referred to behaviour such as throwingstones, abusing people and running around naked. This description issimilar to what Orley (1970) described in a study he conducted among theBaganda.

Participants in nearly all the focus group discussions called thesymptom picture presented in Vignette 1 ‘illness thoughts.’ They recognizedthe symptoms as an affliction, although they did not consider them toconstitute a medical condition. Indeed, the discussion revealed that theparticipants would think it ridiculous if one went to a doctor complain-ing of ‘thoughts.’ One of the participants commented:

It may not be that you have something like fever disturbing you, which youcan take to the hospital, but thoughts . . . Even a friend may not go therebecause this person has nothing itching her. It is thoughts . . . (FGD,women)

For traditional healers the illness was identified as mild madness, that is,omutwe omutambuse, which means that the individual’s head has becomemixed up. The traditional healers perceived witchcraft to be the cause ofthe condition. This indicates a sharp contrast with the view taken by themembers of the community as described earlier. However, this should notbe seen as a difference in explanatory models as far a major depression isconcerned but in support of the community explanatory model. It wasclear among the members of the community that an illness is taken to atraditional healer if it is believed to have a spiritual or cultural cause.

The illness of thoughts or the name given to symptoms of depressionwithout psychotic features was not considered to be caused by spirits orcultural forces although it was recognized that such thoughts could leadto confusion in the head.

Case 2: A 35-year-old Man/Woman with Symptoms of Depression withPsychotic Features

Namubiru/Mubiru is a 35-year-old woman/man. For the past 6 weeksshe/he has been complaining of lack of interest in any pleasurable activity.S/he has withdrawn into her/himself. S/he is not sleeping and not eating.S/he has lost a lot of weight. S/he says that her/his neighbour is bewitchingher/him. She claims that the ancestors are unhappy with her/him and theyare calling her/him to die, telling her/him that s/he is worthless.


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The participants in the men’s focus group identified the case of depressionwith psychotic features as a reaction to one’s failure to fulfil a culturallyprescribed role. They considered the hallucinations and delusionspresented in the case to be strategies to cope with the feelings or failure:

According to demography, when one is 20 years, you must be handsome;30 years, you must be strong; 40 years, you must have money (rich), 50years, you must be wise and a figure to be consulted. Now at that age of his,35 years, he must be strong. Strong enough to do everything so that at theage of 40, he has money, is well established, has a family and everything.Now seeing that he has exceeded 35, then things are not good . . . When leftwith one term (5 years), don’t think you will make it to 40 years and haveeverything, family, house, money so that by the time you are 50, you are theone they refer to for advice giving . . .

But when he looks at things, at the age of 35, those he is with, the youthslike Mayombo (the name is not from Buganda, but is used in this contextas a symbol of success) have their houses and he has nothing to show. Thenhe asks, ‘what is wrong with me?’ In other words, when he reflects insidehimself, he can say, ‘I have been on earth for 35 years now, life expectancyis 43 years and am left with 8 years’. (FGD, men)

The participants in other focus groups and individual interviews identi-fied the case as symptoms of HIV.

Case 3: A 32-year-old Man/Woman with Symptoms of Mania

Sentongo/Nankabirwa is a 32-year-old man/woman. For the past 3 weekss/he has been very argumentative, shouting and fighting people. Spendsmost of the night singing gospel music. S/he says s/he is an important andrich person who owns all the land and houses in the village. S/he also sayss/he has been chosen by God to preach the gospel. S/he spends most of theday wondering around. Sleeps very late and wakes up very early.

All the participants, both in the focus group and individual interviews,identified the symptoms using the label kazoole. Orley (1970) describeskazoole as a concept that was used by the Baganda to describe chronicschizophrenia. This difference might be explained by differences inmethods of data collection used in the two studies. In the current study,kazoole is used as a name for the symptoms intended to describe manicillness according to DSM-IV (APA, 2000).

The participants believed that Kazoole is an episodic condition wherebythe level of functioning is impaired. Individuals could still function andlive in the community when free from symptoms. Thus, ‘I think this manis not mad but just mentally disturbed (kazoole)’ (FDG, men). However,the condition is highly stigmatized because it is recurrent. Some believedit was actually better to have full-blown madness (psychosis). As oneparticipant observed:


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One would live and move with his/her kazoole. It would be up to you, upto the villagers to know that he is a muzoole . . .

Occasionally; it’s on and off . . . kazoole is very bad at least, you’d ratherhave – a mad person. Because I have never seen a mad fellow who couldeven undress, but was taken, treated and healed . . .

But with kazoole!! She is a silent killer. (FGD, women)

If the kazoole is less serious it is called kalogojjano, meaning afflicted bycontinuous talkativeness. Again akalogojjano is seen as temporary and isnot as stigmatized as kazoole.

Case 4: A 30-year-old Man/Woman with Symptoms of AdjustmentDisorder with Depressed Mood

Kato/Nansubuga is a 30-year-old man/woman. Four months ago his/herwife/husband left him/her with six children for another man/woman. Forthe past 3 weeks he/she has been feeling very sad and he/she is always tearful.He/she is complaining of difficulties in breathing, lack of sleep and loss ofappetite. He/she appears dirty and his/her hair is not groomed. He/she saysshe/he is praying so that God can save him/her from his/her misery.

Older women identified the case as jealousy:

Money may be there but jealousy! Jealousy is draining her. Something insideis hurting her: Where is my man!!

Participants in the men’s group thought it was a case of too many thoughtsdue to stress related to single parenting and rejection. Being left withyoung children was an immense challenge in the face of which any manwould be stressed. The Baganda have well-defined gender roles in whichwomen are expected to raise the children and men to provide for thefamily. The role of a man to provide depends on the financial situation,but whatever is provided a woman has to see to it that the family is fed:

. . . thoughts have become too much for him. There is a lot they weresharing, with the wife; now when he thinks of her absence, he says, ‘I willnever have her again’ so he develops the illness of the thoughts as they say. . . He is thinking a lot. Thinking of the family, the wife is gone, the job isin danger, he can’t concentrate on work when thinking of home, he has tolook for food for the children. Now all those thoughts are in him. (FGD,mixed group)

Case 5: A 38-year-old Man/Woman with Symptoms of Dysthymia

Kizito/Namaganda is a 38-year-old man/woman. For the past 4 years he/shehas been feeling uncomfortable, complaining of aches and pains and feelingfeverish. He/she thinks that his/her neighbour is bewitching him/her.He/she has been visiting the health centre frequently where he/she has been


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given many types of medicine with no improvement. He/she has also visitedvarious traditional healers around the subcounty.

The participants identified this as a family disease, HIV, or problem causedby witchcraft (Eddogo). They saw this as a chronic ongoing illness, whichhas refused to get better and which could be attributed to witchcraft, HIV,or to a hereditary family illness. This highlights the lay theory that empha-sizes spirits and witchcraft as the cause of mental illness. However, it alsoincorporates biomedical concepts such as HIV infection. Such findingshave been reported elsewhere (Good & Kimani, 1980; Patel, 1995b). Thegroup of men thought this condition was among the recent conditionsthat have no formal name in Buganda. They associated the condition witheveryday problems of living, particularly a lack of money:

You see, hardest of all is that most of these problems we are experiencingnow were not there at the time of our grandparents who did the naming.They could wake up in the morning, the husband goes hunting and the wifelooks for food. Such problems were not there. Now that they have startedcoming up, they haven’t yet coined names that suit them in our nativelanguages . . . the blacks’ languages; they haven’t coined names for them . . .that such and such a problem is called this in one word. You just study thecondition and perhaps say, ‘that one was caught by the lights.’

In other words, we use the jargon that is currently available . . . ‘Okusi-irana,’ which means someone is stuck, has reached the end. He can’t go thisor the other way. (FGD, men)

For the mixed focus group this condition was associated with worriesabout HIV infection or some chronic ill-defined disease:

That thing . . . do you know that today; so many people are like that? Theyhave that condition. If you take statistics, you will find that people are notfeeling well; one feels uncomfortable, does not want to eat, no longer wantsto work, and feels tired of life. Especially people who have lost their sexualpartners and they are worried that they have been infected with HIV. Theybecome angry and quarrel with the neighbours. They do that because theyhave so many thoughts. (FGD, mixed)

Aetiological Factors Associated with the Onset ofDepressive Symptoms

Participants from both the focus group discussions and individual inter-views identified several factors related to the aetiology of symptomsdescribed in the vignettes. After the analysis these factors were groupedinto four categories: Psychological factors, socioeconomic factors, spirit-ual/cultural factors and biological/physical factors.


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Psychological Factors

These included thinking too much about problems such as bereavement,illness of a close relative, excessive reading (which was brought up mainlyby the youths, who included teachers and students). Relationshipproblems, sexual problems, and sexual abuse came up in the discussionabout failing to fulfil a social role. Both men and women cited these factorsas important in the aetiology of illness of thoughts. However, men andwomen attached more importance to different specific factors. Forwomen, especially the older women, the most important psychologicalfactor was marital problems in relation to a cheating spouse. This is illus-trated in the following citations from the group of older women:

Say you are there and someone tells you that they have found your husbandwith another woman there; you cannot sleep, you cannot even eat, and inthat case it is the husband making you have the thoughts. (FGD, women)


You go on combing thoughts; like with us women, the thoughts may notnecessarily be about jobs, say a friend comes and tells you, ‘When yourhusband was returning home, he passed (branched off) to Nankya’s placefor evening tea.’ Then you remember that he did not eat the food you gavehim for supper. So that makes the woman develop the thoughts. This causesillness of thoughts. (FGD, women)

The symptoms presented in the vignettes were also associated with feelingsof rejection or being cheated, especially when a woman believed that herfamily’s economic situation had improved after a combined effort by bothparties, only to discover that her husband had taken the money to spendwith other women. As one participant in the women’s focus group pointedout:

We may be patient and work hard to get out of poverty, but the time whenwe’ve got the money, when I would also be able to enjoy myself, my husbandneglects me and goes out looking for another woman with big hips to enjoylife. (FGD, women)

Another participant from the same group added:

When you are old and worn out (scrap) . . . You are old and it is makingyou even older . . . Every time you put the palm on the cheek . . . [a posturein which a person supports his/her head with his/her hands as an apparentsign of having worrying thoughts]. (FGD, women)

Although women agreed that poverty would equally precipitate worryingthoughts that could result in illness of thoughts they perceived maritalproblems as a more significant factor in the aetiology of the illness ofthoughts. As one of the participants in the women’s group commented:


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Sometimes having good relationship in marriage is better than havingmoney and misunderstanding every day. Money can be useless if you havemarital problems . . . at least you would rather be with a husband when youare poor, but you are on good terms. (FGD, women)

For men, the most important factors that could elicit worrying thoughtswere poverty, and separation resulting in a man having to look after hischildren alone. A man who is left with children, particularly youngchildren, was more likely to be depressed as the following citation fromthe group of men indicates:

A man could a bricklayer . . . he goes to make his bricks, knowing that evenif he brings home 1000 shillings, the wife will plan well with it and thechildren will get what they need to eat. But if the wife is not there, then heis supposed to look for money, cook and bathe the children. He used to findthem asleep but now they do not sleep. You find them hungry lying therein the sitting room; one is facing this way another that way . . . and you askyourself, ‘is it me that has to look after these children even tomorrow?’(FDG, men)

Concern about HIV infection was another psychological factor identifiedby participants in both the focus group and traditional healers’ interviews.The worries were about HIV infection and the stigma associated withcontracting HIV. This was reflected in the following comments frommixed-group participants:

That man, yes, perhaps there is a woman he made love to and now he hasseen that she is sick. He fears going for the HIV test; he is worried that hetoo is infected and there is no one for him to talk to about it.

And he could be worried that other people have learned of it and nowhe asks himself, ‘now what do they think of me?’ (FGD, mixed group)

Another participant from the same group added:

Some people [are] like that because [they] have had love affairs and theyare worried that their partners have infected them with HIV but fear goingfor the HIV test. They get worried and angry. Because they are angry, theydo not get on well with their neighbours. (FGD, mixed group)

These worries about AIDS signified worries about a chronic stigmatizedillness.

Socioeconomic Factors

The participants in the focus-group discussions identified economicfactors such as loss of income, unemployment, lack of money for schoolfees, lack of basic necessities for one’s children, and so on as some of theimportant socioeconomic factors that could predispose one to depressive


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symptoms. These factors were seen as important by all the participantsregardless of age and gender, and are illustrated by the following citationsfrom various groups.

Men’s group:

It is not madness but once money gets scarce (parts with you) . . . you beginto think and think . . .

Girls’ group:

This problem can be caused by loss of a job. If a man loses his job and hehas a family to look after he is likely to experience this problem because ofover thinking and he gets the illness of thoughts.

Women’s group:

You may be there and your husband has no job. The children are sent backhome from school because there is no money for the fees. And at homethere is not even a penny to buy maize flour for posho [bread made out ofmaize flour which is regarded as food for poor people in Buganda]. Don’tyou see, you can feel like running mad in that situation?

Another participant from the older women’s group commented:

You know, too much poverty gives rise to thoughts. However sick you maybe, if there is money you will get treatment; you may not grow thin like onedisturbed with many thoughts, because whatever you want will be broughtto you, but with poverty you will think and think. You admire . . . I wouldhave eaten food but there is nothing . . . You can’t buy anything, not evenmedicine. You get sick through thoughts.

The participants stressed the importance of psychological and economicfactors. They argued that if all these were satisfactory then there would bea reason to suspect other factors such as spiritual/cultural or biologicalfactors. This line of thought is indicated in this citation from the group ofolder women:

Because you have money, you don’t have misunderstandings with yourhusband, but then you have thoughts! Then it must be something, an illness.But if money is there and you are on good terms with your husband andthe children are going to school; then what kind of thoughts are those? Thenit must be an illness, maybe witchcraft or unhappy ancestral spirits.

This finding that poverty is regarded as an important aetiological factorin depression seems to differ from that of earlier research conducted inother parts of Africa. Earlier studies have indicated that lay people empha-size spiritual or cultural factors in the causation of common mentaldisorders (Patel, 1995b). In the current pilot study, psychological andsocioeconomic factors were seen to play an important role in the onset ofsymptoms described in the vignettes for major depression without


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psychotic features and adjustment disorder with depressed mood. Thedifference could be explained by the techniques used in the two studies.The use of depression subtypes as specific illness categories could haveallowed participants to be more specific in their explanations. Patel’s studyused a much broader category, the concept of common mental disorders,which included the whole spectrum of depressive disorders and more.

Spiritual/Cultural Factors

These spiritual/cultural factors include witchcraft and angry Lubaale(Kiganda ancestral gods). These two were identified as important factorsthat should be suspected if the symptoms seemed to be chronic or associ-ated with psychotic features. Angry Lubaale were particularly suspected tohave caused one’s illness if the patient had not performed certaintraditional rituals as required by the clan. The following citation illustratesthis: ‘Maybe he has been chosen by small Kiganda gods. The Baganda havetheir gods such as Muwanga, Musoke, Kiwanuka, Musisi or Mukasa. Thesecan choose to disturb you if you curse or disobey them’. (FGD, girls)

Biological/Physical Factors

These included genetic factors, substance abuse that was believed todamage the brain, chronic physical illnesses such as HIV infection, andcancer. These factors were identified as important in illnesses that seemedrecurrent such as manic illness and dysthymia. Genetic factors werethought to play an important role in the aetiology of mania, as indicatedin the following citation from the women’s group: ‘But that Kazoole some-times is inborn. Those are cases where we say it is familiar(Byewaabwe/byekika). There it is hereditary. It is in their blood whereby itcomes from the background (ancestors) . . .’ (FGD, women).

HIV infection was another factor that emerged, particularly in the situ-ation where help had been sought from both western medicine andtraditional healers but without improvement. This was the case in thevignette for dysthymia:

But with me I say Namaganda is sick. She has the disease AIDS . . . Yahbecause for 4 years she has had no peace, not happy. Life is continuing todecrease. She is going to traditional healers but doesn’t heal . . . She mustbe infected. She is always thinking. She must be having something drainingher – an illness. An illness; AIDS. (FGD, women)

Drugs and alcohol were seen as further important causes of illness such asKazoole. The manic illness vignette elicited similar responses from allgroups:


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This problem may be a result of too much alcohol. Always drinking. Thiscan cause kazoole . . . even enjaga (marijuana) cause a kazoole. (FGD, girls,mixed group, Individual interview II)

Effects of the Depressive Symptoms

Participants discussed physical, psychological as well as social effects thatmay be brought about by depressive symptoms. The symptoms werebelieved to have effects both on the individual patient as well as on his/hersignificant others.

Social isolation was identified by most of the groups as a serious effectof depression on an individual. This is one of the effects that seems to becommon to all the subtypes of depression. One participant said:

And too many thoughts detach [separate] you from people. You will bethere, you don’t even want anybody to call you, when you see someonelaughing you think s/he is laughing at you . . .

Now, like that Nsubuga, he can’t even fit in with people and that alone isenough to keep him very distant because, the people he used to be with . . .Now he doesn’t like his wife, he doesn’t have hope, he is far from friendsunless he gets money again, that is when he can interact with others again. . . (FGD, men)

Impaired relationships with children were also discussed. Women wereparticularly concerned about the possibility of children being abused bymothers who were having too many thoughts. The quotation from oneparticipant in women’s group illustrates this: ‘Children ask for food,“aren’twe going to eat? We don’t have soap!” This and that, you feel like slappingthe child but . . .’ (FGD, women).

The possibility of women becoming promiscuous was also mentionedby women. Women disclosed that before the HIV pandemic women usedto cope with many thoughts resulting from cheating husbands by lookingfor other men outside marriage. However, they noted that this copingstrategy had been hampered by the fear of HIV. They said:

As the man has treated her like that, the medicine that used to and couldcure such an adulterous man was for you to settle your mind also by gettingsomeone also (a man), but this AIDS really came for us!! That is wherewomen used to rest the mind . . . one settles the mind [thoughts] completelywhereby even when you [the man] come back, she opens for you. Anddoesn’t even quarrel because she knows she did it too . . . Yes, we have asaying: ‘When he gives you ASPRIN, You also give him ASPRIN, don’t fear.’But with HIV, women can not continue doing that. A woman has to think,if I catch HIV, who will look after my children? (FGD, women)



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With me during the time I grew up, during my childhood; where I grew up,I could hear grandmother say, ‘To manage this man!! . . . Get another man!Yes, I will get another man out there.’ And she could go and get him and ongetting back together, they could both be very happy. But now, this diseasereally came for us. You cannot take revenge . . . You can only take revengenow when you know you are already infected. (FDG, women)

Some participants identified possible physical effects of the depressivesymptoms, as this quote from the women’s group indicates: ‘That evenreduces your life. You can’t eat, you lose weight . . . life gets short’ (FGD,women).

Stigma was mentioned as an effect particularly associated with Kazoole,the name that was used by the participants to identify symptoms of mania,which was usually believed to be recurrent. The label Kazoole was believedto have serious implications for the individual’s social life.

Shhh – Keep quiet, that muzoole is coming . . . You see, even if it is deathand she has lost a child, those who see her crying will say, she is crying withKazoole. In other words, you will not be having any human things you canstill do. They always look at you as a muzoole. Even if you go to a funeralceremony somewhere and do a lot of work they will say, ‘After all she is amuzoole.’ (FGD, women)

Sexual relationships among couples were identified as an area that couldalso be impaired by worrisome thoughts.

. . . he doesn’t like to be with them any more; even his wife, he doesn’t likeher. Now what is left is him leaving home and going to sleep outside becausehe doesn’t want to be with his wife. So the marriage goes . . . How can therebe no sex in a marriage? (FGD, men)

Sources of Care for Depression

Lay help from family, close friends, experienced elders and religiousleaders was identified as an important source of help for individuals withtoo many thoughts.

. . . Talking about the problem especially with people who are a bit older . . .Yes she should talk about the problem, but she should have friends to listento her, because you can’t talk about your problem with just anyone. It caneasily go off when there is a person who listens and comforts you. (FGD,girls)

And if family members are closer they can offer better help because theyunderstand him/her better than others . . .

If it is a woman, that is when the husband will tell you, ‘Go to yourmother and stay there for a week.’ (FDG, women)


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Experienced older women were believed to be the best source of help forhow to cope with the stresses of marriage: ‘This woman should seek advicefrom older women . . . She should talk to her Senga [aunt].’ (FGD, girls)

The church was seen as an important source of social support especi-ally in dealing with the problem of social isolation:

Maybe you can take him to church and they pray for him . . . Then whenhe comes back this way to the majority, he can fit in with people. . . . Theycounsel him, he gets saved so that he can come back to people and get somefreedom. (FGD, men)

The participants were fully aware of the challenges related to social with-drawal, which is an important symptom in depressive illness: ‘Helping willnot be easy if this person does not want people close to him/her. Becauseeven if it means hospital, if you are not talking to people it makes thingshard’ (FGD, women).

Traditional healers were recommended as a source of help forsymptoms suspected to be caused by witchcraft or angry Lubaale. Thesewere suspected to have afflicted the patient due to disobedience regardingcultural prescriptions, such as looking after one’s ancestors’ gravesproperly.

The participants’ discussion indicated that in a situation where thecause was not known, the best option was to take the patient to atraditional healer to both identify the cause and obtain treatment for thesymptoms:

. . . a person like that, I don’t know how you can get him and take him tohospital, because they will ask what he is suffering from. That is why peoplesay, ‘Oh, my brother’s child! Let me do something for him. I will go totraditional healers.’ When one is mentally disturbed, those who can get himback to normal are very few. (FGD, men)

The belief that some mental illnesses could not be helped by westernmedicine was also discussed. This was the case especially if the illness wasbelieved to be caused by clan factors or inherited (byekika):

. . . and with us, when our people get such problems which are mental innature, we don’t go for the western medicine . . . especially if it has beencaused by a clan thing (byekika); because we have seen people taken to(hospital) and treated but they have failed to heal . . . Traditionally webelieve that if someone is getting mentally disturbed, you move aroundfor that person seeking help/advice and medicines [‘Omutambuliranomunonyeza eddagala’]. Some times they get well. (FGD, men)

However, lack of mental health services was identified as one of the factorscontributing to seeking help from sources other than western medicine:‘Because the work of those head doctors isn’t spread as yet. Few people


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know that there are people who can help such a person in westernmedicine’ (FGD, men).

Although hospitals were recommended if biological/physical factors weresuspected to be the cause of the symptoms, simultaneous consultation wasa common practice. HIV featured significantly in the discussions, which maybe due to the fact that HIV remains the most threatening illness. It is alsopossible that it is one of the few illnesses whose symptoms are widelyunderstood by the general population due to public health campaigns.However, the psychiatric manifestations of HIV are less widely appreciated.

Discussion

A number of studies have been carried out to identify health belief andexplanatory models held by people suffering from mental health problems(Aidoo & Harpham, 2001; Burrow, 1993; Good, Good, & Moradi, 1985;Kleinman, 1988; Patel, Musara, Maramba, & Butau, 1995; Rippere, 1977,1980a, 1980b; Weiss et al., 1986). The findings are typically consistent withthe biomedical model, indicating that up to 20% believe depression tohave biological origins (genetic or chemical change) and 80% believe it tobe primarily social (stress, bereavement or childhood experience). Studiesthat have focused on eliciting the meaning of the subjective experience ofillness using qualitative methods (Cohen et al., 1994; Gray, 1995; Gregg &Curry, 1994; Patel, Musara et al., 1995; Ying, 1990) have shown consider-able variation between lay explanations and explanations offered bybiomedicine. Few studies of this kind have been conducted in Africa(Aidoo & Harpham, 2001; Patel, Musara et al., 1995) and we have beenunable to find any published studies that have systematically explored layexplanations of depression in Uganda.

The findings reported in this article, though preliminary, suggest thatdepressive symptoms (without psychotic features) are associated withthinking too much and are referred to as an illness of thoughts. This illnessis seen as a nonchronic condition caused by psychosocial, economic andspiritual factors. When depression becomes recurrent or episodic and haspsychotic features, as is the case with bipolar illness, the belief about itscause changes and is regarded to be a clan illness ‘byekika,’ usually causedby Misambwa/clan gods or Mizimu/ancestral spirits. This is closely relatedto the idea of continuity between the living and the dead, prominent inmany African cultures (Good & Kimani, 1980; Patel, 1995a, 1995b). It isbelieved that after death, though the body disintegrates, the spirit lives onand plays an important role in the wellbeing of the living descendants. Ifthese spirits are upset they can cause ill health. If the condition becomeschronic the cause is still believed to be Misambwa or witchcraft or evenphysical illness, particularly HIV/AIDS (see Figure 1). Studies in Africa


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have reported similar findings, indicating that most illness is conceptual-ized as being natural at the beginning, but if it persists and an abnormalaetiology is considered, traditional medicine is preferred as a source ofhelp (Chavunduka, 1978; Gelfand, 1967; Mutambirwa, 1989; Patel, Musaraet al., 1995).

The case vignette for depression with psychotic features was the onlyone that was conceptualized as physical illness. The physical conceptual-ization in this case was related to HIV/AIDS. This conceptualization maybe the result of the methodological approach or contextual aspects.Methodologically, it could be because the vignette emphasized physicalsymptoms that pointed to the HIV/AIDS pandemic affecting thecommunity in Uganda. When other symptoms such as culturally relevantdelusions and hallucinations were included in the revised vignette theexplanation shifted to one of clan issues (byekika).

Contextually, the emphasis on HIV may be an indication of HIV aware-ness among the population. Uganda is one of the countries that has beenseverely affected by HIV/AIDS. More than 1 million children are thoughtto have been orphaned by AIDS (Sengendo & Sekatawa, 1999). It is alsoone of the few countries south of the Sahara that have managed to reducethe rate of infection drastically through public education. In Uganda,according to estimates by UNAIDS, HIV prevalence among adults peaked


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Figure 1 Lay conceptual mapping of depressive symptoms (pilot study data forexplanatory model study, 2003).




at around 15–30% in 1991, and fell to 5% in 2001. If one assumes thatdepression was present before HIV/AIDS then associating depressivesymptoms to HIV could also be interpreted as a change in the conceptu-alization of depressive symptoms. However, since this kind of study wasnot conducted among this cultural group before HIV/AIDS became apandemic it is difficult to know whether such a change has taken place.

The findings seem to indicate that help-seeking behaviour follows aspecific pattern, whereby the afflicted person is expected to start by seekinglay help from both significant relatives and religious leaders. If the illnessfails to respond to the lay help then one consults a traditional healer ormodern doctor depending on one’s suspicions about the causes of theillness. In some cases help from both modern and traditional medicinewas sought simultaneously (see Figure 1). However, there is an indicationthat the traditional healers might be consulted for at least three reasons:

1. When the cause of the illness was unclear and the illness seemed tobecome chronic. In this case a traditional healer acted as a divinerand healer;

2. When the illness was believed to be a traditional illness it was referredto as ‘the clan illness’ (byekika). In such a situation the concept ofKizungu-Kiganda illnesses (European-African) presented by Orley(1970) applies. When an illness is believed to have a traditional causethen western medicine will not be able to help;

3. Traditional healers were also consulted where they seemed to be theonly source of care that was available as far as mental health serviceswere concerned. This can also be explained by the mystery surround-ing the mental health care profession in general. There are clinics withgeneral practitioners in the community but the people still believedthat they could not get help from general practitioners. This may havesomething to do with the teaching of psychiatry in medical schools,which does not equip general practitioners with adequate knowledgeto recognize and treat mental illness.

The findings indicate some inconclusive gender and age differences inthe conceptualization of depression without psychotic features. Bothyounger and older women seemed to attach significant importance to therole of interpersonal relationships at the onset of the illness, while menseemed to attach more importance to the role of poverty and the disrup-tion of gender roles in the onset of illness of thoughts.

Limitations of the Study

The results from this pilot study should be considered preliminary. Somemethodological issues should also be borne in mind when interpreting the


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data. The mobilization of focus-group members relied heavily on the gate-keepers. It is possible that the gatekeeper, who happened to be the localauthority in the area, screened the participants and introduced unknownbias. This can be avoided by screening the respondents recruited by gate-keepers. The use of case vignettes as the basis for discussion may have narrowlyfocused the views expressed by the participants. However, the study aimed toexamine the explanatory models of the whole spectrum of depressive illness.The use of hypothetical case vignettes made it possible to access the views ofnondepressed members of the community. Future research will compare theexplanatory models of clinical samples with the general population.

Acknowledgements

The authors thank the participants from Bajjo village for agreeing to share theirknowledge. Thanks to Sida/SAREC for funding the study and to the regionalresearch ethics committee at Karolinska Institutet (Dnr 03-118), to MakerereUniversity Faculty of Ethics Committee and the Uganda National Council forScience and Technology for approving the study. Thanks to Dr. Seggane Musisi, aSenior Consultant Psychiatrist with Mulago Hospital-Kampala, for reviewing thecase vignettes used in the study. The authors are also grateful to Dr. Stella Neemafor the insights given during the planning of the study and during the analysis.Thank you Joshua for assisting with fieldwork and the transcription of the tapes.We wish to thank Mr. Steve Wicks for help with the English.

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Elialilia S. Okello, MA, is a lecturer at the Department of Psychiatry, and aPhD student at the SIDA/SAREC-Karolinska Institutet-Makerere University. Herresearch interest focuses on the role of culture on health and illness with emphasison mental illness. Address: Makerere University, Department of Psychiatry, P.O.Box 7072 Kampala, Uganda. [E-mail: [email protected]]

Solvig Ekblad, PhD, is a clinical psychologist and Associate Professor in Trans-cultural Psychology at the Karolinska Institutet, Stockholm, Sweden, and Head ofUnit for Immigrant Environment and Health at the National Institute ofPsychosocial Medicine, Solna, Sweden. Dr. Ekblad collaborates with severalnational and foreign research teams in the field of migration and mental health.She has written extensively in both peer-reviewed journals and books and haspresented several articles at international and national conferences in the field ofmigration and mental health. Address: IPM, Box 230, S-171 77, Stockholm,Sweden. [E-mail: [email protected]]


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