Ideological vs. Instrumental Barriers

Contrary to expectation, the case study of south-eastern Nigeria (Ikwuka, 2016) found that ideological barriers were perceived significantly more (83.3%) than instrumental barriers (57.8%). This indicates that inadequacy of services and material poverty, which are easily perceived as the major barriers to good mental healthcare in the developing world, may, after all, not be as inhibitive as socio-cultural factors, stigma and shame, cultural (in)appropriateness of care, the conceptualisation of mental illness, mental health literacy, and a culture of self-reliance. The finding has crucial policy implications. It suggests the likelihood of services being underused even if improved, which corroborates the disturbing observation that most people with psychological distress receive no mental health treatment even when care is free.

Thus, it demonstrates that determining the conceptualisation of mental illness could help in unravelling the reasons for the underutilisation of mental health services. A key policy implication here is the need to prioritise mental health education and cultural competency in care for optimal service uptake. However, the study also revealed a strong positive relationship between perceived ideological and instrumental barriers which reflects a link between ideological and material poverty. This, in consequence, corroborates the suggestion of the human capital theory (Tilak, 2002) which envisages a strong linear relationship between learning and earning, thus underscoring the interaction of ideological and instrumental factors in shaping help-seeking behaviour (Barker, Olukoya, & Aggieton, 2005).

Barriers to Help-Seeking: Socio-demographic Correlates

The World Psychiatric Association (WPA) underlines the necessity of selecting a target group when implementing educational activities and that a more specific definition of the target group facilitates the assessment of programme efficacy (WPA, 2005). The case study of southeastern Nigeria found that the UK-based respondents would be potentially less constrained ideologically and instrumentally from seeking mental healthcare compared to the home- (Nigeria) based respondents. This is to be expected given the potential effects of acculturation and the more developed and accessible UK. healthcare system. Barimah and Teijlingen (2008) did observe that culturally based behaviours change over time towards those prevalent in the host culture.

Yet, that as many as almost two-thirds (63.9%) of the sample could still be inhibited by ideological barriers is indicative of the fact that acculturation might not be enough to prompt an immigrant population in a host Western culture to robustly pursue mental care. Moreover, besides the fact that acculturation itself demands changes in orientation which may engender its own conflicts, studies have shown that higher orientation towards the host culture has not always been found to be an indicator of positive outcomes among immigrants. For instance, Clark and Hofsess (1998) found that an increased level of acculturation towards the host culture was associated with higher rates of depression, drug use, and mortality. A marginalised style of acculturation has also been associated with symptoms such as anxiety and depression (Neto, 2002).

On the other hand, immigrants who identified with their native cultures were found to have more favourable psychological adjustment, and this is after controlling for personality and self-efficacy differences (Chen, Benet-Martinez, & Bond, 2008). This shows that, notwithstanding the prospects of acculturation, immigrants’ autonomy should not be significantly compromised as they contend with the systems of the host culture, which need to demonstrate sensitivity. It has been observed that health professionals’ lack of cultural competency, including adequate knowledge and awareness of the impact of cultural differences in the assessment and treatment of mental illness, constitute additional barriers to the adequate accessing of mental healthcare by immigrants (Gaines, 1998; Idemudia, 2004).

The cultural understanding, meanings and symbols immigrants bring with them are critical in addressing immigrants’ experiences. These were accentuated in the aforementioned critical study by Keynejad (2008), which explored the barriers that constrain ethnic minority groups from adequately accessing mental healthcare in London. Ethnic minorities in the study saw psychotic symptoms as spiritual and identified faith leaders as the appropriate persons to seek help from. They were quite suspicious of mental health services and were unconvinced that medication would be of any use. Many felt their problems to be social rather than medical, while others did not feel that primary care workers had any expertise in mental health. The study further identified that gossip, negative stereotypes, social rejection, and lack of understanding all made it harder for people to identify symptoms as a problem.

Moreover, many were unaware of the available help which could explain the finding of the case study (Ikwuka, 2016) that over a third (38.9%) of the UK-based Nigerian respondents could be constrained by instrumental barriers from accessing healthcare even in a relatively well-developed healthcare system. Keynejad (2008) also reported that those who did access services sometimes found them to be far better than they had anticipated, which shows that people with limited information may overestimate their reservations. Furthermore, the study reported that there was mistrust of the mental health system as people said they expected primary care practitioners not to have enough time to listen to them, to prescribe anti-depressants as a default solution, or be dismissive of their complaints. Users in the study felt their views were rarely consulted, yet many were not equipped with the procedures for registering their complaints should they feel dissatisfied with the services. Studies indicate that the experience or anticipation of unfair and unequal treatment in mental health services generates deeply entrenched mistrust within minority communities and acts as a powerful barrier to accessing care and treatment (Edge & Rogers, 2005; Keating, 2007; Keating, Bobertson, McCulloch, & Francis, 2002).

As a way forward, the respondents in the study by Keynejad (2008) wanted services to be delivered more holistically in the form of a complementary model with alternative therapies. Those not using the services wanted more information about the help available in their own languages, while those using the services wanted more information about their medication and treatment made available in their own languages. Following the study, the author suggested some steps with the potential to improve ethnic minorities’ perceptions of mental health and helpseeking behaviour. These included:

  • 1 Education and promotion that aim at myth-busting and raising the profile and accessibility of primary care
  • 2 Provision of holistic healthcare such as low-intensity talking therapies delivered by ethnically diverse therapists
  • 3 Greater involvement of ethnic minority service users in service user committees as well as one-off events, to consult service users and carers from specific ethnic minority communities in service planning and design
  • 4 Establishment of a system that investigates ethnic minority carers’ needs and determines gaps in the service
  • 5 Cultural competence training delivered to a group of ethnically diverse service providers and clinicians, and provision of chaplaincy services across the diversity of ethnic groups and the breadth of faiths
  • 6 Development of polyclinics which take on board the suggestions of service users towards the development of an integrated model that would incorporate faith, physical and mental health services

Although still somewhat contentious, the UK National Health Service (NHS) does currently provide some of the alternative therapies which

Ideological vs. Instrumental Barriers 103 may be a crucial way of engaging ethnic minority groups by illustrating that services go beyond the Eurocentric biomedical model. Though national interest in the mental health of ethnic minorities seems to have increased in the past decade, the human service professions have historically failed to meet the particular mental health needs of various underserved ethnic groups (Baruth & Manning, 2003). It is of particular concern that empirical investigations of mental health issues pertaining to Africans continue to lag behind in comparison to the volume of research conducted on other minority groups (Betancourt, Green, & Carrillo, 2000). The non-adaptation of services to the needs of African immigrants, and their unique struggles in adapting to a new culture and belief system, impose additional barriers for those of them that suffer from mental illnesses and need treatment.

Nurses in the case study (Ikwuka, 2016) demonstrated significantly less perceived ideological and instrumental barriers compared to the nonnursing occupational groups (students, teachers, and the general public). This would be expected given the training and experience of nurses that should help them burst myths surrounding mental illness, on the one hand, and also give them an advantage in terms of the pragmatics of accessing care. This furthermore underscores the importance of improving mental health literacy as key to emancipating people from ideological barriers that could inhibit them from promptly seeking mental healthcare.

However, the study showed that students significantly predicted perceived ideological barriers. This is disturbing, especially as the onset of serious mental illnesses like schizophrenia is mostly during adolescence and young adulthood (Kleintjes, Lund, & Flisher, 2010). It agrees with the consistent research finding that the gap in help-seeking for mental illness is most striking in young people (Rickwood, Deane, & Wilson, 2007; SAMHSA, 2012; Zachrisson, Rodje, & Mykletun, 2006). A systematic review of literature (Gulliver, Griffiths, & Christensen, 2010) also confirms the leading barriers to young people’s access to mental health services are mostly ideological: stigma, embarrassment, lack of emotional competence and mental health literacy, concern with confidentiality and trust, and resort to self-help. Young adults also demonstrate more pessimism about treatment and prognosis (Kobau, Dilorio, Chapman, & Delvecchio, 2010). It is to be expected that the embarrassment and social isolation that come with stigma will be of exceptional concern for the young student in an age bracket that prizes social and peer acceptance, hence the reluctance to self-disclose, obsession with confidentiality, and recourse to self-help.

Secondly, as youth is stereotyped with anti-social behaviours, there is the likelihood that a society which causally links mental illness to substance abuse and moral failings could be quick to deplore the mental illness of the young as a product of self-destructive behaviour. This coulddiscourage young people from disclosing mental health challenges as a system of adult providers would not earn their confidence. It could also explain why young people show greater help-seeking intentions towards trusted sources such as friends who share common experiences with them (Barker, Olukoya, & Aggieton, 2005; Rickwood, Deane, & Wilson, 2007). It was observed, however, that young people who have established relationships with health professionals were likely to seek help in the future (Rickwood, Deane, Wilson, & Ciarrochi, 2005). Interpersonal confidence is a necessary ingredient of therapy, particularly for the wary youth, to freely relay painful and personal information about their life and health, and to accept guidance through difficult life changes.

The failure to elicit the views of young people on the subject of mental health has been well documented (Department of Health [DOH], 2005; Parish, 2004). Disturbingly too, the review by Gulliver and colleagues (2010) also found that there is a paucity of high-quality research in the area of help-seeking determinants for young people. As an age bracket with a high risk of the onset of serious mental illness, this group would benefit from targeted interventions. Since stigma reduction during the adolescent years increases adolescents’ comfort in discussing mental disorders (Pinto-Foltz & Logsdon, 2009), mental health education (which helps to normalise mental illness thereby reducing stigma) would be a promising intervention. Following an educational intervention in a research study, young people believed that people with mental illness were less distinct, less of a threat and less shameful, and there was no need to keep such people at a safe distance, restrict their activities or hide their mental illness (Pitre, Stewart, Adams, Bedard, & Landry, 2007). The school has proved to be an enabling platform for health promotion schemes (Gale, 2001; Lauria-Horner, Kutcher, & Brooks, 2004: Pinfold et al., 2003; Randhawa & Stein, 2007). Given the necessity of intervention at this stage, radical measures such as the inclusion of mental health literacy in the school curriculum could be decisive. Interventions in schools which facilitate encounters between students and people with schizophrenia have also proved to be particularly promising (Schulze, Richter-Werling, Matschinger, & Angermeyer, 2003; see also Chapter 6, Contact Theory).

Teachers in the case study (Ikwuka, 2016) also significantly predicted perceived ideological barriers which is disturbing, given that they should be instrumental in the improvement of mental health literacy through the school system. This is all the more worrying as it suggests the possibility that ignorance regarding mental illness is being recycled in the school system. It is therefore imperative that teachers are targeted for mental health education, not only for their own mental healthcare (which is crucial given their vulnerability in doing one of the most taxing but least remunerated jobs in the region) but also because of the ideological influence they wield over pupils, including those with mental illness.

The case study equally found that females could be more constrained by ideological barriers than males in seeking mental healthcare. This appears incongruent with the finding that females appear comparatively more positive towards mental illness (cf. Chapter 5, Demographic Correlates of Stigmatising Attitudes) and are also generally more favourably disposed towards seeking mental healthcare than males (Judd, Komiti, & Jackson, 2008: Mackenzie, Gekoski, & Knox, 2006; ten Have et al., 2010). However, besides the fact that females demonstrated more supernatural attribution for mental illness in an earlier study of the region (Ikwuka, Galbraith, & Nyatanga, 2014) which undermines the effectiveness of biomedical psychiatry and is consequently associated with less compliance with the biomedical treatment model (Kurihara, Kato, Reverger, & Tirta, 2006; Rose, 2010), a gender effect appears to be culturally mediated.

Studies that associate females with a greater disposition to seeking mental healthcare are mostly with Western samples. Most of the studies from the more traditionalist and collectivist developing world including Nigeria, report otherwise (Aniebue & Ekwueme, 2009; Gilbert et al., 2007; Lahariya, Singhai, Gupta, & Mishra, 2010). This might be attributed to the prevailing gender bias in these societies. For instance, help-seeking could cause potential damage to females’ marital prospects in these cultures with the likelihood of divorce or husbands taking on second, polygamous wives (see Chapter 7, Culture). While a male marked as ‘mentally ill’ could easily contract marriage in most of sub-Saharan Africa, marriage is almost effectively foreclosed for a woman similarly identified.

The gender bias is further revealed in men and women, placing differential emphasis on the importance of the beliefs and values of their social networks. Whereas women who sought help were more likely to report that family members would not get upset on learning about it, there was no relationship between men’s beliefs about family members’ opinions and their use of therapy (Leaf, Livingston, & Tischler, 1986). Taking cognisance of gender differences in mental health, including risk and help-seeking, would ensure a more gender-sensitive approach in mental health policies.

The case study (Ikwuka, 2016) also found that low education significantly predicted perceived instrumental barriers. Access to information is vital for awareness and access of available services, and those with more education, invariably having better access to information, demonstrate higher rates of help-seeking and treatment utilisation (Al-Rowaie, 2005). In a typical south-eastern Nigeria village setting, information is disseminated to the people through limited channels such as church gatherings, town criers and mobile public address systems. The more educated people who can read, and who also have a better grasp of English, the official medium of communication, have wider access to information including from the print and electronic media.

People with limited information on the available biomedical mental health services may overestimate their inaccessibility. Furthermore, in keeping with the human capital theory, those with low education are also more likely to lack the material resources to access services. With a very low Tertiary Gross Enrolment ratio of 10% (UNESCO Institute for Statistics, 2011), the majority of Nigerians (90%) in the lower education category are therefore at risk of being impeded by instrumental barriers from accessing mental healthcare. This justifies the recommendation by the WHO to scale up mental health services in low and medium-income countries (WHO, 2010). This will involve making services available to more people who need them, increasing the range and variety of services offered, ensuring that services are culturally appropriate or well adapted to contexts and sustaining these services through effective policy, implementation, and financing.

Part III

Pathways to Mental Healthcare

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