Health-seeking behaviour of mentally ill patients in Enugu , Nigeria

Volume 15 No. 1 March 2009 SAJP Awareness of mental illness as a significant cause of morbidity is increasing worldwide. This awareness has increased with the steady decline of morbidity due to nutritional disorders, communicable diseases and other forms of physical illness, especially in countries undergoing epidemiological transition (these are countries where epidemiological attention shifts from declining communicable diseases, malnutrition and problems associated with pregnancy and childbirth, to chronic noncommunicable diseases which are then the dominant public health problems). A significant disease burden is attributable to mental illness globally. Out of the top 10 leading causes of disability throughout the world, 5 are psychiatric illnesses. According to the World Health Organization (WHO), mental illnesses account for 11.5% of the global burden of disease – a figure that is projected to increase to 15% by 2020. Worldwide, 340 million people suffer from mental illnesses, with the majority living in the developing world.

Information obtained included socio-demographic characteristics of the patients, sources of care employed by the patients and their reasons for doing so, and their beliefs regarding psychiatric ailments.Data entry and analysis were done using the SPSS statistical package, and statistical calculations were done at a 5% significance level.

Results
Of 416 questionnaires distributed, 397 were completed and returned, giving a response rate of 95.4%.Two hundred and twenty-three (56.2%) of the patients were male and 174 (43.8%) were female.The age range of the patients was 15 -75 years (mean (SD) 31.6 (11.0) years).Other socio-demographic variables for the patients are shown in Table I.Treatment options first employed by patients are shown in Table II.The majority (34.5%) went to prayer houses, followed by a psychiatric hospital (32.0%).The reasons for choice of place of first treatment are also shown in Table II; the most common reasons were confidence that they would be well managed at such places (46.3%) and ignorance of the existence of psychiatric services at the hospital (14.6%).Most patients eventually selected specialist services after persuasion by friends and relatives (44.8%) or referral by a health care provider (20.9%).Table III shows the relationship between the socio-demographic characteristics of the respondents and choice of specialist service as the first-contact caregiver.Male respondents, those with a high level of education, urban dwellers and respondents who attributed illness to a rational cause, employed specialist services as their first-contact caregiver more than others, and this observation was statistically significant.The most common patient perceptions of the cause of their ailment were demonic and spiritual forces (31.1%).Other causes included psychological stress (20.6%), use of 'hard' drugs (12.4%), poison from perceived enemies (8.3%), and familial causes (2.8%).
However, 24.8% of respondents claimed to be ignorant of the cause of their ailment.Three hundred and sixty-seven (92.4%) expressed satisfaction with their treatment at the hospital.

Discussion
It is important to understand the choices that people make for treating mental illnesses to ensure proper utilisation of available mental health services, and better management and control of mental disorders. 7This study showed the most common first contact for treatment of mental illnesses to be the prayer house (34.5%), followed by a psychiatric hospital (32.0%).Sharma similarly reported a higher preference for spiritualists (38.2%) than psychiatrists (29.4%) in his study of treatment-seeking behaviour of mentally ill patients in a rural area in Beri, India. 7In Nigeria there are still strong beliefs in magico-religious origins of human ailments, especially mental disorders. 8The majority of patients in our study attributed their ailments to supernatural causes, which explains why visiting a spiritual house was their first option.
However, male respondents, urban dwellers, those with aboveaverage literacy levels and respondents who held rational views about the causes of mental illness, first consulted specialist psychiatrists more than other respondents.Similar associations have been reported elsewhere. 3,9,10Socio-cultural practices such as male dominance and the stigmatising nature of mental illness (to which women are possibly more susceptible than men) could explain the observed gender difference in healthseeking behaviour of mentally ill patients. 10Since the first line of care for the mentally ill constitutes the most important stage of the psychiatric pathway to care, 10 efforts are needed towards changing the perceptions of patients regarding the cause of their ailments, to encourage early presentation to psychiatric hospitals and prompt treatment.
articles Patients' most common reason for the choice of place of first visit was confidence that they would be cured there; this factor has been reported previously. 7Ignorance of the availability of mental health services was also common among patients.An urgent need therefore exists to increase community awareness about the scope and existence of mental health services and the amenability of mental illnesses to orthodox care, which should lead to positive attitudes that will enhance timely visits to a psychiatrist as well as prompt treatment of conditions.
The most common reason for the eventual visit to a neuropsychiatric hospital was advice by friends/relatives (44.8%), which demonstrates the role of social networks in decision-making regarding the selection of modality of treatment among mentally ill patients, and is consistent with other reports. 7,11Since the decision of where to seek help involves both patients and relatives, health education efforts should target all members of the community.

Conclusion
Negative perceptions of the causes of mental illness still abound among mentally ill patients and their relatives.This fact is compounded by ignorance of existing mental health services.
Consequently, alternative sources of care are still employed.
There is a need for community health education to demystify mental illnesses as well as to highlight the availability of mental health services; this should create positive attitudes, correct misconceptions and encourage early specialist consultation and better treatment outcomes.Mental health services should be made available to rural dwellers by integrating them into existing primary health care services.
We acknowledge the assistance of E Odoh, C N F Ochie, I Okonkwo and E Chukwu for their assistance in distributing the questionnaires used for the survey.

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Volume 15 No. 1 March 2009 -SAJP each patient from admission.Daily clinics are run by specialist psychiatrists.Ethical approval for this study was obtained from the ethics committee of the University of Nigeria Teaching Hospital, Enugu.Informed verbal consent was also obtained from each patient or relative before recruitment into the study.A structured pre-tested questionnaire was used by medical students specially trained for the survey, to collect data from patients or their relatives.The questionnaire was developed by the authors and pre-tested on patients attending another tertiary hospital in the locality.Questions identified as ambiguous were rephrased.

Table III . Relationship between socio-demographic characteristics of respondents and choice of psychiatric hospital as first place of presentation
articles Volume 15 No. 1 March 2009 -SAJP