Download Mental Health Strategic Communication Framework

Mental Health National Communication
Framework
January 2012 – January 2015
1
Table of Contents
List of Abbreviations ....................................................................................................................... 1
Introduction and Background ..................................................................................................... 2
1.1. Mental Health in Ethiopia ............................................................................................................. 2
1.2. Problem Statement ......................................................................................................................... 8
1.3. Conceptual Model – Pathways for Mental Health, Care and Treatment ...................... 8
Overarching Goal and Objectives ...................................................................................................... 11
2.1.
Guiding Principles ................................................................................................................................... 11
2.2. Creative Briefs by Audience...................................................................................................... 12
2.2.1. Priority audiences by domain ............................................................................................................ 12
2.2.2. Strategies by audience for each domain ........................................................................................ 13
Implementation .............................................................................................................................. 29
3.1. Links with Services ...................................................................................................................... 29
3.2. Research, Monitoring and Evaluation ................................................................................... 29
3.3. Sustainability, Roles and Resources ...................................................................................... 30
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List of Abbreviations
AIDS
ART
HEP
HEW
HIV
IPC/C
mhGAP
M&E
MDG
FMoH
NGO
NIFMH
PEPFAR
PITC
PLHIV
PSA
SWOT
WHO
WrHO
Acquired Immune Deficiency Syndrome
Anti-Retroviral Therapy
Health Extension Professional
Health Extension Worker
Human Immunodeficiency Virus
Interpersonal Communication and Counseling skills
Mental Health Gap Action Program (WHO)
Monitoring and Evaluation
Millennium Development Goals
Federal Ministry of Health
Non-Governmental Organization
National Initiative for Mental Health
U.S. President’s Emergency Plan for AIDS Relief
Provider-Initiated Testing and Counseling
People Living with HIV
Public Service Announcement
Strengths, Weaknesses, Opportunities and Threats
World Health Organization
Woreda Health Office
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Introduction and Background
This framework is planned to contribute to the efforts being made in the World Health
Organization’s Mental Health Gap Action Program (mhGAP). The framework will guide and
coordinate all mental health communication efforts in the country.
This framework was developed in collaboration with key stakeholders including: the Federal
Ministry of Health (FMoH), Amanuel Hospital, Addis Ababa University, The Ethiopian
Orthodox Church, JHU Tsehai, I-Tech and JHU∙CCP. The framework materialized through a
literature review and a framework development workshop that was held with key
stakeholders. A draft of the framework was circulated among all who participated in the
development discussions and workshops for review and input, which this document reflects.
The FMoH has embarked on a program to expand mental health services nationally. This will
greatly improve accessibility and uptake of these services. This National Strategic
Framework for Mental Health and Wellbeing Communication is designed to address
behavioral and attitudinal barriers to maintaining good mental health, uptake of available
services and adherence to initiated health care.
1.1.
Mental Health in Ethiopia
The High Burden of Mental Illness
According to the World Health Organization (WHO), 14% of the burden of disease worldwide
is attributed to mental health problems, of which 75% are in low-income countries. [28] It is
estimated that approximately 450 million people worldwide have a mental health problem
and 1 in 4 families worldwide is likely to have at least one member with a behavioral or
mental health problem. [18]
Even though the majority of the burden of disease in Ethiopia is from communicable diseases,
the prevalence of non-communicable diseases is escalating dramatically. The leading noncommunicable disorders in Ethiopia are caused by mental illnesses, accounting for 11% of
the total disease burden. Schizophrenia and depression are ranked in the ten most
burdensome disorders, above even HIV/AIDS. [1]
Although these statistics are startling, they most likely do not capture the entire disease
burden caused by mental illnesses in the country. It is probable that the actual figures are
even higher; suggesting that mental illnesses are a major health concern and have not
received adequate attention so far. [22]
Despite recent efforts to improve the quality and availability of mental health services, the
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coverage of services is still very low. There are only 40 psychiatrists for the whole of the
Ethiopian population, which has now escalated to 80 million. [28]
Currently only one in 10 of those severely affected by mental illnesses can receive the
treatment they require. [22]
At present, only 1% of individuals with mental illnesses in rural Ethiopia access the necessary
services and are adherent to mental health treatment. Of those who have ever accessed any
form of health services, 9% are lost to follow up. The number of those who have never
accessed services are unknown, but is estimated to be quite high. The major reasons for
poor service uptake and poor adherence to treatment among mental health clients include:
lack of available and accessible services, poverty, lack of knowledge about mental illnesses
and excessive stigma and discrimination within communities. [15, 22]
Culture and Mental Health in Ethiopia
Within the community, it is commonly believed that severe mental illnesses such as
schizophrenia and bipolar disorder are caused by supernatural causes, for example by spirit
possession, bewitchment or evil eye. This often results in affected individuals seeking help
from religious and traditional healers, rather than from health facilities. [5] Such beliefs
within communities often result in the marginalization of people with mental illnesses. [22,
23]
Other mental illnesses such as depression are not well recognized by individuals and the
community, which makes it difficult to treat. [22]
Most Vulnerable Groups to Mental Illnesses in Ethiopia
The table below displays a brief audience analysis of populations most at risk of mental
illnesses:
People with severe
mental illness (SMI)
People with substance
abuse problems
Severe mental illness (SMI) refers to mental illnesses that are
persistent and debilitating, and require long-term interventions.
Treatment for persons with SMI has four goals: (1) reduce or
eliminate symptoms, (2) maximize quality of life and adaptive
functioning, (3) promote and maintain recovery from the
debilitating effects of illness to the maximum extent possible, and
(4) include education for persons with SMI and their families.
Appropriate treatment will be provided for the care of persons
with SMI based on best practices.
Predominantly, the individuals who suffer from substance abuse
disorders are the youth and commercial sex workers in Ethiopia.
It has been noted that those with substance abuse disorders
commonly also suffer with mental illnesses. [16, 2]
3
Children and Adolescents Mental illnesses amongst children and adolescents are shockingly
high in Ethiopia, and it is assumed that it is due to complications
during pregnancy and childbirth. [21] Children with depressed
parents have a 50% greater risk of developing depression
themselves before the age of 20. [26]
People living with HIV
People living with HIV/AIDS are more prone to developing mental
disorders such as depression and anxiety which, in turn, impair
their immune function, reduce their quality of life and adherence
to treatment and contribute significantly to their premature
deaths. In Ethiopia, additionally, HIV and other opportunistic
infections common amongst HIV positive individuals, as well as
side effects of ARTs, can affect the brain and the nervous system,
resulting in disorders like dementia. [22, 6] It should be noted that
some individuals suffering from a mental illness, such as
depression (possibly as a result of or exacerbated by being HIV+),
may display riskier behavior or intentionally put themselves or
others in risky situations or environments (fatalistic attitude).
Women during
pregnancy and after
child birth
People in prisons
Victims of violence and
abuse
People with epilepsy
Elderly
More than one in ten pregnant women and one in 20 postnatal
women in Ethiopia suffer from undetected depression. Around
half of those affected by depression have thoughts of ending
their life. In Ethiopia, perinatal mental disorders contribute to
maternal morbidity, in terms of poorer health, increased disability
and prolonged labor. [12] Perinatal mental disorders have also
been shown to negatively impact on children’s health in Ethiopia,
e.g. increasing episodes of diarrhea, interfering with initiation of
breast-feeding and negatively affecting child cognitive and motor
development. [21, 12]
People in prisons are highly prone to having mental illnesses. [4]
This could be a result of overcrowding, various forms of violence,
enforced solitude or conversely lack of privacy, lack of meaningful
activity, isolation from social networks, insecurity about future
prospects (work, relationships, etc), and inadequate health
services - especially mental health services - in prisons. [22]
Victims of violence and abuse often also develop mental illnesses
due to the harshness of their experiences. Women who have
been abused when they were children are likely to develop major
depression in adulthood. [27]
It is estimated that approximately 25% of the patients receiving
treatment at Amanuel Hospital are treated for epilepsy. Those
suffering from epilepsy are traditionally believed to have a
demonic possession and that their condition is contagious,
making them a stigmatized and ostracized group. [22]
Life expectancy in Ethiopia is increasing and more people are
living into old ages. Although several non-governmental
organizations are now providing services for the elderly mentally
ill in Addis Ababa, demand for mental health services by the
elderly is very low and does not reflect the likely burden in the
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population. Studies from Ethiopia have shown that increasing age
appears to be a risk factor for poorer mental health.
Mental Health Services
There is one specialized psychiatric hospital in Addis Ababa, the Amanuel Specialized Mental
Hospital. Additionally, psychiatric and substance abuse services are provided at St. Paul
Hospital, Zewditu Hospital, and the Armed Forces Hospital, as well as in the prison and police
services in Addis Ababa. Outside of Addis Ababa, mental health care is provided in Adama,
Harar, Hawassa, Jimma and Mekelle. A new hospital is in the process of being built with
anticipated completion date of 2012. [22]
The lack of high-level mental health professionals is being addressed through the Psychiatric
Nurse Training Program, sponsored by the WHO, which has increased the number of trained
psychiatric nurses in Ethiopia over the last 5 years. [22] Although these units have provide
services in different parts of the country reducing the patient load in Addis Ababa, it is
evident that the units are often weakened by high staff turnover and lack of opportunities for
career progression. [3]
In the past 5 years, psychotropic medication availability has improved drastically; however,
there are some inconsistencies in drug availability, accessibility and affordability throughout
the country. [22]
Mental Health, a National Priority
According to the National Mental Health Strategy (2011), mental health should be a national
priority especially since it is an area that has been overlooked and relates directly and
indirectly to a number of the Millennium Development Goals (MDG):
MDG 1 - To Eradicate Extreme Poverty and Hunger - This MDG associates very well with
mental health. Poverty can both aggravate existing mental health problems and can increase
the chances that people develop mental illnesses. It has been observed that many people
diagnosed with mental illnesses such as depression, bipolar disorder, and schizophrenia in
Ethiopia are unemployed either as a result of being unable to engage in work and take
responsibilities, or because they are marginalized by the community due to their condition.
[14, 15]
MDG 2 - To Achieve Universal Primary Education - This MDG is closely related to the mental
health of children. Undetected and untreated mental illnesses increase the likelihood that
children will drop out, under-perform and fail to register for school. [24, 25]
MDG 3 - To Promote Gender Equality and Empower Women - This MDG is also very closely
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related to mental illnesses. In Ethiopia, where gender violence is common, men who suffer
from depression and substance abuse disorders are more likely to abuse their wives or
partners.Women who have suffered abuse, especially if often, are at a high risk of
developing mental illnesses like depression and anxiety. [7]
MDG 4 - To Reduce Child Mortality - This MDG is highly affected by the health and well-being
of mothers. Child illnesses and mortality increase substantially if mothers have undetected
and untreated mental illnesses. [8]
MDG 5 - To Improve Maternal Health - This MDG is also greatly affected by maternal mental
health; especially since one in 20 women in Ethiopia is affected by depression after
complications during childbirth. [12]
MDG 6 - To Combat HIV/AIDS, Malaria and other Diseases - Communicable diseases
represent the leading cause of disease burden in countries like Ethiopia. However, such
diseases have been noted to either cause additional health concerns, like mental illnesses, or
intensify existing mental illnesses. It is estimated that a third of HIV positive people on
antiretroviral therapy (ART) are suffering from undiagnosed mental illnesses. [13] The health
of HIV positive people who also have mental illnesses is greatly affected as they tend not to
adhere to their ARTs. [9] In general, individuals who suffer from mental illnesses are at high
risk of contracting other communicable diseases as a result of their behavior being
influenced by their mental illness. Lack of mental health services and stigma and
discrimination towards people with mental illnesses also increases their vulnerability to
acquiring HIV, malaria and other diseases. People with mental illness may often be targeted
in violence and abuse, including sexual abuse and neglect. If stigma toward people with
severe mental illness is strong in the community, including internalized stigma among those
with severe mental illness, that creates a power dynamic that increases the power of the
perpetrator and the vulnerability of the person with mental illness.
Scaling up treatment for mental illnesses will consequently improve the quality of life for
individuals with mental illnesses and their caregivers, as well as decrease the mortality rate,
as it is evident that the provision of psychiatric medications saves lives. Increasing the
availability of services will also contribute to the eradication of stigma and discrimination.
[23]
Political Commitment and Efforts Currently Being Made
It is evident that there is very high political commitment to improving mental health care and
increasing coverage of service availability. A Mental Health Technical Working Group has
been created with various key stakeholders and the aim of bringing the national health
strategy into reality. [22]
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The FMoH is currently planning a significant scale-up of mental health services in
collaboration with mhGAP, whose aim is to scale up services for mental health, neurological
and substance use disorders for low and middle income countries. [28]
The National Initiative for Mental Health (NIFMH) was established with the guidance and
sponsorship of the First Lady, Azeb Mesfin, to guide the development of national mental
health services in Ethiopia. NIFMH has initiated the construction of the new Gefersa
Psychiatric Rehabilitation Hospital, a state of the art facility, which will be fully equipped to
provide medical help to individuals and families seeking mental health services. [22]
The Psychiatric Nurse Training Program, sponsored by the WHO, has trained psychiatric
nurses who provide services in established psychiatric units in various regional states. [3]
These units receive technical support and mentoring from psychiatrists and senior psychiatric
nurses from Addis Ababa. Amanuel Hospital also organizes various workshops annually,
which provide opportunities for psychiatric nurses to discuss various case studies and share
their experiences with each other. [22]
Alongside the Psychiatric Nurse Training Program, Addis Ababa University has additionally
started a small postgraduate training in psychiatry and neurology for medical doctors.
Furthermore, in a collaborative agreement between the JHU-Tsehai project and Amanuel
Hospital, a training curriculum has been developed and pilot tested to improve the
competence of service providers to diagnose and treat mental illnesses. Both urban and rural
health extension workers are currently being trained.
Communication Efforts
Very little effort has gone into developing communication materials for mental health in the
country. Amanuel Hospital has drafted the content for drug information booklets for
individuals diagnosed with a mental illness and who are prescribed medication for their
condition. These need to be reviewed and completed. Furthermore, JHU-Tsehai has
developed a training curriculum and service provider handbook.
SWOT
According to the analyses undertaken in the development of the National Mental Health
Strategy, the following strengths, weaknesses, opportunities and threats were identified for
strengthening and expanding mental health services.
Strengths
 Recent expansion of training
Weaknesses
 Low resources; inaccessible services
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

programs
Appropriate use of allocated budget
Expanding centers for the treatment
of substance use disorders
Opportunities
 Political commitment
 Improving infrastructure
 Expanding health sector
 Decentralization
 Becoming a leader in providing
mental health services
1.2.




Most of the budget used by hospital
Lack of parity
Inadequate quality of care
Limited resources for non-medication
alternatives (e.g., rehabilitation;
psychological treatment)
 Lack of organized referral system
 Difficulties in staff retention
 Inadequate focus on supervision and
ongoing training in PHC
Threats
 Low budget and other resources
 Lack of alternative services
 Stigma and abuse of mentally ill
persons
 Poor implementation or use of
available research evidence
 Lack of evidence base for evaluating
health service developments
Problem Statement:
This National Strategic Framework for Mental Health Communication addresses issues
surrounding the high prevalence of mental illnesses, the low uptake of available mental
health services, poor adherence to medication among mental health clients, frequent loss to
follow-up, stigma and discrimination toward people with mental illnesses, and a general lack
of knowledge about mental illnesses in communities.
1.3.
Conceptual Model – Pathways for Mental Health Care and Treatment
A workshop was held in Addis Ababa to develop the Ethiopia National Strategic Framework
for Mental Health Communication. The development took place in partnership with
communication and health experts from governmental and non-governmental organizations
(NGO), including clinical service providers and representatives of implementing partners.
The Framework development process employed the ‘Communication Pathways Model’, a
conceptual communication model used worldwide, and applied it to the Ethiopian context.
The model (shown below) envisages three domains for communication interventions:
1.
Social/Political/Environmental
2.
Services
3.
Community/Individual
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The National Strategic Framework is designed to identify schemes for communicating with
priority audiences in each of these domains.
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2.1.
Overarching Goal and Objectives
Communication interventions outlined in this Strategic Framework will contribute to the
following goal and objectives:
Goal: All Ethiopians will benefit from a comprehensive mental health care and treatment
services.
Social/Political/Environmental Objective: To make mental health among priorities so that
it is addressed publicly on a national scale by decision makers and federal and regional levels
in order to foster awareness and understanding around mental health as well as compassion
for mental illness
Service Delivery Objective: To provide reliable and client-friendly mental health care and
treatment services that are accessible to all Ethiopians and to improve service linkages and
referrals nationally.
Community/Individual Objective: To adopt an accepting and supportive community for
individuals with mental illnesses and their families as well as achieve and maintain good
mental health and wellbeing at the household level.
According to WHO’s definition of mental health, “Mental health is a state of well-being in
which an individual can realize his or her own abilities, interact positively with others, cope
with the stressors of life and study, work productively and fruitfully, and contribute to his or
her own family and community.” This definition does not refer to the absence of mental
illness, but addresses “mental well-ness”. Thus, this framework does not exclusively address
those already affected by mental illnesses, but the larger community as well, in an effort to
create awareness about and prevent mental illnesses and promote mental health and wellbeing.
2.2.
Guiding Principles
The Ethiopia National Strategic Framework for Mental Health Communication and its
implementation will be guided by the following principles:
Behavior change-oriented: For maximum impact, communication interventions should have
specific and measurable behavioral objectives, address factors that influence behavior,
and reflect a multi-channeled approach. Channels and interventions should be
complementary and mutually reinforcing.
Audience-centered: The design of messages, materials, and communication interventions will
rely on a thorough understanding of the audiences for which they are intended. This
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includes pretesting messages and materials, as well as involving audience members in
the development of approaches and materials.
Evidence-based: Communication interventions and strategies will be based on research and
lessons learned through prior and ongoing programs.
Culturally appropriate: Communication will take into account cultural norms, beliefs, and
practices that influence attitudes toward and the uptake and adherence to mental health
care and treatment services, and will be delivered in a culturally sensitive manner.
Community participation: The engagement of communities is essential in formulating a strong
response that is locally appropriate and draws on available resources. Communities must
be involved in addressing stigma and care-related issues.
Services-linked: All communication will refer mental health clients and caregivers to service
providers and/or will be implemented at the service delivery sites.
Human rights: The framework reinforces equity of access, confidentiality of services and
information, and gender-sensitivity.
Commitment and Coordination: Commitment to building local capacity and coordinating
partner efforts in mental health communication is essential.
Community Involvement: Community leaders and caregivers contribute to the success of
the mental health program. Community leaders, including religious leaders, and
caregivers are well-suited for refer individuals with suspected mental illnesses to mental
health services.
2.3.
Creative Briefs by Audience
2.3.1. Priority audiences by domain:
I.
Environmental:
a.
Federal and regional level policy/decision makers
b.
Journalists
II.
Service delivery:
a.
Service Providers
b.
Outreach Workers
III.
Community/Individual:
a.
Community Leaders
b.
Traditional Healers
c.
Caregivers
d.
Individuals who have not accessed any mental health services
b.
Individuals who have accessed mental health services
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2.3.2. Strategies by Audience for Each Domain:
Political/Social/Environmental Domain
Audience 1: Federal and Regional Level Policy/Decision Makers
Most policy makers in Ethiopia are adult men living in urban areas; however, in recent years,
more and more women are becoming involved in the country’s policy and decision making
process as ministers, parliamentarians, heads of directorates and heads of regional health
bureaus. These policymakers are usually older than age 30, have a high level of education
(i.e. typically a university degree or higher), and their incomes tend to be above the average
wage. In terms of politics, they tend to be loyal to their political party and possess significant
decision-making power. They also believe that Ethiopia can be transformed into a middleincome country and are interested in contributing to that goal. Most policymakers are
concerned with meeting development targets. Parliamentarians who are members of the
budget and health committees have the most influence on the health budget as well as its
allocation within the health sector.
Policymakers are committed to growth and transformation and understand that healthy
families and children are the cornerstone of this goal. However, policymakers may not know
the significance of mental health in maintaining the overall health of families and
communities and hence have not prioritized it.
Communication Objectives:



Policymakers will believe that mental health is a serious problem.
Policymakers will believe that the expansion of mental health services is a priority.
Policymakers will allocate additional resources for the expansion and improvement of
mental health services nationally.
Key Messages:



The allocation of additional resources for mental health will create healthy and
productive citizens who will directly contribute to the growth and transformation of
Ethiopia.
There is no health without mental health.
By availing mental health services, you are relieving some of the “burden” on families
to care for individuals with mental illnesses and be able to better contribute to the
growth of the country as individuals with mental illnesses, their caregivers can be
more productive. It will also relieve the burden in health facilities saving time and
other resources.
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Strategic Approaches
Channels
Illustrative Activities
Advocacy
Interpersonal
Advocacy video to be
disseminated to
policymakers
Mediafocused/Evidencebased
TV/Radio
Panel discussions and
briefings for
policymakers
Journals/Newsletters
Experience-sharing
tours to countries that
have strong mental
health services
Events
Audience 2: Journalists
Media professionals in Ethiopia have diverse demographic characteristics. They include both
males and females; some are well educated whilst others have a high school degree. They
are typically between the ages of early twenties to late forties, are of middle income and live
in urban settings. Most media institutions are profit-making and focus on news that
contributes to higher sales volumes. The media lack accurate, up-to-date information on
mental health and mental illnesses, which can lead to dissemination of misinformation that
fosters misconceptions and stigma. Although media personnel tend to be closely in touch
with realities at the community level, they are also subject to strong cultural and personal
values, beliefs, norms, and perceptions that may affect objectivity in reporting. Immediate
influencers of media personnel are managers in the workplace and funding/sponsoring
organizations. The media in Ethiopia is very powerful and can be used as a useful tool to
influence the public.
Communication Objectives:




Increase awareness and knowledge of mental illnesses among media professionals.
Improve and increase accurate and influential reporting on mental health, well-being
and mental illnesses.
Increase interaction of media with other key stakeholders (policymakers, community
groups, donors, etc.) to facilitate dialogue and partnership around mental health,
wellbeing and mental illnesses.
Additional resources will be made available for the expansion and improvement of
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mental health services nationally.
Key Messages:



Learning more about mental health and mental illnesses will enable you to give
accurate information to the public and become a trusted source of information.
You have a powerful and influential role in minimizing stigma, decreasing
discrimination and increasing demand for mental health services.
You can directly contribute to enhancing the quality of life of people living with
mental illnesses and their caregivers.
Strategic Approach
Channels
Illustrative Activities
Advocacy
Trainings
Orientation through
training, newsletters
Evidence-based
Meetings, workshops
Press kits and briefings
for media professionals
Events
Competitions for
excellence in reporting
on mental health
Print materials (fact
sheets, newsletters)
Coverage of personal
success stories that can
influence personal and
community action
Electronic media
websites, satellite video
conferences, CD-ROM
videos
Resource center
Resources on MH and
related issues housed
somewhere in different
formats
Service Delivery Domain
Audience 1: Service Providers (General Practitioners, Nurses,
Health Officers)
Most service providers are men, with ages ranging from 25 to 45. Most have over 12 years of
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education and are married with children. Most service providers are dedicated and well-respected by
their communities.
For the most part, service providers care about their clients, despite difficult conditions in their work
environment, such as lack of necessary equipment or medications, insufficient human resources for
health, and inadequate supportive supervision that hinders them from maximizing their potential to
serve their clients. Similarly, many lack confidence to provide any mental health services, and consider
it the job of more specialized facilities. Although service providers are fairly compensated as compared
with civil servants, their remuneration is not commensurate with their workload and responsibilities.
Generally, they lack incentives and recognition for good performance and have limited opportunities
for self-development or education.
Communication Objectives:




Improve service providers’ mental illnesses diagnosis skills.
Enable service providers to provide the necessary treatment, if available at their
facility, to patients diagnosed with mental illnesses.
If the appropriate treatment or services are not available at their own facility, enable
service providers to refer individuals diagnosed with mental illnesses to facilities that
can provide the necessary care and support.
Reduce stigma among service providers towards individuals with mental illnesses
Key Messages:








By diagnosing and treating individuals with mental illnesses, you will be decreasing
the burden on health facilities in the long run. Many individuals who repeatedly return
to services are those who have mental illnesses, have not been diagnosed yet and
have not received the treatment for their condition.
Severe mental illnesses can be prevented by diagnosing and treating patients with
mental illnesses early.
Be conscious and empathetic to the emotional, psychological and economic
conditions of the patient.
Encourage patients to come with their caregivers when appropriate and involve the
caregivers in the treatment and follow-up of the patients.
Improve the knowledge and understanding of caregivers towards the patients in
order to support the health and well-being of the patients.
Maintain good relationships, communication and rapport with patients and their
caregivers to help improve the quality of care you provide. This will directly reflect on
the patient’s improvement in health.
You can improve the quality of life of patients with mental health illnesses.
Improving the health of a patient, physically and mentally, is rewarding.
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Strategic Approach
Channels
Illustrative Activities
Advocacy
Interpersonal
Organizing experience
sharing meeting and
creating opportunities to
share best practices
Skill building
Trainings
Trainings covering
technical issues related to
mental health as well as
IPC/C skills
Jobaids
Print materials
Medical
journal/Newsletter on
mental health issues and
latest developments
Printed materials with
relevant information on
mental health and pocket
references
Development of directory
(living document available
online and in print) of
mental health and
supportive services to which
individuals diagnosed with
mental illnesses may be
referred
Media Oriented
TV/radio
TV/radio spots that show
the importance of mental
health and the role that
all health service
providers can play to
ensure mental wellbeing
of individuals that seek
services
Panel discussions on
dealing with MH issues
and delivering high
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Strategic Approach
Channels
Illustrative Activities
quality service that
broadcasted on TV and
Radio
Evidence Based
Hotline
Providing information on
Mental Health and related
issues
Resource Center
Resources on MH and
related issues housed
somewhere in different
formats
Audience 2: Outreach Workers (Health Extension Workers (Rural) &
Health Extension Professionals (Urban))
The country-led Health Extension Program (HEP) has trained and deployed over 34,000
Health Extension Workers (HEWs) throughout the country – two for each village (i.e. one
HEW for 500 households) since 2003. HEWs are predominantly young women between the
ages of 18 and 30 and are high school graduates. HEWs complete a Health Promotion and
Disease Prevention Interventions package followed by a one-year intensive training. The
package is comprised of 16 key components, including maternal and child health, hygiene
and environmental sanitation, referral services, and health education and communication.
Health Extension Professionals are nurses who work in urban areas. The majority of these
health workers come from the communities that they serve.
Communication Objectives:



Improve mental illnesses diagnosis skills of outreach workers.
Empower outreach workers to refer individuals diagnosed with, or those suspected to
have, mental illnesses to facilities that could provide the necessary care and support.
Provide outreach workers with the necessary skills to provide care and support to
individuals and their caregivers at the home level.
Key Messages:



Improving the health of your patients (objectively and subjectively) is rewarding.
You can improve the quality of life of your patients.
Severe mental illnesses can be prevented by diagnosing and treating patients with
mental illnesses early.
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



Be conscious and empathetic to the emotional, psychological and economic
conditions of the patient and their caregivers.
Involve the caregivers of patients in the treatment and follow-up of your patients.
Improving the knowledge and understand of the caregivers of your patients will
support the health and well-being of your patients.
Maintaining good relationships, communication and rapport with your patients will
help improve the quality of care you provide. This will directly reflect on the
improvement of health of your patients.
Strategic Approaches
Channels
Illustrative Activities
Advocacy
Interpersonal
Organizing experience
sharing meeting and
creating opportunities
to share best practices
Skill building
Trainings
Trainings covering
technical issues related
to mental health as
well as IPC/C skills
Jobaids
Print materials
Print job aids and
pocket references
Development of directory
(living document
available online and in
print) of mental health
and supportive services
to which individuals
diagnosed with mental
illnesses may be referred
Media Oriented
TV/radio
TV/radio spots
Panel Discussions
Evidence Based
Hotline
Providing information
on Mental Health and
related issues
19
Community/Individual Domain
Audience 1: Community Leaders
Typically community leaders are men between 25 and 80 years of age. Most are married
with children, have completed secondary education or higher, and earn an income slightly
above the minimum wage. They are usually well accepted and influential in their
communities, and are often committed to community mobilization and taking ownership for
change. Most of their work is resource constrained due to inadequate funding, lack of skilled
manpower, and poor linkages to services. They have a tendency to be conservative and
highly religious which makes them slow adopters of new ideas. They have a tendency to
believe that mental illnesses are a result of curses that can only be treated by traditional and
religious methods.
Communication Objectives:







Improve the knowledge of community leaders (religious, elders, etc.) on mental
illnesses and available care and treatment.
Empower community leaders to promote available diagnosis and treatment services
at health facilities.
Empower community leaders to establish support groups at the community level
amongst those who have mental illnesses as well as those caring for individuals with
mental illnesses.
Encourage community leaders to contribute to reducing misconceptions and stigma
around mental illnesses.
Advocate for an informed, accepting and supportive environment for individuals with
mental illnesses.
Increase empathy among community leaders towards the community’s needs and
advocate for them to create support platforms (e.g. facilitating community discussions
about mental health illnesses; planning activities or events that address emotional,
religious and economic concerns).
Increase awareness of community leaders on how to maintain good mental health
and wellbeing so that they can set a positive example for others.
Key Messages:



Learn the facts about mental illnesses and share this knowledge with others in the
community.
Assist community groups in organizing and addressing mental illnesses in the
community (e.g. encouragement to go to health services for professional treatment,
care and support, stigma reduction).
By taking action for recognition of mental health illnesses as well as promoting
treatment and support, you will be addressing a problem that is typically hidden in
20


the community and you will be more respected by community members who rely on
you to protect the community and help those in need.
You can improve the quality of life of the community.
Encourage community support for mental illnesses in order to help families of
individuals with mental illnesses are not stigmatized and benefit from shared
community responsibility to care for individuals with mental illnesses, therefore
creating a healthier and happier community.
Strategic Approaches
Channels
Illustrative Activities
Advocacy
Interpersonal
Organizing experience
sharing meeting and
creating opportunities
to share best practices
Skill building
Trainings
Trainings covering
technical issues related
to mental health as
well as IPC/C skills
Print materials
Print job aids and
pocket references
Development of directory
(living document
available online and in
print) of mental health
and supportive services
to which individuals
diagnosed with mental
illnesses may be referred
Media Oriented
TV/radio
TV/radio spots
Panel Discussions
Evidence Based
Hotline
Providing information
on Mental Health and
related issues
Audience 2: Traditional Healers
Traditional healers comprise both men and women who have very little or no formal
educational backgrounds, with mid-level economic status. They are typically conservative,
21
highly religious, and supportive of traditional and cultural values and ways. As traditional
healers, they are strong advocates of traditional medicine and suspicious of modern medicine.
They may have a tendency to view health facilities and health professionals as competitors
that also negatively influence the community. They are usually well respected and influential
among community members, especially those who have minimal education and the elderly,
who also have very strong traditional and cultural values and beliefs.
Communication Objectives:





Respectfully improve the knowledge of traditional healers on the available care and
treatment for mental illnesses at health facilities that could support their traditional
treatments.
Increase understanding among traditional healers that modern and traditional
treatments can supplement one another.
Promote services at health facilities as being supportive to the services and treatment
that they offer.
Empower traditional healers to refer patients to modern health facilities for second
opinions.
Encourage traditional healers to provide an accepting and supportive environment for
individuals with mental illnesses.
Key Messages:




Learn the scientific facts about mental illnesses and share this knowledge with
other traditional healers and community members.
By taking action for recognition of mental health illnesses as well as promoting
treatment and support, you will be addressing a problem that is typically hidden
in the community and you will be more respected by community members.
Establish and maintain a working partnership with modern medicine that will
strengthen and complement traditional health.
Become informed about mental illnesses and use that knowledge to address the
community’s needs directly, therefore regaining the faith of the younger, formally
educated people in the community.
Strategic Approaches
Channels
Illustrative Activities
Entertainment
Community gatherings, Community
community
conversations and
conversations
supportive low literacy
materials
22
Strategic Approaches
Channels
Illustrative Activities
Informal education
TV/radio
TV/radio spots
(dramas)
Establish linkage
between traditional
healers and health
facilities
Audience 3: Caregivers
As a result of the widespread prevalence of mental illness in the country, and the diverse
economic statuses in the country, caregivers of individuals who have mental illnesses include a
wide mix of people of all ages, economic statuses, living environment and education levels.
Likewise, these individuals represent diverse religions and ethnicities. Caregivers face very strong
stigma and discrimination the community as well as health workers and may often feel that they
are the only one who has someone with a mental illness under their care. Stigma toward oneself
for relation to and caring for an individual with a mental health illness may also cause caregivers
to live in shame and hide the truth from the rest of the community. They choose to hide the
people under their care, including locking them away from the world.
Communication Objectives:









Increase awareness among caregivers about mental illnesses and available care and
treatment.
Increase awareness of caregivers about signs and symptoms that indicate a need to
access mental health services.
Empower caregivers to seek the necessary care and treatment for individuals under
their care and support.
Encourage caregivers to discuss concerns and share what they have learnt about
caring for someone with mental illnesses with other community members who may
have similar concerns and insight.
Enable caregivers to identify which health facilities provide mental health services,
and what specific services are provided at each facility.
Increase understanding among caregivers that caring for someone with mental
illnesses is challenging and that they need to prioritize their own health and wellbeing.
Empower caregivers to maintain good mental health and wellbeing and set a positive
example for others.
Caregivers should feel proud of themselves for caring and supporting someone who needs
their help.
Empower caregivers to break the stigma from the community and self stigma by
23
sharing their experiences and educating other community members about mental
health illnesses and advocating for an increase or improvement of mental health
services available in their community.
Key Messages:













Caring for someone who has one or more mental illnesses can be very challenging.
Make sure to prioritize your own health and wellbeing by taking good care of yourself
and seeking the support of other community members, support groups or services.
The healthier you are, the more able you will be to care for others.
Improving the health and quality of life of the people under your care is rewarding.
You can improve the quality of life of the people under your care.
Severe mental illnesses may be prevented by diagnosing and treating patients with
mental illnesses early.
Mental illnesses can be managed with appropriate treatment obtained from health
facilities providing mental health services.
Be conscious and empathetic to the emotional and psychological conditions of the
people under your care.
It is very important to help the people under your care to stick to the advice that
their service providers provide them. Make an effort to go with them for their checkups and health visits.
It is very important to understand the condition of the people you care for and to
know about the symptoms that their illness causes.
Seek medical attention as soon as you realize that their symptoms are coming back or if
you observe any other strange symptoms.
If the people you are caring for are taking medicines for their mental health condition,
it is very important to consult their health provider if they want to take other drugs or
medications, even if they are over the counter drugs.
Feel free to talk to your service provider about any questions and concerns that you
might have.
Share with others how mental health services have helped you and the people for
whom you care.
Encourage people to discuss their challenges with a community leader who may be
able to influence individuals with a mental illness to seek care.
Strategic Approaches
Channels
Illustrative Activities
Community
Mobilization
Community outreach
activities
Community
conversations and
supportive materials
24
Strategic Approaches
Channels
Illustrative Activities
Establishment of
support groups
Media-oriented
TV/Radio
TV/radio spots
(dramas)
Testimonials of other
caregivers
Clinic-focused
Face-to-face
counseling at health
services
Print materials with
facts about mental
illnesses and their
prevalence, prevention
of mental illness,
promotion of mental
health and well-being,
location of facilities
that provide mental
health care
Audience 4: Individuals who have not accessed any mental health
services
This group represents a diverse range of ethnicities, ages, genders, religions and socio-economic
statuses. They may be medically eligible for mental health services or not.
The mental health of those eligible for services can range from very severe mental illnesses to
more minor and often overlooked illnesses. Individuals with severe, undiagnosed mental illnesses
are often locked up and hidden away from the rest of the community, due to the belief that they
have been cursed with their condition.
Individuals who have not accessed any mental health services are likely to have incomplete
information about available mental health services or have misconceptions about mental illnesses
in general. This group comprises most of the community and is likely to be influenced by the
media, community leaders, family members and peers.
Communication Objectives:

Increase awareness among individuals who have not accessed any mental health
services about mental illnesses and available care and treatment.
25




Increase awareness of individuals and their families about signs and symptoms that
indicate a need to access mental health services and empower them to seek services
for themselves and others.
Enable individuals and families to identify which health facilities provide mental health
services.
Empower individuals and families to discuss concerns and share what you have learnt
about maintaining mental and emotional wellbeing, signs and symptoms that indicate
the need to access mental health services as well as available services with other
community members.
Empower individuals and families to maintain good mental health and wellbeing and
set a positive example for others.
Key Messages:




Make sure to prioritize your health and wellbeing by taking good care of yourself and
seeking the support of other community members, support groups or services.
You can maintain your own mental health and emotional wellbeing by adopting
healthier lifestyle.
Severe mental illnesses can be prevented by diagnosing and treating symptoms early.
Mental illnesses can be managed with correct treatment obtained from health
facilities providing mental health services
Strategic Approach
Channels
Illustrative Activities
Community mobilization
Community outreach
activities
Community
gatherings/conversations
and supportive materials
Media-oriented
TV/radio
TV/radio spots (dramas)
Face-to-face counseling
at health services
Print materials with facts
about mental illnesses
and their prevalence,
prevention of mental
illness, promotion of
mental health and wellbeing, location of facilities
that provide mental
health care
Print materials
Materials with information
on how individuals can
26
Strategic Approach
Channels
Illustrative Activities
maintain mental health
and emotional wellbeing
by adopting simple
lifestyle, signs and
symptoms that require
accessing mental health
services, and available
services
Audience 5: Individuals who have accessed mental health services
The number of people currently using mental health services is increasing steadily. They are
mostly adults, residing predominantly in urban areas. It is very likely that this group faces a
number of challenges around stigma, gender inequality, and, on the whole, fear of letting
others know about their condition. In instances of moderate to severe mental illness, it is
possible that this group of people was, or still is, hidden away from the rest of the
community, suffering feelings of disgrace and humiliation. Lack of community support is very
prominent and problems with accessibility and affordability of services are common.
Therefore, individuals with mental illnesses may routinely engage with traditional healers and
practice religious rites such as fasting and using Holy Water in an attempt to cure their
illness. Among the groups that influence their behavior are their caregivers, family members,
peers, health care providers, and religious and community leaders.
Communication Objectives:





Enable individuals with mental illnesses know more about their mental illness and
others as well as available care and treatment.
Empower individuals who started treatment to adhere to medication and advice
provided to by health service providers.
Increase awareness among individual who have already accessed mental health
services about signs and symptoms that indicate a need to return to mental health
services.
Empower individuals with mental illnesses and who have accessed mental health
services to discuss your concerns and share what they have learnt with people who are
close to them.
Empower people who have accessed mental health services to maintain good mental
health and wellbeing and set a positive example for others.
27
Key Messages:









Take your medication as advised by your service provider in order to help improve
your quality of life.
Taking your medication is a commitment and you should not stop unless your service
provider advises you to do so, even if you feel better.
Understand your condition and know about the symptoms it causes.
Seek medical attention as soon as you realize that your symptoms are coming back
or if you feel any other strange symptoms.
If you are taking medicines for your mental health condition, it is very important for
you to consult your health provider if you want to take other drugs or medications,
even if they are over the counter drugs.
Feel free to talk to your service provider about any questions and concerns that you
might have.
It is your responsibility to maintain good health and a good quality of life.
Share with others how mental health services have helped you.
Try to involve a person who is close to you in your health care by talking to them
about how you feel, telling them about your condition and asking them to support
you.
Strategic Approach
Channels
Illustrative Activities
Clinic-focused
Face-to-face counseling
at health facilities
Counseling and clinicbased client education
Community mobilization
Community outreach
activities
Print materials to support
drug adherence
Community gatherings
Community
Community conversations gatherings/conversations
and supportive materials
Media-oriented
TV/radio
TV/radio spots (dramas)
Print materials
Print materials with facts
about mental illnesses
and their prevalence,
prevention of mental
illness, promotion of
mental health and
wellbeing, location of
facilities that provide
28
Strategic Approach
Channels
Illustrative Activities
mental health care
Notes


Communication interventions should maintain a balance between
service demand creation and available services.
The WHO yearly mental health themes should be considered during the
design of communication interventions (for example, depression - a
global crisis, for October 10, 2012).
Implementation
3.1.
Links with Service
Implementation of this Strategic Framework will only succeed if MH communication is closely
linked to available services. During the design workshop, partners identified two means of
creating a strong linkage with services as they become increasingly available:


Provide a list of facilities offering mental health services to all health care providers
including HEWs and HEPs.
Provide referral services and other relevant information to health facilities offering
mental health services through the Wegen AIDS Hotline and the Fitun Warmline.
The Federal Ministry of Health regularly tracks availability of mental health services through
reports from Regional Health Bureaus. This information can be used to compile a list of
health facilities offering mental health services, and can be updated annually and provided to
the hotline, warmline and health providers.
3.2.
Research, Monitoring and Evaluation
Formative Research: Prior to implementing this communication framework, it is
recommended that some qualitative research be undertaken to support the development of
specific interventions. For example, information derived from focus group discussions or indepth interviews with health workers, WHO officers, Health Extension Workers, Health
Extension Professionals, caregivers, individuals who have not initiated care and treatment,
29
and individuals who have initiated care and treatment will be useful in designing specific
materials and activities for them. In addition, all materials and communication tools should
be pretested among audience representatives prior to finalization.
Monitoring and Evaluation: In order to track progress, effectiveness, and reach of
communication interventions, it is necessary to develop a strong monitoring and evaluation
(M&E) system. The M&E system should measure output indicators as well as behavioral
outcome indicators based on the framework objectives. The output and outcome indicators
could include:
Output Indicators:
 Number of people reached through meetings or group discussions.
 Number of radio and/or television programs/PSAs broadcast.
 Number of communities implementing mental health communication activities.
 Number of mental health communication materials produced and distributed.
 Number of mental health advocacy meetings held.
 Percent of audience reached with media messages about mental health and wellbeing.
Outcome Indicators:
 Percent of audience with positive attitudes toward mental health and wellbeing.
 Number of individuals who have accessed health care.
 Number of individuals with mental health illnesses on proper treatment.
 Percent of the community that knows where to go for mental health services.
 Rate of loss to follow-up among individuals on treatment.
 Percent of WHO officers who demonstrate mental health as a priority.
 Amount of federal budget allocated to mental health services.
 Number of individuals seeking mental health care and treatment from traditional
healers
 Percent of caregivers who feel overburdened
 Percent of caregivers who feel there is adequate support services available to them
and the people under their care.
 Percent of Health Extension Workers who refer clients to mental health services.
 Percent of Health Extension Professionals who refer clients to mental health services.
 Percent of doctors who refer patients to mental health services
3.3.
Sustainability, Roles and Resources
In order to ensure maximum efficiency of programming, avoid duplication of efforts and
30
reduce conflicting information and messages about mental health, a mental health
communications working group should be established and comprised of all key stakeholders.
This working group will use the mental health communication framework as a platform for
planning and implementing relevant activities. The group will also develop mechanisms to
coordinate activities to keep one another up-to-date, facilitate opportunities for collaboration,
develop standard approaches and materials that can be used across various audiences,
ensure program activities are linked for maximum impact (when appropriate), reduce
programming gaps, and share high-impact practices and lessons learned.
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