Abstract
In South Africa, neuropsychiatric disorders rank third in their contribution to overall burden of disease. Stigma, lack of mental health awareness, and limited access to health services and to appropriate treatment contribute to the high level of unmet need for treatment of neuropsychiatric conditions. Little is known about how young adults make decisions to access mental health services and how their adult family members influence these decisions. This study explored young adults’ perceptions of the influence their adult family members on their own mental health service uptake. We conducted semi-structured in-depth interviews with a convenience sample of 21 people (18–24 years) from KwaZulu-Natal Province (KZN). Thematic analysis of interviews found that: young people had partial knowledge of mental health conditions and services; both adult family members as well as peers and other community members influenced mental health care seeking behaviours. Participants who had accessed mental health services attested to their long-term benefit. Transition to adulthood was a time of mental health challenges. The results point to the need to scale up community-level awareness on mental health conditions in rural South Africa. This can include targeted education interventions to increase knowledge of mental health, and ways to adjust to the stresses of the transition to adulthood. More research is needed to further understand the gendered dimensions of peers’ influence of mental health service uptake.
Introduction
Mental health conditions account for 11.1% of the total burden of disease for low and middle income countries (Patel, 2007). In South Africa mental health conditions are the third largest source of overall burden of disease (Meyer et al., 2019). Despite this, few studies have been conducted to better understand mental health epidemiology and care needs in South Africa (Burns, 2011). Data from the 2004 South African Stress and Health Survey (SASH) found a 16.5% 12-month prevalence and 30.3% lifetime prevalence of common mental disorders among adults (Herman et al., 2009).
Mental health services in South Africa are severely underfunded with limited resources allocated compared to other national health priorities (Lund et al., 2009). Even where mental health services are available, there is evidence of a treatment gap, with only about 25% of people who require treatment accessing care (Williams et al., 2008). A study conducted in 2015 by Mahlathi and Dlamini reported that 84% of the South African population who rely on the public health system (Mahlathi & Dlamini, 2015) are discouraged from taking up mental health services because of long waiting times, rushed appointments, old facilities, inadequate disease control and prevention practices, and poor quality of care (Naidoo, 2012). Similarly, a 2014 study in the North West province of South Africa found that lack of access to health facilities, lack of awareness of mental health conditions, and lack of appropriate treatment and stigma were barriers to uptake (Egbe et al., 2014). This study also found that many people with mental disorders do not seek care due to poor mental health literacy, which includes a lack of information and knowledge of the signs and symptoms of mental health problems, a lack of awareness of service availability, stigma, and misinformation about treatment (Egbe et al., 2014).
Globally, adolescents and young adults (18–25 years old) are at high risk of mental health challenges. A 2018 survey by the South African Federation for Mental Health (SAFMH) found that 25% of learners (15–19 years old) reported having experienced feelings of sadness or hopelessness, 18% had attempted suicide, and a further 18% had considered suicide (Statistics South Africa, 2020). The 2015 South African Mortality and Causes of Death report showed that nationally, 125 deaths of young people aged 15–24 years old were due to intentional self-harm, including self-poisoning, drowning, strangulation and jumping from a high place (Statistics South Africa, 2020). These deaths accounted for 1.3% of the total number (9,548) of unnatural deaths in this age category in 2015 (Statistics South Africa, 2017).
Mental health problems are common among university students globally, with the 12-month prevalence of common mental disorders estimated to be above 30% in many universities (Auerbach et al., 2018). Early intervention and effective treatment lead to improved outcomes and reduce the morbidity and mortality associated with mental disorders. Yet the mental health treatment gap among university students is marked. Data from 21 countries collected as part of the World Health Organization (WHO) World Mental Health Surveys conducted between 2001 and 2021 indicated that an average of only 6.4% of students with mental disorders received treatment in the preceding 12 months (Auerbach et al., 2016). A study of a sample of first-year students from two well-resourced universities in South Africa found that only 28.9% of students with common mental disorders had utilized mental health care services in the preceding 12 months, despite having access to free student counselling services on campus (Bantjes et al., 2020).
A study conducted in Australia among 18–25 year olds that aimed to understand barriers and facilitators on the pathway to mental health care reported that family has the greatest influence on emerging adults’ intentions to seek help from mental health sources (Wilson et al., 2011). According to this study, young people who feel emotionally competent to express their feelings and have established, trusting relationships with potential help providers may seek help through talking to their family and friends, with family being more important for younger adolescents (Wilson et al., 2011). Results from the Australian Bureau of Statistics 2007 National Survey of Mental Health and Wellbeing (NSMHWB) revealed that 86% of those who did not seek treatment for their mental health problem did not believe they needed any type of professional mental health care (Australian Bureau of Statistics, 2007). Focus group research suggests that such beliefs might be particularly strong for young people (Wilson et al., 2011). An expert opinion study published in 2007 by Rickwood et al., also from Australia, suggested that young people may believe that seeking informal help from sources such as friends and family is sufficient, and thus that treatment is unnecessary. It is increasingly recognized that seeking help for psychological problems proceeds through stages and usually starts with resort to informal sources (Rickwood et al., 2007). Beyond this, little is known about how young people's mental health seeking behaviour is influenced by their adult family members. In this exploratory study, we explored young adults’ perceptions of the types of influences their family members have on their mental health service uptake by: (1) examining young people's understandings of mental health conditions and available services; (2) identifying the influences on young people's mental health seeking behaviours; and (3) reviewing their experiences in seeking mental health services.
Methods
The study draws on the Health Stigma and Discrimination Framework, a global, crosscutting framework based on theory, research and practice, which has been applied to a range of health conditions, including leprosy, epilepsy, mental health, cancer, HIV and obesity/overweight (Stangl et al., 2019). This framework can be used to generate research foci, to explore multiple health issues, and consider the interaction between multiple identities, social inequalities and health issues. In this study, the framework was used as an overarching framework to guide its design.1
Setting
The study was implemented in two predominantly rural districts; uMkhanyakude and King Cetshwayo within KwaZulu-Natal Province, South Africa. These districts are in the northern part of KwaZulu-Natal with a combined estimated population of 1,660,225 accounting for approximately 15% of the province's total population (Statistics South Africa, 2018). Health care facilities are geographically distant from each other. uMkhanyakude has 64 health facilities (19 mobile clinics, 58 fixed clinics, 1 Community Health Centre and 5 district hospitals). King Cetshwayo has 70 health facilities (16 mobile clinics, 63 fixed clinics, 1 Community health Centre and 6 district hospitals). Neither district has a specialized psychiatric hospital (KwaZulu-Natal Department of Health, 2019). The best available prevalence data estimates that mental disorders in KZN province affect 956,000 adults, accounting for 13.5% (Burns, 2014) of a total estimate of 7,029,521 adults living in the province.
Recruitment and sampling
This study targeted rural young adults living in the uMkhanyakude and King Cetshwayo districts. Prospective participants were obtained from a database belonging to Umthombo Youth Development Foundation (UYDF), which operates in these districts. UYDF seeks to address the shortages of health care staff at rural facilities by providing bursaries to rural youth who then work at their local hospital after graduation. Prospective participants were students enrolled in health sciences degrees (such as medicine, dentistry, speech therapy and pharmacy) at various South African universities. The researcher (NM) contacted UYDF's Director to request access to their bursary recipients to recruit for participation in the study. UYDF reached out to all students who met the enrolment criteria to explain the purpose of the study and, with their permission, shared contact details of those who expressed an interest in participating. The researcher (NM) then contacted potential participants to provide additional information about the study so that they could make an informed decision as well as to seek written informed consent from those who voluntarily agreed to participate. Consent forms were in either isiZulu or English based on their preference of language. Using convenience sampling, we sampled purposively for diversity in age and gender. All student details were kept confidential and the UYDF was not aware of which students had participated in the study.
Data collection
For this exploratory qualitative study, we conducted one-off, individual, in-depth interviews, which are appropriate for understanding people's attitudes and experiences (Rubin & Rubin, 2012). Interviews were conducted at the height of the Covid-19 pandemic, therefore as a precautionary measure to minimize the spread of infection, interviews were conducted using virtual platforms (Skype, Zoom, or MS Teams as preferred by participants). Video was not used, in order to save bandwidth. Each interview lasted approximately one hour. We used a semi-structured interview guide that included four topic areas: (1) Getting to know the participant and their family history, which helped us get an understanding of their background and the relationship with their families; (2) Participants’ health belief systems relative to their adult family members’ health belief system. This area explored participants’ own health belief systems to gain their understanding of mental health conditions and the services available; (3) Participants’ perceptions of their adult family members’ knowledge, attitudes, and biases about mental health issues; and (4) Participants’ lived experiences of stigmatization, whether enacted or anticipated, including self-stigma, around mental health from their families and wider social network. Interviews were conducted using a mix of Zulu and English which both the data collector (NM) and participants were fluent in.
Data analysis
The interviews were audio recorded and transcribed. Notes were also taken during the interview. The data analysis process relied on transcribed data captured from the 20 interview recordings. Case descriptions of each participant’s responses were developed and compared to establish distinct concepts and broad themes. The second phase aimed at further coding the broad categories to identify more specific themes. The data analysis process was done manually by the researcher.2
Ethical considerations
The project was reviewed and approved by the Stellenbosch University Health Research Ethics Committee (HREC) reference number: S21/07/138. UYDF provided approval for students in its database to be contacted by telephone to explain the purpose of the study and invite them to participate. Potential participants were then emailed informed consent forms which they reviewed, signed and emailed back. All interviews were conducted in a private space (e.g., home, student residence, park, etc.) that was sufficient to maintain participant confidentiality.
Findings
A total of 20 participants were interviewed: 10 women and 10 men, between the ages of 18 and 24 years old with a median age of 21.5. Of these participants, eight had accessed mental health services (five women, three men).
Knowledge about mental health conditions and services
During interviews, participants expressed levels of understandings of mental health conditions. Generally, participants noted that: “Mental health has to do with being in a healthy state of mind.” One participant indicated that they were not aware of mental health conditions until they enrolled in university: “For the longest time it was something I never took serious, I thought mental health conditions rarely affected Black people” (Male, 23). It was through a university module on mental health conditions that he learned that these conditions could affect anyone regardless of race. Some participants provided more detailed answers: “Mental health conditions refer to neuropsychiatry conditions that can affect anyone, some of the conditions include depression, anxiety and bipolar” (Female, 22). “Mental health conditions have to do with not being in a good state of mind causing stress and anxiety” (Female, 23). All participants were able to name more than one mental health condition such as bipolar, depression, dementia and schizophrenia. Additionally, participants were able to indicate resources and services that could be accessed for mental health support, including primary health care facilities, counsellors, social workers and psychologists.
A 22-year-old male participant relayed a story about their neighbour who claimed that he could see and speak to God. The community did not regard this behaviour as a concern, nor was it identified as a mental health condition. There was a belief that he had supernatural powers. This participant indicated that, having taken a module on mental health in university, he was of the opinion that this was a mental health condition: “I understood this behaviour as delusion of grandeur which is a form of a mental health illness.”
Participants indicated that in their community, health conditions were likely to be classified as illnesses requiring traditional interventions and not Western practices. They reported that mental health conditions were associated with witchcraft in their communities, and therefore seen as requiring intervention by a traditional healer rather than a primary health care facility or other medical service. One participant shared that two of their siblings have been diagnosed with schizophrenia. He recalled: Before the family referred them to health facilities, the family consulted traditional healers as they believed that the siblings had been bewitched, it took my father a lot of convincing before he agreed to have my siblings referred to mental health services.
Participants who came from religious homes, which were predominantly Christian, shared similar experiences in terms of their families’ approach to mental health conditions. The adults in their families did not view mental health illnesses as conditions that required medical intervention. The young people were encouraged to “pray, read the Bible or speak to a pastor,” because, according to the elders, mental illnesses involved demonic behaviour that could be cured by spiritual deliverance.
The influence of family members and others on help-seeking
All participants considered the views of others in seeking mental health services. While some participants took into account the views of their adult family members, others, especially young men, strongly considered the perceptions and experiences of their friends in seeking mental health services. Enacted and anticipated stigmatization, as well as self-stigma, around mental health from their families and wider social network played a role in informing the decision of some participants to seek mental health services or not.
All participants who had used mental health services described getting advice to do so from family members or peers. A 22-year-old man indicated that he had a friend who suffered from a mental health condition and who spoke quite openly about his struggles with depression and that he was seeking professional help. The friend spoke about how the condition affected his emotional wellbeing and how being able to seek medical advice helped him cope. The participant reported: It was encouraging seeing someone close to me who had experienced similar struggles to what I was facing. Seeing him being open about his issues made me realize that I could get help too. I was also motivated that our circle of friends didn’t think this was an anomaly and there was no judgement. My friend talked me through the process and encouraged me to speak to someone. It was through this support that I booked an appointment and started consulting with a psychologist.
Participants who opted not to utilize mental health services were also influenced by family members and peers. Their anticipation or experiences of negative judgements, rejection and ridicule deterred them from seeking mental health services. For example, a 24-year-old male said that mental health was not something he had a clear understanding of until he was in university. This participant indicated that despite learning about various conditions, symptoms and available services, he was “uncomfortable” at the thought of sharing his feelings with a stranger. Taking that step would be an admission that he was unable to deal with his problems. Most worrying for him, however, was the concern that his circle of friends would see him as weak.
A 20-year-old man who was struggling psychologically and emotionally, and this was affecting his academics, did not seek mental health services but decided to temporarily interrupt his studies and return home. He opted to be around his family because he thought this would improve his condition. As a young man in a rural area, he was expected to be out with other young men at all times, whether attending imicimbi3 (ceremonies) or herding cows. However, he indicated that all he wanted was to be by himself. This participant recalled the comments of his uncle as follows: You are a man, you should be out doing what other men do and not lock yourself in the house as if you are a woman. Don’t let life get you down. We all go through these things. It will eventually go away.
Others also expressed this view of the need to deal with problems on one's own. For example, a 24-year-old man saw managing his mental health stressors as part of being an adult: I don’t understand how someone else can solve my problems, I’m the one dealing with the hardships. My friends have gone through similar experiences, and they were fine, it's all a matter of time, things will eventually settle, and I’ll be okay.
Experience of those who accessed mental health services
Participants who had accessed mental health services indicated that they were unsure of what to expect, but once they attended services the benefits became clearer as they found it easier to be comfortable and to effectively implement recommended coping strategies. For example, a 24-year-old man reported that he made use of mental health services after agonizing over the decision for about three months: I had been unwell for about three months, I kept hoping it would go away but it did not. I always felt tired, the smallest things seem to upset me, and I generally felt like I was not coping, and I wasn’t sure who to speak to. I suspected that I might be depressed and eventually booked an appointment with one of our online counsellors.
A 22-year-old male recalled that he was very uncomfortable with the recognition that he might have a mental health condition, let alone that he needed to seek help. His ongoing difficulties coping with his emotions and even with simple life challenges forced him to seek help: I was very unsure when I visited the facility, unsure what to say, what to do and what the nurses would think of me. I, however, encountered an old nurse who was very kind and made me feel comfortable in talking about my struggles. I felt really good just from that one visit which encouraged me to go for a follow up visit.
Transition to “adulthood” as a time of mental health risk
Participants said that young people are prone to being affected by mental health conditions. According to them, the transition after completing secondary school—whether to higher education, workforce or unemployment—was extremely challenging. This transition triggered feelings of uncertainty and emotional upheaval, which in some cases spiralled into mental health conditions. For example, a 21-year-old woman recalled being forced to take a gap year after she completed her secondary school leaving examination as she was unable to enrol into university. She struggled with depression for months without talking to anyone. She recalled: At the time I wasn’t sure what was wrong with me, I knew I was not okay emotionally, but I didn’t know how to explain this to my family, I had not even considered speaking to a health professional as I wasn’t aware that this was potentially a condition that one could seek professional help for.
Similarly, another 20-year-old man decided to temporarily interrupt his studies and return home as he was struggling with the academic transition from high school to university, and this affected him psychologically and emotionally. This young man's struggles were exacerbated by the family's expectation that he graduate and financially support his three younger siblings. Struggling at university and potentially not being able to provide for his siblings meant he was failing himself and his family. This weighed heavily on him but he said: “The last thing I thought was that I needed to work on my mental health so I could deal with other issues affecting my personal life.”
A key recommendation from this group was that mental health should be taught in secondary schools, possibly as part of the “Life Orientation” module. According to participants, the earlier young people learn about mental health conditions and services available for support, the better their chances of being able to identify symptoms amongst themselves or others and access mental health services appropriately.
Discussion
This exploratory study aimed to explore young adults’ perceptions of the types of influences their adult family member have on their mental health service uptake in KwaZulu-Natal. We found that young adults who were university students in the health professions had some knowledge of mental health conditions and available services. They were strongly influenced by others (adults and peers) in deciding whether to access mental health services. Those who had accessed mental health services found they had long-term benefits. All of the participants considered the transition to adulthood to be challenging and a time of increased risk for mental health conditions.
Our findings are similar to those of a mixed-methods study that explored factors that influence the uptake of mental health services in sub-Saharan Africa, which found that barriers included: stigma/discrimination, poor knowledge, poverty/inability to pay for services and belief in spiritual causes/traditional healers (Ibiloye & Essat, 2020). In our study, participants also identified traditional beliefs associated with mental health conditions as a barrier to accessing mental health services. Participants expressed that in rural communities, mental health conditions are more likely to be seen as an outcome of witchcraft. A national survey conducted with 3,651 adults in South Africa between 2002 and 2004 using the World Health Organization Composite International Diagnostic Interview (CIDI) found that traditional healers were consulted by 9% of the respondents while 11% consulted a religious or spiritual advisor (Sorsdahl et al., 2009). As a result of the association of mental health with witchcraft, there was a higher probability of being referred to a traditional healer as opposed to a psychologist, social worker, etc. This is further supported by Sorsdahl et al.’s (2009) study which explored the use of traditional healers and other forms of alternative care for the treatment of common mental disorders in sub-Saharan Africa. They found that depending on the family's belief system, some participants were referred to traditional healers while those from religious homes were referred to their spiritual advisors such as pastors.
Our study found that one of the reasons participants opted to not seek mental health services was the belief that they could cope on their own or self-treat. The coping strategies or self-treatment cited by participants included integrating physical exercise into their daily routine, self-isolation and, at times, the minimization or denial of symptoms. A qualitative study conducted with data extracted from the SASH survey to examine structural and attitudinal barriers to treatment initiation among South Africans with mental disorders and to investigate predictors of treatment dropout revealed similar findings (Bruwer et al., 2011). In the SASH survey, face-to-face interviews were conducted with 4,315 adult South Africans living in households or hostel quarters (Herman et al., 2009). The most frequently cited reason for not seeking professional help was a low perceived need for treatment (Bruwer et al., 2011). The SASH study further indicated that among those who recognized the need but did not access treatment, attitudinal barriers to treatment seeking were reported more frequently than were structural barriers (Herman et al., 2009).
Participants in our study reported that, in seeking mental health services, they took into consideration the perceptions of their families. A similar finding was reported by Moses (2010) in a qualitative study that examined adolescents’ perceptions of being treated differently because of mental health problems by family members, peers and school staff. He concluded that efforts to combat stigmatization of youth with mental health disorders must help family members, peers and school staff overcome their inclinations to make negative assumptions and discriminate against these youth (Moses, 2010).
Participants cited stigma as one of the biggest influences in accessing mental health services. Having grown up in families and sometimes communities where there was limited understanding from a scientific perspective of mental health issues influenced their own understanding and acceptance of mental health conditions even when they were exposed to health information in university. Most participants recalled witnessing, as a familiar sight, individuals being stigmatized because of their mental health conditions and this became a barrier to their own uptake of services. The risk of receiving a lifetime label as “uhlanya” (lunatic) was cited as a strong deterrent to seeking professional help. Findings of a qualitative study that explored the experiences of psychiatric stigma by service users in order to inform interventions to reduce such stigma and discrimination in South Africa echo the sentiments shared by participants in our study (Egbe et al., 2014). Egbe et al. (2014) found that psychiatric stigma was perpetuated by family members, friends, employers, community members and health care providers. Misconceptions of mental illness linked to traditional health beliefs often led to delays in help-seeking.
Participants who had family members with a better understanding of mental health conditions and related services were more likely to access these services. Participants emphasized a need to provide mental health awareness to adults including the sensitization of secondary school teachers to support efforts for early identification of mental health symptoms. Those participants who had sought mental health services attributed this to the support they received in disclosing their symptoms to their families and friends. We found that having family or friends who had accessed mental health services and had obtained positive outcomes were key drivers in young adults’ own decision to seek these services. This is consistent with the study by Ibiloye and Essat (2020) which found that facilitators of uptake included positive health outcomes and testimonies of other service users.
This study addresses a major gap in the literature by focusing on young adults’ mental health seeking behaviours and how these are influenced by adult family members. A strength is that the semi-structured in-depth interviews allowed participants to provide detailed descriptions of their own experiences and understanding of mental health services. The study has important limitations including its relatively small sample size of participants who were university students in health professions recruited from the UYDF, an organization supporting rural youth. The findings should therefore be extrapolated with caution, and only to similar settings. The interviews were conducted via teleconferencing platforms with the video turned off. Hence, we were also unable to analyse participants’ body language or non-verbal cues of their comfort in response to questions. We did not collect much detail about participant's own mental health experiences but focused on their perceptions of influences on these experiences as well as their advice for how we might improve mental health services.
Conclusion
Many studies suggest that traditional beliefs are an important factor in delaying seeking mental health services in rural areas of South Africa (Sorsdahl et al., 2009). In contrast, we found that some families from rural settings, despite upholding traditional beliefs, positively influenced mental health care seeking. This may be due to changing social norms and greater access to information, or be an artefact of the sample, which was composed of young adults who were health professional students recruited through a development NGO. However, given the modest level of knowledge of mental health among this relatively educated group, we suggest that there is an urgent need to scale-up community-level awareness programmes on mental health conditions in rural South Africa. In doing this, it will be important to engage traditional leaders and healers in the design and implementation of programmes. Studies show that satisfaction with care administered by healers is high in many cases for individuals with mental disorders (Abbo, 2011) and evidence also indicates that delays in accessing formal mental health services are common where healers feature in the pathway to care (Stein et al., 2013). Further, lecturers should be engaged to support university students in increasing their knowledge on mental health conditions, especially in preparation for a time of mental stress as they transition to adulthood. More research is needed to further understand the gendered influence of peers on young people's mental health service uptake and how best to support the transition to adulthood.
Footnotes
Acknowledgements
I hereby acknowledge Umthombo Youth Development Foundation (UYDF) who provided approval to access study participants who played a big role in providing valuable data as part of this study.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Graeme Hoddinott received financial assistance from the European Union (Grant no. DCI-PANAF/2020/420-028), through the African Research Initiative for Scientific Excellence (ARISE), pilot programme. ARISE is implemented by the African Academy of Sciences with support from the European Commission and the African Union Commission.
