FAMILY SUPPORT AND RESILIENCE AMONG DEPRESSION SURVIVORS:

A CASE OF CLIENTS OF STRONG MINDS IN WAKISO DISTRICT

List of Abbreviations

WFMH- World Federation for Mental Health

WHO- World Health Organization

MDD- Major Depressive Disorder

DE- Depressive Episode

MD- Major Depression

MDE- Major Depressive Episode

WMHS- World Mental Health Survey

NIMH- National Institute for Mental Health

APA- American Psychological Association

CBT- Cognitive Behavior Therapy

ECT- Electro Convulsive Therapy

ICD- International Classification of diseases

DSM- Diagnostic and Statistical Manual of mental disorders

SSRIs- Selective Serotonin reuptake Inhibitors

UBOS- Uganda bureau of statistics

IPT-interpersonal psychotherapy

SMI- Severe Mental Illness

CHAPTER ONE

1.1 INTRODUCTION

Depression is one of the common mental health disorders sometimes referred to as “mood disorders” (WHO, 2012). So, this chapter will look at the definitions of; Mental Health as viewed by different scholars; depression as a mental health disorder; depression survivors, resilience, support provided by family members to depression survivors, protective factors; the background of the study, purpose of the study, the problem statement, conceptual framework, the objectives of the research and lastly research questions and hypothesis.

Depression is defined as, “a mental illness characterized by feelings of low energy, feelings of guilt, hopelessness, worthlessness, sadness, depressed mood, suicidal tendencies, loss of interest among other symptoms (WHO, 2012; APA, 2013). However these depressive symptoms vary from mild, moderate to severe episodes. Even so, not all people have the same depressive symptoms, it should be noted that depression varies from person to person (APA, 2013). For one to be diagnosed with depression, according to DSM-5^th edition, he / she must experience five or more symptoms during the same two weeks and at least one of the symptoms should be “depressed mood or loss of interest” (DSM 5^th edition).

World Health Organization (WHO, 2015) defined mental health as, “a state of well being in which the individual realizes his or her own abilities, can cope with normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her community”.

According to the Global Burden for Disease study (GBD, 2010) and World Health Organization (WHO, 2017), depression alone was observed to be the single leading cause of disability worldwide (11% of all years lived with disability) and is the single major contributor for the over- roll global burden of diseases with an estimate of 4.3% (WHO Action Plan, 2013- 2020).

However, certain contributing factors have been linked to / are thought to contribute to depression and these include; genetic factors (hormonal levels), environmental and sometimes certain illnesses like HIV/AIDS, Corona virus, diabetes; loss of a loved one; sometimes certain medications may also cause depression. Depression may also occur due to “un- known” causes affecting any one irrespective of age, gender, race, religious affiliations, culture or social status (Garcia, 2019).

WHO report (WHO, 2017) ranked Uganda among the top six countries out of the 50 African countries with the highest number of people suffering from major depressive disorders with northern Uganda being the highest region affected according to a Wayo Nero study (2014). According to this Wayo –Nero Study of 2014, it was observed that at least three out of ten people had MDD with females at 29% and males at 17% according to a distribution by gender (Wayo Nero Study, 2014-2015).

Furthermore, a recent analysis on mental illnesses according to an analysis by Ministry of Health Information System (DHIS, 2019) Lukwata (Daily Monitor, 2020) affirmed that Butabika National Referral Mental Hospital in Kampala District recorded the highest mental cases of 40,588 in the country followed by Gulu district whose regional referral mental hospital recorded 20,994 cases then Wakiso district with 11,723 cases. In Uganda according to Musisi & Owiny (Daily Monitor, 2020) statistics showed that the leading mental illness cases between the years of 2015 and 2018 were alcohol abuse followed by depression with cases at 43,873 and 38,226 respectively.

According to a Mental Health Care Uganda journal by Molodynski (Molodynski, 2017), observed that 35% of Ugandans suffer from some form of mental disorder of which 15% require treatment (Basangwa, 2004; Ndyanabangi et al, 2004; Bailey 2014), yet many families of those afflicted by mental illnesses like depression still prefer to seek treatment from traditional healers or their local churches before seeking proper medical services (Kizito, 2012; Bailey, 2014).

Uganda Bureau of Statistics (UBOS, 2006 – 2013) estimated that seven percent of households in Uganda had a disabled member of which 58% had at least one person with mental illness. Due to the over whelming numbers of mental illness in the past, Butabika Hospital which was opened in 1955 now operates as the National leading Referral mental institution in Uganda and offers a range of services which include; inpatient (750 at one time visiting) and outpatient (about 100 who come daily (Basangwa, 2010); other services include; mental care, psychiatric training, community education and resettlement assistance (Butabika Hospital, 2017).

Families are known to be the major source of care, support and love, sometimes that support may be a cure for depression (according to an article by Kyotalengerire,  New Vision, 2020). Families or care takers have been known to contribute emotionally, financially and socially. Emotional support can sometimes be a great source of recovery according to family systems theory (Bowen, 2000; WHO, 2017). Families have a huge impact on depression but it should also be noted that depression also has a huge impact on families (Strong Minds, 2015). Family members may offer support to the depressive person inform of reminding them to take medications, listening to them or encouraging them to comply with other treatments thereby enabling the depression survivor to be able to recover quickly or bounce back.

In addition even with family support, there are still many hindrances preventing proper treatment for mental illnesses such as depression. For instance, it is important to note that there is still a lot of stigma associated with depression (Ssebunnya et al, 2009; Molodynski, 2017); other factors such as poverty also undermine the care giving duty (Bailey, 2014). Care givers have been noted to invest a lot of time and will in order to meet the patients’ basic needs. These needs could be in terms of food, shelter, finances for transporting the patient to receive treatment or paying medical bills (MacLeod, 2018 ); other aspects such as spiritual nourishment is also a part of the care givers’ un- described role (Koenig et al, 2012; Bonelli et al, 2012).

1.2 .0 Background of the study

1.2.1 Historical Background of the Study

Globally, 300 million (an equivalent of 4.4% of the world’s population) people majority of them women are living with depression (WFMH, 2012, WHO, 2015). Strong Minds asserts that depression is one of the most neglected health problems especially in Africa despite the growing factors that contribute to its ever increasing rates such as conflicts, extreme poverty, unemployment, sexual violence, widowhood among others (Strong Minds, 2015). In Africa, Strong Minds noted that 90% of Africans suffer from depression (90 million) of which 60 million are women who have no access to effective treatment. According to a report titled “depression and other mental disorders” released by WHO conducted in 2015, Djibouti was reported to be the most depressed country in Africa with 5.1% of its population depressed (CGTN, 2015).

A UN article, (2014) and WMHS (2012) both asserted that almost every year, nearly one million people die due to suicide related to depression most of whom are females. In addition, according to the World Mental Health Survey carried out in 17 countries, it was observed that 1in 20 people reported to have heard a depression episode in the previous year (WMHS, 2012) thus ranking depression third in the global burden for diseases and is projected to rank first by 2030. In East Africa, Uganda in particular mental illnesses like depression have traditionally been considered a curse with the treatment provided for by traditional healers in the form of casting out evil spirits or performing ritual sacrifices to “appease the gods” (Kiwawulo, 2010; Nsereko, 2017). This could be attributed to; fear associated with stigma, lack of knowledge for what mental-ill health is and a lack of awareness for proper treatments available.

Additional research by Strong Minds and World Health Organization (Strong Minds,2014; WHO, 2017) both argued that depression afflicts women twice as much as their male counterparts causing severe impacts that range from physical to mental disability none the less, depression is known to affect families. For instance, Strong Minds Organization (2014) observed that children whose mothers suffer depression may tend to have “less secure attachment” relationships, “malnutrition” may also occur in such families and this may result into other consequences such as “low school attendances” (Strong Minds, 2014).

There are many organizations in Uganda that deal with mental illnesses such as Mental Health Uganda, Butabika hospital but one of the leading organizations in Africa and Uganda seriously addressing the issue of depression is Strong Minds according to a BBC pod cast titled, “People fixing the world”(Katsana BBC World Service, 2020).Through the use of Group Interpersonal Psychotherapy (IPT-G), Strong Minds has treated about 5,000 depressed women of which 3,200 women were recorded to have been reached by the Strong Minds Staff-led peer Groups, with another 1,200 depressed patients currently receiving treatment from the volunteer peer-led groups (Strong Minds Impact evaluation report, 2014- 2015).

IPT-G was first tested by Johns Hopkins University in rural Uganda (JHU, 2002) and found to be cost effective; the approach (IPT-G) was discovered to suite the African culture whose roots are communal based (Bolton et al, 2003; Strong Minds Impact evaluation report, 2014-2015). This approach (IPT-G) uses models such as role plays and the use of other visual charts as a way to effectively communicate to group members in order to enable them identify their depression symptoms and triggers. IPT-G has proven to be very successful in combating depression with success rates of nearly 93% and almost 300-400 women have treated each year for depression by Strong Minds (Strong Minds, 2014/2019 report).

Organizations like Strong Minds therefore aim not only at resolving the current depression states of patients but also equipping them to further prevent future depressive episodes from reoccurring since most depressed people tend to relapse from time to time (Strong Minds, 2014). This is done by encouraging depression survivors to maintain good social net works among the group members coupled with other resilience boosting strategies in order to avoid relapse.

Similar studies on depression have been carried out in DRC Congo in 2013 by Johns Hopkins Bloomberg School of Public Health with the aim of reducing depression among female sexual violence survivors and achieved a 90% success rate in the reduction of depressive episodes. Another yet important study carried out in Uganda by Strong Minds in 2014 was a pilot study to assess whether IPT-G approach was effective in treating depression in Uganda. The method used was quantitative research method which comprised of 244 depressed female participants participating in the treatment intervention while the control group had 36 depressed females all from different parishes and towns (Bulenga and Maganjo respectively) within Kampala suburb.

In this pilot study conducted by Strong Minds (2014) which was termed as , “phase one”, the Patient Health Questionnaire-9 (PHQ-9) which is a quantitatively based depression diagnostic tool was used to assess patients. Patients were recorded at pre-assessments. Interpersonal psychotherapy as an approach was used and this took about five-16 weeks; then again a post – assessment was recorded during week 17.The results according to Strong Minds (2015 impact evaluation report) were as follows:

The results according to this pilot study showed an increase in depression free rates with 92% of the patients declared depression free after 16 weeks of IPT-G intervention; this also had an impact on the lives of these depression survivors and their families with most of them gaining satisfactory employment (12%); most of these women reported eating regularly (13%), most families also appeared to be housed probably due to increased incomes. Additionally, the children of these depression survivors now seem to be attending school more regularly (15%) and above all, most of these survivors seem to have built stronger social networks that act as support for them (22%).

It should be noted however that Interpersonal Psychotherapy (IPT-G) is not the only approach available; there are other approaches such as Cognitive Behavial Therapy (CBT), Behavioral Activation, and use of antidepressants like selective serotonin reuptake inhibitors (SSRIS).

IPT- G when applied in the African context is still the most cost effective and efficient approach (Strong Minds, 2014). Today, according to Strong Minds Impact evaluation reports, (2015-2019), 75% of depression survivors still continue to meet even after group terminations and have continued with their strong social networks even outside their daily struggles.

When one experiences a traumatic or disastrous experience which then leaves them with a negative emotion but is able to work through those emotions, bounce back and thrive, that is then known as “resilience” (APA, 2014). According to resilience studies by Todd & Rotternberg (2010), they noted that resilience factor is an important element when it comes to achieving appropriate mental health. Rudwan argues that, the presence of resilience indicates one’s ability to deal with everyday stressors and overcome them despite daily challenges of life (Rudwan, 2018). Belgrave et al (2000) and Herrman et al (2011) both agree that resilience cuts across all age groups and can be applied to children, adults, elderly and adolescents ranging from various ethnic groups to people of different social economic backgrounds.

Since there is a link between reduced depression and improved physical wellbeing of most depression survivors, the results therefore are; these survivors now become enabled to continue to function well and perform their family tasks such as nurture their children, perform other household duties among others as they now have been equipped with techniques to avoid relapse or re-occurrence of future depressive episodes such as maintaining strong social support systems and seeking counseling (Strong Minds, 2015).

1.2.2 Theoretical Background of the study

Several depression theories have been proposed to try to explain the concept of depression differences between gender ; the role of resilience among depression survivors and how these survivors are able to bounce back even after a traumatic experience. These theories include; Biological / hereditary differences theory (Wilhelm, 2003); Gender Based role identity theory among others. This study however will be guided by the Family Systems Theory developed by Dr. Murray Bowen (1978).

1.2.2.1 Biological / Hereditary differences

This theory focuses its attention on hormonal differences between males and females (Wilhelm, 2003). Biological theory looks at issues such as estrogen depletion which is responsible for menopause in women with symptoms such as hot flashes thus an increase in depressive rates more in women than men. Other issues such as pregnancies, menstruation may also contribute to depression rates being more common in women than in men (WFMH, 2012; Basangwa New Vision, 2019).

Important to note is that while women experience menopause, men too undergo a similar symptom called mid-life crisis. With mid-life crisis, feelings of unhappiness, worry and disappointment are experienced. Some individuals (between the ages of 45-65years) may feel trapped in an identity / lifestyle they experience as constraining hence the need to make changes in their lives. Numerous studies in developed countries have confirmed that there is a link between family support and depression. The relationship between these variables can based be explained using the gender based role theory.

1.2.2.2 Gender Based Role Identity Difference

This theory looks at the roles of males and females in our society for instance; there are certain gender roles that are limited or labeled as “female roles”, for example a woman’s role as a mother, wife, care taker among bucket load tasks contribute to stress in everyday life (Basangwa New Vision, 2019) . So this theory will illustrate how gender differences influenced by environment may lead to depression. Certain family responsibilities put women at a greater risk of depression compared to men. Christine (2017) also noted that there are certain gender inequalities that can affect women’s mental health or attempt to explain the gender gaps in depression for instance she stated issues such as gender work place harassment,  discrimination at certain careers that may lead to one getting depressed, among others (Christine, 2017).

In addition, according to an article by Nakasujja (New Vision, 2019) noted that there are more women visiting Butabika hospital due to a lot of pressure on themselves. Basangwa (New Vision, 2019) also observed an increment in the number of females who visit Butabika hospital (450 out of the 950 were women with depression) and this could be attributed to reasons such as;“a lot of competition to be the perfect wife, best mother, best employee and this can be over whelming and can lead to depression especially when they fail in any role” then judge themselves for that failure (Basangwa New Vision, 2019).

According to Chimamanda, in her book titled “we must all be feminists”, she asserts that most women in many African cultures “are taught to be competitive amongst themselves right from childhood to adult hood; taught not to openly express their thoughts as its not lady-like or not to complain as this is seen as a sign of weakness” (Chimamanda, 2014). Competition when unhealthy tends to lead to stress and these unexpressed thoughts as they pile up may cause worry which can later result into depression although many people might view depression as a sign of laziness (Zartaloudi,2011).

Additionally, male roles such as the provider, protector may also contribute to everyday stress especially when they fail or face challenges meeting these requirements. Zartaloudi (2011) in a Health Science journal stated that there is growing evidence that supports that men too are equally prone to depression as women are although with most men, they tend to suffer silently not seeking treatment for depression but instead, may talk about other problems such as alcohol and anger issues (Zartaloudi, 2011).

Marriage is viewed by each partner differently and so are the roles involved also viewed differently in the eyes of each spouse depending on one’s up bringing (Wilhelm, 2003). Since our societies have labeled women in the past as “child care takers” (Hong &Coogle, 2016) this stereotype is hard to break and the tradition has continued over time however, it is important to note that there are some families today with men as the care takers (Mc Donnell & Ryan, 2013).

1.2.2.3 Family Systems Theory

Family systems theory was developed in the fields of clinical psychology and psychiatry which used psychotherapeutic methods intended for families. Murray Bowen (1978) argues that a family is “an emotional unit” whereby one member of the family cannot be looked as an individually or in isolation but rather as a part of the family (connectedness to each other) to which he /she belongs. Each family member has a role to play and in every family there are set rules that each member must respect in order for the family to function well. It is important to add that families are interconnected together with the environment so when there is a disruption in the family system this will affect other parts of the extended structure (Moleli, 2017).

Family Systems theory looks at the roles and responsibilities of family members in order to have a functional family (Bowen, 2000) for instance, when a family member is depressive, other family members may come in to perform the tasks or duties of the depressive member for example by providing care and support to the patient; support could be in terms of finances, spiritual or social support (WHO, 2017). When other family members fail to take on the slacking tasks, then this disrupts the whole family structure creating arguments that may lead to development of dysfunctional families in the long run.

Hendrick & Young (2013) asserted that family members should focus their attention on positive related factors that may help the depressive person recover quickly for instance instead of lowering the patient’s self esteem, as a family, other members can work on ways to improve the depressive person’s resilience to a given situation for example acting as a listening ear to the patient and other support roles so as to avoid recurring episodes; or by finding other ways that boost depressive family member’s self esteem as a family. According to World Health Organization fact sheet on mental disorders   (WHO fact sheet, 2017), stated that support from friends and families played a key role in management of depression. For instance, all family members may decide to plan activities that may foster togetherness and unity and this may be a stepping stone to recovery for the depressive patient (WHO fact sheet, 2017).

1.2.4 Conceptual Background of the study

Family Support is the independent variable and the study will focus on care provided by other family members towards the recovery of depression survivors to avoid relapse. Focus will be on only three dimensions (scales) of family support such as social support, financial and spiritual support. Resilience as the dependant variable will focus on three dimensions such as community support, family coherence and personal competence while Psycho-social wellbeing on the other hand is the moderating variable and will focus on the approaches used by depression survivors to avoid relapsing alongside strengthening protective factors as to build resilience hence avoiding relapse.

1.2.5 Contextual Background

Strong Minds is a non- government Organization founded by Sean Mayberry in 2013 with the aim of treating depression in Africa. Today, Strong Minds is treating women across Africa with other branches in countries like Zambia. In Uganda Strong Minds is located in Kampala and Wakiso districts respectively. The mission of strong Minds is to improve the mental health of women while their goal is to treat 2 million women and girls in Africa by 2025 through the use of IPT-G approach.

Wakiso district is located in Central Uganda and is the country’s second largest city and suburb. Wakiso is boarded by Luwero to the North, Mukono to the east and kalangala in L. Victoria to the south. Coordinated of the district are 0024N; 3227E with head quarters located approximately 20 kilometers (12miles) by road Northwest of Kampala.

1.3 Problem Statement

Depression is a silent killer which affects both males and females but still receives little attention from the public yet it is the 2^nd leading cause of disability with approximately 4.4% of the world’s population diagnosed with it (WFMH, 2012, WHO, 2015). According to Moeti (World Mental Health day, 2017) asserted that Depression alone affected an estimate of 10% of employed people globally causing them to take time off from work averaging about 36 work days lost as a result of depression (Moeti, 2017).  Due to the ever increasing numbers of people suffering from mental illnesses like depression, 10^th October was declared World Mental Health day (WFMH, 2012, Odoki, New Vision, 2018); Its goal is to create awareness, educate people and end stigma associated with mental illnesses across the world (Moeti, 2017).

Youth and young adults are the most affected with mental illnesses such as depression with more than 50% of mental illnesses appearing before the age of 14 years then 75% re-appearing by age 24 (Odoki, New Vision, 2018). The prevalence of depression globally is that nearly 300 million people suffer from it (WHO, 2015); in Africa, about 90 million people suffer from depression (StrongMinds, 2015). In Uganda 1,747,769 cases (4.6%) of depressive disorders were recorded and 332,539 total years lived with disability as a result of depression (according to African exponent, Wabai 2019). Regionally in Kampala district, Butabika national referral hospital alone reported 4,394 first time admissions and 1,752 re-admissions (in-patient and out-patients respectively. At other regional hospitals in Uganda, between 170 and 360 were seen at in-patients and 748 and 2500 are seen at out-patients a year (WHO proMIND country report, 2012).

Even with the ever increasing mental illness cases in Uganda, only one percent of Uganda’s national budget was directed towards primary care and psychiatric services as reviewed by WHO-AIMS tool (Bailey, 2014). This means that a larger percentage of those affected by mental illness like depression may not be able to obtain access to proper treatment.

Organizations such as Strong Minds through their approach (ITP-G) have embarked on treating depression across Africa (StrongMinds Impact evaluation report 2014-2015). According to their most recent therapy cycle (3) report of 2018, statistics showed that during pre- therapy, 11% were found to have severe depression, 46% had moderate to severe depression while 43% had moderate depression. During their post therapy (week 14), StrongMinds recorded those with severe depression at 1%; 4% had moderated to severe depression while 14% had mild depression. Those who had been declared depression-free were 81%. This was based on the PHQ-9 depression screening tool (StrongMinds impact evaluation report, 2015).

Nonetheless, mental illnesses like depression can be treated with psychological therapies for example CBT, ECT and or combined with the use of pharmacological medications such as antidepressants although they are expensive (Moeti, 2017; New Vision, 2019). However, with the presence of families that are already available, psycho-education can be provided to them to aid in understanding what and how to handle depression; while to the depression survivor, counseling should be provided in order to help avoid relapses.  So this research will focus on family systems theory which will explain how family support coupled with resilience and protective factors may lead to survivor recovery hence avoiding future relapses and as a counseling psychologist, with continuous sensitization and involvement of family members alongside clarifying and emphasizing mental health counseling for both males and females alike, depression prevalence’s will be reduced.

1.4 Purpose of the study

The purpose of this study is to assess the relationship between family support and resilience of depression survivors among clients of Strong Minds in Wakiso district.

1.5 Objectives of the study

This study will be guided by the following objectives.

1. To establish the levels of family support of depression survivors among clients of Strong Minds, Wakiso district.
2. To establish the levels of resilience of depression survivors among clients of Strong Minds, Wakiso district.
3. To assess the relationship between family support and resilience of depression survivors among clients of Strong Minds, Wakiso district.
4. To examine the mediating effect of protective factors on the relationship between family support and resilience.

1.6 Research Questions

RQ 1.What is the level of family support for depression survivors among clients of Strong Minds, Wakiso?

RQ 2.What is the level of resilience of depression survivors among clients of Strong Minds?

RQ3. What is the relationship between family support and resilience of depression survivors among clients of Strong Minds?

Operational Definitions

According to Medical Dictionary, Depression is defined as “a mental state of altered mood characterized by feelings of sadness, despair and discouragement. There are two frequently used classification systems which include the ICD-10 (International Classification of diseases, 10th edition) and the DSM-5^th edition (Diagnostic and statistical Manual of Mental Disorders, fifth edition).

Depression as defined by American Psychological Association states that depression is a “common mental disorder that presents with symptoms such depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration” (APA, 2013). These symptoms must cause significant distress or impairment and for one to be diagnosed as having depression, he/ she must present with five or more symptoms for more than two weeks.

Well Minds Psychotherapy (January, 2019), on the other hand defines depression as a, “mood disorder which causes persistent feeling of sadness and loss of interest in the things that usually bring pleasure affecting how one feels, thinks and behaves and can in many cases affect our day to day life while” Johns Hopkins School of medicine also defined depression as, “a whole-body illness which involves the body, mood and thoughts affecting the way one feels about things and themselves”.

The US Department of Health and Human Services (2015) defines resilience as the ability to “adapt to, withstand and recover from adversity and stress”.

Rutter (Rutter, 2013) defines resilience as “the ability to have good outcomes even after experiencing serious stresses in life which may be better than that of their counter parts”, who suffered the same adversity.

Resilience as per the American Psychiatrically Association (APA, 2014) is defined as a process of adapting well when one is faced with tragedy, a traumatic event or other significant sources of stress in their lives.

Family responsibility as defined by Levin-Epstein, (2006) refers to, “more than working fathers or mothers caring for children but also includes any worker caring for another family member”.

A structure refers to members of the family such as parents, children and kin while function refers to how families are able to satisfy physical and psychological needs of each member in order to survive (Georgas, 2004).

A theory is a set of interrelated concepts, ideas that have already been scientifically tested and combined to provide clarity, expand our understanding of people, behaviors and our societies.

Depression Episode according to WHO (2017) is defined as an episode that involves depressed mood; loss of interest and enjoyment coupled with an increase in fatigue.

Relapse is defined as

1.7 Conceptual Framework

Conceptual Framework showing the relationship between Family Support and Resilience

Independent variable                                          Dependent variable

Intervening variable

Figure 1: Source: By Literature Review (Zimmerman & Brenner, 2010) (Strong Minds, 2019) (WHO report 2015) (Nsereko, 2014) (Mukalazi New Vision article, 2019), (Moeti, World mental Health day, 2017), (Basangwa, 2004) American Psychiatric Association and DSM-5^th edition (APA,2013, 2014) ,Wilhelm (2003), (WHO 2013-2020), NIMH (2013) Depression Booklet, WHO (2017), Shelton- DSM 5, Resilience scale for Adults (RSA, 2003) and modified by the researcher.

This Conceptual frame work will examine the relationship between family support as the independent variable and resilience as the dependant variable. Protective Factors will be reviewed as the intervening variable between the independent and dependant variable. The aim of this study is to assess the relationship between family support and resilience of depression survivors among clients of Strong Minds using three dimensions of Family support (e.g. social support, financial and spiritual) and Resilience (family coherence, external support and personal Structure) and how protective factors such as (therapy received i.e. IPT-G combined with personal characteristics aid in the treatment for depression in order to avoid relapse. The Family Systems theory will be centered on in order to assess the relationship between family support and resilience of depression survivors.

1.8 Significance of the study

The study may provide further information to future researchers who would like to review studies on depression as literature review for those who intend to carry out similar studies.

The research may benefit Counselors and Mental Health practitioners who deal with depression clients as a guide for research.

The research may benefit policy makers try to understand the importance of mental health & possibly fund mental health research further.

After completing the research, the researcher will acquire knowledge and skills to carry out future research studies.

1.9 Content Scope of the study

This study will focus on Family support in terms of care for depression survivors & a combined influence of Family support, resilience of depression survivors among clients of Strong Minds in Wakiso District coupled with protective factors such as self- esteem and how these survivors tend to hang on without relapsing (i.e. what approaches they use). StrongMinds was chosen because of the work they are doing in trying to treat depression across Africa. StrongMinds is one of the leading Organizations in Africa seriously addressing the issue of depression, treating and training surviours to carry out their own volunteer therapy groups with success rates of nearly 93% so that in the event of a relapse, survivors and new recruits can still be able to support one another even without the presence of a staff member from StrongMinds (StrongMinds, 2014; BBC pod cast, 2020) therefore, the researcher would like to assess family support of those who have passed through StrongMinds Organization.

1.9.1Geographical Scope

StrongMinds head office is located in Bugolobi Plot 30 Luthuli Rise, 4.5km via old Port bell road and spring rd in Kampala with branches in Wakiso, Iganga ,  Mukono and Kampala district. Wakiso district is located in central Uganda and is the country’s second largest city and suburb. To the north, Wakiso is boarded by Luwero, to the east by Mukono and kalangala in Lake Victoria boarders to the south. By road, Wakiso headquarters located in Wakiso district is approximately 20km (12miles) Northwest of Kampala; coordinates of the district are 0024N; 3229E of the equator.

1.9.2Time scope

The study will be conducted within seven months that is to say from March to September 2020 during which the researcher will use the time to collect, analyze the data, discuss the findings and then present the final findings.

CHAPTER TWO

LITERATURE REVIEW

2.1 Introduction

This research seeks to investigate the relationship between family support and resilience of depression survivors among clients of Strong Minds, a non- government organization that has embarked on treating depression using an approach known as Group Interpersonal Psychotherapy (IPT-G) and will apply mixed method approach to allow triangulation of data in order to obtain accurate results.

In this chapter, the researcher will attempt to examine the views of other scholars and authors on family support, protective factors and resilience of depression survivors. The main source of data will be articles, journals, books, reports and other online sources with the aim to establish the research gap. The review of literature will start with discussions on Family systems theory which is the foundation theory of the study. Literature will be viewed basing on the objectives i.e. the level of family support; level of resilience of depression survivors; relationship between family support and resilience of depression survivors and lastly the mediating effect of protective factors on the relationship between family support and resilience of depression survivors among clients of Strong Minds Wakiso district, Uganda.

2.2 Theoretical Framework

 Family Systems Theory

The study will be guided by the Family systems theory which dates back to 1978 by Bowen Murray and he viewed families as “a unit not an individual”. Systems theory assumes that all people are important and each person plays a part in the way the family functions in relation to each other. This theory was developed and put forth especially intended for family therapy using psychotherapeutic methods. Other scholars like Kabeer (Kabeer, 2001) put forth that families are an “emotional unit” whereby one member of the family cannot operate as an individual however each family member is connected to one another. The theory therefore focuses on the roles and responsibilities of family members in order to have more functional families. Support can be in terms of care offered for instance social support towards each other, financial, spiritual or even tasks performed.

In a similar research conducted in America by the Gerontological society of America, 2019 (Volume 74 .No.2), aimed at explaining the gender gap in care giving burden of partner care givers, using the stress appraisal model; research findings noted that gender differences could be explained using different conditions of burden which they divided into three dimensions of; primary stressors, secondary stressors and hours of care giving. Data from the Netherlands’ older person’s and informal care givers survey with a minimum data set of 1,611 care givers was obtained. The results showed that women experienced greater partner care giver burden than men. As of other caregiving literature obtained from various scholars, the results showed that female caregivers are more burdened than male caregivers (Mc Donnell &Ryan, 2013; Pennning &Wu, 2016). The above article also noted that both men and women had a positive association towards “burden” and more primary stressors such as help from other care givers thus illustrating how family responsibility / support cuts across both genders.

Another similar research was aimed at looking at the impact of severe mental illness (SMI) on family members and the community where the patients came from (BMJ article, Wubalem et al, 2019). The results according to this research paper showed that the impact of severe mental illness induced physical health problems such as extreme fatigue, insomnia, headaches and other psychological effects such as depression. The results also indicated that SMI affected the children of parents with these conditions. For instance, it noted that children of parents with severe mental illnesses had poor school performance, had nutritional problems among others. The research focused on low and middle income countries for example Uganda, Ethiopia, Brazil and Thailand.

In Uganda today for instance, StrongMinds piloted an adolescent project (StrongMinds, 2018 / 2019) aimed at targeting adolescent boys and girls who suffered from depression both in and out of schools in Wakiso district. This project began in February 2018 and by early 2019 began to make progress. The pilot project was in conjunction with Ministry of Education in Wakiso district. The Strong Minds Group interpersonal psychotherapy was employed but modified to suite and appeal to the youth. StrongMinds expected to reach more than 4,000 adolescents who suffered from depression. Their findings are yet to be published.

2.2.1 Family Support

Support in this context will be viewed in terms of social, financial and spiritual support as discussed below.

Dr. Bronfenbrenner an American Psychologist and his ecological theory fronted by Moleli (Moleli, 2017) assumes that human beings are all “inter-dependent” with our environment. That is to say, when there is a change in one part of the system all other parts may be affected (family members) and vise versa. For instance, death of a family member may affect the other living relatives sometimes even disrupting the whole family structure and the environmental systems too. World Health Organization (WHO, 2017) observed that social support has a big impact on the recovery of an individual for example; the presence of family / social support may reduce vulnerability of the depressive member to relapse. For instance, according to literature reviewed by StrongMinds (StrongMinds, 2014-2019), Basic Needs Uganda (Basic Needs, 2015) below are some of their findings.

According to StrongMind’s therapy (IPT-G), many depression patients and survivors have been helped and reconnected back with their families; many have also been helped to gain meaningful employment (12%) so that they are now capable of taking care of themselves and their families (Strong Minds, 2014; Basic Needs, 2015), the finances from their businesses can also be used to access proper treatment should the need arise. Charity organizations such as Basic Needs Uganda (Basic Needs, 2015) work with survivors of mental health by assisting them to set up small businesses from which they are able to earn a living; Basic Needs Uganda which is a charity Organization sometimes provides trainings to these depression survivors so that they too can become self reliant and through the use of these new skills, these depression survivors are able to provide for themselves and their families in future (Basic Needs, 2015; MHU, 2020).

Due to the fact that mental illnesses affect any one regardless of the age, gender, social-economic status, one strategy that was employed by Butabika Referral Hospital was the “Peer Support System” as a tool in creating awareness about the dangers associated with drug abuse and alcohol that may lead to mental illnesses (Butabika East London Link, 2013). According to an article by Odoki, (New Vision, 2018) in a piloted peer support program carried out by Butabika East London Link in Uganda, it was observed that peers tend to listen more to their fellow peers instead of elders (Butabika East London Link, 2013). So, this Peer Support Program was aimed at improving mental health and creating awareness about the dangers of drugs & alcohol usage (Butabika East London Link, 2013). In addition, parents and guardians were encouraged to share information that they felt was important with their children but also provide a listening ear to them when it came to concerns put forth by their children.

According to Ministry of Health Press statement on World Health day, (2017) it was noted that conditions such as depression affects a lot of youths and young adults so this calls for serious attention to be these age groups (Odoki, 2018, MOH press statement on world health day, 2017). Prayer is another “un –identified” role of care givers in the family towards the recovery of depressed family members. Prayer and meditation have been known to reduce stress, anxiety and depression (Koenig et al, 2012). Koenig noted in his book, “handbook of religion and health” that spirituality and mental health were related in terms of satisfaction, happiness and moral values.

“When we turn to God / higher power we receive God’s attention to his love for us; He is able to comfort us, nurture us and offer us help that heals our spirit man.”The book of Isaiah Chapter 40: verse10 reviews God’s love for us and talks about how God will “uphold us with His righteous right hand.” The same bible in Romans 8:26 illustrates how to pray; encourages us that when in times of weakness, one needs to bring him / herself before God. Prayer and meditation in communal settings together with family has been known to strengthen support and connections in our relationships with other people (NIV Bible, revised 1978).

It should therefore be noted that ongoing support along with continuous counseling should be provided to the care giver / family members and the patient as many care givers expressed a lack of knowledge on how to care for those suffering from conditions like depression (WHO, 2017). In addition, women who spend more time caring for the afflicted family member (s) or friend(s) and less time on other activities may tend to experience more problems than men (Pavalko & Woodbury, 2000; Savundranayagam & Montgomerg, 2010).

In terms of gender, scholars such as Swinkels, Calasanti and Mc Donnell (Calasanti, 2010; Mc Donnell & Ryan, 2013; Swinkels, 2019) all observed that men and women experience care giving differently. They described care giving in relation to women as an “obligation and responsibility” while to men, according to Hong (Hong & Coogle, 2016) observed that men tend to “step away” from care work. Hong et al also noted that conditions for care in terms of intensity of care giving are experienced differently for men and women (Hong & Coogle, 2016). Glauder (2016) observed that societical views towards gender norms are such that caring is normally associated with “women’s work” hence more women opting for care giving roles as opposed to men.

Care giving according to Mc Donnell & Ryan, (2013) in relation to other reviewed literature by scholars such as Marks et al (2002) noted a consistency in care giving burden affecting mostly women. For instance, they noted that female care givers are more burdened than their male counterparts (Marks, Lambert & Choi, 2002; Mc Donnell & Ryan, 2013; Penning & WU, 2016). This could be due to the fact that care giving has mostly been associated with the feminine gender (Glauder, 2016) while the male roles of provider and financer are predominantly male related however, it is very important to note that today there are also care givers who are males.

2.2 .2 Resilience and Depression Survivors

Resilience is the ability to, “bounce back” even after adversity / a traumatic experience or a major tragedy or other significant sources of stress (APA, 2014). Rutter (2013) described resilience as the “ability to have good outcomes even after experiencing serious stressors in life.”  Resilience theory according Hendrick & Young (Rutter, 2006; Hendrick & Young, 2013) addresses how individuals are able to “adapt to” and “jump back” from life’s stressors. Therefore it should be noted that it is possible for an individual to change their thoughts, behaviors or actions and adapt to life more positively even after a devastating situation. Hendrick & Young (2013) suggested that resilience should be viewed as an on-going process through which the individual develops coping strategies which can then be later used to bounce back (Lowdermilk & Brunachel, 2013) however, these resilience building strategies vary from person to person.

2.2.3   Personal Structure (High Vs Low Resilience)

It is important to understand how resilience may influence depression. Wingo et al (2010) noted that different individuals may undergo certain kinds of traumas leaving them vulnerable to develop either psychological or behavioral problems after the tragedy and may not recover while others on the other hand, even after experiencing certain major adversities or traumas, are still able to bounce back and meet life’s challenges more willingly (Wingo et al, 2010). It should be noted therefore that resilience plays an important role in one‘s ability to bounce back after a traumatic event. There are individuals with high levels of resilience and those with low levels of resilience. Highly resilient individuals may be able to bounce back quickly compared to individuals with low levels of resilience hence no relapse for those individuals who are highly resilient and vise versa (JA Min et al, 2013).

According to a Canadian journal of psychiatry vol.56,no.5(2011) they noted that there many sources of resilience such as personal factors, biological and environmental factors nonetheless, there are certain resilience factors that may help an individual cope or increase resilience. Individual / personal protective factors include self-esteem, openness & self efficacy while societical /environmental protective factors such as; support from spouses, community members, children, work-mates, peers, good schools, among others may help increase resilience.

Biological factors on the other hand look at early harsh environments, brain development and functioning. For instance, harsh environments may affect brain structure, functioning and neurobiological systems. It was noted in the above journal that, “changes to the brain may affect size, sensitivity to receptors and neurotransmitters affecting the capacity to moderate negative emotions thereby affecting resilience to adversity”.

2.2.4 Family Coherence

Families are the basic unit of society. In a family when dealing with children for instance, the presence of a stable adult in the form of parents, older siblings or grandparents may help to reduce fear of being left alone; children may also be able to socialize thus creating stronger bonds with their family members, creating warmth, emotional support & learning to trust starts from the family setting (Hendrick, 2013, Chen, 2019). Social support systems when offered by one’s friends and family may increase one’s ability to bounce back and thus become productive and hence reduce vulnerability which in turn may prevent relapses. Therefore one may say, when there is support, there is a likelihood of resilience (Hendrick, 2013; WHO, 2017).

According to research by Chen and Jama Pediatrics, (2019) they noted that, those individuals with strong family bonds / cohesive family relationships in their adolescent years had lower depressive symptoms from early adolescence to mid-life (late 30s to early 40s) than those individuals who had experienced less positive family relationships. Important to note is that resilience is not a trait that we are born with nonetheless any one can develop it as it’s an important life skill. According to Gail, (Child welfareInfor, 2014) these protective factors help to boost family’ s over roll well-being and that of the once afflicted individual; for families with depression survivors, encouragement to practice resilience building strategies and skills, then applying them to everyday life challenges can help avoid relapses.

Certain barriers to resilience should be addressed in order to avoid relapses especially when dealing with depression survivors. These barriers or factors are those that hinder or delay the recovery process of an individual for instance;

Psychological barriers such as fear, anxiety and persistent re-occurrence of depression, stress among others keep the patient in a constant worry state so that he / she is not able to think positive instead, their thought pattern is characterized by negativity. When a family member is depressive, the whole family is affected and this could have negative effects to the family as a whole system and to the individual (Bowen, 2000, Strong Minds evaluation report, 2015).

Spiritual barriers too may in some way hinder recovery where by the patient may associate the illness as some form of “punishment by God” thus delay the journey to recovery (Stratta et al, 2012). Therefore, it is important to understand the patient’s triggers for instance depression triggers then work together with them to develop copying strategies hence quickening the recovery journey and avoiding relapses.

2.2.6   Protective Factors

This will look at inter and intra individual levels of positive functioning which includes one’s relatedness with others and self- referent attitudes that look at a sense of personal growth. Emphasis will be on therapy received such as Group interpersonal psychotherapy employed by Strong Minds Organization and strengthening Protective factors such as self esteem in order to promote positivism while avoiding relapse.

2.2.7 Therapy received – (G-IPT)

Group Interpersonal Psychotherapy also known as “talk therapy” is a community based therapy that looks at the relationship among group members.(StrongMinds, 2014) With this therapy, community members who suffer from depression come together and form groups so as to discuss their depression triggers, root causes then, come up with ways or strategies to prevent themselves from relapsing. The groups are divided into two i.e. staff-led and volunteer led groups. The IPT-G meetings carried out by StrongMinds usually take about 12-16 weeks and are divided into cycles for example Peer therapy Groups (PTG)- cycle 1 and (PTG)-2 and are led by a trained facilitator from within the communities (i.e. volunteer- led groups) where these depressive survivors are based or by a staff member from StrongMinds (StrongMinds, 2014) .

It is important to mention that StrongMinds does not run centers but treats clients for depression via Group therapy where each group comprises of between 12-15 participants and a trained facilitator who then meets with the clients at one of the clients’ selected homes. According to StrongMinds’ standard, one is considered to be depression free when they meet the minimum symptoms for depression (StrongMinds impact evaluation report, 2015).

Approaches such as G-IPT therapy are designed to bring depression survivors together so that they can learn from each other and foster togetherness, boost family and communal resilience among group members by strengthening community support towards these depression survivors. In the recent year of 2019, approximately 2,343 depression survivors were treated by StrongMinds in Wakiso district (basing on StrongMinds minimal symptoms for depression) and currently, there are 1,778 StrongMinds therapy groups; Peer therapy groups and volunteer treated are about 565 in Wakiso district alone. Through IPT-G, one may say StrongMinds has managed to register success basing on the increasing number of both Peer therapy groups and volunteer therapy groups registering high numbers of depression survivors (StrongMinds evaluation report, 2015).

2.2.8 Self Esteem

Research also indicates that there is a relationship between depression and self-esteem. That is, when depression is present; self-esteem decreases (Sbicigo, Badeira& Dell Aglio, 2010). Self-esteem is defined as, “an individual’s evaluation on his / her worth (Steiger, Robin & Fend, 2014) so those individuals with low self-esteem may tend to display negative behaviors as self-esteem affects behavior (Clemes & Clark, 2012) and those individuals with greater mental health tend to have greater resilience and high self – esteem (Elliott, 2016).

According to a research article by Henriksen et al on the role of self-esteem (2017), noted that adults who possess high self-esteem were more likely to have higher levels of happiness than those individuals with low self-esteem (Henriksen et al, 2017). Other scholars such as Orth, Robins & Roberts (2013) in their longitudinal study which included nearly 3000 participants also supported the idea that low self-esteem contributed to depression but not vice versa therefore one may say depression is not a consequence, rather low self – esteem may contribute to depression (Shahar & Henrich, 2010). Important to note is that high self-esteem plays a protective role in the development of good coping strategies (Orth et al, 2013) while low self esteem may leave individuals more prone to depression and at times may also be related to antisocial behaviors and suicidal ideation (Klein, Kotov & Bufferd, 2011; Erol & Orth, 2011 ).

In order to help depression survivors avoid relapse, depending on the severity of episodes, treatments such as psychotherapies, problem- solving therapy should be made available for the depressed person(s) however, psycho-education should be provided for family members too (WFMH, 2012). When families are educated about depression, trained on proper communication skills, trained on how to build resilience and proper problem solving skills, this then may reduce relapse rates in other words, depression rates may go down.

2.2.9 Strengthening Protective Factors

There are a number of ways to build self esteem and these include;

Avoid dwelling on one’s weakness. By accepting that every human being has weaknesses, instead of beating up one’s self about it, we should accept our weaknesses and try to work on the ones that can be worked on but those that cannot be worked on, one should learn to come to terms with them and move on (Maertz,)

Quit comparing one’s self with others. Many people with low self esteem tend to compare themselves with other people whom they see have excelled in the areas of their interests. This therefore may make those individuals with low self esteem to feel defeated or harbor feelings of defeat or resentment towards those who have succeeded. However, it’s important to only focus on one’s progress and success instead of comparing one’s self with others (RMIT University,)

It is very important to replace negative self talk with positivism. I.e. we need to learn to develop a more positive message/ affirmations towards ourselves such as , “am unique and will be appreciated by others for that; also learning to foster a more positive voice that is more positive and supportive (Maertz, ) . It is also important to engage in physical exercise that keep one busy and these self care activities help us feel good about ourselves and hence increase self esteem(Nantume, daily monitor, 2020) .

Resilience skills can be increased in a family in order to foster understanding and show affection to its members hence promote long term healthy mental development into adulthood while balancing one’s life as we go through / deal with stressful events in our lives for instance;

Planning ahead of time as a family . Due to the connectedness within families, each member should be encouraged to perform their tasks, duties and pick up another’s task in case one member of the family isn’t feeling well (Zimmerman & Brenner, 2010). It is also important to discuss the stressors one feels, then come up with coping mechanism to prevent one from breaking down completely; as a family, it is also vital to spend time together for example physical activities like exercises, going to the beach, visiting friends, among others. This may aid in stress reduction for the family or on individual basis (Nantume, Daily Monitor, 2020).

Family members can employ new strategies when things don’t seem to be working for instance involving family members in problem solving and decision making can play a role in avoiding relapses, anger or rebellion in families (Gail, 2014). This can be attributed to the fact that everyone in a family wants to feel a sense of belonging and this is one way of ensuring family connectedness. There are other ways on enhancing resilience skills in an individual however, it should be noted that what may work for one may not suite another individual so depression survivors should be encouraged and helped to find what best works for them and their families too.

2.2.9 Relationship between Family Support and Resilience of Depression Survivors

Mood disorders like depression are treatable and preventable conditions when diagnosed early (Zartaloudi, 2011; Moeti, 2017) with each type requiring different treatment approaches such as the use of antidepressant medications and psychotherapies which offer useful treatment and are commonly employed in treating the effects of depression (NIMH , 2015). If mood disorders for example depression is left untreated for long periods of time, it may become recurrent causing impairments or it may cause unnecessary suffering that interferes with people’s daily-life activities and can even lead to suicidal tendencies (WFMH, 2012; Basangwa, New Vision, 2019). It should be noted that depression affects anyone regardless of the age, gender, cultural background, ethnicity, religion or social economic status (Garcia, 2019).

Families or care givers are a great source of support for the depressive family member (they can be fathers, mothers, siblings or any other next of kin) according to World Health Organization (2017). The quality of care provided will determine whether the depressed person will recover or not. Since depression affects moods of the afflicted individual, this can be transferred to the family. Feelings such as anger, sadness, and irritability among other negative emotions and behavior patterns can affect the family as whole disrupting relationships that may cause the affected individual (s) to have feelings of rejection; increased stress levels paving way for depression or more relapses in the future.

In a longitudinal study of adolescents to adult health by Chen and Jama (2019) which began around 1995- 2017, their observations were; Individuals who lived in a cohesive home with the presence of a significant adult who was understanding and always present created secure attachments and warmth between family members hence creating positivism for the teens present at the time (Chen, 2019). They also noted that emotional support encouraged the development of skills that would later be used as coping strategies in the event of adversity hence boosting their self-esteem which in turn helps build resilience in the face of challenging experiences (Chen, 2019).

2.3 Resilience in African Context

2.4 Economic Implications of Depression to Families, Communities and a Nation .

To Families

Often people with depression may feel un-interested to carry out daily tasks so this falls to the care takers or family members present and this may turn out to be difficult to certain extent towards the family members playing this role with many implications affecting social relationships within the household (Wubalem et al, 2019). Depression according to WFMH affects around 5-10% of adolescents and about 10-15% of adults (WFMH, 2012).

Since depression is well-known to interfere with one’s ability to function on their jobs or within their respective families, this then in turn reduces social and economic productivity (WFMH, 2012); low family unity or may strain the environment in such homes in terms of finances, food among others (Wubalem et al, 2019). Depressive persons may not be able to work (depending on the severity of the illness) and from time to time may need to be facilitated to hospitals, may need refills for their medications or even physical attention in terms of grooming and feeding (Wubalem et al, 2019; Nantume, daily monitor, 2020). So sometimes family members may not be able to work because they have to care for their depressed member and this in turn affects their incomes and saving in general (WFMH, 2012). In the long run, poverty may set in along with other house hold hardships especially when there are no government subsidies on anti- depressant medications or little to no budget for mental illnesses in general making such communities with high numbers of mental challenges poverty stricken.

Treatment cost of major depressive disorders (MDD) is high. Many people diagnosed with MDD or MDE depending on the severity of the illness may receive anti-depressants or sometimes a combination of treatments (psychotherapy and anti-depressants) but these treatments aren’t cheap (Karampampa, 2011). For example the new medications (SSRIs) selective serotonin reuptake inhibitors such as floxetine and sertraline, among others are known to be highly prescribed due to their positive impact on the disease along its safety profile. Other treatments such as CBT and ECT which are also effective with positive long lasting results are expensive. However, according to literature from Luppa and colleagues, they noted that the costs of pharmacological treatments made up 6%-29% of the total direct costs (depending on the year of study conducted).

In Germany for example, an observational study noted that “in-patient (in rehabilitation centers and hospitals) costs accounted for 68% of total direct costs (according to 2009 prices) higher compared with anxiety disorders.” Luppa and colleagues noted that the average direct costs due to MD ranged from US$1000 to US$ 2500(according to 2003 prices) and depending on the country. Similar studies by Hawthorne & colleagues also noted the costs of pharmaceutical treatments to take about 30% of total direct medical costs. Families with people having MDD tend to have lower incomes compared to households without depression. However, it should be noted that it is not yet clear whether depression is the primary cause or a consequence of both. Low incomes could also be attributed to job loss or low wages.

To Communities and Nations

When depression is not treated in childhood, it may result into social and economic consequences that may be projected in adulthood. For instance Jenkins et al (WFMH, 2012) observed that in many high-income countries according to longitudinal studies carried out, depression may result into poorer educational attainment (60%), reduced employment opportunities, relationship difficulties when in adulthood (i.e. marital dissatisfaction has been noted to have a strong relationship with depressive symptoms),high divorce rates, high crime rates, among others while in low-income countries, there may be income inequalities creating wealth gaps among different groups (Kessler, 2012, Wubalem et el, 2019).

Another observation was in parents with depression and their children’s development. Jenkins et al noted that children of depressive parents tend to drop out or miss school due to the fact that they have to provide informal care to their ill parents(Jenkins et al, 2012, Strong Minds evaluation report, 2015); these children’s levels of functioning was also affected due to poor performance at school ; problems with nutrition for the children and as a result, special attention and care  should be provided for such children which also requires money to facilitate (Wubalem et al, 2019).All these later affect the national income of that country due to the fact that much of the household incomes are spent on treatments rather than productive work force that can be taxed to generate revenues.

Major depression disorders affect work places inform of “Days out of work”. According to World Mental Health survey, it was recorded that MDD had the highest number of days out of role with approximately 62,971 respondents across 24 countries who were assessed for a wide range of common physical and mental disorders as well as for days out of role in a 30 days interview. The results according to WMH surveys recorded MDD at 5.1% of all days out of role hence the 4^th highest population attributable risk proportion of all the disorders considered (Kessler, 2012). In addition, studies in the US found that both MDE and MDD contributed to over-roll lost work performance with an estimate of $30.1 billion to $51.5 billion losses on annual salary equivalent to human capital value (Kessler, 2012).

Corona Virus and Mental Health in Uganda

With the current global Corona virus pandemic that has seen a shift in the way we now work and associate with each other, mental illnesses such as depression which is associated with stress and anxiety is on the rise (Nantume, daily monitor, 2020). This can be attributed to the start of Covid-19 which has resulted into un-employment / job loss; the lockdown which left many people uncertain of the future amidst ever rising infection cases and death;  domestic violence; food shortage, among others. There is an increase of people facing mental health challenges today as they struggle to meet everyday expectations amidst losses made during lockdown.

Access to mental health care facilities and medications has become a challenge as many regional referral health treatment units which used to provide treatment to the public have now been turned into Covid-19 centers for treating Covid-19 patients. This means that the majority of those seeking mental health treatments may not receive scheduled treatments due to factors such as the increased transport costs, curfew hours, financial constrains, the lack of support from the medical staff since the deployment of the army to replace most of the medical teams. All this has increased the turnover of those seeking treatment for mental illness such as depression at Butabika hospital (Nakku, daily monitor, 2020).

According to Dr. Nakku, Butabika hospital that once received between 800-900patients per week received about 1,050 cases new admissions (between July 12 and July 18). This increase could be attributed to more mental breakdowns brought about by the stress of Covid-19, anxiety for what the future holds or as a result of fewer mental health care units available (Nantume, daily monitor, 2020).

Conclusion

Depression can be managed and treated using various treatments. Family members and communities should be encouraged to work together in order to curb stigma associated with mental illness in order to avoid high relapse rates. Information on building social networks and its importance should be provided to depression survivors; trainings on how to identify their triggers among other copying strategies should be prioritized, encouragement, love towards depression survivors should be demonstrated, public awareness of mental health and mental illnesses, sharing information on available treatments and continuous counseling in order to tackle stigma associated with mental disorders and other illnesses such as Covid-19 should be prioritized.

Lastly more research should be carried out in the fields of mental health by both Ministry of Health and private individuals among others but most important, families should be allowed to be part of the treatment especially for recurrent disorders like depression. This research will use a mixed method approach because it will allow triangulation of data so as to provide the most accurate results.

2.5.0. Research Hypothesis

HP1. There is a relationship between Family support and resilience of Depression Survivors among clients of Strong Minds.

HP2. There is no relationship between Family support and resilience of depression survivors among clients of Strong Minds.

CHAPTER THREE

METHODOLOGY

3.1 Introduction

This chapter describes the procedure that will be followed to come up with the research results. It will cover the research design, target population and sample size. This chapter also shows the sampling techniques and procedures, data collection methods, research instruments and how the results will be tested for reliability and validity along with procedures for data collection and analysis. Ethical considerations and anticipated limitations will also be reviewed.

3.2 Research Design

This study will be conducted through a mixed method design. According to Johnson et al, (2007), mixed method research design is a type of research where the “researcher combines both quantitative and qualitative approaches for a broad purpose of breath and depth by using different methods for different inquiry of components in order to facilitate understanding and justification.” The purpose of mixed methods design is to heighten knowledge and validity hence eliminating bias (Johnson and Christensen, 2017).

Mixed method research design dates back to as further than 1989 (Brewer & Hunter 1989, p.28) who saw this method as a “research style in its own right, distinctive in own way and more conventional”; other scholars such as Datta (1994) who called this research design the “3^rd paradigm” in evaluation of research found “18 evaluation studies” dating back from 1959 to 1992 while other others such as Goodwill & Turner (1996), Greene, Caracelli and Graham all reported 57 mixed method evaluation studies (1989). Many other scholars also accredited mixed method research design such as Rossman & Wilson, (1991), Loos in his “community based needs assessment model” (1995) , Kinnick & Ricks in their “barriers to student success” (1993) among others.

The research design was selected because it allows for triangulation of both qualitative & quantitative data so as to obtain accurate results; mixed method designs also allows for clarity and illustration of the results from one method with results from another method (Johnson et al, 2017). However, mixed designs are also known to take more time, resources and also require the researcher to develop expertise in both qualitative and quantitative analysis techniques.

For the qualitative strand, a case study design will be adopted as to better understand the relationship between family support, moderated by protective factors such as self esteem influence resilience of depression survivors. Since cases studies focus on smaller samples, its aim is an in-depth analysis and provide insight into particular problems using a variety of sources such as data from field notes, direct observations and interviews in order to investigate a research problem. For the quantitative and qualitative strand, cross-sectional survey will be adopted as they tend to collect large data within a population of interest at one point in time (Creswell, 2013).

3.3 Area of Study

The study will be carried out in Wakiso district which came to existence in November, 2000 through a parliamentary enacting. Located along Hoima road, 16km from Kampala City, Wakiso is the second largest district in Uganda and the second most populated district with a population of approximately 2,007,700 people according to the National Population and Housing Census (NPHC, 2014) with population projections expected to rise even higher by 2020. According to distribution by gender, 47.5% are males and 52.5% are females.

Wakiso also has higher depression rates among adolescents and youths as compared to other districts in Uganda. This could be attributed to stress, urbanization (approximately 85.6% live in urban areas compared to 14.4% in rural settings), anxiety due to un- employment among others (UBOS, 2019).Wakiso district is located in Uganda’s central region and is boarded by districts such as Kampala, Mpigi, Luwero, Nakaseke, Mityana, Mukono and Kalangala. Wakiso district consists of 882 administrative units, four municipalities (Kira, Nansana, Makindye, Ssabagabo and Entebbe MC); with 12 Municipal Divisions however, for this study the researcher will carry out research in the areas of Namugongo, Kireka, Kirinya, Bweyogerere and Acholi quotas.

There are nine town Councils and six sub counties in Wakiso district. Parishes number 148 and 704 villages according to Wakiso district investment profile (2018).Wakiso has about 105 health facilities, secondary schools total about 309 while primary schools total about 1,015.The number of households are estimated to be 503.442 with an average size of four people per household.

3.4 Target Population

The term Population is defined as the complete collection of all the elements / items of interest in a particular investigation (Kabir, 2016). Target Population refers to an entire group from which information is desired, obtained and then conclusions are made (Kabir, 2016). The target population should have similar features that are of interest to the researcher for instance in this study, the respondents will be young married couples (20-35 years) who have attended Strong Minds therapies (depression survivors) because this age group is more prone to challenges such as raising children, monetary problems, single parenting, unemployment among others..

According to Strong Minds minimum standard of depression (2019) statistics, nearly 2,343 depression survivors were treated in Wakiso district. Strong Minds therapy groups are 1,778 in total however, in Wakiso district there are 565 peer therapy and volunteer groups with each group consisting of 12-15 participants. According to StrongMinds, their mandate is to treat 5% males and 95% females (StrongMinds, ).

3.5   Sampling

3.5.1 Sample Size

A sample is a collection of some subsets of the population. A sample can also be defined as a part of the population that represents the characteristics of the population (Kabir, 2016). A sample size is normally used to generalize the results obtained from the sample to be representatives of the entire population from which the sample was drawn. Multiple sampling approaches will be used to arrive at the final participants for instance, of the 565 peer therapy groups in Wakiso district, the researcher will employ random sampling which will allow every participant an equal chance of being selected then, simple random sampling and lastly stratified sampling will be employed.

Mugenda and Mugenda (2003), argues that it is impossible to study the whole targeted population and therefore the researcher shall take a sample of the population. A sample is a subset of the population that comprises of members selected from the population. Using Krejcie and Morgan’s (1970) table for sample size determination approach, a sample size of depression 331survivors will be selected from the total population of 2,343.

Table 1: Population, Sample size and Sampling technique

Source: Strong Minds Uganda, (2013)

3.6 Sampling Procedure, Design and Technique

The study will employ probability sampling and the goal of this procedure is to select a reasonable number of participants that represent the target population (Mugenda & Mugenda, 2003). Simple random sampling method will be employed in order to randomly select the peer therapy groups of which only 30 out of the 565 of these therapy groups will be considered. Numbers will be given to every member of the accessible population (the depression survivors) within the 30 Peer therapy groups within Wakiso district. These numbers will then be placed in a bag or container then, a number will be picked randomly. The numbers which will correspond to the subjects will then be included within the sample. This will be done in the different sub-counties, parishes where these depression survivors are located, still within Wakiso district.

Next, from the sample obtained during the simple random sampling, in order to determine how many males and females will participate, the researcher will then use stratified random sampling method. From the within the sub- groups obtained from the sample above, the researcher will further divide the sub-groups into two or more sub-groups called strata using a given criteria, then a given number of cases will be randomly selected from within each population of the sub-group. For instance, the researcher may decide to divide the sub-groups using odd or even numbers then decide to take the even numbers from each strata then use them to determine the number of males and females from each population sub-group. Stratified sampling method is advantageous because it ensures inclusion in the sample and within the sub-groups (strata) which could have been omitted by other sampling methods.

The researcher will obtain an introductory letter from her university and present it to Strong Minds headquarters requesting permission to conduct research within their facilities / communities of operation. A cover letter will also be provided accompanying the research instruments in order to explain the purpose of the research to staff members and respondents.

Once permission is granted, the researcher will proceed to collect qualitative data from the using interviews and focus group discussions while quantitative data will be collected using questionnaires. The data will be collected by the researcher for purposes of interactive feedback from the respondents. The data collected, (qualitative data) will then be analyzed through sorting, categorizing and evaluating data then data will be presented in table form and creating figures.

3.7 Data Collection Instruments

This refers to the tools to be used for collecting data and how they will be developed. Questionnaires and Interviews will be used as the main source of data collection. The selection of these tools will be guided by the nature of the study, the objectives of the study as well as the time available. The researcher is mainly concerned with views, feelings, opinions and attitudes. Such information can be best collected through the use of interview techniques and questionnaires (Bell, 1993).The researcher intends to use semi structured questionnaires which will help the researcher balance between quality and quantity of the data collected. Questionnaires will also be used since the study is concerned with measuring variables that cannot be directed observed such as views, perceptions and feelings of respondents (Touliatos& Compton, 1988).

3.7.1 Questionnaires

3.7.2Self-AdministeredQuestionnaire

A questionnaire is a pre-formulated set of questions given to respondents to which they record their answers (Amin, 2005). The questionnaire will be designed to gather perceptions related to family support in terms of care provided; the role played by resilience in order to prevent depression survivors from relapsing. The study will use questionnaires with closed ended questions as they are easy to analyze and present in a usable form.

The researcher’s choice for using questionnaires is that, a lot of information is collected over a short period of time. In addition, information needed can be easily described in writing. Questionnaires’ are cost effective and can reach a wide range of respondents within the shortest time. The questionnaire will use the likert scale with five category response scale with (1) representing “strongly disagree” and 5 represented by “strongly agree”. Numeric scales enable the use of quantitative analysis (Mugenda & Mugenda, 2009).

The Beck Depression Inventory scale which consists of 21 items will measure from 0-5 where 0 will be used to assess Depressive symptoms; The PHQ-9 (Patient health Questionnaire-9)item depression scale consisting of 9 items will also be used to determine severity of initial symptoms but most importantly monitor symptoms changes and treatment effect over time with scores ranging from “0” representing “Not at all” and “3” representing “Nearly every day”; while Resilience will be measured using the Connor- Davidson Resilience Scale (CD-RISC) that comprises of 25 items each rated on a 5-point scale (0-4) with  higher scores reflecting greater resilience.

3.7.3 Interviews

3.7.4 Semi Structured Interviews (SSI)

Semi structured Interviews are an effective qualitative method for learning about the perspective of individuals related to a particular topic. These interviews allow for a detailed exploration of a particular individual point of view and they are more personal than questionnaires. SSI are also effective as the researcher works directly with the respondents thus obtaining further opportunity to probe, then carry out follow up questions so as to get in-depth information.

3.7.5 Focus Group Discussions (FGD)

Focus group discussions are used to obtain participants’ views; document the discussions and interactions between these participants in relation to particular topics using a focus group interview guide that will be developed by the researcher and will act as a guide for the group discussions. With FGD, it’s easy to draw out data from the respondents more than on individual basis as young married couples tend to shy away when explaining their experiences thus it also captures a range of opinions within these groups using limited time and resources while allowing for constructive& interactive feedback. While conducting FGD, the researcher can observe respondents emotions and other non-verbal communication that may not be easily captured by other tools such as questionnaires.

3.8. Data Analysis

This is the process of transforming raw data into useable information in order to add value to the statistical output (Amin, 2005). The data will be organized, interpreted and presented into a more usable size. Quantitative data will be analyzed using descriptive and inferential techniques.

3.8.1 Quantitative Data Analysis

3.8.2 Descriptive Analysis

Data from questionnaires will be coded and captured using SPSS soft ware version 20.0, which is a computer based program for social sciences used to generate both descriptive and inferential data. Data will be analyzed using measures of central tendencies such as mean, mode, median and standard deviations. Measures of central tendencies are used to describe how close a measure or variable is to the central measure.

3.8.3 Inferential Analysis

Inferential data analysis will be used to draw conclusions concerning relationships and differences found in research results. Inferential data analysis techniques that will be used include Pearson’s correlation (r) to establish the relationship between the dependant and independent variables.

3.9. Reliability

Reliability refers to the capacity of the research instrument to generate or provide similar results based on the same understanding across different samples (Amin, 2005).

Sekaran, (2003) and Huck (2007) both argue that the reliability of an instrument indicates the consistency and stability with which the instrument measures the concept and then measures the goodness of a measure. In order for a scale to be deemed consistent, Cronbach Alpha which is the minimum internal consistency measure should be used to measure reliability and should be equal to or above 0.70(Hinton et al, 2004), Robison (2009).

Therefore a pilot study will be conducted in other areas within Kampala district (Binna, Luzira and Mutungo) in order to determine whether the data collection instruments for examples questionnaires produce similar or desired responses which provide clarity and accuracy so that data results are reliable . In order to meet the accepted standards, Cronbach Alpha’s score values should be equal to or above .70, then the instrument will be deemed reliable (Whitley, 2002, Robinson, 2009).

3.9.1 Validity

Mugenda describes validity as the degree to which the results obtained from the data actually represent or cover the phenomenon and variables under the study (Mugenda & Mugenda, 2009, Ghauri & Gronhaug, 2005). Amin, (2005) recommended minimum CVI of 0.7 to be used. Validity will be tested using content validity index which involves judges scoring the relevancy of the questions in the instruments in relation to the study variables.

The formula for Content Validity Index is;

CVI =

Where CVI = content validity

n= number of items indicated relevant.

N = total no. of items in the instrument

In this study, validity will be achieved by establishing content validity. The researcher will achieve content validity by using the experts to assess the validity of the research instrument. The experts especially research supervisors and consultants from Kyambogo University will be given data collection tools to assess whether the items in the instruments are valid in relation to research topic, objectives, and questions. From the instruments they will assess the validity of some questions. Those declared invalid will be dropped, others adjusted, while the valid ones will be maintained.  Then content validity index (CVI) will be computed by dividing the number of items declared valid by total number of items/questions in the data collection instrument.

3.10. Ethical Considerations

A letter of authorization will be sort from the department of Psychology and presented to Strong Minds requesting for permission to conduct the study. Since this is a special population, considerations for a counselor within Strong Minds will be sort and requested for purposes of interventions should the need arise.

The study will observe the principles of research ethics which include;

• Informed and written consent will be obtained from participants.

The researcher will brief the respondents on the importance and the benefit of participating in the study. This will be done through the use of disclosure forms which will be given to each participant should they wish to participate. Respondents will be encouraged to take part in the study voluntarily however, should at any one time a participant wish to withdraw, then their decision will be honored.

• Confidentiality

All information provided by the respondents will be treated with maximum confidentiality. This will be attained through the use of codes and pseudo names instead of actual names. Questionnaires will be distributed directly to the respondents and collected immediately after they have been filled.

• Honesty

Honesty will be upheld throughout the research process in reporting data, coding results and methods & procedures in order to avoid misinterpretation of data and distrust. All sources will be acknowledged by means of references.

3.11 Anticipated Limitations

The researcher anticipates finding uncooperative respondents during data collection process however, she will effectively build rapport so as to break the ice. In addition, one of the staff members / community workers whom the respondents are familiar with will be trained and requested to participate so that the clients / respondents feel at ease to respond (that will be done on request from both sides).

The researcher will ensure that all questions are well explained with the aid of interpreters in order to avoid misinterpretations or irrelevant information filled in as a result of differences in literacy levels. In addition pre-testing will be carried out by the researcher from a different depression survivors’ group who will not be part of the main study to assess whether the responses will be what the researcher hopes to obtain with the final group participants. If the responses are answered similar to what the researcher expects, then the research will continue with the questionnaires however, if the responses do not completely correspond with the information the researcher intends to obtain, then the questions will be edited so that they are relevant and provide the necessary information needed.

Due to the current Corona virus pandemic within Uganda and the world at large that has affected  daily livelihoods of many people with increasing community infections and escalating death toll, all this has amplified mental illnesses such as depression therefore, the researcher anticipates difficulty organizing FGD due to the restrictions by government on gatherings, curfew hours that are still in place; the presences of LDUs, the researcher also fears getting infected from within the communities where research will be carried out as not all communities are adhering to guidelines such as social distancing and mask wearing however the researcher intends to follow the recommended SOPs that were put in place even though some respondents may not adhere to them.

In addition, as a result of Covid-19, that has left many unemployed, the researcher anticipates having difficulty to resources inform of capital to cover the costs of printing questionnaires and transportation to different areas of reach however, the researcher intends to fund raise from among her family, friends and well-wishers.

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