Research proposal

Family Support and Resilience among Depression Survivors:

A case of clients of Strong Minds

In Wakiso District

CHAPTER ONE

1.1 INTRODUCTION

This research will examine the relationship between family support as the independent variable and depression survivors as the dependant variable. Resilience will be reviewed as the intervening variable between the independent and dependant variable. Depression is one of the common mental health disorders sometimes referred to as “mood disorders”. Mental health studies can be traced as early as 1840 fronted by Dorothea Lynde Dix who founded the mental health movement with the hope that this would change the way people with mental disorders were viewed and treated. So, this chapter will look at the definition 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; the background of the study, purpose of the study, the problem statement, conceptual framework & the objectives of the research; research questions and hypothesis.

Mental Health is much more than a state of the Mind, wellbeing with the absence of a disease or a disorder. World Health Organization (WHO, 2015) defines 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”.

Depression is still a very serious and complex condition with many research studies still being carried out to pin point the actual causes. However, contributing factors such as genetic factors (hormonal levels), environmental and sometimes certain illnesses like HIV/AIDS, diabetes or loss of a loved one, sometimes medications may cause depression. Depression may also occur due to an “un- known” causes affecting any one irrespective of age, gender, race, religious affiliations or social status.

Depression is defined as, “a mental illness characterized by feelings of low energy, feelings of guilt, hopelessness, worthlessness, sadness, depressed mood (WHO, 2012; APA, 2013). However these symptoms vary from mild to severe and they also vary 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).

Ministry of Health, Uganda (as cited by Mutegeki, 2019) defines depression as, “a common mental disorder that presents its self with persistent low moods (sadness) or loss of interest in pleasurable activities”. The term “depressive” according to Merriam Webster Dictionary refers to “one who is affected with or is prone to psychological depression”. Therefore depression survivors are those who were once affected by depression but have now been declared depression free.

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 ; Northern Uganda being the highest region affected. At least three out of ten people have MDD with females at 29% and males at 17% according to a distribution by gender (Wayo Nero Study, 2014); followed by Wakiso district with depression rates high in adolescents. According to a country report (Mental health & poverty report, 2008), 35% of Ugandans suffer from some form of mental disorder of which 15% require treatment (Basangwa, 2004 as cited by Ssanyu, 2007; Kizito, 2012).

Families are known to be the major source of; care, support and love sometimes even cure for depression. They contribute emotionally, financially and socially. Emotional support can sometimes be a great source of recovery. Families have a huge impact on depression but it should also be noted that depression also has a huge impact on families. Family members may offer support to the depressive person inform of reminding them to take medications or encouraging them to comply with other treatments thereby helping the depression survivor to bounce back / recover quickly. This bouncing back after a major traumatic event / ability to adapt and recover after suffering a major adversity in life is referred to as resilience. Resilience per the Australian community Psychologist (2010) is defined as “bouncing back” from adversity.

Scholars such as Calasanti and Mc Donnell (Calasanti, 2010; Mc Donnell & Ryan, 2013) both stated 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) noted that men tend to “step away” from care work.

Families or care givers are a great source of support for the depressive family member (they can be fathers, mothers, siblings or next of kin).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 of anger, sadness, and irritability among other negative emotions and behavior patterns can affect the family as a 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.

However, it should be noted that there is still a lot of stigma associated with depression and other factors such as poverty undermine the care giving duty. Care givers invest a lot of time and will in order to meet the patients’ basic need such as food, shelter, finances aimed for transporting the patient or paying medical bills; spiritual nourishment is also a part of the care givers’ un described role.

Uganda Bureau of Statistics (UBOS, 2006, (13) 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), mental care, psychiatric training, community education and resettlement assistance (Butabika Hospital, 2017).

Walugembe (New Vision, 2020) stated that, “ there was an increase in the number of mental health cases from 4,274 in 2005/ 2006 to 5,604 in 2006/ 2007”. According to reports from the financial year of 2009/2010, Butabika provided inpatient mental health care to 4,394 patients (these were first time admissions) and the number of re-admissions were 1,752 patients. At regional hospitals, between 170 and 360 patients were seen in in-patient services while those who received out- patient services were between 748 and 2500 (at the different facilities) a year WHO pro Mind country report, 2012). In addition, it is important to note that there is no reliable national level data for population based prevalence.

Even with the ever increasing mental cases in Uganda, Ministry of Health (MOH, 2019) only allocated two percent of its national budget to mental illness. This means that a larger percentage of those affected by mental illness will not be able to obtain access to proper treatment yet depression is one of the most common mental illnesses in the world with nearly 300 million suffering from it. Mental health research according to WHO Country report, (2008) acknowledged that in Uganda, mental health has not yet taken priority with most publications carried out within the last five years done by international agencies for their agenda (2-4%).

It should also be noted that according to research findings by WHO-AIMS (Country report, 2008 pgs 83- 88) mental health is not viewed as a priority area as compared to other diseases such as HIV/AIDS yet this  silent killer is claiming many lives from among Uganda’s working class (cite). Mental illness is still highly stigmatized even within the medical field with most health workers not able to differentiate between mental health and mental illness. This is evident of low awareness levels expressed even among health workers.

1.2 .0 Background of the study

1.2.1 Historical Background of the Study

Globally, 300 million people majority of them women are living with depression (WHO, 2017). Mental illness, depression in particular 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 among others (Strong Minds, 2015). In Africa, 90 % of Africans suffer from depression (90 million) of which 60 million are women who have no access to effective treatment. Nigeria is the most depressed country in Africa with seven million diagnosed with the condition (as cited by Sunday, 2018) and worldwide is ranked 15^th.

UN (UN article, 2014) stated that almost every year, nearly one million people die due to suicide related to depression most of whom are females 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 have traditionally been considered a curse with the treatment provided for by traditional healers in the form of casting out evil spirits (Nsereko, 2017; Kiwawulo, 2010). 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.

According to research by Strong Minds (Strong Minds,2014) depression afflicts women twice as much as their male counterparts causing severe impacts that range from physical to mental disability; affecting children by causing low school attendances. It was also observed that children whose mothers have depression tend to have less secure attachment relationships and this may result to other consequences such as an increase in the number of street children. Patel et al (Patel, 2001; Strong Minds, 2014) states that, “there is a link between malnutrition, violence, poverty and depression”.

He noted that an increase in poverty may lead to increased violence hence the result, an increase in the prevalence of mental -ill health. In agreement to the link between poverty and mental illness, Michael, chair person for the committee on health while addressing parliament agreed that there was a link between poverty, drug abuse and mental disorders (New Vision, Parliamentary Prinary, 2018).

One of the leading organizations in Africa seriously addressing the issue of depression is Strong Minds .Through the use of their 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. This approach was tested and found to be effective for the African community. The approach uses models such as role plays and the use of visual charts as a way to effectively communicate to the group. IPT-G has proven to be every successful in combating depression with success rates of nearly 93%. Nearly 300-400 women are treated each year for depression by Strong Minds.

Interpersonal Psychotherapy also known as talk therapy is a community based therapy that looks at the relationship among group members.(Strong Minds, 2014) With this therapy, community members who suffer from depression come together and form groups so as to discuss the depression triggers, root causes then, come up with ways or strategies to prevent them from relapsing. These meetings usually take about 12-16 weeks and are led by a facilitator within the communities where these depressive survivors are based. IPT-G was first developed and tested in Uganda by Johns Hopkins University in 2002 because it suited the African culture whose roots are communal based. 224 patients were treated and depressive symptoms reduced by 93% in 2002 with very minimal numbers still experiencing depression (mainly due to the program coming to an end).

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 networks 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 results according to this study showed an increase in depression free rates with 92% of the patients declared depression free after 12 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 appear to be housed probably due to increased incomes.

Another important impact recorded was 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 was the most cost effective and efficient approach. Today, according to reports from strong Minds, 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. Belgrave et al., (2000; Med Science, 2018) argues that resilience studies 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. Research on resilience has become more popular in psychology with most studies now looking at positive outcomes as opposed to the previous negative outcomes of life.

Since there is a link between reduced depression and improved physical wellbeing of most depression survivors, these survivors now become enabled and can 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 (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 and the role of resilience among depression survivors and how they are able to bounce back even after a traumatic experience. These theories include; Biological / hereditary differences theory (Wilhelm, 2003); Age prevalence theory; Gender Based role identity theory among others. 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.

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 so this may increase depressive rates more in women than men. Important to note is that while women experience menopause, men too undergo a similar symptoms called mid-life crisis. 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 is another theory which 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. So this theory will illustrate how gender differences influenced by environment can lead to depression. Certain family responsibilities put women at a greater risk of depression compared to men.

According to an article by Nakasujja (Nakasujja, 2019) noted that there are more women visiting Butabika hospital due to a lot of pressure on themselves. Basangwa (New Vision ,2019) as directly quoted states that, “there is 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. Most women in many African cultures are taught to compete amongst themselves right from childhood to adult hood, taught not to openly express their thoughts as its not lady-like and 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 when they pile up may cause worry which can later result into depression.

In addition, male roles such as the provider, protector may also contribute to everyday stress especially when they fail or face challenges meeting these requirements accompanied by an unsupportive spouse or family in general. 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 few families today with men as the care takers.

There are also other theories that attempt to explain family responsibilities and family theories  such as ; Family development theory, Life course, family systems theory, ecological and feminist theory among others but for this paper the research will focus mainly on Family Systems theory as it is the most proven to yield effective results.

1.2.2.3 Ecological systems theory

Uriel Bronfenbrenner an American Psychologist developed and fronted the Ecological Systems theory. Ecological theory according to Moleli (Moleli, 2017) assumes that human beings are all interdependent with our environment. Therefore a change in one part of the system will affect other parts (family members) and vice verse.

1.2.2.4 Family systems theory

Family systems theory was developed in the fields of clinical psychology and psychiatry which used psychotherapeutic methods intended for families (Kabeer, 2001). Murray Bowen (Bowen, 2000) argues that a family is an emotional unit whereby one member of the family cannot be looked at 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.

This theory looks at the roles and responsibilities of family members in order to have a functional family 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, spiritually or social support. When other members of the family fail to take on the slacking tasks, then this disrupts the whole family structure creating dysfunctional families.

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). Another important factor to consider when looking at depression survivors is resilience. Resilience theory according to Zimmerman & Brenner (2010; Hendrick & Young, 2013) states that attention should be focused on positive related factors (these reside within the individual such as self esteem and self efficacy); social and individual variables that have disrupted development ranging from mental distress to behavioral problems creating poor health outcomes. So depression patients should be encouraged to develop strategies that work for him or her in order to foster their recovery.

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.

Quality of care (resilience in particular) will be reviewed. Quality of Care is the intervening variable and this research will focus on approaches used by depression survivors in order to avoid relapsing. Dimensions of resilience such as social support systems (low vs. high support), family coherence and personal competence will be reviewed.

Survivor recovery on the other hand is the dependant variable. This research will focus on relapse rates and the approaches used by these depression survivors in order to avoid relapse. Approaches such as IPT-G will be reviewed. This study will therefore concentrate on investigating how survivors of depression hang on without relapsing; approaches they use and family support provided by their family members towards their recovery.

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 district 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 of Kampala. 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  

Mental illnesses such as depression is a very serious health issue today but still receives little attention from the public with many people still believing that depression is a weakness and a curse especially in Uganda with many seeking treatment from traditional healers instead of hospitals according to a New vision article (as cited by Chris, Okello, 2010 & Neema, 2007). Due to the ever increasing numbers of people suffering from mental illnesses, 10^th October was declared world mental health day (Jimmy, 2018; Davis, 2017). Its goal is to create awareness, educate people and end stigma associated with mental illnesses across the world. 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 (Jimmy, 2018). Basangwa argues that about 35% of Ugandans suffer from some form of mental disorder of which 15% require treatment (Basangwa, 2004, as cited by Ssanyu, 2007).

In Uganda, according to an article by Francis, as cited by Kizito (Butabika hospital, 2012) stated that currently there are only 32 psychiatrist for a population of 34million (Francis, 2012; cited by Kizito, 2012).Chisholm (Department of Mental health, 2012) noted that mental ill health constitutes 10% of the global burden of diseases. Even with the existing mental health policies and laws developed in Uganda to try identify key barriers to mental health development and implementation (Country report, 2008; Mental health Act, 2014), the results according to a field work study conducted between August 2006 and 31 march 2007(Country report, 2008; WHO pro Mind, 2012) revealed that there was a lack of public awareness on mental health and mental illness; stigma still played a key role; low priority was given to all mental health service delivery at all levels and low levels of mental health research.

Organizations such as Strong Minds through their approach (ITP-G) have embarked on treating depression in women and adolescents. According to their most recent therapy cycle (3) report of 2018, statistics showed that during pre- therapy11% were found to have severe depression, 46% had moderated to severe depression while 43% had moderate depression. During their post therapy (week 14), Strong Minds 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. Much of the treatment available (IPT-G) is provided to the individual who has been diagnosed with depression  however, many family members are left un attended to; family members do not know what depression is or what kind of care to offer their depressed family members, issues of isolation and stigma are not addressed too. So  the role of this research is to assess the role of family support towards recovery of depression survivors 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, perception of this once stereotyped silent killer will be reduced. Nonetheless, mental illnesses can be treated with treatments that include; CBT, the use of antidepressants and interpersonal psychotherapies among others. This research will focus on the family systems theory which will explain how family and social support provided may lead to survivor recovery hence avoiding future relapses.

1.4 Purpose of the study

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

1.5 Objectives of the study

This study intends to focus on the following objectives:

1.5.1 Main objective:

To assess the relationship between family support and resilience among depression survivors at strong minds, Wakiso district.

1.5.2 Specific objectives

1. To assess the relationship between family support and resilience among depression survivors at strong minds, Wakiso district.
2. To assess the relationship between family support and relapse among depression survivors at strong minds, Wakiso district.
3. To examine the combined influence of family support, resilience and relapse among depression survivors at strong minds, Wakiso district.

• Research Questions

RQ 1.What is the relationship between family support and Resilience among depression survivors?

RQ 2.What is the relationship between family support and relapse among depression survivors?

RQ3. What is the relationship between resilience and relapse among depression survivors?

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, 2002). 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 Psychological 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. In addition, 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”.

1.8 Conceptual Framework

The aim of this study is to explore the relationship between family support, resilience and depression using three dimension (eg social support, financial and spiritual ) and how approaches such as IPT-G is used as a treatment for depression. The Family Systems theory will be centered on in order to assess the relationship between family support and resilience among depression survivors as illustrated in figure 1 below.

Conceptual Framework showing the relationship between family support and resilience among depression survivors .

Independent variable                                          Dependent variable

Intervening variable

Figure 1: Source: By Literature Review (Zimmerman &Brenner, 2010) (Strong Minds, 2019) (WHO report 2015) (Uganda country Report. Patel, 2001) (Basangwa, 2004, as cited by Ssanyu, 2007) American Psychiatric Association and DSM-5^th edition (APA, 2002, 2013) Wilhelm (2003) and modified by the researcher .

1.9 Significance of the study

The study will 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 will benefit Counselors and Mental Health practitioners who deal with depression clients as a source of literature review from this research.

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

1.10 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 and depression among survivors of Strong Minds and how these survivors tend to hang on without relapsing (the approaches used).

1.10.1 Geographical Scope

Strong Minds 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.

1.10.2 Time scope

The study will be conducted with four months, that is to say from January to March 2020 during which the researcher will use this time to collect data, 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, resilience among depression survivors at Strong Minds, a non- government organization that has embarked on treating depression using a mixed method approach to allow triangulation of data in order to obtain accurate results.

In this chapter, the researcher attempts to examine the views of other scholars and authors on family responsibility and resilience towards 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; the relationship between gender and depression, resilience and depression & a combined influence between gender and resilience of depression survivors at strong Minds Wakiso district, Uganda.

2.2 Family Systems 

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 each other. The theory focuses on the roles and responsibilities of family members in order to have 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, 2017 (as cited by J Gerontol, vol 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. The method used was- data from the Netherlands’ older person’s and informal care givers survey with a minimum data set of 1,611 care givers. The results showed that women experienced greater partner care giver burden than men to which they related women to have experienced secondary stressors such as relational, financial problems among others. They also noted that both men and women had a positive association towards “burden” and more primary stressors such as help from other care givers. This illustrates how family responsibility/ support cuts across both genders although women tend

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 cited by Wubalem et al, 2019). The results according to this study 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 included SMI effects to the children. It noted that children of patients with severe mental illnesses had poor school performance, had nutritional problems among others. The research focused on low and middle income country for example Uganda, Ethiopia, Brazil and Thailand.

Literature reviewed from a Strong Minds recovery story (Strong Minds, 2018) surrounding depression talked about a victim’s recovery journey from depression and how social support from a family friend changed her life. After witnessing the long black nights her mother underwent (Afiya), recalled the pain and sadness in her mother’s eyes and how she no longer had to go to school because she was responsible for caring for her mother and the family. All hope was lost until her mother with the help of a friend, started attending Strong Minds therapies and through this, she learnt of what depression was; the myth that she was possessed as referred to by her husband was now clarified as a mental disorder.

Afiya’s mother after several weeks of interpersonal psychotherapies, learnt what her triggers were, she also learnt new coping mechanisms and within several weeks, she had regained her joy and today, she is now providing for her family. Many children of depressed mothers of school going age tend to have low school attendances or even school dropouts and this could be attributed to the need to carry on the burden to provide care for the sick member of the family.

In Uganda today for instance ,Strong Minds piloted an adolescent project (Strong Minds , 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. Strong Minds expected to reach more than 4,000 adolescents who suffered from depression. Their findings are yet to be published.

2.2.1 Family Support in relation to Resilience among Depression Survivors

Bronfenbrenner an American Psychologist and the theory according to Moleli (Moleli, 2017) assumes that human beings are all interdependent with our environment. This is to say, a change in one part of the system affects the other parts (family members) and vise versa. For instance, the death of a family member may affect the other living relatives sometimes even disrupting the whole family structure and the environmental systems too.

Family members or care givers are a great source of support for the depressive family member (they can be fathers, mothers, siblings or next of kin). Since depression affects moods of the afflicted individual, this can be transferred to the family. Feelings of anger, sadness, and irritability among other negative emotions and behavior patterns can affect the family as a 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.

According to Strong Minds therapies (IPT-G), many depression patients have been helped and reconnected back with their families; many have also been helped to gain meaningful employment 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 work with survivors of mental health by assisting them to set up small businesses from which they are able to earn a living; sometimes trainings are provided to these clients so that they too can become self reliant and through the use of these new skills, the 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 regard less of the age, gender, social-economic status, one strategy that was employed by Butabika 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. According to an article by Jimmy, (Jimmy, 2018) in a piloted peer support program carried out by Butabika East London Link in Uganda, it was noted that peers tend to listen more to their fellow peers instead of elders. This support program was aimed at improving mental health and creating awareness about the dangers of drugs & alcohol usage. 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 their concerns. 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) .

However, it should be noted that there is still a lot of stigma associated with depression and other factors such as poverty undermine the care giving duty. Care givers invest a lot of time and will in order to meet the patients’ basic need such as food, shelter, finances aimed for transporting the patient or paying medical bills; spiritual nourishment is also a part of the care givers’ un described role.

Prayer or meditation has been known to reduce stress and depression. When one is a Christian it is important to pray to God for strength. When we turn to God 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 and encourages us that when in times of weakness, one needs to bring him / herself before God. Prayer in communal settings together with family strengthens support and connections in our relationships with other people.

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

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 to affect 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.

2.3.2 Resilience and Depression

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 (Rutter, 2013) describes resilience as the ability to have good outcomes eve after experiencing serious stressors in life. Resilience varies across cultures; what may be seen as resilience in Uganda may or may not be considered resilience in other parts of the world.

Resilience theory according Hendrick & Young (Hendrick & Young, 2013; Rutter, 2006) addresses how individuals are able to adapt to and rebound from life stressors. Therefore it is possible for an individual to change their thoughts, behaviors or actions and adapt to life more positively. Hendrick & Young 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); Personal / individual protective factors such self esteem, self control, optimism among others promote resilience in depression survivors. Resilience can be measured using values or tools such as family coherence (unity); social support systems and personal competence.

According to a journal by Medical & Basic Science (2018) they noted that there are certain resilience facilitators or factors that may help an individual cope and they are divided into two i.e. individual / personal protective factors for instance self esteem & self efficacy while societical protective factors include; social support from spouses, communities, children , workmates and family members .In addition, with children for instance the presence of a stable adult in the form of parents, older siblings or grandparents also helps to reduce fear of being left alone; children may also be able to socialize thus creating stronger bonds with their family members & learning to trust starts from the family setting. Social supports systems when offered by one’s friends and family may increase one’s ability to bounce back and thus become productive (Hendrick, 2013).

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 welfare Infor, 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 skills and 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. According to the family systems theory,

Spiritual barriers where by the patient associates the illness as some form of punishment by God may delay the journey to recovery. Therefore, it is important to understand the patient’s needs /triggers for instance depression triggers then work together with them to develop copying strategies thus quickening the recovery journey and avoiding relapses.

There are a number of ways resilience skills can be increased in a family and these include;

Planning ahead as a family is important. Due to the connectedness within  families (Zimmerman & Brenner, 2010) 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. It is also important to discuss the stressors one feels and then come up with coping mechanism to prevent one from breaking down completely; as a family it is important to spend time together for example physical activities like exercises, having time to go out  together among others. This may aid in stress reduction for the family or on individual basis.

Depressive survivors should also be encouraged to review their past experience and let them be their teachers in life. When family members provide love and support to each other, emotions such as hurts and pains including difficult past experiences become lessons for the future. 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 belonging and 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.

2.4. 1 Family responsibility, resilience and Depression

Depression is still a very serious and complex condition with many research studies still being carried out to pin point the actual causes. However, contributing factors such as genetic factors (hormonal levels), environmental and sometimes certain illnesses like HIV/AIDS, diabetes or loss of a loved one, sometimes medications may cause depression. Depression may also occur due to an un- known causes affecting any one irrespective of age, gender, religious affiliations or social status. Depression is defined as, “a mental illness characterized by feelings of low energy, feelings of guilt, hopelessness and worthlessness, sadness (WHO, 2012) however these symptoms vary from person to person.

Families are known to be the major source of care, support and love sometimes even cure (or not) for depression. They contribute emotionally, financially and socially. Emotional support can sometimes be a great source of recovery. Families have a huge impact on depression but it should also be noted that depression also has a huge impact on families. Family members may offer support to the depressive person by reminding them to take medications or encouraging them to comply with other treatments too.

Mood disorders like depression are treatable conditions, 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. If mood disorders for example depression is left untreated for long periods of time, can become recurrent causing impairments or it can cause unnecessary suffering that interferes with people’s daily-life activities and can even lead to suicidal tendencies. It should be noted that depression affects anyone regardless of the age, gender, cultural background, ethnicity, religion or social economic status.

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

In order to help depression survivors avoid relapse, talk therapy should not only be for the depressed person but should include family members too. 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 addition, information on them importance of building social networks, helping them identify their triggers among other copying strategies , encouragement, love, public awareness of mental health and mental illnesses , sharing information on available treatments and counseling in order to tackle stigma associated with mental disorders, more research  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 Hypothesis

Research Hypothesis

HP1. There is a relationship between Family responsibility, resilience and Depression.

HP2. There is no relationship between Family responsibility and depression.

CHAPTER THREE

METHODOLOGY

3.1 Introduction

This chapter describes the procedure that will be followed to come up with the research results. It covers the research design, study population, 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 (Mugenda &Mugenda, 2009).

3.2 Research Design

The study will adapt a mixed method design because it will allow triangulation of both qualitative & quantitative data as to obtain accurate results.

3.3 Study Population

Population is defined as the complete collection of all the elements of interest in a particular investigation (…….source). A population is the totality of objects or persons having similar features that are if interest to the researcher and where the implications are to be made. The study population will be 150 survivors of depression from strong minds out of the 3,200 reached by the Strong Minds Peer Therapy Groups.

3.4 Sample Size

A sample is a collection of some subsets of the population. 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 (source….)

The study will consider young adults between the age group of 35-44 years old and a sample size of about 150 will be considered from Wakiso district.

3.5 Sampling Techniques and Producers

The study will employ purposive sampling technique because it aims at providing desired information for the study. According to Sekaran (2003), says that it is sometimes essential to provide desired information for the study from specific people who can provide the desired information because they have it or match the criteria for the research. Therefore, only participants who best suit the study which in this case will be the survivors of depression will be considered.

3.6 Data collection Methods

3.6.1 Questionnaire

A questionnaire is a pre-formulated set of questions given to respondents to which they record their answers. These questions will be closed ended in type. The questionnaire will be designed to gather perceptions related to family responsibility and the role played by resilience in order to overcome depression.

The researcher’s choice of questions will be guided by the fact that questionnaires give clear and specific responses and also due to the fact that they enable respondents to express themselves clearly and freely. Careful considerations will be given to the design of the questionnaire (Mathews, Fox & Hunn, 2007).

3.6.2 Interviews

Interviews will be used to gather information from respondents as they are more personal than questionnaires.  Interviews are also effective as the researcher works directly with the respondents thus obtaining further opportunity to probe and then carry out follow up questions so as to get in-depth information.

3.7 Data Collection Instruments

3.7.1 Questionnaires

The study will use a Self-administered Questionnaires with closed ended questions. Closed ended questions are easy to analyze and present in a usable form. The questionnaire will use the likert scale with five category response scale with one representing strongly disagree and five represented by strongly agree. Numeric scales enable the use of quantitative analysis (Mugenda & Mugenda, 2009).

3.7.2 Interview Guide

Interview guides will be used to gather qualitative data and get in-depth understanding on how family responsibility may lead to depression.

Creswell, (Creswell, Research Design : Qualitative , Quantitative and Mixed method Approaches , 2014) agrees that an interview guide consists of questions that an interviewer asks face to face during interviews. An interview guide is a list of structured questions designed in such a way that they address all key research questions which are then administered face to face during an interview.

3.8 Pretesting of Data Collection Instruments

The principles of reliability and validity are cornerstones of scientific research methods (Kent, 2001). Reliability and validity concepts are important in defining and measuring for bias or distortions.

3.8.1 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) argues 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.

A pilot test will be conducted on about 40 respondents from within the depression survivors from strong minds in order to assess the consistency of the questionnaires in terms of results. The results will then be subjected to Cronbach Alpha reliability test and data collected from this pilot test will be subjected to Statistical package for Social Science (SPSS).

All variables will be subjected to this test and a yielding of an alpha value of 0.70 and above is accepted so, will allow the researcher conclude that the instrument is consistent hence reliable in accessing the variables under the study.

3.8.2 Validity

Validity refers to the degree to which the results obtained from the data actually represent the phenomenon and variables under the study (Mugenda &Mugenda, 2009). Content validity will be measured using Content validity Index (CVI) using the formula below;

CVI= Number of items declared valid

Total No. of items

For the instrument to be declared valid and considered relevant in assessing the variable the data collected is subjected to the above test and the CVI is expected to be above 0.70.

3.9 Procedure of Data Collection

The researcher will obtain an introductory letter from Kyambogo University, Department of Psychology requesting for permission to carry out research at Strong Minds.

3.10 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 then be analyzed using both qualitative and quantitative methods.

3.10.1 Quantitative Data Analysis

Data from questionnaires will be edited, coded and captured using SPSS software that helps to generate descriptive statistics (with the aid of percentages and frequencies) and infernal statistics (such as coefficient of determination and regression, spearman correlation) which will enable the researcher to make meaning and interpret the findings then later make conclusions of the study objectives, hypothesis and research questions.

3.10.2 Qualitative Data Analysis

This will involve identification, describing and interpretation of the themes in textual data and determining how these themes help answer the question at hand. Qualitative data will be presented in graphs and summaries form.

• 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. A cover letter will also be drafted accompanying the research instruments explaining the purpose of the study.

The study will observe the principles of research ethics which include; Privacy, informed consent, accuracy and confidentiality (Amin 2005). Respondents will be briefed about the benefits and risks of their participation. This will be done using a disclosure form which will be given to the participants should they wish to participate in the study.

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

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

Anticipated Limitations

Limited resources inform of capital to cover the different areas of interest however, the researcher intends to fund raise from among her family & friends.

The researcher anticipates finding uncooperative respondents during data collection process however , she will effectively build rapport so as to break the ice.

The researcher will ensure that all questions are well explained with the aid of interpreters in order to avoid misinterpretations as a result of literacy levels.

References:

Uganda Bureau of Statistics . (2005) . 2002 Uganda population and housing census, Main Report. Entebbe, Uganda

Kigozi, F., Ssebunnya, J., Kizza, D., Cooper, S., & Ndyanabangi, S. (2006 (10). An overview of Uganda’s mental health care system : results from an assessment using the world health organization’s assessment instrument for mental health systems (WHO- Aims). International journal of mental health systems 4, no.1 (2006 (10):1

Ndyanabangi, S., Basangwa, D., Lutakome, J., & Mubiru, C. (2004).  Uganda mental health country profile. International Review of Psychiatry, 16, (1-2), 54-62.

Roehr, Bob. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders (DSM-5), fifth edition . 2013

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http://www.un.org/development/des

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http://www.who.int/mental_healthprevention/genderwomen/en/

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