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FAMILY SUPPORT AND RESILIENCE AMONG DEPRESSION SURVIVORS: A RESEARCH PROJECT ON CLIENTS OF STRONG MINDS IN WAKISO DISTRICT ISABELLA MOSHI AMOLI 18/U/GMCP/19884/PD RESEARCH PROPOSAL SUBMITTED TO FACULTY OF EDUCATION DEPARTMENT OF PSYCHOLOGY IN PARTIAL FULFILMENT OF THE AWARD OF MASTERS OF COUNSELLING PSYCHOLOGY DEGREE OF KYAMBOGO UNIVERSITY October 2021
Declaration I, Isabella M. Amoli, do hereby declare that this research proposal titled, “Family Support and Resilience among Depression Survivors; A Research Project on StrongMinds in Wakiso District” is my original work and it has never been submitted to any institution of higher learning for any academic award. Resources cited have been well acknowledged and indicated in the references list. Isabella. M. Amoli Signature…………………………. Date………………… Approval This is to certify that, Isabella. M.
Amoli has successfully written this research proposal titled, “Family Support and Resilience among Depression Survivors; A research project on Strong Minds in Wakiso District” under my guidance and it is submitted with my approval, to guide the student in her data collection exercise. Name: Professor David Kami Olema Signature: ………………………………….. Date: ……………………………………….. Name: Dr. Katigo Kaheeru Jokshan Signature: ……………………………………. Date: …………………………………………. Acknowledgement Special thanks and appreciation go to the Almighty God through His Son and my good Lord Savior Jesus Christ for the everlasting and endless grace, through the good health and knowledge He has granted unto me throughout my life.
I would like to use this opportunity to express my gratitude to my supervisors Prof. Olema David Kami and Dr. Katigo Jokshan Kaheeru for the constant support and guidance. I another special way, I would like to appreciate Madam Winnie Kyosaba, Ms. Gladys from the Counseling Department of Kyambogo University, Dr. Jane Namusoke and all those who have been there for me in terms of constant encouragement towards successful completion of my Degree of Masters of Counseling Psychology. I would like also to extend my sincere and heartfelt thanks to my family, most especially my parents Mr. Edwin and Mrs. Helen Mande, Uncle-Professor WW Anokbbonggo (Mulago Hospital) for believing in me and encouraging me to finish my research.
In addition, special thanks message to Dr. Wilson Gude for the continuous support and reminder that hard work pays; my sisters (Solomy & Donna) and brother (Elly); Hon. Benson and Agnes Obua-Ogwal, Adikini Suzan (Strong Minds) and all those who prayed with me and supported me in every way possible. Lastly, special thanks to you my dear sister Phiona, it’s been one year since you departed although, your constant strength during your battle with Lupus has taught me the importance of resilience even in the amidst of adversity.
Thank you for your support and teaching me the importance of prayer, forgiveness and meditation. To God be the Glory. Table of Contents Declaration i Approval ii Acknowledgement iii List of Abbreviations and Acronyms viii CHAPTER ONE 1 1.1 Introduction 1 1.2 .0 Background of the study 4 1.2.1 Historical Background of the Study 4 1.2.2 Theoretical Background of the study 7 1.2.2.1 The Biological / Hereditary differences Theory 8 1.2.2.2 Gender Based Role Identity Difference 8 1.2.2.3 Family Systems Theory 9 1.2.3 Conceptual Background of the study 10 1.2.4 Contextual Background 11 1.3 Problem Statement 11 1.4 Purpose of the study 13 1.5 Objectives of the study 13 1.6 Research Questions 14 1.7 Operational Definitions 14 1.8
Significance of the Study 16 1.9 Conceptual Framework 17 1.10 Scope of the Study 18 1.10.1 Content Scope of the Study 18 1.10.2 Geographical Scope 18 1.10.3 Time Scope 19 CHAPTER TWO 20 LITERATURE REVIEW 20 2.1 Introduction 20 2.2 Family Systems Theory 20 2.2.1 Family Support 22 2.2.2 Resilience and Depression Survivors 24 2.2.3 Resilience 25 2.2.4 Family Coherence 26 2.2.5 Protective Factors 27 2.2.6 Therapy received – (G-IPT) 28 2.2.7 Individual Factors 29 2.2.8 Strengthening Protective Factors 30 2.3 Relationship between Family Support and Resilience of Depression Survivors 32 2.4 Economic Implications of Depression to Families, Communities and a Nation. 34 2.5.0.
Research Hypothesis 38 CHAPTER THREE 39 METHODOLOGY 39 3.1 Introduction 39 3.2 Research Design 39 3.3 Area of Study 40 3.4 Target Population 41 3.5 Sampling 42 3.5.1 Sample Size 42 3.6 Sampling Procedure, Design and Technique 43 3.7 Data Collection Instruments 44 3.7.1 Self-Administered Questionnaire 45 3.7.3 Semi Structured Interviews (SSI) 46 3.8. Data Analysis 47 3.8.1 Quantitative Data Analysis 47 3.8.2 Inferential Analysis 47 3.8.3 Qualitative Data Analysis 47 3.9. Reliability 48 3.9.1 Validity 48 3.10. Ethical Considerations 49 3.11 Anticipated Limitations 50 REFERENCES: 53 List of Abbreviations and Acronyms APA American Psychological Association CBT Cognitive Behavior Therapy DE Depressive Episode DSM Diagnostic and Statistical Manual of mental disorders ECT Electro Convulsive Therapy ICD International Classification of diseases IPT Interpersonal Psychotherapy MD Major Depression MDD Major Depressive Disorder MDE Major Depressive Episode NIMH National Institute for Mental Health SMI Severe Mental Illness SSRIs Selective Serotonin reuptake Inhibitors UBOS Uganda Bureau of Statistics WFMH World Federation for Mental Health WHO World Health Organization WMHS World Mental Health Survey
CHAPTER ONE 1.1
Introduction Depression is one of the common mental health disorders sometimes referred to as “mood disorders” (WHO, 2012). It 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 (APA, 2013).
Basing on DSM-5, it is given that for one to be diagnosed with depression, he/ she must experience five or more symptoms in a period of two weeks and at least one of the symptoms should be “depressed mood or loss of interest”. The above may be contrasted from how the World Health Organization defines depression (Truschel , 2020). World Health Organization (2015) defined mental health as a state of wellbeing 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”.
Global Burden for Disease (2010) and World Health Organization (2017) observed depression alone 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, 2013; Charlson et al., 2013). 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 and certain types of medications may contribute to depression in certain individuals.
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). Uganda was ranked by WHO (2017) 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 most affected region (Mugisha, Muyinda, Malamba & Kinyanda, 2015). In the observation made by the authors, at least three out of ten people had Major Depressive Disorders with females at 29% and males at 17% according to a distribution by gender (Mugisha et al., 2015).
A recent analysis on mental illnesses by Ministry of Health Information System affirmed that Butabika National Referral Mental Hospital in Kampala 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 (UNHRS, 2019). In Uganda, 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 (Musisi & Owiny, 2020).
Molodynski (2017) made an observation that 35% of Ugandans suffer from some form of mental disorder and of these, 15% require treatment (Kiwawulo, 2010; 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 medical services (Bailey, 2014). Uganda Bureau of Statistics (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 (Kiwawulo, 2010). Other services include; mental care, psychiatric training, community education and resettlement assistance (MDAC, 2017). Family Support and Depression Families are known to be the major source of care, support and love, sometimes that support may be a cure for depression (Kyotalengerire, 2020). Families have been known to contribute emotionally, financially and socially.
Emotional support can sometimes be a great source of recovery according to the 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. Family members may offer support to the depressive person in form of reminding them to take medications, listening to them or encouraging them to comply with other treatments thereby enabling the depressed person to recover quickly (Katia, 2015). It is important to note that there is a lot of stigma associated with depression that undermine recovery (Ssebunnya et al, 2009; Molodynski, 2017); Other factors such as poverty also undermine the care giving duty (Bailey, 2014). 1.2 .0
Background of the study 1.2.1 Historical Background of the Study Globally, 300 million of the world’s population, majority of them being women, live with depression (WFMH, 2012, WHO, 2015) . StrongMinds report asserts that depression is one of the most neglected health problems especially in Africa. The growing factors that contribute to its ever-increasing rates which include conflicts, extreme poverty, unemployment, sexual violence and widowhood (Katia, 2015) .
In Africa, StrongMinds report noted that 90% of Africans suffer from depression (90 million) of which 60 million are women. Most Africans having no access to effective treatment (Ndyanabangi et al, 2004, Bailey, 2014) . 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 America, 2015). World Mental Health Survey (2012) and WHO (2012) asserted that almost every year, nearly one million people die due to suicide related to depression.
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 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 of proper treatments available. Katia (2014).
and WHO (2017) also argued that depression afflicts women twice as much as their male counterparts, causing severe impacts that range from physical to mental disability. Depression is known to affect entire families too. For instance, StrongMinds as an organization observed that children whose mothers suffer depression tend to have “less secure attachment relationships,” “malnutrition” and this may result into other consequences such as “low school attendances” (Katia, 2014).
There are many organizations in Uganda that deal with mental illnesses such as Mental Health Uganda and Butabika Hospital however; one of the leading organizations in Africa that is addressing the issue of depression is StrongMinds (Katsana BBC World Service, 2020). Through the use of Group Interpersonal Psychotherapy (GIPT), StrongMinds 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 (Katia, 2015). Group Interpersonal Psychotherapy (GIPT) was first tested by Johns Hopkins University (2002) in rural Uganda and found to be cost effective.
The (GIPT) approach was found to suite the African culture whose roots are known to be rooted within their communities (Bolton et al, 2003; Katia, 2015). The approach (GIPT) uses models such as role plays and visual charts as a way to communicate to group members in order to enable them identify their depression symptoms and triggers. The model has been successful in combating depression with success rates of nearly 93% and almost 300-400 women have been treated each year (StrongMinds, 2019).
Organizations like Mental Health Uganda, Basic Needs Uganda and StrongMinds aim not only at resolving the current depression states of patients but also equipping depression survivors with strategies to further prevent future depressive episodes from reoccurring since many depressed individuals tend to relapse from time to time (Katia, 2014). This is done by encouraging depression survivors to maintain networks within families and among the group members coupled with other resilience boosting strategies and strengthening protective factors in order to avoid relapse.
Research studies on depression were 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 study carried out in Uganda by StrongMinds in 2014 was a pilot study to assess whether GIPT approach was effective in treating depression in Uganda. The study 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 (Katia, 2014). In this pilot study which was termed as, “phase one”, the Patient Health Questionnaire-9 (PHQ-9) tool was used to diagnose patients.
Interpersonal psychotherapy was used for about five to 16 weeks; again, a post – assessment was recorded during week 17. The results showed a decline in depression rates with 92% of the patients declared depression free after 16 weeks of GIPT intervention; GIPT also had an impact on the lives of these depression survivors and their families with most of them gaining satisfactory employment (12%); Most of the women reported eating regularly (13%), most families also appeared to be living in proper housing probably due to increased incomes.
Additionally, the children of these depression survivors now attended school more regularly (15%) and above all, 22% of these survivors seem to have built stronger social networks that act as support for them (Katia, 2014). It should be noted however, that Interpersonal Psychotherapy (IPT) is not the only approach available. There are other approaches such as Cognitive Behavioral Therapy (CBT), Behavioral Activation, and use of antidepressants like Selective Serotonin Reuptake Inhibitors (SSRIS).
These antidepressants are known for their positive impact on the disease while CBT and ECT are known for their long-lasting effect (Karampampa et al., 2011). 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). Todd and Rotternberg (2010) noted that the resilience factor is an important component when it comes to achieving proper 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 adults, elderly and adolescents from various ethnic groups and 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 and perform other household duties since they now have been equipped with strong social support systems to avoid relapse (Katia, 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 & Pingoud, 2003); The Gender Based role identity theory and the Family Systems Theory. 1.2.2.1 The Biological / Hereditary differences Theory This theory focuses on hormonal differences between males and females (Wilhelm & Pingoud, 2003).
It 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 and menstruation are known to contribute to more depression rates among women than in men (WFMH, 2012; Mutegeki, 2019). It is important to note that while women experience menopause, men too may undergo a similar symptom called mid-life crisis.
With mid-life crisis, some men between the ages of 45-64 years’ experience feelings of unhappiness, worry and disappointments and may feel trapped in an identity/ lifestyle they experience as constraining hence the need to make changes in their lives. 1.2.2.2 Gender Based Role Identity Difference This theory looks at the roles of males and females in 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 and care taker (Mutegeki, 2019).
This theory illustrates how gender differences influenced by environment may lead to depression. In a news article by Nakasujja (2019), it was noted that there are more women who are visiting Butabika hospital due to a lot of pressure on themselves. Mutegeki (2019) also observed an increment in the number of females who visited Butabika hospital. Out of 950 persons who visited Butabika Hospital for depression, 450 were females whereas 300 were males with depression. This could be attributed to reasons such as; “a lot of competition to be a perfect wife, best mother,” best employee and this can be over whelming and can lead to depression especially when they fail in any role. (Mutegeki, 2019).
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 although most men tend to suffer silently not seeking treatment for depression but instead, choose to 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 depending on one’s up bringing” (Wilhelm & Pingoud, 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 (McDonnell & Ryan, 2013). 1.2.2.3 Family Systems Theory The family systems theory was developed in the fields of clinical psychology and psychiatry which used psychotherapeutic methods intended for families.
Murray Bowen (1978) stated 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 to which he /she belongs. Sometimes families may act as a listening ear or help one cope with whatever situation he / she is dealing with, so this kind of support is important when trying to combat depression (WFMH, 2012). This connectedness makes family members interdependent on each other with each family member playing a role within the family unit while respecting set rules in order for the family to function well.
The 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 depressed, other family members may come in to perform the tasks or duties of the depressed member for example by providing care and support to the patient 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 which may make the family dysfunctional in the long run.
Hendrick and Young (2013) noted 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, other members can work on ways to improve the depressive person’s resilience such as providing a listening ear to the patient or by finding ways to boost the depressive family member’s self-esteem (WFMH, 2012). The World Health Organization fact sheet on mental disorders (WHO, 2017), states that support from friends and families play a key role in the 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, 2017). 1.2.3 Conceptual Background of the study Resilience will be the Dependent Variable and focus will be on three dimensions such as external support, family coherence and personal structure /competence. 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 while Protective factors on the other hand is the moderating variable and will focus on the personal characteristics such as self-esteem alongside therapy received by depression survivors in order to avoid relapse. 1.2.4 Contextual Background StrongMinds is a non- government Organization founded by Sean Mayberry in 2013 with the aim of treating depression in Africa. Today, StrongMinds is treating women (and has now included men) across Africa with other branches in countries like Zambia.
The mission of StrongMinds 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 GIPT 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 Lake Victoria to the south. Coordinates of the district are 0024N; 3227E with headquarters 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 first leading cause of disability in terms of years lost due to disability with approximately 4.4% of the world’s population diagnosed with it and a major contributor to overall burden of diseases (Marcus, 2012; WFMH, 2012; WHO, 2015, Schlein, 2017). According to Moeti (2017), 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, 10th October was declared World Mental Health day (WFMH, 2012; Odoki, 2018). Its goal is to create awareness, educate people and end stigma associated with mental illnesses across the world (Moeti, 2017). The 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 (WFMH, 2012; Odoki, 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 (Katia, 2015). In Uganda 1,747,769 cases (4.6%) of depressive disorders were recorded (Wabai, 2019). 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 treated at in-patients and 748 and 2500 are seen at out-patients a year (WHO, 2012).
Organizations such as StrongMinds through their approach (GITP) have embarked on treating depression across Africa (Katia, 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 (Katia, 2015). In addition, the pre-study consultations made by the researcher with one of the medical doctors from Butabika Hospital, it was revealed that Butabika Hospital diagnoses and manages depression on individualistic basis. For instance, with some clients, anti-depressants are used while with others, psychological treatments.
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). 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. Counseling should be provided in order to help avoid relapses. So, this research will explain how family support coupled with protective factors may lead to resilience hence avoiding future relapses.
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. To establish the levels of family support of depression survivors among clients of Strong Minds, Wakiso District.
To establish the levels of resilience of depression survivors among clients of Strong Minds, Wakiso District. To assess the relationship between family support and resilience of depression survivors among clients of Strong Minds, Wakiso District. To examine the mediating effect of protective factors on the relationship between family support and resilience among clients of StrongMinds. 1.6 Research Questions RQ 1. What is the level of family support of depression survivors among clients of Strong Minds, Wakiso District? 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? 1.7 Operational Definitions Depression: This study will adopt the definition of Depression as given by the Medical Dictionary which is a “mental state of altered mood characterized by feelings of sadness, despair and discouragement.” Depression according to American Psychological Association is defined as 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, for example he/ she must present with five or more symptoms for more than two weeks.
Schimelpfening (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”. Resilience Wulff, Donato and Lurie (2015) define resilience as the ability to “adapt to, withstand and recover from adversity and stress”.
It is 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 (Rutter, 2013). It is a process of adapting well when one is faced with tragedy, a traumatic event or other significant sources of stress in their lives American Psychiatrically Association (APA, 2014). Support Family Support 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”.
It is a structure that refers to 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). 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 This is defined by the American Society of Addition Medicine as the recurrence of behavioural or other substantive indicators of active disease after a period of remission.
It happens when an individual had gotten control over the behaviour but is re-experiencing a period of uncontrolled behavior (Parks & Marlatt, 2003). 1.8 Significance of the Study The study will enable counseling psychologists 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 and 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 Conceptual Framework Conceptual Framework showing the relationship between Family Support, Protective factors and Resilience Figure 1: Conceptual Framework This Conceptual framework will examine the relationship between Family Support as the independent variable and resilience as the dependent variable. Protective Factors will be reviewed as the moderating variable between the independent and dependent variable.
The aim of this study is to assess the relationship between family support and resilience of depression survivors among clients of StrongMinds using three dimensions of Family support (e.g. social support, financial and spiritual) and Resilience dimensions for instance (family coherence, external support and personal Structure) will be viewed; Protective factors such as (therapy received i.e. GIPT combined with personal characteristics that may aid in the treatment for depression in order to avoid relapse will also be viewed. 1.10 Scope of the Study 1.10.1
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 StrongMinds in Wakiso District coupled with protective factors such as self- esteem and how these survivors tend to live on without relapsing (i.e., therapy they receive such as GIPT). 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 survivors 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 (Katia, 2014; BBC pod cast, 2020).
Therefore, the researcher would like to assess family support of those who have passed through StrongMinds Organization. 1.10.2 Geographical Scope StrongMinds head office is located in Bugolobi Plot 30 Luthuli Rise, 4.5km via old Port Bell road and Spring road in Kampala with branches in Wakiso, Iganga, Mukono and Kampala districts. 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. 1.10.3 Time Scope The study will be conducted within seven months that is to say from March to September 2021 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 In this chapter, the researcher will attempt to examine the views of other scholars and authors on family support, other protective factors and resilience of depression survivors.
The main source of data will be articles, journals, books, reports and other online sources with an aim of establishing the research gap. 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 StrongMinds Wakiso District, Uganda.
A cross-sectional survey employing both qualitative and quantitative approaches will be used and a mixed method approach will be employed in order to allow triangulation of data so as to obtain accurate results. 2.2 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”. The theory (Family Systems 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. Swinkels, vanTilburg, Verbakel and vanGroenou (2019) conducted a study to explain the gender gap in care giving burden of partner care givers using the stress appraisal model. The research findings noted that gender differences could be explained using different conditions of burden among care givers in the Netherlands which they divided into three dimensions namely; 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.
Sampling literature from various scholars showed that female caregivers are more burdened than male caregivers (McDonnell & Ryan, 2013; Pennning & Wu, 2016). The research 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. Similarly, Fekadu, Mihiretu and Craig (2019) carried out research in 20 different countries namely 14 European countries, USA, Asia (6), Africa (6) and Latin America (4), to look at the impact of severe mental illness (SMI) on family members and the community where the patients came, results 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.
There was also an indication SMI affect the children of parents with these conditions (38.7%, 35.6% and 15.2% of these children had lifetime psychiatric disorders). Children of parents with Severe Mental illnesses had poor school performance, had nutritional problems among others. For example, Children whose parents suffered from MDD were reported to have higher mortality than their healthy counterparts (Fekadu et al., 2019). The above research also focused on low- and middle-income countries.
In Uganda for example, 836 mothers of children admitted with malnutrition as a result of maternal depression according to a case control (Ashaba et al, 2015). In Ethiopia, a cross section study was carried out with a sample of 301 caregivers of people with SMI (like schizophrenia) focusing on spouses, siblings and children. The results according to this cross-sectional study done in Ethiopia illustrated that most family members found care giving to be burdensome but were coping (Assefa, Shibre, Asher & Fekadu, 2012). 2.2.1
Family Support Family Support in this context will be viewed in terms of social, financial and spiritual support as discussed below. In an observation made by World Health Organization (2017), it was indicated that social support has a big impact on the recovery of an individual for example; the presence of family / social support such as parents and siblings may reduce vulnerability of the depressive member to relapse.
Charity organizations such as Basic Needs Uganda 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 also 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 may now be able to provide for themselves and their families in future (Basic Needs, 2015; MoH-Uganda, 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 (Odoki, 2018). The author also observed that peers tend to listen more to their fellow peers instead of elders.
So, this Peer 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 youths when it came to concerns put forth by them (Odoki, 2018). Ministry of Health Uganda (2017) 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).
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, the 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 / hopelessness, one needs to bring him/ herself before God. Prayer and meditation in communal settings according to Koenig et al. (2012), 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, scholars like Savundranayagam & Montgomerg both noted that 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). Other scholars (Calasanti, 2010; Mc Donnell & Ryan, 2013; Swinkels, 2019) 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). Glauber (2016) observed that societal 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.
Therefore, care giving according to Mc Donnell & Ryan, (2013) in relation to other reviewed literature by scholars such as Glauber (2016) show a consistency in care giving burden affecting mostly women. 2.2.2 Resilience and Depression Survivors Rutter (2013) described resilience as the “ability to have good outcomes even after experiencing serious stressors in life.” Resilience theory according to Hendrick and 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. The authors went ahead to suggest 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. However, these resilience building strategies vary from person to person (Lowdermilk & Brunachel, 2013). 2.2.3
Resilience (i) Personal Structure (High Vs Low Resilience) It is important to understand how personal structure may influence one’s ability to bounce back after under-going a tragedy. Wingo et al (2010) found out that different individuals may undergo certain kinds of traumas leaving them vulnerable to develop either “psychological or behavioral” problems after the disaster and may not recover while others on the other hand, even after experiencing certain major adversities or traumas, may 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 vice versa (Min et al, 2013). According to Gillis (2011), 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 and self-efficacy while societal /environmental protective factors such as; support from spouses, community members, children, work-mates, peers, good schools, among others all these 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 & Young, 2013, Chen & Harris, 2019).
Depressed individuals tend to harbor feelings such as hopelessness, worthlessness, guilt among others so when there is family support, negative thoughts may reduce (WHO, 2012, APA, 2013) therefore, 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 & Young 2013; WHO, 2017).
Chen and Harris (2019) 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 is 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. 2.2.5
Protective Factors These focus on 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 is put on therapy received such as Group interpersonal psychotherapy and strengthening Protective factors such as self-esteem in order to promote positivism while avoiding relapse. Environmental factors External /societal support systems such as co-workers, friends or neighbors who are supportive may provide help to one by working out problems together thus reducing stress.
For instance, within these networks or support systems for example within StrongMinds volunteer led groups, some members may be or may have undergone similar issues and may be able to provide guidance or strategies that have worked for them to other depressive individuals which may provide some insight to the new depressive individual hence later these strategies then become tools used to avoid relapse (Katia, 2014). Spending time with people within our social networks may also provide a sense of security and belonging. This ensures that one is not alone which also reduces feelings of isolation, hopelessness and loneliness (Katia, 2014).
Having support groups for example joining groups of people who have undergone depression may help one see that they are not alone and may help one realize that there are ways to get through depression. For example, the GIPT approach which was employed by StrongMinds in 2014 had a strong impact on the reduction of depressive symptoms. According to their findings it stated that, 94-97 % of patients treated by StrongMinds were recorded to be depression free after participating in the 16-week GIPT (Katia, 2014).
Because GIPT focuses on inter-personal relationships of the depressed group members, this approach (GIPT) helps members identify their triggers and root causes then work on strategies that help overcome these triggers. Therefore, one can state that, since depression is episodic, these new strategies and skills obtained through GIPT addresses both immediate and long-term impacts of depression, the support systems created enable a sense of belonging and security (Katia, 2014). 2.2.6 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.
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. Within StrongMinds Organization, the groups are divided into two i.e., staff-led and volunteer- led groups. The GIPT 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 who uses a structured model over a period of 16 weeks in order to help group members identify and build strategies to combat root causes and triggers of depression (Katia, 2014).
From within the communities where these depressive survivors are based, a member is identified and trained so that she / he can later facilitate meetings even after completion of their sessions or help new depressive clients who might later join the group and these are the volunteer-led groups (Katia, 2014). StrongMinds 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 (Katia, 2015). Approaches such as GIPT 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 GIPT, 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 (Katia, 2015). 2.2.7
Individual Factors (i) 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.
(2017) on the role of self-esteem, 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 and Robins (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 & Robins, 2013) while low self-esteem may leave individuals more prone to depression and at times may also be related to anti-social behaviors and suicidal idealization (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 stigma associated with mental ill-health and relapse rates in other words, depression rates may go down. 2.2.8 Strengthening Protective Factors There are a number of ways to build self-esteem with the key being first identifying what is keeping one down then do something about it for instance; Avoid dwelling on one’s weakness and practice patience with self.
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 (WFMH, 2012,) it’s important to have a positive attitude and believe in one’s self and this helps to overcome self-doubt. 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 focus on one’s progress and success instead of comparing one’s self with others and also talking to friends or family who may help improve them (RMIT University, 2009, WFMH, 2012). 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, “I am unique and will be appreciated by others for that; also learning to foster a more positive voice that is more positive and supportive (WFMH, 2012). It is also important to engage in physical exercise that keeps one busy for example sports or having fun with friends and family like picnics among others and these self-care activities help us feel good about ourselves and hence increase self-esteem (Nantume, 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 example; Planning ahead of time as a family builds supportive and positive relationships. 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).
To discuss the stressors one feels, then come up with good coping mechanism to prevent one from breaking down completely. To spend time together for example in physical activities like exercises, going to the beach and visiting friends. This may aid in stress reduction for the family or an individual (Nantume, 2020). Family members can employ new strategies for example joint problem-solving skills 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). Creating a sense of belonging as a way of ensuring family connectedness while enriching skills and communication . 2.3
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 anti-depressant medications and psychotherapies which offer useful treatment and are commonly employed in treating the effects of depression (NIMH, 2015). However, if mood disorders for example depression are 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 (both family and the individual) and may even lead to broken families but worse still, suicidal tendencies (WFMH, 2012; Mutegeki, 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) and the quality of care provided will determine whether the depressed person will recover or not (WHO, 2017). Since depression affects moods of the afflicted individual, this can be transferred to the family.
According to Robinson, Rodgers and Butterworth (2008) and Fekadu et al, (2019) they noted that providing care may not directly lead to mental health problems however the experience one may undergo may create an environment that can cause mental health challenges such as increased stress levels. Robinson et al stated that sometimes because of the relationship between the carer and the recipient, the carer may ignore his/her feelings which may then affect their wellbeing in the long run. While, other scholars on the other hand like Magliano et al (2002) and McDonnell and Ryan (2013) looked at care giving burden in terms of hours of care giving and severity of the disability.
Other feelings such as anger, sadness, and irritability among other negative emotions and behavior patterns can affect the family as a whole disrupting relationship 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 (Magliano, et al., 2002, Robinson et al., 2008, McDonnell & Ryan, 2013). In a longitudinal study of adolescents to adult health by Chen and Harris (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 & Harris, 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 & Harris, 2019). 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 (Fekadu et al, 2019).
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 (Fekadu 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 (Fekadu et al, 2019; Nantume, 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 et al., 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. Other treatments such as CBT and ECT which are also effective with positive long-lasting results are very expensive in terms of duration and cost. 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, Fekadu et al, 2019, 2019). Another observation was in parents with depression and their children’s development. 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 (Katia, 2015); these children’s levels of functioning were 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 (Fekadu 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 in form 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 4th 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 Covid-19 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, 2020). According to Dr.
Nakku, director for Butabika Hospital, the facility (Butabika Hospital) that once received patients between 800 and 900 per week saw an increase in admissions between the months of July 12 and July 18 of about 1,050 cases yet the bed capacity is only 550, with 350 registered cases for Out Patients (Nantume, 2020). This can be attributed to the start of Covid-19 which has resulted into other challenges for example ; un-employment / job loss; the lockdown which left many people uncertain of the future amidst ever rising infection cases and deaths; domestic violence; food shortage, among others. This surge in depression cases could be as a result of all daily struggles to meet everyday expectations amidst losses made during lockdown (Nantume, 2020).
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 (Abalo, 2021). 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 constraints, 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 (Abalo, 2021).
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 Hypotheses HP1. There is a significant positive relationship between family support and resilience of Depression Survivors among clients of Strong Minds. HP2.
There is a significant positive mediating effect of protective factors on the relationship between family support and resilience among clients of StrongMinds. 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 & Christensen, 2017).
Mixed method research design dates back to as further than 1989 (Brewer & Hunter, 1989) 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 “3rd paradigm” in evaluation of research found “18 evaluation studies” dating back from 1959 to 1992 while other others such as Goodwill and 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 has been 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 & Christensen, 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 (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 Kirra Town council, Wakiso town council, Nsangi, Busukuma and Ssabagabo- Makindye. 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.
StrongMinds 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, 2019). 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 317 survivors will be selected from the total population of 1,777. Table 1: Population, Sample size and Sampling technique Category _Population size _Sample size _Sampling Technique _ _Male _244 _44 _Simple random sampling _ _Female _1,533 _273 _Stratified sampling _ _Total _1,777 _317 _ _ _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).
There are 30 parishes within Wakiso district and all will be considered. Simple random sampling method will be employed in order to randomly select the participants from within the 30 parishes out of the 565 of these therapy groups. In each therapy group, there are between 12 -15 participants. From the 30 parishes, the researcher will randomly sample 11 individuals from each therapy group and parish. This will be obtained by dividing the 317-sample size by 30 and the number 11 is obtained. These 11 individuals will consist of both males and females.
Then, for therapy groups that have more than 11 participants, numbers will be given to every member of the accessible population (the depression survivors). These numbers will then be placed in a bag or container then, a number will be picked randomly. The first 11 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 (317), 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 stratum 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 Self-Administered Questionnaire 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). Self –esteem will be measured using the Rosenberg Self-esteem scale (RSES) which is a 10-item Likert type scale with items answered by self-report on a point scale where “1” represents “strongly agree” and “4” represents “strongly disagree”. This scale was developed by Morris Rosenberg in the mid-1960s and is used to globally today to measure self-esteem while Resilience Scale for Adults (RSA) will be used to measure resilience. This scale was developed by Friborg et al.,
(2003) as a self- report instrument aimed at measuring six protective factors in adults and been recommended for use in health and clinical psychological populations. The scale has 5-point scoring items that examine both intra & inter-personal protective factors that promote adaptation to diversity for instance family cohesion, external support, and personal competence among others. Windle et al, (2011) stated that Resilience scale for adults is highly useful when assessing protective factors such as family coherence, social support among others as these protective factors safeguard against mental disorders. 3.7.3
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. 3.8
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 Data from questionnaires will be coded and captured using SPSS software 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. 3.8.2 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 dependent and independent variables. 3.8.3
Qualitative Data Analysis A thematic analysis will be adopted to analyze the qualitative data for the study. The researcher will start by reading transcripts for familiarization purposes and thereafter, she will code for common phrases that will discuss the same ideas. The researcher will then compare codes whereby similar idea phrases will be grouped together in the same category and irrelevant codes will be eliminated while similar category codes are put under respective themes.
An in-depth interpretation will follow by comparing results that will be obtained from different study participants. Data presentation will then follow and this will be in form of themes to be supported by verbatim quotes of the study participants. 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.
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