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REARCH _WOMEN AND MENTAL HEALTH in NRB 1998_ 2014

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REARCH _WOMEN AND MENTAL HEALTH in NRB 1998_ 2014

  1. 1. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 WOMEN AND MENTAL HEALTH IN NAIROBI, KENYA A Situation Analysis: July 1997. Reviewed 2014. Researched and Compiled by Shibero Akatsa
  2. 2. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 Copyright by S. A. Darby 1998. All rights reserved The right of S A. Darby to be identified as the author of this work has been asserted by S.A.Darby, in accordance with the Copyright, Designs and Patents Act, 1988. Publisher prefix 0 9535071 ISBN 0 953507106 First published in 1998 by: REFLECTIONS 2 Streather Road. Four Oaks Sutton Coldfleld. Birmingham, West Midlands B75 6RD Tel/Fax: 0121 308 0988 E-mail: s.aka.-darby@pop3.poptel.org.uk
  3. 3. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 TABLE OF CONTENTS TITLE PAGE NOS. CONTENTS i - ii INTRODUCTION iii PREFACE iv ACKNOWLEDGEMENTS v 1. EXECUTIVE SUMMARY 8-9 2. OBJECTIVE OK STUDY 10 Problem identification 10 Long term aims of study 10 3. METHODOLOGY 11-14 Methods and justification 11 Study sites 1I Profile of sample group 12 Local participation 12 4. DATA COLLECTION 13 Briefing and training 13 Protesting of study tools 13 Data collection process 13 Data analysis 13 Social/political environment 14 5. NAIROBI, KENYA WIDER CONTEXT 15-18 Kenya 15 Nairobi 18 6. FINDINGS 19-31 Literature search 21 Qualitative and quantitative analysis 2I Profile of participants 21 Sample group analysis 22 Mental health diagnosis 23 Service providers feedback 24 Health professionals on mental health 24 Local non government organisations service providers 25 Qualitative/quantitative study feedback 25 Focus groups feedback 27 7. CONCLUSION 32 Summary 32 8. RECOMMENDATIONS Development consultants 34 Proposed project 34 9. BIBLIOGRAPHY 36 10. APPENDICES 38 Justification and purpose of situation analysis In d ivid u al interviews sample questions Sample questionnaire Focus group themes ALMA ATA: Primary health concepts and challenges M in is t r y of Health : Kenya's health policy
  4. 4. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 INTRODUCTION Various research studies on mental health in developing countries, reflect major short comings that limit the development of effective and appropriate mental health interventions Apart from being highly academic, these studies focus on curing the numbers of visible sufferers through the understanding that the origins of their illness is due to the sufferers inability to readjust to the norms of society, often turning to personality traits and biological factors Alternatively there are those studies that argue that the individual 's mental welfare is dependant on social group influences and their environment Both schools of thought fail to recognise the need to identify high risk groups and prevent mental health illness before attempting to cure it when it has become irreversible The biggest shortcoming however, are the eurocentric models and theories used to test ' western developed ' hypotheses, m environments where traditions and cultures greatly affect the behaviour and attitudes of communities This ignores and undermines the power of indigenous cultures and those traditions that govern and dictate individual and community behaviour. These are major clues in understanding individual and community responses, which affect individual mental welfare. Study Objectives The overall objective of the study is to explore the factors leading to the high rates of mental health disorders in women in Nairobi, with the aim of developing appropriate and effective mental health interventions for women and the community at large. The study and need for action has been initiated by numerous women living and working in Nairobi, and after further reading on past research in this area of women, urbanisation and mental health This study Women and Menial Health in Nairobi Kenya, aims to address the shortcomings of studies done on mental welfare in developing countries. It focuses on tackling a major stress to communities i.e. urbanisation. Because of the existing vulnerabilities and pressures women face as a group, they are the focus of the study. To obtain the required information, a practical, cross cultural and social model, sets out to examine the cultural and social context that women exist in, within Nairobi Women at all levels are involved in discussions that are relevant to their everyday lives, this is with the aim of giving the study in-depth understanding of the shared cultural meanings, behaviour and experiences shared by women and other sections of the community Tins process also helps the study identify those groups at risk and those already suffering from mental health disorders on the streets and in communities. Tins study then links individuals suffering from mental health disorders and those at risk, back into the community (through understanding how the communities work), making it possible to draw on community action, in developing appropriate, effective and acceptable interventions that can be acted upon by individuals and the community.
  5. 5. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 Shibero Akatsa-Darby Born in 1960 in Kakamega Western Kenya, Shibero is one of seven siblings, Shibero's parents migrated from Kakamega to live in Nairobi city in the early sixties It was in Nairobi that Shibero had her primary and high school education After high school., Shibero went to the USA for further studies where she graduated with a BSc in media production and speech communication On her return to Kenya, Shibero was employed as a human resources and management consultant by an international audit and management consultancy, where she worked for three years. Here she was single, with a well paid job, a car and her own flat. Little did she know that this was only the beginning of her troubled life in Nairobi as a single working woman. She found herself faced with a cross section of stresses and challenges. She begun to suffer from migraines. She became extremely unhappy in Nairobi. Shibero now realises that she was one of many women in Nairobi, who had been suffering from mental health disorders. She considers herself fortunate. Other female friends had not survived. A close high school friend had committed suicide, two other high school colleagues had suffered from mental breakdowns without recovering, two of her female cousins had also had breakdowns, with one of them irreversible since 1994, her eldest sister too, has had two strokes leaving her totally incapacitated She had been diagnosed as being clinically depressed. All these women once lived and worked in Nairobi, and had been resourceful and productive members of the community. Shibero's way of coping with her mental state whilst in Nairobi, was to resign from her job, sell her car and move to the UK, where she hoped for better opportunities professionally and in search for peace of mind It was in the UK, that Shibero found help for her mental welfare. She has since done post graduate studies and qualified as a psychotherapist; a relationship therapist, a drugs and alcohol abuse counsellor/educationist, and a personal development trainer. Since 1993 Shibero has been practising in the UK, as a counsellor/therapist guided by qualified supervisors, case discussion groups and running personal development workshops. Her other work experiences in the UK include personal and life skills training and development, human resources management, quality management, community development and international community development and project development She currently sits on the board of an international development organisation based in Leicester UK, and in 1995 sat on the board of an international health development sending agency, based in London She has also written several published articles for a couple of international development organisations in London. Shibero is a member of a women's Educational Trust based in the Midlands (Birmingham) This study was inspired by Shibero's personal experiences and the numerous women in Nairobi who had been affected by mental health disorders (append .32). Since the completion of the study, Shibero's sister has since passed away.
  6. 6. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 ACKNOWLEDGEMENTS In Nairobi, Kenya A special thanks, to all those 170 women, who disclosed their personal stresses, in the completion of the questionnaires and participated in the focus groups. I hope this piece of research is a tool that will enable us to put in place interventions that will help make our lives in the Nairobi communities more manageable and less stressful, whilst enabling us to take the opportunities presented by urbanisation. I would also like lo thank all those men and women who got involved in any of the discussions at an informal level, and to the following. ABANTUL: Ms Wahu Karaa. Regional Programme Manager Dept for International Dev: Mr. David Fish: Head of Development Division and Ms. Jackie Munch. Health & Population Field Manager Centre For Family Studies: Ms. Mary Mujomba. Programme Officer and Ms Dolorita Onguru. Assistant to Director Home Economics Association for Africa: Ms .Jean Kiviu. Secretary General Kenya Medical Women's Ass: Mrs. Abigail Kidero and members who participated Kenya Army Medical Centre: Professor James Ayugi; Kwengo: Mr. Chris Ovucho. Membership Liaison Officer Ministry of Health: Documents department. Schizophrenia Found.of Kenya-Ms Lillian Kanaiya, Karen Syn-thesis Architects: Mr Anzaya Akalsa: Professional Touch - Mrs Mbithe Anzaya: Langata Simba Air Cargo Ms Sophie Ambale: Research Assistants - Loreen Wanjiri, Susan Kaai. Tibag Talitwala. Wabugha Kubo. Praxedes Ndindi. Bilha Muna. And for all the endless support from the following in the UK, without whom the research may not have taken place. Thank yon. Skillshare Africa Leicester. UK: Board of Trustees. Skillshare Africa. Leicester. UK: Dr Cliff Allum. Director Barrow Cadbuiv Trust. Bum UK: Mr Erick Adams. Director Women Acting In Today's Ms Joan Blancv . Director Society (WAITS): Development Consultants: Skillshare Africa. Valeric Griffith. Tina Garamzcgi Dept of Urban Development Academic Collaborations &. Policy. South Bank University. Professor Trudi Harpham London/School For Tropical Medicine Ms Ilona Blue: Assistant Researcher World Health Organisation Ms Grisette: Documentation Depart.
  7. 7. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 1. EXECUTIVE SUMMARY The study Women and Mental Health in Nairobi, Kenya, was initiated by women li ving and working in Nairobi It set out to explore the factors leading to high rates of mental health disorders of women in urbanisation i.e. Nairobi, with the aim of developing appropriate and effective mental health interventions, for women, families and communities Methodology To obtain the required information, a practical, cross cultural and social model, was developed with the aim of examining the cultural and social context that women exist within Nairobi. Women at all levels were involved in discussions that were relevant to their everyday lives, this we hoped would give the study in- depth understanding of the shared cultural meanings, behaviour and experiences shared by women and other sections of the community. We hoped this process would also help the study identify those groups at risk and those already suffering from mental health disorders on the streets and the communities. The study then linked individuals suffering from mental health disorders and those at risk, back into the community (through understanding how the communities work), making it possible to draw on community action, in developing appropriate, effective and acceptable interventions that can be acted upon by individuals and the community The study methodology that was used involved four types of research activities: A literature search involving the collection and review of information on women and mental health disorders in urbanisation, in the form of research reports, publications, magazines and literature conducting of ‘key informant’ interviews with various service providers of health related services, and services for women in Nairobi in depth focus group discussion wi t h women wit hin Nairobi a questionnaire that measured mental health disorders, developed by WHO (The SRQ-20 questionnaire) in 1988 to assess mental health status especially for use in developing countries The questionnaire allows a non-specialised person to identify individuals with mental health problems12. The main aspects of the questionnaire concern anxiety, depression and psychosomatic problems, which according to medical and community studies, are the most frequent expressions of mental troubles. The ‘cut-off’ point for the SRQ-20 used for differentiating probable cases from non-cases was 7/8. This was decided upon after analysing past SRO-20 research implemented in Kenya, i.e.Kisii, Kisumu and Kenyatta National Hospital. 3 The questionnaire also included women's various stresses, support services, recommendations, and socio- economic details All research methods were deployed to ensure effective evaluation and assessment of women and mental health in Nairobi The methodological steps were: Collating relevant data on women and mental health disorders at a global level - this was to obtain a situational understanding of the implementation issues of the ground research. Developing research instruments for the interviews and focus group discussions. The aim of this was to identify critical issues which would form the basis for the unstructured discussions, and the questionnaire Finally, the various data was processed and synthesised to write the report The research contained both quantitative and qualitative performance indicators. 8
  8. 8. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 Preparation for the study begun in July 1996 and was supported by the following organisations in the UK:  Skillshare Africa, an international development organisation based in Leicester. UK.  Women Acting In Today's Society (WAITS), a West Midlands community based, women's educational trust UK.  Barrow Cadbury Trust, a UK based funding trust for community based projects.  Two research academic collaborators from South Bank University in the School of Tropical Medicine. London. UK. Field work in Nairobi was scheduled started in July 1997, over a period of 14 working days. Main Findings Women face a host of socio-cultural and socio-economic problems, highlighting the subordinate and extremely vulnerable position they have in society. Inequities lead to legal, social and economic helplessness, dependency on others, chronically low self esteem and low aspirations. This situation finds most women without sustainable coping skills or family or community support, that if they had would make a difference in preventing or reducing physical and mental health problems. Within the adult population, there is a particular peak of depression in women aged 30 - 45 years. This affected their family relationships, their ability to parent their children and function within their work place. Mental health disorders arc also affecting girls as young as twelve years old. Evidence within the community suggests that the public, including health professionals, arc unaware of mental health issues, with many believing it to be an illness that is incurable and or non- preventable. This consequently creates phobias and 'taboos', stigmatizing ill mental health, which is perpetuated from generation to generation. Recommendations Based on recommendations of all those people involved in the study, and guided by World Health Organisation's ALMA ATA Primary Health Care Concepts in a Changing World An urban focused project, managed by women, that will work in partnerships with community based organisations, local NGOs, local institutions, health professions and individuals, sharing resources, information, education and life experiences The project should aim to: Promote the self reliance and mental well being of women, families and the urban communities, through providing a comprehensive support service that will aim to:  build and promote community and individual mental health support  create and promote social awareness on mental health issues  raise the profile, self esteem and opportunities for women, through access to information and life  skills development  advocate and lobby on behalf of women, on issues affecting women's mental welfare  carry out research and development activities on women, family and mental health, with the aim of developing appropriate services for those affected. The proposed project should aim to be inclusive, recognising that men need to make an equal contribution to the development of the service. 9
  9. 9. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 2. OBJECTIVE OF STUDY The main purpose of the study was to explore factors contributing to women's mental health disorders in Nairobi, given the fact that Nairobi city has seen rapid changes since independence.9 2.1 Problem Identification Evidence that women arc not coping effectively is a grave concern expressed and identified by friends, relatives and families in Nairobi affected by mental health disorders, by sufferers, health professionals, and finally by local and international research development academics and World Health Organisation (WHO) The above groups say that the numbers of people suffering from ill mental health is on the increase, evident in the overcrowded mental institutions with spillage of patients onto the streets of Nairobi. The situation is now urgent. As one woman succinctly summarises the need for action: “Yesterday it was….x…. for all I know, kesho ni mimi (tomorrow is me), or my children. What would 1 do, where would I go? And what would happen to my family?" The groups expressed the need to pool resources that would help develop interventions that women, families and communities would benefit from. 2.2 Long Term Aims of Study To enable women in Nairobi to develop a project that will provide families and those communities affected by or are at risk of mental health disorders to achieve the following: Develop social support systems, interventions etc relevant to the stresses faced daily within their communities, consequently reducing the numbers of women and families suffering from mental health disorders. Create an understanding of mental health issues i.e. education, detection, and prevention in families and communities, consequently creating greater and healthier knowledge and altitudes on mental health welfare. Develop support systems/ interventions for those families/ people caring for those affected by mental health disorders. 10
  10. 10. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 3 METHODOLOGY OF STUDY 3.1 Methods and Justification The quantitative methods (append 14) used allowed the study to obtain a wide range of specific and factual information from a large cross section of women in Nairobi Structured questions in the form of a questionnaire, were designed and translated into Swahili. (National language) The questionnaires were designed to elicit the following information from women: socio-demographic features mental health assessment, using *SRQ-2() questionnaire social support networks main life stresses The qualitative (append 35) methods allowed for deeper understanding from women, regarding their experiences within the context of their social world and the customs and traditions which govern their welfare. This method also allowed for deeper understanding of the wider communities altitudes and awareness of mental health issues, as well as understanding the health services and how they arc managing this particular aspect of health, especially with women Unstructured in-depth discussions were implemented through use of focus groups with women who had completed the questionnaires (append .15). Topics for discussion were based on the following themes: socio-cultural/ socio-economic expectations, attitudes and pressures from the wider community main life stresses affecting women's mental health individual and community social support systems and attitudes ill mental health women's attitudes/ feelings towards themselves and their mental welfare One to one interviews with un/structured questions were also used with local non-government organisations, mental health professionals, church and community representatives. (append 33). 3.2 Study Sites The study was to be implemented within Nairobi city and its environs, mainly those areas within a fifteen mile radius from the city centre, namely the following estates: Nairobi West. South “C” Upper Hill, Kenyatta. Kibera, Kileleshua. Langata. Westlands,Parklands. Pangani. Lavington. Woodley. Ngong Road. Starehe. Jogoo Road, and Buru Buru The selected sites represented a cross section of socio-economic features 11
  11. 11. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 3.3 Profile of Sample Group Women from the ages of 18 - 55 years, living within the described areas at the time of data collection The rationale behind choosing this age group was that this group was identified as being high risk for mental health disorders because they arc at the forefront of urbanisation Women were interviewed ad-hoc within their homes or at their places of work and or on the streets of Nairobi. 3.4 Local Participation Apart from the sample group, local non-government organizations (NGOs), lead health decision makers, health professionals and community leaders were invited to participate in the study at random. The following finally accepted to lie involved in the study: Abantu For Development Department for International Development (DFID) Centre For Family Studies (CFAFS) Home Economics Association For Africa Kenya Medical Women's Association Ministry of Health National Council For NGOs Oasis Counselling Centre and an Anonymous Counselling Centre Schizophrenia Foundation of Kenya 3 Church representatives from Nairobi based churches A total of 18 interviews took place, all on the premises of the individual organisations. 12
  12. 12. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 4. DATA COLLECTION Six research assistants were recruited by a qualified and experienced graduate Researcher. 4.1 Briefing and Training Two days were allocated to briefing the research team by the lead researcher The briefing focused on: background of the study understanding of the study tools data collection procedures personal safety and debriefing procedures 4.2 Pre-testing of Study Tools The following were the tools that were pre-tested: questionnaires focus groups discussion questions one to one interview questions Study tools were pre-tested at random and informally within various communities, prior lo being used during the final study. This ensured information relayed and received was clearly understood responded to accordingly. The pre-testing also ensured that the questions being asked conveyed the same meaning to the interviewees and interviewers. 4.3 Data Collection Process Quantitative data, along with the allocated sites were distributed to the research assistants. The teams met every two days to review and debrief after data collection. Any problems or issues concerning the data collection, or personal concerns flagged up by the collection, were discussed. Qualitative data was collected through taped interviews. 4.4 Data Analysis All data collected was entered into the computer and analysed and interpreted by the research team, a consultant statistician and two development consultants. 4.5 Social and Political Environment Nairobi was in turmoil during the study. One week prior to the study, there were political riots occurring and a number of people had been killed by the police.
  13. 13. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 The International Monetary Fund had also suspended a major loan to Kenya because of the lack of economic reforms previously promised by the Kenyan government. Kenya was also due to have elections before the end of the year i.e. 1997. BACKGROUND AND WIDER CONTEXT OF NAIROBI, KENYA 5.1 Kenya Geography Kenya, an East African country, highlights the undergoing rapid urbanisation process. Kenya is bordered by Ethiopia and Somalia on the north and north-east; by Sudan on the north-west and by Uganda on the west, by Tanzania on the south and by the Indian Ocean to the cast. Straddling the equator. Kenya enjoys a tropical climate and is famous for tourism due to its many game parks. It is also famous for its exports of tea. coffee, flowers, pineapples and green beans, (and for its long distance runners!). Population31 Kenya's population increased from 5.4 million in 1948 to 15.3 million in 1979. It now has a population of 28.4 million people, all of who belong to 13 different tribes mainly Kikuyu 22%, Luhya 14%, Luo 13%, Kalenjin 12%, Kamba 11%, Gusii 6%, Tribal traditions and political loyalties arc a significant factor in people's lives. Kenya has the fastest population growth in Africa, estimated to be at 3.8 per cent per annum, with fertility rates estimated at 5.4 births per woman (1996). 50.4 % of the population comprises of women., 49 6% of men, with life expectancy is at 51 years for men (1996) and 52 for women. Net migration rate is -0.34 migrant(s)/1000 population mainly from the rural areas. Religion 32 Christianity has expanded rapidly from about 25% to about 73% in recent years, with about 19 % traditional religions and 6% Muslim, Education 32 Swahili and English arc the main written and spoken languages. Out of a total population of over 15 years of age, the literacy rates of males arc at 86.3 % and females at 70%. Employment 32 The labor force totals 8.7m with agriculture providing employment for over 75% of the population and non- agriculture 20%-25% in 1993, with females at 39% and males at 61%. New employees into the jobs market number 0.4m - 0.5m per year. The government estimates the informal productive sector i.e. jua kali: welders, metal workers, mechanics, carpenters, and construction workers and hawking i.e. small scale businesses in perishable goods e.g. sweets, cooked food, charcoal soft drinks etc. range from 1.47m (199.3) to 6.54m (1994 -6). Public Health32 Hospital beds number about 40.000, there are several private hospitals, health centres and dispensaries. There was one doctor per 7.410 inhabitants in 1993. Child malnutrition was estimated to be 22% in the period 1985- 93.
  14. 14. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 Malaria is the main endemic health problem and totals more than 25% of all reported illnesses countrywide. In terms of mortality, malaria accounts for 6% mortality of all cases admitted to health institutions Diarrhoea diseases are the fourth leading cause of death in children under five years of age in Kenya and accounts for 4% of all outpatient cases. AIDS is a growing menace. The HIV -positive population is estimated at I 27m in 1996 -it was 448000 in 1990. AIDS was connected with about 80,000 deaths in 1996. 10 - 20% of HIV/AIDS occur in Nairobi. Projected 1996 figures for male HIV related deaths in Nairobi total 56.000 and women 40.000. “Empirical studies in Kenya have consistently shown that approximately 20% of patients seeking outpatient care in both public and private institutions do suffer from some form of mental illness Majority of patients present with physical symptoms which lead to misdiagnosis and numerous and often repeated wasteful and expensive investigations and prescriptions. Despite acceptance that mental well being is essential to good health, this apparent widespread psychiatric morbidity has not significantly influenced the planning of health services in the health public service” 8 Legal System The Kenya legal system is based on English common law, tribal law, and Islamic law, a judicial review in the High Court and accepts compulsory ICJ jurisdiction with reservations. Hospital beds number about 40.000 are several private hospitals, health centres and dispensaries. There was one doctor per 7.410 inhabitants in 1993. Child malnutrition was estimated to be 22% in the period 1985-93. The Constitution prohibits discrimination on the basis of a person's "race, tribe . place of origin or residence or other local connection, political opinions, color or creed" However, the authorities do not effectively reinforce all these provisions. Women in the Legal System 32 Violence against women is a serious and widespread problem. The number of rapes reported to police has increased from 1.274 in 1993 to 1.455 in 1995 and 1.020 in the first 6 months of 1996. Figures on assaults on women and girls rose from 4.580 in 1994 to 4.889 in 1995 and 3.674 in the first half of the 1996. The available statistics probably under report the number of incidents, however, since social mores deter women from going outside their families or ethnic groups to report sexual abuse. The Government condemns violence against women, and the law carries penalties of upto life imprisonment for rape, however, the rate of persecution remains low because of cultural inhibitions against publicly discussing sex, the fear of retribution, the disinclination of police to intervene in domestic disputes, and the unavailability of doctors who might otherwise provide the necessary evidence for conviction. Furthermore, wife beating is prevalent and largely condoned by much of the Kenyan society. Traditional culture permits a man to discipline his wife by physical means and is ambivalent about the seriousness of spousal rape. It also permits a man to have more than one wife (polygamy). Men are also expected to pay ‘dowry’ i.e. payment in money or cows to future in-laws, in exchange for their daughter. This practice gives men permission to treat their wives as they wish, often reminding them that they (wives), belong to the man and his family. Women experience a wide range of discriminatory practices, limiting their political and economic rights and relegating them to second class citizenship. The Constitution extends equal protection rights and freedoms to men and women, but long lacked a specific prohibition of discrimination on grounds of gender. Constitutional provisions continue to discriminate against women by allowing men, but not women, to automatically bequeath citizenship to their children. While the Government has ratified international conventions on women's rights, it has not passed domestic enabling legislation. The task force on laws relating
  15. 15. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 to women, established by the Attorney General in 1993 has yet to make its report. Women continue to face both legal and actual discrimination in other areas. For example, a woman is legally required to obtain the consent of her husband or father before obtaining a national identify card or a passport. In practice, a woman must also have her husband's or father's approval to secure a bank loan. According to a pension law, a widow loses her work pension upon remarriage, whereas a man does not. The Law of Succession which governs inheritance rights provides for equal consideration of male and female children. In practice, most inheritance problems do not come before the courts. Women are often excluded from inheritance rights or given smaller shares then male claimants. A widow cannot be the sole administrator of her husband's estate unless she has her children's consent. Child rape and molestation are rapidly growing problems. There are frequent press reports of rape of young girls, with rapists often middle aged or older. Legally, a man does not “not rape” a girl under fourteen, if he has sexual intercourse with her against her will; he commits the lesser offence of “defilement”. The penalty for the felony of rape can be life imprisonment, while for defilement upto five years imprisonment. Values and Beliefs32 Kenya culturally has a mixture of indigenous traditional and modem values and beliefs, brought about by western influence through Christianity and urbanisation, and tribal beliefs and practises. Most tribal beliefs and values have some common themes e.g. patriachism. This manifests itself through the supremacy of the male. Sons are important to the family because they perpetuate the family name and inherit any family property or wealth. Traditionally daughter’s arc useful to their families as future investment i.e. brought in cows/money from potential in-laws. Another common theme within most tribal beliefs and values is the low status of women. Discrimination begins al the earliest stages within the family and preference for sons is the norm. Often, even if a girl is desired, she is seen as less valuable than a boy and consequently she deserves less investment from family resources, and often seen as somebody who will only be valuable to future in-laws. She is given differential treatment in her education, healthcare, work options and general care. 16
  16. 16. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 5.2 Nairobi Nairobi, the capital of Kenya located in the centre of the country, hosted the Third World Women's Conference held in 1985. The population of Nairobi is estimated to be 1,346,000 million. Population growth has been exacerbated by rural-urban migration, causing an alarming effect on its services. More recently, high birth rate has become the most important factor, with the population growth of Nairobi having been estimated to be 7% per annum. Over half of the population comprises of children under the age of fifteen. 16 One prediction estimates that Nairobi will be a mega-city of 15million by 2021. 34 Economic Survival Formal employment i.e. employed in private and public sector, is still a significant source of employment, but informal self- employment is growing at a more rapid rate. Informal self -employment in Nairobi grew by 27.7 % annually between 1980 and 1984. whereas formal waged employment grew by 18 % annually during the same period It is now estimated that informal employment is growing at 40 - 60 per cent annually. 9 By 1990. it was estimated that 110.347 people were engaged in some sort of informal sector activity. Informal employment i.e. retailing, otherwise known as hawking, is an important source of income in Nairobi and is largely a response to harsh urban socio-economic environment. Most of the hawkers are women who trade in perishable goods, i.e. vegetables and fruit as well as sweets, cigarettes, charcoal, cooked food. fish, meat and soft drinks. Hawking plays a central economic role in a significant number of households in Nairobi Overall, there arc an estimated 40.000 small businesses in Nairobi. There is no doubt the significance of the sector in terms of providing employment at low cost and in generating an economic output which contributes to the economy of Nairobi as a whole. 9 Unemployment rate in Nairobi, is estimated to be at 35% (1994 est) 32 17
  17. 17. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 6. FINDINGS 6.1 Literature Search: Women Mental Health and Urbanisation "Since time memorial, women have been drawers of water, hewers of wood, labourers, preparers of food, bearers of children, educators, health care providers, producers and decision makers. There is now a growing recognition and concern that the stresses imposed on women affects their physical, emotional and mental well-being”27 And for those women in the midst of urbanisation, their mental and physical welfare situation is even bleaker. Real life cases of women in this environment, reflects their struggle in a quagmire of socio- cultural and socioeconomic pressures and changes, escalating their rates of mental health disorders i.e. depression and anxiety. So far, the highest mental health disorders brought about by urbanisation, are of women in Africa at 22% whilst for men at 14% 21 The impact of this problem has diverse effects not only on women, but on children, the family unit, the community and on economic productivity (with women being a major part of the work force). As World Bank Development Report 1993 summarises: “There is growing evidence from both developed and developing countries, that the prevalence of common mental health disorders (depression and anxiety) among women is higher than that of men. A large number of women are thus at risk of serious mental health problems which must be treated before leading to irreversible nervous breakdowns. " In spite of all the empirical evidence of women's mental health in urbanisation, women's mental health issues continue to be neglected by national and international policy makers, thus highlighting the lack of value and recognition of women as an important resource within society and in development 29 6.1.1 Opportunities for Women in Urbanisation In many ways urbanisation offers a unique opportunity for women to change their lives and escape some of the oppressive traditions of the past and of village life which has excluded them from positions of control and stifled their initiative. Living and working in the city offers women the prospect of education and self-development and the prospect of learning new skills and of earning an income2 6.1.2 Barriers Facing Women in Urbanisation The reality is however, many women face a host of socio-cultural and socio-economic problems, highlighting the subordinate and extremely vulnerable position their have in society compared with men. 14 Social discrimination makes it difficult for women to achieve mastery by direct action and assertion. Inequities lead to legal, social and economic helplessness, dependency on others, chronically low self esteem and low aspirations. In this emotional state, women experience loss of control, helplessness, disempowerment, shame, guilt, anger, feelings of inadequacy and being overwhelmed by the situations they find themselves existing in. 24 Many women therefore find themselves without sustainable coping skills that if they had
  18. 18. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 would make a significant difference in preventing or reducing physical and mental health problems 6.1.3 High Risk Groups of Mental Health Disorders Within the adult population, women between the ages of 15 and 49 appear to suffer around twice the rates of mental disorders seen in men. There is also a particular peak of depression in women aged 30 to 45 years. Young people, especially girls starting as young as 12 years of age. arc at the forefront of the effects of urbanisation and arc particularly vulnerable to the effects of the rapid change, which infiltrates into their lives through their families and their school and community environment. Children with depressed mothers tend to have more behavioural problems than children of healthy mothers who show no signs of depression. Mothers arc unable to work and have difficulties parenting children, and arc vulnerable to related physical problems1 . 6.1.4 Social Support Systems In addition to long term difficulties and life events, a lack of social support systems, has been even more detrimental to women's mental health in urbanisation. Social support systems are reducing within families due to the reduction of extended families for those women who migrated from the rural areas, an increase in single parent families due to bad relationships, deaths of spouses, post-natal depression due to poor relationship leading to inadequate support. Yet families should be the anchoring point where women should be able to draw social support. 10 18
  19. 19. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 6.2 Qualitative and Quantitative Analysis The questionnaire was answered by 170 women living and or working within Nairobi City Centre during the period of July/ August 1997 Seven focus group discussions, with upto six women in each group, consisting of those women w ho had participated in completion of questionnaires, were held. The following is the profile of those who participated in the overall study: 6.2.1 Profile of Participants Age in years 18 -25 =21% 26-35 = 37% 36-44 -32% 45-55=10% Status Married = 52% Single = 42% Other e.g. Widow = 6% Formal /Informal Education High School = 30% University = 29% College e.g. secretarial = 18% Other e.g. informal = 10% Polytechnic = 7% Primary = 6% Occupation Employed = 57% Self Employed = 14% Unemployed = 12% In Education - 8% Homemaker = 5% Other = 4% Those with Children Yes = 5 2 % No = 48% 19
  20. 20. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 6.3 Sample Group Analysis The 18-25 age groups made up about a three quarters of the study group. Majority of them, were open to change and optimistic about their future. Their main focus was to prepare themselves for a better future than their mothers or older female siblings had experienced, through education and developing themselves before committing to a relationship or family. They saw a good education as enabling them to have more choices about what to do with their lives, using it as a stepping stone to financial security and emotional independence. These groups were mainly single, without children, and still living at home with their parents or older relatives. Most were in full time education and or unemployed and looking for jobs. A handful in the group, felt locked and resigned to the pressures of city life. The 26 - 44 age groups were the majority in the overall study. Majority of the women in this age group were employed full lime and or self employed. Few were full time homemakers or unemployed. Most of these women had attended university, polytechnic and college. More than half were married, the rest were single with a couple widowed. More than half of the women in the group had children. This group was enthusiastic, fully involved and supportive of the study, identifying fully with the stresses brought about by a changing environment. They were eager to be involved in any change that would help support them in dealing with the stresses faced in the work place, homes and in the community. The 45 - 55 age groups were the minority and appeared reluctant to participate in the study. The few who did participate reflected cynicism about the purpose of the study and its benefits. They reflected resignation and acceptance of their lives in the city. Majority of women in this group had finished their education at primary or lower high school, with some having had secretarial training or informal education. Overall, a couple reflected a need for change and willingness to invest in change. 20
  21. 21. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 6.4 Mental Health Diagnosis (SRQ-20) Disorder Absent = 62% i.e. 106 in sample group Disorder Present = 38 % i.e. 64 in sample group The most severe cases were between the ages of 30 - 45 years. 6.4.1 Symptoms Monitored and Experienced The 38 % suffering from mental health disorders experienced the following symptoms during the month of June 1997. Decreased Energy Factors:  Found decision-making hard.  Had lost interest in things (generally).  Were easily tired.  Found it difficult to enjoy daily activities.  Daily work was suffering.  Fell constantly tired. Somatic Symptoms Factors  Suffered headaches.  Slept badly.  Had a poor appetite.  Had experienced stomach ‘apprehension’.  Had poor digestion.  Had shaky hands. Depression and Anxiety Factors  Felt nervous, tense or worried.  Were unhappy with self/ life.  Were easily frightened.  Felt weepy.  Felt worthless.  Felt suicidal.  Felt useless to the community 21
  22. 22. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 6. 5 Service Providers Feedback and Findings The service providers interviewed were mainly health professionals and those local NGOs involved in providing support. The researcher team and consultant reported the following from recorded, interviews 6.5.1 Health Professionals on Mental Health Majority of people suffering from mental health disorders arc not in touch with the health services but those who are tend to present with a variety of superficial physical symptoms, caused by their underlying mental state. Lack of understanding of mental health disorders by the public health professionals. This has tended to reflect a false picture of people suffering from ill mental health. Most women are treated by male practitioners, making it difficult for them to disclose their stresses at both a physiological and social level. This is due to the male-female power dynamics already existing between the two. Evidence of ill mental health in Kenya, is reflected in the government's Health Policy Framework which highlights the rising numbers suffering from ill mental health, however ill mental health is not a priority and public health continues to focus on sexually transmitted diseases and other illnesses due to resources. 8 Most people suffering from ill mental health go to the local dispensary when the illness has reached an acute stage. Eventually the patient will sec a GP, who will then refer the patient to a psychiatrist. “On seeing them once or twice, they disappear into the community and I never see them again, we (the public: system), lack an outreach component, and we are already overstretched Outreach for these women would he a good way of providing support for those women suffering in the community.” Depression is a very common presentation. This has also been noticed in younger women, and it is growing i.e. upper primary and lower secondary school (12 to 18 year olds). This is mainly due to pressure from parents and other stresses in the home and in the community. Post natal depression is very common, due to the woman's mental state before and after the period of giving birth. 6 5 2 Accessibility of Local Non-Government Organisations (NGOs) in Nairobi At the time of the study there were: NGOs whose objectives arc to provide a service for women in Kenya were at 40. This information is registered with the National Council for NGOs; a self regulatory non-partisan body, comprising all NGOs registered under the NGOs Co-ordination Act of 1990 in Kenya. Of the registered NGOs. 28 were urban focused, seven of which had been disbanded but were still on the books, leaving 21 still registered.
  23. 23. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 Of the 21 registered NGOs, were found in the telephone directory. Researchers expressed the difficulty in knowing what the existing services for women arc. because of lack of information and the tedious process involved in accessing whatever little information there was available. 6.5. 2. 1 Dissemination of Information on Service Provision It is not the norm for NGOs to disseminate information on their services to the public cither through papers, radio or leaflets in public places where their target groups are likely to be. Reasons given for this was money - costly. Most of the organisations relied on word of mouth to inform their target group. Most of the local NGOs worked in isolation. There was a clear lack of linkage and sharing of information with other NGOs. Reasons given for lack of networking or linking with other NGOs were mainly due to: funding disputes: disagreements on how service provision should be implemented: disagreements on individual motivations versus the organsiations objectives and tribalism. 6.5.2.2 NGOs in Women's Mental Health in Nairobi Nil (0) NGOs worked directly with women and communities on the issues of mental health education and prevention, yet all those interviewed were able to quote examples of women in their communities and or friends who arc victims of ill mental health. One of the NGOs interviewed focused on women's physiological/physical well being and research. The NGO is run by volunteer doctors. They were not involved in any activities in the area of women's mental health One of the NGOs interviewed, focused on empowering women already in positions of influence, with the aim of affecting policy making decisions in issues concerning women. One other NGO (regional) focused on family planning and reproductive health, through working with both men and women in management positions, who would filter down their learning to the various communities Another regional NGO focused on providing for at which home economists in Africa deliberate on issues affecting the profession and families. Mental health was an issue that this NGO had been considering in their programme plans. Two other NGOs dealt with both men and women, providing a counselling service from a counselling centre. One had a religious focus. All the NGOs interviewed expressed keen interest in linking in with any future project that might arise from this study. The three church representatives interviewed, agreed that they were often faced with people suffering form mental health disorders and were willing to be a part of sharing any mental health education programme that would help others.
  24. 24. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 6.6 Focus Group /Questionnaires Feedback The focus groups participants ranged from 18-49 years of age. Care was taken to select only those women who had completed the questionnaire and were willing to participate in the study All the women interviewed found the conversations to be pleasant and relevant. Several of them expressed the view that this was an occasion for them to talk openly about matters they experienced daily, in isolation. They found it a relief to know that they were not on their own In general they disclosed their concerns without feeling threatened and on occasion becoming emotional while narrating their stories. They said they found the process of being and sharing with each other, empowering and very supportive. These were the major issues raised by the focus groups and from the rest of the questionnaire. Researchers reported the following key findings: 6. 6. 1 Socio-Cultural and Socio-Economic There is pressure for women to be in a 'committed' heterosexual relationship by a ‘certain age’. There are expectations and pressures from the community for women to have children by a certain age and be within a committed relationship. Women without a husband/ partner face covert and overt pressure from the community at large and in many cases, from the woman's family of origin. A single woman who has children out of marriage tends to struggle more with coping effectively financially and emotionally as a single woman and parent. 54 percent of women feel responsible for the welfare and discipline of their children. Most women worry about their children getting involved in drugs, alcohol, crime, contracting HIV, and in the case of daughters, sexual abuse. Having overall responsibility for the welfare of the children is extremely stressful to women, because they feel confused about what parenting approach to take. The traditional approach most women grew up with proves to be non- effective and detrimental to the relationship with their children, given the environment their children arc living in. Women are often blamed and used as scapegoats by family and the community for any adverse symptoms in their children at any age, and in their family. Women arc expected to straddle the traditional role of a woman i.e. to bear children, look for and prepare daily meals, nurture the family ensuring good health, and look after the home. Additionally women arc also expected to go out to work, where they arc faced with work discrimination and at the end of the month, juggles whatever money they have to pay the monthly bills. Most women feel some of the tribal traditions they arc expected to adhere to by society, have lost
  25. 25. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 the original meaning in the current environment and arc being used by many men to further oppress them e.g. bride price - originally a token, paid to the bride's family by the groom's family, showing appreciation and a promise to look after their daughter polygamy - permission for the man to have more than one wife. Women say: "Just because a man has paid cows to my family, he feels he has got the right to treat me how he wants, like I am his thing.” “Many men feel that it is their right to lime as many wives mistresses as they want... you dare not question. Just be happy that you have got a husband. “ 6.6.1.1 Family Relations Expectations for women to behave in a way defined by the in-laws, tends to create friction in the lives of those women who are married. This then seeps into the woman's own relationship and family. Many relationships arc volatile and/ or unhappy, due to the husband's dependency on alcohol, other women, drugs, violence, unemployment, finances etc. On the whole, relationships are difficult to manage due to internal and external pressures the family face daily. There arc many women who opt to stay in a volatile and unhappy relationship, viewing it as the easier option to being single. However the number of single women is on the increase, due to emotionally and physically abusive experiences in past relationships. Women say: "Wife beating is so serious in many relationships, and unless you stop it, you will be beaten to death in front of your own children". "It's always our 'fault', when anything goes wrong in the family or in the home”. 6.6.1.2 Economic/ Political Environment 90 per cent of women identify the economic environment as harsh. This is mainly due to the discrimination and sexual harassment they face as women in the workplace. Male counterparts earn more for the same job as women, and yet many women feel responsible for paying the household bills with the little money they earn. This leads to borrowing money which often leads to debt. Some women who share the economic burden with a husband/ partner, face a treble burden because regardless of the two incomes, the woman is left to manage all the bills. An issue that often leads to domestic violence or emotional abuse, if the woman dares to protest. "I have no finances to take the children to school, yet my husband is working as well. So what do I do?" "Unemployment... any job will do, no matter how well educated you are and regardless of how little they are paying you ..."
  26. 26. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 6. 6 1.3 Violence 90 per cent of women in the groups have experienced some or all of the following: Sexual abuse, domestic violence, emotional abuse, street violence and sexual harassment and discrimination The extents of violence women say, is largely hidden and widely denied by women, victims and the community at large. Women feel unsafe and see themselves as easy targets, with little protection from the law "I was walking down the street coming from work, close to Serena. Out of the blue this wan grabbed me from the back and started to choke me. I was so scared. I struggled and ran away. There were people watching. Nobody came to help me”. "You go to the police and they will harass you even wore. Shauri yako tu (it is your problem), they tell you. 6. 6.1.4 Life Events 48 per cent of women viewed illness and deaths as contributing to their ill mental health disorders. Women are faced with the responsibility of the welfare of their families as well as nurturing the survivors of family deaths. There is little concern regarding their own welfare. This entails a lot of anxiety. They feel their social and socio-cultural roles, puts them at risk of more personal losses. They see themselves as especially vulnerable and emotionally reactive to these stressors There is acknowledgement of the lack of support in coping with traumatic life events, e.g. deaths, unemployment, sexual and emotion abuse, post-natal depression, discrimination, miscarriage etc. Some women feel they cannot express their feelings to their families and friends when these events happen in their lives. The feelings of shame, guilt, anger, failure, and sadness, leave them feeling isolated and alone. One woman says: "Who can I talk to who would understand? So, I pray and keep quiet.” 6.6.1.4 Legal Rights 90 per cent of women were not aware of any legal rights they could exercise. None of the women in the sample group had used the police as a means of support. There were strong feelings about the police being some of the worst offenders to women. 26
  27. 27. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 6.6.1.5 Mental Health Awareness and Attitudes Most of the women repeatedly reported suffering from diverse ailments, many of which are of psychosomatic origin, but only seek help when the problem becomes serious, at which point they go to the clinic. Treatment at the clinic is curative. Most women are unaware of the relationship between daily stresses, and the psychosomatic ailments they experience. There are other priorities that prevent women from paying attention to their mental health problems. Moreover, if problems relate to mental health, the social and cultural environment results in them being concealed as much as possible, and only recognised when severe breakdowns occur. Some of the women have relatives or know of families where a member of the family has experienced severe mental health breakdowns. When this happens, the sufferers are taken into mental institutions; the only place where sufferers go can go, despite the institutions being overcrowded. There are very limited places those suffering mental health disorders can go. One woman says: “You can see these people (sufferers) roaming around on the streets of Nairobi from Mathare” Due to lack of mental health services, many families affected by mental health disorders are forced to move back to the rural areas, where they are looked after by relatives. Because mental illness is considered a 'taboo', a large number of sufferer’s are either hidden away by their families, and/ or the illness is not spoken about, because of the shame/embarrassment attached to mental illness. One woman tells her sad story: "People did not want me to talk about my situation. They found it too embarrassing and shameful. I was discouraged from talking about it within the community, church, friends, etc. They wanted me to keep my children hidden away. My husband did not want to hear about it, and this brought a rift in our family. The illness brought a lot of grief and pain to my family. I was then advised to put them into Mathare (a mental institution). 1 did. They came out worse than before. Next, I had no choice but to go private, where one psychiatrist told me that I was wasting my money on my children. I struggled on my own, looking for medicine, which is very expensive ..." 6. 6.1.6 Attitudes On Personal Welfare Low self esteem was highlighted, which affected the way women handled their stresses. "We (women) are covering up a lot. You see someone telling you that they did not eat last night, and they are laughing...” The groups acknowledged that they face a lot of stress, but felt it was a 'normal' state of their lives. "There is so much we are hiding, but what can we do? We do not have a choice…” 6. 6.1.7 Recreational Activities A small percentage of women are involved in activities promoting their own well being. For most, thoughts of ‘well-being’, enjoying activities or relationships, was seldom mentioned. Most felt they did not feel entitled to such ‘luxury’, as their time was taken up by managing their already complex lives. Developing recreational activities was thus difficult due to lack of time and money.
  28. 28. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 6. 6.1.8 Sources of Support Women get their support from a range of sources Most speak to friends and relatives, and a few to neighbours and some to doctors, others spoke to nobody 11 percent of women used their family as a means of support. 20 percent who keep their problems to themselves. One can only sadly conclude that many women have lost trust and faith in using the family unit for support, due to the lack of support and pressures experienced from their immediate and extended families. 18 percent of women find support in their female friends, who they feel able to share experiences with, consequently drawing support from shared experiences. 17 percent of women attend church as a means of support, however talked about how little they disclosed their inner turmoil to the church group. None use the legal system i.e. the police and lawyers/ solicitors etc. 7 percent use NGOs, whilst 65 percent of the women where not aware of the existence of any NGOs who could help them. A number of women feel that some local NGOs provide help with an underlying religious theme and feel they would rather not use this support, because of the underlying religious pressures. There was a general cynicism about the function of local NGOs expressed by the few who have interacted with them. Many women asked: "Which people are they actually helping”? There were concerns regarding service charges requested by NGOs, which they could not afford. A few had joined small informal groups (office and community based) that helped them financially. 9 per cent used ‘other’ means e.g. writing letters to an agony aunt, prayer, counselling. Some women used alcohol to cope with their stresses. 28
  29. 29. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 7. CONCLUSION This study, is ample evidence reflecting the reality of women in Nairobi Kenya, as high risk and suffering' from mental health disorders, often going undetected and untreated, recognised by health professionals only when the disorders reach an acute and irreversible stage. The study highlights the origins of mental health disorders in women, as coming from the continuous challenges and demands brought by urbanisation, in addition to socio-cultural and socio-economic pressures. Their status as women too, presents additional pressures. The high risk groups and sufferers are mainly women between the ages of 26 - 44 years old working and or living in Nairobi. Young girls as early as twelve years old are also high risk, due to being caught in the midst of the 'new ways' brought by urbanisation, and the 'traditional ways demanded of them by their families and the wider community. 7.1 Summary The report highlights the issues of mental health disorders in women as a problem in Nairobi and the current mental health and related support services as having infrastructures that are not meeting the changing needs of women's mental welfare in Nairobi. Health service providers continue to use outdated interventions, as opposed to empowering women and communities with sustainable coping and preventative life skills that would enable them to take control of their mental welfare Failure for organisations to identify those groups vulnerable to ill mental health, develop systems to deal with women's mental health needs, has also led to inequality within service provision in both the public health service and within current support services for women, consequently women's health issues continue to be neglected and ignored, reflected in the public health service. Family support systems are also on the decrease, so those women and families affected by mental health disorders have got little or no choice about where to go for help. There are real serious mental health issues affecting women and families in Nairobi that need addressing, preferably using a different approach from the current health service provision. Failure to deal with the issues in the study means that communities will continue to violate and abuse women, break down the family unit and continue to perpetuate the stigma of ill mental health, leaving the Kenyan women, families and communities, ignorant and dependant on the system to determine their social and mental welfare. It is crucial for these issues to be redressed from a human rights aspect as well as to enable those women living and working in Nairobi move towards sustainable mental welfare. 29
  30. 30. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 8 RECOMMENDATIONS "People cannot achieve their full potential unless they are able to take control of those things which determine their health. This must apply equally to men and women.” 25 8.1 Health Professionals - Recommendations for Action Non-medical interventions to cope with the mental health disorders i.e. support groups e.g. alcohol and drug problems, post natal depression, family relationships, emotional and physical abuse. . A focus on an emerging high risk group i.e. pre-teen and teenage girls, starting from twelve years upwards. To involve community leaders and groups e.g. church leaders, community groups, thus working directly with individual communities and needs. Outreach as a major component in reaching those affected by mental health disorders 8.2 Women in Sample Group - Recommendations For Action Mental health education and awareness inclusive of all sections in the community. This would help break the stigma associated with mental health disorders, and help the wider community understand mental health issues. It would also help people understand how to identify and prevent mental health disorders, before it becomes irreversible. Places where women can draw support and share experiences with each other. Women isolate themselves when they are under extreme stress for fear of recriminations for having 'failed' and for fear of not being understood. Sharing experiences during the study proved to women how empowering sharing their experiences was, because of the common ground they shared and how supportive women were about the various stresses they faced as women. Social and Life Skills training and awareness to help those under stress cope with the practical concerns faced daily e.g. keeping yourself safe, dealing with loneliness, parenting skills, relation ships, unemployment, managing money, communication, career development and guidance, job skills training etc. Information and awareness on groups/ agencies within the community, that women can draw on to help them cope at a legal, financial, and or social-cultural level e.g. domestic violence, rape, street violence, small business enterprise, finances/ loans for women, legal rights, housing, career development etc 30
  31. 31. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 8.3 Development Consultants - Recommendations for Action "People cannot achieve their full potential unless they are able to take control of those things which determine their health. This must apply equally to men and women”.25 Given the standards of world health, identified by the ALMA ATA 4 documents (see appendix...) and the findings from this report the following is recommended: 8.3.1 Proposed Project An urban focused project managed by women, that will work in partnerships with community based organisations, local institutions, local NGOs, private and government health workers and individuals, sharing resources, information, education and life experiences. The proposed project aims to be inclusive, recognising that men need to make an equal contribution to the development of the service. 8.3.1.1 Project Description Promote the self reliance and mental well being of women, families and those urban communities, affected by mental health disorders, through providing a comprehensive support service that will aim to:  Build and promote community, individual and family mental welfare support/interventions.  Create and promote social awareness on mental health issues within the urban communities  Raise the profile, self esteem and opportunities for women through access to information and life skills development.  Advocate and lobby on behalf of women, on issues affecting women's mental welfare.  Research and Development on women, family and mental welfare issues 8.3.1.2 Target Group The focus to be women between the ages of 26 - 45 years, working and or living within Nairobi city. This however, is only a starting point. 8.3.1.3 Justification for Target group In addition to everyday stresses, women living and working in Nairobi are faced with additional stresses from within the workplace. Because the economic environment in Nairobi is largely male oriented, the socio-cultural and socio-economic behavior and altitudes towards women in the work place, is largely negative Working women face continuous sexual harassment and discrimination, as well as being
  32. 32. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 exposed to physical violence and emotional abuse, not only in the workplace, but to and from work on the streets, In the formal work place, women are promoted more slowly than men and get less pay, often bearing the blunt of job retrenchments. In the informal sector, where over half the hawkers are women under 32 years of age and 30% are aged between 33 and 40 years of age and married and with children (sec 5.2) female headed households almost always earn less than male counterparts. This disparity can be explained by the fact that males have a better chance of obtaining employment in the formal and or informal sector. During a working day, women continue to juggle their family and work lives, often taking their young children with them to their places of work (in the informal sector), and those in the formal sector, have to look for childcare whilst at work, and or take their children to work with them (a rare situation in the private sector). Family shopping is carried out mainly during lunch breaks during work time, or after work. In addition to all this, women take care of any family crises that may arise during the day or the evening before e.g. take the children to hospital, look for new baby-sitters, visit and look after a widowed or sick relative etc. This group of women also face overt and covert pressure from the community, mainly for breaking the traditional role of women where they are beginning to make choices for themselves e.g. to marry or not, have children or not or when, pursue career, have financial independence etc. At the end of a working day, this group of women then turns to fulfilling their roles as mothers, wives, single women, careers, and for many, manage the family finances at the end of each month 32
  33. 33. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 BIBLIOGRAPHY 1. Cox. AD. Puckering C; Pound A Mills. H: The impact of maternal depression in young children. Psych . 1987, 28: 917-928. 2. Dankelman, I. and Davidson, J. (1993) Women and environment in the Third World. 3. Dhadphale et al 1982, 1983, Kigamwa 1991 Mental health in Kisii, Kisumu and Kenyatta National Hospital, Kenya. 4. E.Tarino; E.G. Webster. Primary Health Care Concepts and Challenges in a Changing world. Alma Ata revisited. WHO/ARA/CC/97.1 5. E. SPaykel: Depression in women 6. Frieda L. Paltiel: Women and mental health. A post Nairobi perspective 7. Gove, W.R. (1984): Gender differences in menial health and physical illnesses; the effects of fixed and nurturant roles. 8. Government of Kenya: Ministry of Health. Kenya's health policy framework, 1996 9. Graham Alder: USAID/Dev. Consultants: 1993. Nairobi's informal settlements 10. Harpham, T. (1994): A research role for social scientists, public health professionals & social psychiatrists. Social Science & Medicine, 39 (2): 223 11. Harpham T. & Ilona Blue: Urbanisation and Mental Health in Dev. Countries 12. Harding et al. 1980:. (SRQ-20) 13. Hosken, F. (1987): Women, urbanisation and shelter. Development forum, May '87 14. Human Development Report: UNDP 1994 15. Ilona Blue: Urban inequalities in mental health 16. Kenya Population Census Report: Kenya High Commission Nov. 1997 17. Kiesler, C. a. 1985. Policy implications of research on social support and health. 18. M. Beusenberg & J. Orley: A user's guide to the SRQ-20. WHO/MNH/PSF/94.8 19. M. Abas, J. C. Broadhead, P Mbape & G. Khumalo -Sakatukwa: Defeating depression in the developing World: A Zimbabwean Model. 20. Moser, C, Dennis, F. and Castleton, D (1991): Women, Crisis and development in the third world. 21. Orley J. Litt, B & Wing. J.K: Archs. G.P. 36. 513 - 520 1979 22. Payless, E. S. 1991: Depressionin women. Vol.15823.
  34. 34. Women and Mental Health in Nairobi, Kenya. A Situation Analysis. Shibero Akatsa 1997 - 1998 23. Peggy A. Thoits: Stress, Coping and Social Support Processes: Where are we ? What next? 24. Rosenfield. 1989. 25. The Ottawa Health Promotion Charter: First Intern, promotion Conf. - Nov. 1986 26. WHO/ARA/CC/97.1: Primary health care concepts in a changing world 27. WHO/FHE/MNH 93.1 28. WHO (1987) Women & Mental Health: A Post Nairobi Perspective. World health statistics quarterly, 40(3) 29. World Resources O. P. 1996 30. World Bank World Dev Report 1993: Investing in health. Oxford Univ. Press. 31. World Report, Kenya Internet References 32. Kenya factbook.http:www.odc 33. The US Department of State: Kenya report on human rights practises for 1997 http://www. stste.gov/www/global/human rights 34. Ross, R. W - The complete guide to Nairobi 34

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