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InPsych 2014 | Vol 36

August | Issue 4

Psychology in current issues

APS Grant provides insights and resources for managing traumatic brain injury in Botswana

The APS Grant for Intercultural and/or International Projects of up to $10,000 supports innovative projects that have an intercultural and/or international focus, particularly in countries where psychology is an emerging discipline. Ms Lingani Mbakile-Mahlanza, a clinical psychologist from Francistown, Botswana (nominated by Professor Jennie Ponsford MAPS from Monash University), was awarded an APS Grant in 2012-13 for a project that examined the experiences and perceptions of traumatic brain injury (TBI) in Botswana, a small middle income country in southern Africa. The project documented the problems experienced by people with TBI and their families, as well as examining their beliefs about injury causes and treatment, experiences within the healthcare system and local community, and psychosocial adjustment. Lingani shared her observations and insights about the APS Grant project in her home country with InPsych.

What is the status of neuropsychology as a discipline and clinical practice in Botswana?

Psychology in Botswana is in its infancy, with the training of psychologists only beginning in 2004. The University of Botswana currently offers two undergraduate psychology programs and no graduate programs. Consequently, there are very few trained psychologists in Botswana, and the number of psychologists is estimated at 0.03 per 100,000 people. Only a few clinical psychologists have been trained to graduate level outside the country. Neuropsychology as a specialty has not yet emerged. The slow growth of clinical practice is related to a variety of factors including the cultural orientation of Batswana (people who are from Botswana), where help is usually sought within the family system, and continued consultations with traditional healers and church elders as well as (or instead of) health professionals.

What are the more immediate and longer term mental health and wellbeing issues confronting the people of Botswana?

Stigma against mental health problems is a major issue, and mental illness is still largely taboo. Attitudes about mental health issues tend to be coloured by a sense of shame and negative judgement. This stigma is arguably due both to a lack of understanding about causes of mental health problems, and to beliefs about their etiology related to sorcery and witchcraft.

What made you focus on traumatic brain injury?

Botswana has one of the most severe HIV/AIDS epidemics in the world. Most of the government’s resources are therefore directed towards the management and care of people with HIV/AIDS, which affects roughly 17 per cent of the population. As might be expected under these circumstances, care and service development for people with other conditions, including TBI, are extremely limited, and there are no programs or support systems specific to TBI. Until now, much of the research on TBI in Africa has been based on clinical and epidemiological data, and limited work has focused on the experiences of patients, caregivers or key service providers. I decided to focus this research on TBI in an effort to advance recommendations for health care workers in relation to management and appropriate intervention strategies for patients with TBI. It is anticipated that this project will improve quality of care provided to TBI survivors in Botswana.

What have been the most important outcomes of your project?

I conducted over 70 interviews with individuals with moderate to severe TBI, their caregivers and healthcare workers recruited from hospitals in Gaborone and Francistown, Botswana. The interviews were conducted in their native language; I am both a native of Botswana and a qualified clinical psychologist. Thematic analysis of the interview transcripts confirmed and also added to existing findings in the area of culture and beliefs about injury. Half of the injuries were sustained as a result of assaults, a far higher proportion than would be seen in Western countries. The other 50 per cent resulted from motor vehicle accidents.

These people experienced the same injury-related changes as people from other parts of the world, including cognitive and behavioural problems, and reduced capacity for independence in mobility and activities of daily living, work or study and social participation. Beliefs regarding the causes of injury were however quite different. Amongst the participants with TBI and their caregivers, the most common themes that emerged from a qualitative exploration of their beliefs regarding the causes of injury were attributions to witchcraft, punishment for past wrongdoings, bad karma or religious phenomena, such as the will of God. A significant proportion indicated that people would seek treatment from traditional practitioners or healers, who utilise supernatural forces to heal ailments or ‘chase away’ misfortune. Within a traditional medicine structure, treatment may entail re-establishing harmony with the social and spiritual world.

An understanding of the experiences of individuals with TBI and their families as well as healthcare providers has also provided unique and invaluable information regarding their needs. For example, the study revealed that communication was extremely problematic in healthcare settings. It was characterised by inadequate or sometimes no information given to those injured and their caregivers by healthcare providers. Moreover, provision of care was impeded by insufficient staff, limited supplies and lack of training of nurses. The current healthcare system would therefore appear to be ill-equipped to meet the needs of TBI survivors in Botswana.

Another important outcome of this project is the insight that the experiences of people with TBI are inseparable from those of their families and their wider communities. Despite the lack of services and information provided, it was evident from this study that Batswana have a strong sense of family and strong community ties. It is clear that people with TBI and their immediate families cope well and show resilience in the face of this adversity. There was a strong sense of responsibility towards the injured person, whereby families made caring a top priority. This sense of togetherness and support was evident for most participants, and embodies the essence of family functioning in this culture. On the other hand, the families of injured individuals frequently reported becoming isolated from more distant relatives and friends, who lacked understanding of the injury. This was possibly a reflection of the view held in the community that brain injury is akin to a mental health disorder, with profound implications in terms of stigma.

In light of these findings we plan to produce an information resource for individuals with TBI and families in Botswana, describing the most common problems associated with TBI and suggested coping strategies.

How did the APS Grant assist you in your work in Botswana?

There is currently inadequate information available to survivors of TBI and their families post-discharge. The APS Grant provided funding to support the cost of transcription and translation of interview data and will also be used to develop a culturally appropriate resource manual for individuals with TBI and their families. Funding will be used for the preparation, production and distribution of this resource manual.

What excites you most about practising neuropsychology in Botswana and what kind of challenges are you likely to face?

I am very excited about doing the ground-breaking work in this discipline. There is clearly a big need for neuropsychology in Botswana and I am really looking forward to starting this service. Having come to Australia on a Botswana government scholarship some years ago, I am eager to go and give back to the country.

Psychology practice in Botswana faces many challenges. Firstly, the discipline is minimally regulated. There are currently no regulatory demands made on psychologists apart from registration with the Botswana Health Professions Council, which requires a minimum of a Masters degree in psychology. Secondly, because psychology is a new discipline, there is still limited insight among patients as well as some health professionals about the role of psychologists. In addition, the referral system is problematic. Psychological services can only be accessed when the person has been admitted to a psychiatric ward, and there are no psychologists in the community. There is also a lack of resources for psychologists, for instance, there are no psychological tools/tests available. Further, as a result of the low numbers of trained psychologists, there are no supervision arrangements in place. Remuneration for psychologists is also very low despite postgraduate training.

Is there a take home message for psychologists here in Australia, and as global citizens?

Understanding the cultural perspectives of patients is extremely important in order to provide effective assistance. Culturally-based beliefs about illness and treatment may override Western style healthcare interventions. Communication of information about health conditions to patients and families in the treatment process is therefore vital, as is education of the broader community. It is important to recognise that strong family support may have a positive influence on adjustment to injury, so consideration of the supports that are in place for patients could provide some indication of their ability to cope with TBI and its ongoing effects.

What did you and Jennie learn from working together on this project about the process and challenges of intercultural collaboration in conducting psychological research?

Seeking permission and co-operation form the hospitals in order to conduct this project was challenging. Having the direct involvement of a native of Botswana in the project was essential, both in terms of navigating the healthcare system and understanding cultural issues associated with this. However, more importantly this provided the medium of communication with the patients, caregivers and healthcare providers, who could be interviewed in their own language by a person who was part of their culture. Even with this local knowledge, translating certain constructs, including those relating to emotional issues, proved challenging. The combination of being a native of the country, speaking the language and having clinical psychology training was important to overcome this challenge.

Thanks to Heather Gridley for arranging this interview.

The 2012-13 APS Grant was awarded jointly to two different projects. The recipient of the other 2012-13 APS Grant, Dr Katie Dawson MAPS, was interviewed in the June 2014 edition of InPsych for her project developing a brief psychological intervention for humanitarian crises (see www.psychology.org.au/inpsych/2014/june/APS-Grant/).


APS Grant for Intercultural and/or International Projects 2014

CALL FOR APPLICATIONS

Applications are now open for the 2014 APS Grant to encourage and support innovative projects that have an intercultural and/or international focus. Applications should aim to develop and implement a project that is culturally meaningful for the target country or community and its people, and that promotes intercultural collaborations between Australian psychologists and those in the specified region.

The value of the Grant is $10,000, which can be divided into smaller Grants for two or three separate projects. The Grant is to be used to support the establishment and implementation of a successful and sustainable project. The Grant is not intended to support research projects unless there is a clearly demonstrable outcome in relation to the aims of the Grant.

Further information on the criteria for the Grant can be obtained from www.psychology.org.au/about/awards/intercultural/

Closing date for applications is Friday 3 October 2014

For enquiries about the Grant please contact interculturalgrant@psychology.org.au

References

Disclaimer: Published in InPsych on August 2014. The APS aims to ensure that information published in InPsych is current and accurate at the time of publication. Changes after publication may affect the accuracy of this information. Readers are responsible for ascertaining the currency and completeness of information they rely on, which is particularly important for government initiatives, legislation or best-practice principles which are open to amendment. The information provided in InPsych does not replace obtaining appropriate professional and/or legal advice.