South Sudan: Socio-anthropological study on perceptions of mental health and traditional means of approaching it

Handicap International (HI) is an independent and impartial international aid organization working in situations of poverty and exclusion, conflict and disaster. Working alongside persons with disabilities and other vulnerable groups, our action and testimony are focused on responding to their essential needs, improving their living conditions and promoting respect for their dignity and their fundamental rights.
Handicap International is a not-for-profit organization with no religious or political affiliation. It operates as a federation made up of a network of associations that provide it with human and financial resources, manage its projects and implement its actions and social mission. For more details on the association: http://www.handicap-international.fr/en/s/index.html

1-1- Mental Health in South Sudan
Independent since 9 July 2011, South Sudan is currently classed as one of the world’s poorest countries with an almost non-existent infrastructure and access to basic services. The maternal mortality rate (around 2,054 for every 100,000 live births) and the infant mortality rate for the under 5s (135 for each 1,000 live births) are the highest in the world. The country has a population of 8 million (almost 400,000 of whom live in Juba) on a surface area of 43,033km2, and is ravaged by regular tribal conflict and the challenge of controlling the substantial mining and crude oil resources on its border with Sudan. The vast majority of the population (80%) lives in rural areas.
Conflict in the country now known as South Sudan can be traced back to 1955, with several attempts to initial peace, the Comprehensive Peace Agreement, 2015 Addis Abba IGAD lead peace talks and finally recently signed peace agreement. During this protracted time of conflict, millions have been reported to have died due to fighting, drought and food shortages. Due to the period of protracted conflict it is estimated that almost one third of the population will be suffering with mental health issues including post-traumatic stress disorder. Recent humanitarian crisis commencing on 15th December 2013, displacing over 1.5 million people, is only exacerbating an already critical situation as it is expected that the incidence of mental health disorders will increase by 10-20% .
Experience shows that countries recovering from a war situation have a high instance of mental health issues, but how these are tackled depends on the quality of the general health care system. In most cases, a low-income country is not able to implement an expensive dedicated mental health programme and will tend to integrate mental health care into the general practice system, which is generally in the process of being rebuilt. In South Sudan, the context is relatively similar to other comparable countries where, post-crisis, the ability to deal with health-related challenges depends on the implementation of policies, strategies, capacities, and advocacy and coordination work. It is in this environment that HI wishes to intervene to improve the way mental health issues are being addressed.
As far as causation of mental morbidity is concerned, there are many factors similar to any other world community, but delayed health-seeking behaviour, illiteracy, cultural and geographic distribution of people and trauma resulting from ongoing conflict seems to be special for South Sudan
Access to adequate mental health care always falls short of both implicit and explicit needs. This can be explained in part by the fact that mental illness is still not well understood, often ignored, and considered a taboo. The mentally ill, their families and relatives, as well as professionals providing specialized care, are still the object of marked stigmatization. These attitudes are deeply rooted in society. The concept of mental illness is often associated with fear of potential threat of patients with such illnesses. Fear, adverse attitude, and ignorance of mental illness can result in an insufficient focus on a patient's physical health needs. The belief that mental illness is incurable or self-inflicted can also be damaging, leading to patients not being referred for appropriate mental health care.
The attitude of individual patient toward his or her mental disorders is important as far as health seeking is concerned. It is pertinent to study the perceptions, myths, beliefs, and health-seeking behavior for mental health of population. Myths and beliefs are also responsible for practices which could be harmful to health.

1-2- Mental Health and Psychosocial Support programme
450 million people throughout the world experience difficulties as a result of their mental health. Conflicts, displacement, incarceration in rundown institutions, chronic disease, the causes of imbalance are numerous.
Handicap International developed a mental health and psychosocial support programme, entitled “Touching Mind, Raising Dignity”, in four countries where Handicap International has been working for many years: Lebanon, Madagascar, South Sudan and Togo.
The common factor between these four countries is that they have all experienced chronic social, economic and political crisis which has resulted in poor social and health conditions, undermined public infrastructure in general, and damaged each person’s ability to ‘live together’, all of which are motors for development
It is against this background of chronic crisis that HI has chosen to develop various intervention models, with the aim of improving the mental health of individuals and their communities. These models, all of which are defined according to the local institutional, partnership and professional context, aim to meet the needs of people living with mental health issues in order to prevent any risk of social condemnation, be it in the form of discrimination, stigmatization, social exclusion or seclusion.
The aim of this programme is to improve the social and community involvement of people living with mental health disorders so that they can regain their full capacity to live with dignity in their environment. To do this, Handicap International proposes to develop innovative intervention models and pilot schemes that involve working with people who suffer from mental health distress and disorders and who live in closed, rundown environments (specialist psychiatric hospitals and prisons). Hl’s approach in the field of mental health is essentially community-based and allows: The prevention of psychiatric collapse for people with a high level of psychological distress.
The support of existing coping mechanism at the families and the community level
The strengthening of local capacities of community based services.
The advocacy for the rights of people with mental health problems.
In South Sudan, The project aims to implement the necessary and appropriate services to deal with the mental health related issues, on the one hand to address the urgent need to empower people suffering from a mental health problem living in a deteriorated environment such as prisons and hospitals or camps and on the other, to introduce and support the stakeholders to set a structural framework through a national action plan to develop appropriate community based services and supporting people with mental health problems getting out of prisons and hospitals and going back to their communities. The project is working with authorities to develop the first ever mental health policy and action plan through mobilizing different stakeholders.The project intends to build the capacity of Psychiatry department in Juba Teaching Hospital so that it can deliver services to increased number of people. Juba Central Prison also receives support to create therapeutic environment for people with mental illness lodged there.
At community level, the project intends to strengthen local organisation which can lead identification, referral and follow up of people having mental health problems through community mobilisers and volunteers in order to support the integration and acceptance of people with mental health problems.

2-1- Why this research?
The research is resulting from a will to promote innovative knowledge management. The research will help in adjusting and adapting the current project interventions in line with the findings. The knowledge on perceptions about mental health problems among community service providers and local authorities will help in understanding the reason why people with mental health problems are either locked up in prisons and hospitals or are hidden in the community. In addition, this study will support the HI teams and their partners in delivering our actions relating to the public acceptance of people with mental disorders in consistence with the perceptions and traditions of the country. It will also help in correct and effective identification of people having mental health problems and referring them to appropriate services respectful of their rights. It is realized that the understanding on perception of society groups such as family members, health workers, traditional healers, other service providers toward persons with mental health problems. The study would help in knowing the good and bad practices in the community, services providers and local authorities, language which community use or understands, what they mean by mental health problems, what do they think about causes and whom they go if they identify person has mental health problems. It should also describe the dynamic of the relations that is built between people with mental health problems and the different stakeholders. It should highlight the negative and positive interactions that can lead either to the empowerment of people with mental health problem through a proper care and support or the deterioration of the wellbeing and ultimately the abuse of their human rights.
Finally, it should bring the light to the current referral pathway that people with mental health problems and their caregivers take to seek support.
Alongside this study, another one that aims to describe and analyze the emergence mechanisms, formation processes, capacity of action and sustainability factors of formal and informal peer support groups operating within specific systems and targeting people living with mental health problems is planned in same area of intervention (Juba).

2-2- Research objectives

• General objective of the research

To describe in-depth understanding on perceptions of mental health among various groups of communities, the dynamic of the interaction between people with mental health problems and the different stakeholders and the traditional means of approaching the issues of mental health in South Sudan.

• Specific objectives

• To know the perceptions toward mental health among the families, various community members, leaders, services providers and the local authorities and identify myths and belief rooted in the society and among service providers.
• To describe the dynamic of the interaction between the person with a mental health problem and the family, the community, the service provider and the local authority.
• To understand and analyze the referral pathway for people with mental illness
• To analyze the understanding of traditions, practices and skills among community members related to mental health.

2-3- Location: Juba city, South Sudan 2-4- Target Population

• Users of mental health and psychosocial services and their caregivers
• Community leaders, traditional healers, general community members, local authorities
• Existing basic and specific service providers addressing the needs of persons living with psychosocial disabilities;
• Authorities ruling over the mental health.
  2-5- Methodology

This is qualitative anthropological study that will use different methods such as the participant observation, group and individual interviews with relevant stakeholders in order to capture the understanding and social perception regarding the mental health problems and meet the expected outcomes.
A literature review regarding the subject is expected in order to enrich the study.
Data collection tools can be an observation grid and a grid of semi directive interview, adapted to different profiles to query. The data collection tools should be subject to a validation of Handicap International.

2-6- Ethics

The expected technical offer shall includemechanisms to be implemented so as to ensure:

• the protection & safety of HI teams and participants in the research
• informed consent of all respondents
• the confidentiality of sensitive and personal data
• the scientific validity of the research
• the possibility to use and exploit the information contained in the research
• the adoption of a comprehensive and participatory approach

2-7- Specific survey constraints

The research protocol will be validated by HI committee composed by technical focal points and South Sudan program team.
The proposed methodology in the technical offer should be participation-oriented in line with the requested qualitative approach.

3-1- General objective of the expert mission

The expert will ensure the implementation (final protocol), the realization (collection, processing & analysis), the monitoring and the exploitation of the research results.

3-2- Expected results of the mission
(1) A written protocol is finalized.
From the technical proposal and in collaboration with the reference person of Handicap International, a protocol is written. This document provides key elements of the implementation of the research and contains,a minima: introduction with background of the research, state of art, interest of the research ; presentation of the objectives (general & specific), with target population, location; presentation of the methodological framework: study design, selection of participants, data collection, data treatment, data analysis, quality monitoring mechanisms; responsibilities of the expert; time schedule; budget; ethics considerations.
(2) Field visit consisting of 3 weeks
(3) Report writing and finalization for 1 week

3-3- Deliverables Final Protocol
Final data collection tool (interview guides, questionnaires)
Research report

3-4- Time Schedule & budget
The research will be conducted during the 1st quarter of 2016. 1 month of mission will be required for the study. Exact dates will be agreed during the recruitment.
The budget for the research will be approx. 7500Euros. This amount is to cover the consultancy fees, International return air fare to Juba, visa, insurance and taxes if any.

Requested profile

• Mandatory:

• Minimum Diploma: Master in Socio Anthropology or sociology with at least 5 years of experience in conducting socio-anthropology related researches
• Experience in the mental health sector
• Proven and recognized experience in methods of data collection, treatment and analysis (particularly qualitative data)
• Experience inparticipatory research approaches
• Analysis, synthesis and writing demonstrated capacity (provide a list of publications)
• Knowledge of the working languages (written &oral): English

• Desired:

• Recommended experience in conducting surveys/researches
• Ability to work in collaboration with public and associative actors
• Familiar with the African context

Applications must include:
• About the consultant:

• A curriculum vitae (training, experience in the areas mentioned above, lists of key publications)
• References

• A letter of motivation • About the technical proposal:
  A methodological proposal to conduct this research, including, a minima:

• Understanding of the issues of the research and of the terms of reference;background of the research; presentation of the objectives (general & specific); location; target population; presentation of the methodological framework: study design, selection of participants, data collection, data treatment, data analysis, quality monitoring mechanisms; ethical considerations

• A financial proposal including, a minima, details of consultancy fees and operational costs of the research.

• Decision about the methodology will be made upon proposal of the applicant in his/her technical offer and subsequent discussions and validations with HI technical unit.

Please, send all required documents before January 20th 2016 to the following address: oc.development@hi-sudan.org