A year in Uganda

Uganda is classified as a low-income country, with almost a third of the population estimated to be living below the poverty line. Life expectancy is 59 years, and the prevalence rate of mental health conditions high. Uganda has the youngest population in the world, with 77 per cent being under 30 years of age. It's one of the fastest growing populations, with an average fertility rate of 7, as compared with 1.8 in the UK. The chance to address the mental health of children and adolescents drew us to Uganda for a year of volunteering.

Butabika National Referral Hospital was opened in 1955. With Makerere University, it provides training for professionals employed in mental health units in regional hospitals and community services throughout Uganda. In 2004, the Butabika - East London link was established, a multi-disciplinary collaboration between East London NHS Foundation Trust and Butabika National Referral Hospital. The link aims to improve mental health in Uganda and also in the UK, through mutual learning and collaboration. Over the years, there have been more than 50 professional development placements at East London NHS trust for Ugandan colleagues, whilst over 100 professionals from the Trust have volunteered in Uganda. The link has raised more than £1 million for mental health services in Uganda.

A significant part of our role was to assist with the Advanced Diploma in Child and Adolescent Mental Health (CAMH), provided by Mbarara University of Science and Technology at Butabika. The two-year program was established in 2013 by the East London NHS Foundation Trust, to enable qualified mental health or child health professionals to specialise in child and adolescent mental health. There were several other planned roles and responsibilities for the funded CAMH project, and more that we identified ourselves during the volunteership.

Along the way, there were challenges and rewards, and at times our experiences were overwhelming. Here, we pause to reflect upon and share lessons from our time in Uganda.  

Clinics, research, films and more

Two or three days per week, we were involved in outpatient clinics at the children's ward. This mostly involved assessment of commonly presenting conditions such as anxiety, depression, autism, somatisation disorders, learning disabilities and epilepsy. Psychology is still in its infancy in Uganda, and some families were disappointed when referred for talking therapies rather than receiving medication, or medical treatment such as scans. We had to call upon and develop our skills in succinctly explaining and selling psychology!

We travelled together to locations all over Uganda to join meetings of staff trained in CAMH. These meetings enabled staff to share their successes and challenges, and to feel less isolated – some clinicians were the only child specialist in their hospital. Each host of the meeting would put on an educational event for the wider hospital. These were a great opportunity to spread the message about the importance of CAMH. The meetings gave us a good overview of the health and mental health systems throughout Uganda, and were a fantastic chance to see the country! Despite its traumatic history only a few decades ago, Uganda is now a safe and stable country. The countryside is beautifully green, and there are many opportunities for amazing hiking, cycling, white water rafting in the River Nile, and seeing all kinds of wildlife: from tree-climbing lions to endangered gorillas.

There's a lack of psychological literature in Uganda generally, and even more so in relation to children's mental health. So we were both keen to carry out small research studies. Kirstie noticed that psychosomatic disorders were one of the most common presentations in clinic, and was interested to investigate this further, particularly due to the scarcity of literature on the topic on the African continent (Dekker et al., 2018). Tara was keen to investigate tics and Tourette disorder in Uganda, having previously heard that it did not exist in sub-Saharan Africa (Robertson et al., 2008), or at least that there is very limited literature.

Most Ugandans were welcoming of and collaborative with the research. We submitted an application to the local institutional review board, which was detailed, but not to the same level as that in the UK. Interestingly, we were obliged to pay a fee to go through the process, which did not seem entirely ethical to us! We hope to analyse the data this year, and to then inform practice and teaching in child mental health in Uganda.

One of the most enjoyable and encouraging parts of the role was to provide supervision to nursing and medical students, as well as undergraduate and trainee psychologists. We were able to supervise some very bright, able students, who left us feeling positive about the future of psychology in Uganda. In addition, we taught (and learnt from) keen, qualified professionals from a variety of cadres on the CAMH diploma. These professionals are providing a sterling service of clinical work to children and families, as well as teaching their colleagues about the importance of child mental health, all over Uganda.

Donations of cognitive tests from all over the world enabled us to establish a weekly cognitive assessment clinic on the children's ward. Tara established several workshops at Makerere University to enable clinical psychology trainees to learn and use these tests themselves – some of the first cognitive tests in Uganda. They proved an invaluable resource, due to a high prevalence of neuropsychological conditions combined with intense pressure for Ugandan children to perform at school. Many children are at boarding schools, which can run from 4.30am to 10pm. The resulting reports enabled children's behaviours and school performance to be better understood, and we were able to provide concrete ideas for schools to support children in more positive ways.

In the footsteps of previous UK volunteers, we created an online fundraising project, which was very successful. The funds enabled us to facilitate many practical projects, which we hope will make a difference to the service. For example, we received paint from a local company and repainted the children's ward; we established a new speech and language clinic, with half a day per week from Joseph Isimbwa (one of only about 60 speech therapists in East Africa); and paid for a UK film-maker to travel to Uganda to make two brief documentaries on epilepsy and autism, featuring Ugandan professionals and service users. The films have been displayed via donated tablets from Camara Education in clinics in all district general hospitals in Uganda. They are being translated into several Ugandan languages as well as sign, and are also freely available online.

We also received donations from Miss Pride of Africa (UK), which allowed a social worker to resettle 18 children back to their families. Inappropriate admissions and extended stays of children on the ward once treatment was completed creates overcrowding – one of the biggest problems ward staff were facing. Many of the children had neurodevelopmental or intellectual disabilities, rather than mental health problems. However, as many children were brought by police or members of the community, and some were unable to speak, these children were very difficult to place back with their families. Many were returned to the hospital, creating an adverse psychological impact on staff and the care of other patients on the ward.

Time and safety nets

Time is a very loose concept throughout Uganda. On clinic days, families turn up and wait in line (sometimes all day) until they're seen. Initial assessment appointments often last two hours, partly due to the use of interpreters, but mainly due to the fact that many families would not be returning (frequently due to constraints from work or travel costs). We had to do our best to provide a comprehensive assessment, formulation and management plan, all in one session. However, some families did return, and – given the warm, friendly and frequently very open nature of Ugandan people – we could often reach an enriched collaborative understanding in only one meeting.

The therapeutic environment was very different to any of the experiences either of us had while in the UK. The physical context of the ward was often loud and chaotic. Low levels of staffing combined with large numbers of both inpatient children and outpatient families waiting to be seen in the same place, as well as up to 30 medical, nursing or psychology students coming and going from the clinic rooms. There were a number of serious incidents on the ward during the volunteership, including the sudden, unexpected deaths of two children. These experiences were emotionally challenging, particularly as post mortems, safeguarding procedures and debrief meetings are not used.

However, the main challenge within the therapeutic context was not physical, our fellow professionals, or the presentations of the children and teenagers. It was the lack of 'safety net' in the system. Risk, concerns, unmet needs and desperation exists in every country in the world, but the lack of systems to consistently respond to these difficulties made our work very difficult. The social care system is highly limited in Uganda and social workers are few and greatly over-stretched in their work. This meant that social problems (no housing, food or school fees) were at the top of the problem-list and needed to be fixed before psychological input could be in any way useful.

Additionally, families were frequently referred to medical professionals, as children on medication would also be much more likely to come back to be reviewed and to receive repeat prescriptions. As a result some children were overmedicated, or on the psychiatrist's second or third choice of medication, due to regular medication shortages. Often, there was no alternative.

A steep learning curve

Patience and flexibility were essential. Our plans for the day were more of a loose guide, and we had to be prepared for any eventuality. We would often be quite limited in relation to toys and resources available, whilst power cuts and water outages were relatively regular. This presented an opportunity to improvise, and to draw on well-honed therapeutic skills for communicating, understanding and interpreting. This was quite a steep learning curve, given differences in language, communication, belief systems, values and many other factors. Our understanding and cultural competence grew over the course of the volunteership, but it was fascinating to realise that our backgrounds led to contrasting assumptions: on the one hand, that we were 'experts', and on the other hand, that we could not possibly understand life and culture in Uganda.

Our medical knowledge grew across the year. In Uganda, epilepsy and other syndromes such as cerebral palsy were often first seen in mental health services, rather than by a neurologist or paediatrician. Whilst we would refer on to appropriate professionals, we learnt a lot 'on the job', and from our colleagues. We did have a knowledgeable multi-disciplinary team to work with, and of course each other.

We left full of admiration for the perseverance and resilience of our colleagues – they are understaffed, on little pay, and manage tough situations every day. Such events are not unusual on the children's ward, but anyone considering a volunteership should be prepared for difficult events with lower levels of support than may be available in NHS practice. As a way to support volunteers in the future, we have both offered to provide regular support and supervision, should it be requested.

-       Dr Kirstie Fleetwood Meade is a Chartered Counselling Psychologist and Systemic Practitioner, based with AWP NHS; South Gloucestershire CAMHS. [email protected].

-       Dr Tara Murphy is based in the Community Mental Health Team, Saint Helena Island. [email protected]

'We would like to thank the staff at Butabika Hospital and our colleagues on the Diploma in Children's Mental Health; Kirstie's supervisor Pierre Cachia (Counselling Psychologist) whose generous pro-bono supervision provided essential support in challenging times; Dr Alyson Hall, Consultant Child Psychiatrist and Mr Edmund Koboah from Butabika and East London Link for their enthusiasm, support and collaboration during the volunteership.'

For more information about the Butabika – East London Link see https://www.butabikaeastlondon.com http://www.mhinnovation.net/organisations/butabika-east-london-link or email Edmund Koboah [email protected]

A short version of the article will be published in CBT Today magazine. the official magazine of the British Association for Behavioural & Cognitive Psychotherapies, December 2019.

Key sources

Dekker, M. C., Urasa, S. J., Kellog, M., & Howlett, W. P. (2018). Psychogenic non‐epileptic seizures among patients with functional neurological disorder: A case series from a Tanzanian referral hospital and literature review. Epilepsia Open, 3(1): 66-72.

Kigozi, F., Ssebunnya, J. Kizza, D., et al. (2010). An overview of Uganda's mental health care system: Results from an assessment using the world health organization's assessment instrument for mental health systems (WHO-AIMS). International Journal of Mental Health Systems, 4, 1.

Molodynski, A., Cusack, C., & Nixon, J. (2017). Mental healthcare in Uganda: Desperate challenges but real opportunities. BJPsych International, 14(4), 98-100.

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

Roberston, M., Eapen, V., & Eugenio Cavanna, A. (2009). The international prevalence, epidemiology, and clinical phenomenology of Tourette syndrome: A cross-cultural perspective. Journal of Psychosomatic Research, 67(6), 475-483.