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Date: 2015-11-30
Title: Combating Barriers to Care in Rural Uganda

MGH Global Psychiatry research fellow Dr. Christine Cooper-Vince recently returned from Mbarara, a small town in southwest Uganda, after working alongside local clinical and research staff to assess the local climate of psychiatric care and develop culturally appropriate strategies to overcome barriers to care.

This is not Dr. Cooper-Vince’s first visit to Mbarara—earlier this year, she was welcomed by the Psychiatry Department of Mbarara Regional Referral Hospital (MRRH) and the Mbarara University of Science and Technology (MUST). Over the course of that week in July, Dr. Cooper-Vince joined the clinical team at MRRH on ward rounds, visiting each of the hospital’s 25 patients and their accompanying family members to discuss their personal cases and treatment plans. Many struggled with symptoms of psychosis, presenting within the context of mood disorders, psychotic disorders, alcohol and substance abuse, trauma, and HIV. Unlike inpatient psychiatric care in the US, almost all patients were accompanied by a family member throughout their entire hospital stay. This family member not only provided collateral information for treatment planning, but also attended to the patient’s meals and hygienic needs and aided in behavior management of acutely symptomatic patients. Dr. Cooper-Vince noted that the ubiquity of accompanying family members may present a unique opportunity for intensive family engagement in inpatient psychiatric interventions to enhance continuity of care after the patient has returned home.

Beyond the potential for support within families, a remarkable community had also formed between family members of patients at the hospital. Due to their extended stay, the family caretakers built an organic culture of social support that many in the US still struggle to create. When discussing this aspect of her trip, Dr. Cooper-Vince recalled some of the relationships she noticed during her rounds. “I observed two mothers who were accompanying their adult children on the ward that I was told had become as close as sisters during their several-week stay,” she remarked. “I was inspired by the unique strengths of the cultural context to build social support for family members of people with severe mental illness.”

Despite the strengths in this setting, many barriers to care were still profoundly apparent. Stigma and culturally-based religious beliefs often caused those with mental illness to be hidden from society, only seeking professional assistance when their symptoms progressed beyond the family’s ability to safely care for them at home. Some patients showed marks caused by physical restraints applied by concerned family members prior to hospitalization. Further, limited funding significantly restrained staffing on the ward, as well as the department’s efforts in community outreach, resulting in many patients facing extended travel and wait times to receive basic care. Despite this, the hospital’s motivated staff was dedicated to developing solutions to overcome barriers to treatment.

In light of some of these issues, Dr. Cooper-Vince gave lectures to hospital staff on technological innovations for enhancing access to care. The staff led discussions on integrating mobile phone use in outpatient care, as many of their patients live too far away to have regular follow-up visits. Family-based cognitive-behavioral interventions were also discussed in light of the strong culture of inpatient family involvement. These discussions have continued even after Dr. Cooper-Vince finished her trip, as the hospital hopes to implement training initiatives in the near future. Dr. Cooper-Vince’s next trip to Mbarara is scheduled for early 2016, where she is looking forward to continue her work with the hospital and university teams.

Dr. Cooper-Vince’s first trip to Mbarara was supported by an MGH Center for Global Health Travel Award. Dr. Cooper-Vince is child psychologist and post-doctoral fellow in the MGH Chester M. Pierce, MD Division of Global Psychiatry.


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