A jelly fish stuck to my stomach Experiences

“A jelly fish stuck to my stomach”: Experiences of mental distress among women in the Maldives Husna Razee¹, Jan Ritchie¹, Maurice Eisenbruch² ¹School of Public Health and Community Medicine, UNSW ²School of Psychology, Psychiatry and Psychological Medicine, Monash University. . • Women rarely complained of feeling depressed, Introduction Study Setting sad let down or suicidal. Instead they presented with etiological expressions. Population • Total: 270, 000 • 41% of population < 15 years of age. • Capital Male’: 74, 069 • Description of a certain experience as ‘illness’ or distress and the presumed course of treatment developed in one cultural group, may not be applicable to people who share a different set of cultural beliefs about illness and treatment (Kleinman, 1980). • Miscommunication occurs in the absence of an understanding of the cultural norms, values and beliefs of the patients (Guindon & Sobhany, 2001) leading to misperceptions and quite possibly to misdiagnosis (Patel, 2001; Wagner et al. , 2006). Phenomenology of Mental Health (Emic) • 1190 small coral islands • 199 inhabited • Religion: Islam. Buddhism practiced prior to 1153 AD. • Economy based on tourism & fishing Mental Health Services • No reliable data on mental health situation • Main focus: diagnosis of common and severe mental illnesses and treatment with pharmacotherapy • No trained mental health professionals outside capital island. No psychiatric nurses or social workers. • This seminal study provides an empirical understanding of Maldivian women’s mental wellbeing and contributes a proposed foundation for mental health policy development. • Findings of this study may be useful to educate and inform mental health practitioners about culturally congruent and culturally competent approaches to mental health promotion for Maldivian patients and patients who share their cultural concepts such as South Asians. Aim • Explore the social and cultural context of Maldivian women’s emotional, social and psychological wellbeing and the subjective meanings they assign to their wellbeing. • Research question: How is suffering and distress of Maldivian women experienced and expressed? Method § Method of inquiry. Ethnographic study/ feminist epistemological position. § Data collection: primarily participant observation in the natural setting and in-depth interviews. § Study sites: capital island Male’, northern islands of Kaafu Guraidhoo and Raa Alifushi ; and Southern islands of Thaa Villifushi , GA Thinadhoo and Seenu Hithadhoo. § Participants: women (28) health care professionals trained in biomedical healing interventions (2 primary care workers, 3 physicians, 2 psychiatrists, 1 psychologist), and 8 traditional healers. § Sampling strategies: purposeful sampling, snowball sampling and opportunistic sampling. Extreme or deviant case sampling to ensure informants with characteristics of interest included. § Data analysis based on principles of grounded theory to identify and organize themes from data. Etiological idioms of distress Birugathun – extreme fright Dhilanegun – burning Dhuniyein moyavun – insanity Fikuru boduvun – thinking too much (worrying) Gaiga rissun – body aches and pains Hiy dhathivun – heart distress or tightness around the heart Haasvun – panic, nervousness Jinni moyavun – spirit possession Moyavun – crazy Naaru – Nerves Sihuru – malevolent magic Somatic Symptoms Boluga rissun – headache Burning Dizziness Fainting Gaiga rissun – body aches and pains Cognitive and perceptual Feeling lonely Lack of concentration Loss of interest Ominous dreams Sadness Seeing things Suicidal thoughts Thinking too much Worrying worthlessness Behavioral symptoms Aggression Getting angry Hitting others Loss of appetite Conclusion Results • Participants’ (women) demographic profile: 19 – 60 years, basic literacy skills to those with university qualification, marital status – single to those in a polygamous marriage, all except one had 2 or more children, few were economically active. Only two had been previously diagnosed with a mental illness. • Women expressed their emotional distress in somatic metaphors. • Feels like a jellyfish stuck to my stomach. • My heart complains. • I don’t know what people say when they talk to me. I was turned to stone. • Someone is digging my stomach. • The pain was like nails being driven into me. • I felt like the four corners of the horizon are closing in on me. • My throat is sunk. • The trees looked dead. Everything I looked at appeared dead to me. • Women experienced their distress in their physical body as aches and pains, burning, feelings of cold and heat in their limbs and wind. I started getting body aches. Like my back would ache. So much I cannot even sit like this. Chest pains… that day it would be chest pains. I got x-rays done. Tests done. A lot of tests. At this time all the money I earned was spent on doctors. But they could not find a cause for my problem. No disease. All those consultations and nothing wrong with me. (35 year old woman speaking of her distress following her fiancé jilting just prior to their wedding). • Cultural idioms of distress were anchored in different parts of the body; heart was the main seat of emotion. • Maldivian women present symptoms of mental distress in culturally specific ways. Similar to previous research (Bhui et al. , 2001) this study shows that the ways in which women present mental distress cannot be confined to clinical nosology and diagnostic frameworks provided in the medical model. • Women’s experiences of distress are embedded in the cultural notions of being a good woman and how culture defines and structures women’s place within the family and society. • In clinical practice there is a need for practitioners to listen beyond the physical state of the body communicated through pain and to pay attention to the social and moral realms. Health care providers need to build skills related to recognition of mental illness through a ‘culturally informed inquiry’ (Raguram et al. , 2001). Literature cited Bhui, K. , Bhugra D. , Goldberg, D. , Dunne, G. & Desai, M. (2001). Cultural influences on the prevalence of common mental disorder, general practitioners’ assessments and help-seeking among Punjabi and English people visiting their general practitioner. Psychological Medicine July, 31(5), 815 -825 Guindon, M. , & Sobhany, M. (2001). Toward cultural competency in diagnosis. International Journal for Advancement of Counselling, 23(4), 269282. Kleinman, A. (1980) Patients and Healers in the Context of Culture. Berkeley, University of California Press. Patel, V. (2001) Cultural factors and international epidemiology: Depression and public health. British Medical Bulletin, 57(1), 33 -45. Raguram, R. , Weiss, M. G. Keval, H. & Channabasavanna, S. M. (2001) Cultural dimensions of clinical depression in Bangalore, India. Anthropology & Medicine, 8(1), 31 -46. Acknowledgements & further information This research would not have been possible without the close collaboration of the Maldives Ministry of Health and Department of Public Health and Women’s Committees of the respective field sites. Photos contributed by Shahina Ali. Further information: Contact Husna Razee. Email: husna. razee@unsw. edu. au