• Patience Mhlanga

When asked to offer his opinion about mental illness, a Zambian man precisely stated that “mental illnesses are caused by witchcraft.'' He further substantiated his statement by questioning the usefulness of seeking medical help for witchcraft-related mental illnesses. In his own words, he said, “ Zambian doctors aren’t trained in treating witchcraft, so it’s much helpful to access help from readily available traditional healers.”

The aforementioned statements reveal three things:1) there are diverse perceptions of what causes mental disorders, 2) mental disorders aren’t treated as a medical issue, and 3) people are seeking mental disorder treatment, but spiritual treatment. Seeking out spiritual or traditional interventions for mental disorders is the norm for many Zambians. In Zambia, approximately 70-80% of people who suffer from mental illnesses consult traditional health practitioners before seeking out medical help. Why is this the case? Among other reasons, inadequate access to mental health services compounded by stigma, discrimination, and lack of education about mental health, are primary drivers. To put this stigma into perspective, a Zambian woman alluded to how, for instance, once people know that you have a mental illness, they immediately stop treating you as a person. For the sake of emphasis, this is equivalent to attacking the personhood of people living with mental disorders. In Zambia, the stigmatization of mental illness is ubiquitous, with the majority coming from family members, community members, and at times, health care workers.

The stigmatization of mental illness is well noted in Zambia’s Mental Disorders Act 1951, where people with mental disorders are referred to as idiots, imbeciles, and invalids. Efforts to repeal the Mental Disorders Act 1951 are still ongoing, with the latest news indicating that in 2019, the Mental Health Bill passed its first reading review in the parliament. Although this effort is encouraging, further delays in the repeal continue to prove that mental health is not receiving enough attention.

It is pleasing that more Zambians are becoming comfortable with discussing mental health, but more serious discussions need to happen at the governmental level. Among those who are discussing mental health, they have noted difficulties with finding the right language to describe their mental health status. One man mentioned that “ I do experience depression, but I am hesitant to seek help because I don’t have the right language to articulate my mental health problem in a way health workers can understand.” At times when I visit the clinic to access mental health services, I am prescribed Panadol and simply advised to “stop thinking too much.” That is it,” says one woman living in rural Zambia.

While mental health affects both urban and rural populations, the rural Zambian population is disproportionately affected by severe mental health disorders. Similarly, another woman shared her struggle with defining mental illness. In her own words, she defined mental illness as a “brain problem” that occurs when a person is “not thinking straight.” Others noted that learning about mental health is like learning another foreign language, while some still believe that mental illness is a disease for rich people.

From these comments, two things are obvious:1) lack of mental health education has a direct effect on one’s ability to describe their mental illness symptoms, 2) health care workers lack the necessary training needed to diagnose and treat mental health illness, and 3) lack of mental health education contributes to harmful beliefs about mental illness. A key takeaway is that mental health education can help patients to describe their symptoms in a way that facilitates timely diagnosis and treatment.

In Zambia, mental health and psychiatry are only taught at two Zambian institutions- Zambia University and Chainama College of Health Sciences. Even worse, mental health has not been included in the health care service package; for instance, in the Zambian Ministry of Health budget, less than 1% of funds were allocated towards mental health services. Another concern is that mental health services are not integrated into the primary health care system. Research studies have suggested that the integration of mental health services into primary health care can significantly improve the provision of mental health services. The lack of attention toward mental health is also evident in the poor surveillance infrastructure. For instance, the exact burden of mental disorders in Zambia is unknown; however, hospital admissions associated with mental disorders suggest a prevalence rate of 3.61 and 1.8 per 10 000 population for acute psychotic states and schizophrenia, respectively. By contrast, other researchers have estimated the burden of mental disorders in Zambia to be 20%. The World Health Organization(WHO) reported that the Zambian psychiatric workforce accounts for only 0.06%. In 2017, the total number of governmental and non-governmental mental health professionals in Zambia was 474, and there were 2.94 total mental health workers per population of 100,000(ibid).

There is still work to be done to increase access to mental health services and empower people living with mental illness in Zambia. If we want to be intentional about improving mental health, we have to create an enabling environment, where people can openly share stories of struggle, resilience and healing. With an enabling environment, more people can begin to treat mental health as a public health priority. As one Zambian woman said, “ mental health is another good development for us.”

1.Mayeya J, Chazulwa R, Mayeya PN, et al. Zambia mental health country profile. Int Rev Psychiatry. 2004;16(1-2):63-72. doi:10.1080/09540260310001635113

2.Mental health and poverty project. Mental health policy development and implementation in Zambia. A situational analysis. 2008

3.Press Statement : Mental Health Bill passes first reading in Parliament

4.Bjorklund RW, Pippard JL. The mental health consumer movement: implications for rural practice. Community Ment Health J. 1999;35(4):347-359. doi:10.1023/a:1018714024063

5.University Partnerships for International Development, edited by Barbara Cozza, and Patrick Blessinger, Emerald Publishing Limited, 2016. ProQuest Ebook Centra.

6. Mwape L, Mweemba P, Kasonde J. Strengthening the health system to enhance mental health in Zambia: a policy brief. Int J Technol Assess Health Care. 2012;28(3):294-300. doi:10.1017/S0266462312000347

7.Mwape L, Mweemba P, Kasonde JM. Strengthening the health system for mental health in Zambia. Lusaka: Zambia Forum for Health Research; 2010

8.Mwape, L., Sikwese, A., Kapungwe, A. et al. Integrating mental health into primary health care in Zambia: a care provider's perspective. Int J Ment Health Syst 4, 21 (2010).

9. Munakampe MN. Strengthening mental health systems in Zambia. Int J Ment Health Syst. 2020;14:28. Published 2020 Apr 16. doi:10.1186/s13033-020-00360-z


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  • The Moving Well Project

Our Annual Report for 2020 is now available. Click here to view on our site or you can download.

MWP 2020 Annual Report
Download PDF • 7.00MB

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  • The Moving Well Project

We received a number of great questions at our Kickoff Event during the Q&A portion of the program. If you missed the event, please check out the live recording. Since we were unable to answer all questions due to time constraints, below are the questions we received that we were unable to address. Please do not hesitate to contact us if you have additional questions!

Can you describe the content of the programs in a bit more detail for the truckers and fish traders?

All of our programs are developed and implemented using a three-staged approach which entails adaptation and design, monitoring and evaluation, and scaling up. We work closely with the populations throughout each stage in order to obtain continuous feedback so that we tailor the programs to ensure their relevance and impact on the ground.

Male Long Distance Truck Drivers

Male Long Distance Truck Drivers:

Among migrant and mobile populations, truck drivers have been specifically noted as at-risk of both poor mental health and physical health outcomes. In collaboration with the International Organization of Migration, Zambia, MWP conducted a qualitative and quantitative needs assessment among truck drivers along three trucking routes in Zambia. In the study we found that long distance truck drivers are at an increased risk of: 1) trauma and ongoing daily stressors, 2) delays and long waiting hours at borders, 3) exposure to crime and violence, 4) poverty, 5) stress related to resisting temptation of sexual interactions with sex workers or migrant women, 6) traffic accidents and 7) other job-related safety concerns. Multiple psychosocial problems such as intimate partner violence, substance use, loneliness, anxiety and depression-like symptoms were noted to be related to HIV sexual risk behavior (specific behaviors included inconsistent condom use, multiple concurrent partners along their route, and transactional sex).

In addition to exposure to trauma and ongoing daily stressors as a part of the job as noted above, the COVID-19 pandemic potentially may exacerbate mental health problems and HIV risk among this population. Currently most truck drivers in Zambia are transporting essential goods from neighboring countries to Zambia. Upon arrival, truckers are forced to self-quarantine for 14 days. As this happens at every border, this may significantly delay the route for truck drivers who travel through multiple countries for one delivery, increasing stress, mental health problems and economic strain. Further, controls are weak at the quarantine locations (e.g., schools, hostels, stadiums), living conditions are poor and women who engage in transactional sex frequent the designated areas, increasing HIV risk behavior.

Our program for the truck drivers will adapt an evidence-based behavioral health program through a series of remote group support sessions to address HIV risk behavior, lack of HIV testing, mental health problems and stress, COVID health risk information, risk mitigation and other related outcomes of the COVID-19 pandemic.

Female Fish Traders

Female Fish Traders:

In Zambia, about 1 million people are supported by the fishing industry. As a highly gendered occupation, women dominate the fish trading business, traveling long distances to the rivers and lakes to buy fish from fishermen and subsequently travel to sell fish in the marketplace. HIV prevalence among females between the ages of 15-59 in Zambia is 14.9%. Among women who spend time away from home for more than one month, HIV prevalence is 15.5% and 17.3% among women who have slept 3 or more times away from home in the past 12 months. Although limited data are available, it has been estimated that HIV prevalence is 24% or higher in some fishing communities in Zambia with no indication of decline. Based on a needs assessment conducted by the MWP team, the following contribute to an increased risk of HIV infection among Zambian female fish traders: 1) an inability to negotiate condom use, 2) gender-based violence, 3) transactional sex for transportation to and from fishing camps with truck drivers, 4) “fish for sex” deals with fishermen, 5) multiple concurrent sexual partnerships, 6) lack of economic alternatives and 7) easily accessible alcohol and substance use to cope with stressors. Based on the needs assessment findings, we have recently conducted a series of focus group discussions aimed to adapt an evidence-based, gender-specific and trauma-informed health and mental health program. Fish traders were actively involved in reviewing each component and stage of the program by providing ongoing feedback. In addition, discussions with the fish traders entailed soliciting information on additional components that should be added based on their specific needs.

Our program for the fish traders would entail an evidence-based emotional coping and problem-solving program using both in person and remote sessions, which addresses COVID-19 health risk information, post trauma symptoms, substance abuse, economic alternatives to fish trading during the pandemic and annual fish ban, HIV risk behavior and other related COVID-19 outcomes.

How is MWP linked to the Zambian local government (or any other Sub-Saharan African Government)? And how long have they done so? may you please give us examples. Are your programs linked to policy change in any way? If so, how.

Since Dr. Michalopoulos began her work in Zambia, she has worked closely with the local government. Throughout years of conducting formative research among truck drivers and fisherfolk, Dr. Michalopoulos has built relationships with the Ministry of Health, Ministry of Community Development and Maternal and Child Health as well as the Ministry of Transport and Ministry of Chiefs. MWP has had a long-term relationship with the former Chief Mental Health Officer, late John Mayeya and is currently working with the current Chief Mental Health Officer. MWP believes firmly in working collaboratively with the Zambian government so that information can be shared and effective programming can be integrated into policy. We recognize and firmly believe that MWP cannot, and should not, work in a silo. We have developed strong relationships with other NGOs, UN organizations, universities, and most importantly with trusted local leaders of the populations we work with in Zambia so that we may collectively inform sustainable change.

Why is MWPs objective focused on truck drivers and fish traders?

To date, we have primarily worked with labor migrants in Zambia (i.e. long distance truckers and fisherfolk). Our work with truckers and fisherfolk was largely informed by Dr.Michalopoulos’ mentor at Columbia University, Dr. Nabila El-Bassel, who conducted research aiming to understand risk factors for HIV among labor migrants in Central Asia. Dr. Michalopoulos was interested in this area of research as it applies to migrants in Zambia after having conducted other research projects there. In addition, Dr. Michalopoulos was most interested in the relationship between mental health and HIV risk. Working with truck drivers and fisherfolk was largely based on preliminary discussions with partners on the ground who knew these groups to be at high risk for HIV and trauma exposure. While MWP is dedicated to developing programs to address the health and mental health needs of truckers and fisherfolk, we are also keen to expand in time to other migrant populations (both forced migrants and other labor migrants).

What are some of your future research priorities? Which types of organizations are/would you consider partnering with for this work?

We are particularly excited to work with both governmental and non-governmental organizations that can provide services that align with, but may be outside of, the MWP wheelhouse. As such, we will then be able to partner to further provide services to help improve the well-being of migrant populations in Africa. We have had discussions with organizations to conduct a mapping exercise of the health and mental health services along a fish trader route in order to provide feedback to the government on the current state of available services. We also hope to expand our priorities to address the health and mental health needs of other populations such as cross-border traders, girls who are trafficked, refugees and asylum seekers. We’re willing to explore opportunities to partner with organizations that may focus on areas outside of our area of expertise if their overall goals are in line with our mission.

Family throwing out fishing net

What was your inspiration behind creating the Moving Well?

MWP was formed based on many years of formative research among truckers and fisherfolk in Zambia. When Dr. Michalopoulos decided to transition from academia and pursue a professional opportunity at USAID, she did not want to let go of her commitment to developing programs to address the health and mental health needs of truckers and fisherfolk in Zambia. In addition, she had built strong relationships with both governmental and non-governmental organizations in Zambia that remain important to maintain in order to make a sustainable impact on vulnerable communities throughout Africa.

How difficult is it to deal with the trauma of the individuals you are standing for? What do you do to help manage the potential vicarious trauma?

A part of our mission is to build the capacity of local clinicians and other support staff. Clinical skill-development is not only based on strengthening techniques to address mental health problems, but on learning how to take care of oneself as a clinician who may be holding painful emotions and feelings for the client. As such, we believe that intentional self-care and strong, supportive supervision is critical in doing this work.

How can/will the work you are doing in Zambia be applied to other regions of the world?

We believe that our approach can be applied to multiple contexts in various regions throughout the world. At the same time, we believe that doing this work with a decolonization lens is crucial and requires taking the time to build relationships with community members and stakeholders in order to truly understand the needs of the population as well as their ideas for sustainable solutions. With that in mind, MWP hopes to serve communities in other regions, but we believe that the necessary steps to do this will take time.

In relation to the above mentioned, what other countries is MWP currently working in?

To date, we have primarily focused on working with fisherfolk in Zambia. We have also worked with long distance truckers from Zambia, Zimbabwe, The DRC, and Tanzania. We have relationships with organizations in South Africa, Malawi and Zimbabwe and are hopeful to expand.

How has your work been impacted by the pandemic?

We had just developed our website and were just getting our program off the ground when everything shut down. It was initially so disheartening to think we would not be able to work with the various communities in Africa in the way we had envisioned. But then we put our heads together and thought about the potential impact of the pandemic on the populations we work with in Zambia. We used that as an opportunity to share the aims of MWP with our friends, family and colleagues while at the same time running a small fundraising campaign to provide COVID-related health prevention packages to fish traders in Lusaka. We successfully raised enough funds to provide these packages and conduct a brief survey on the impact of COVID-19 on over 100 fish traders!

Does the work of MWP benefit the United States?

Our model can be applied to migrant populations within the US. Further, through our work with migrant populations in Africa we can build the knowledge-base of our understanding of health and mental health problems as they relate to mobile populations globally.