‘It’s Safer for Her to Stay at Home’.
In Butajira, a town of 33,000 people in central Ethiopia, researchers from Addis Ababa University found schizophrenia was five times more prevalent in men than women. “Typically it’s closer to 1-to-1, or in some cases it’s 1.2 for males to 1 for females, but to have this stark a contrast of 5-to-1 is really unique,” says MPH student Senait Ghebrehiwet.
To find out why, she and MPH students Tithi Baul and Juliana Restivo joined a qualitative study in Butajira led by Christina Borba, assistant professor of psychiatry at the School of Medicine and director of research for the Department of Psychiatry at Boston Medical Center (BMC). The study was part of a collaborative project between the School of Medicine/BMC Department of Psychiatry and Addis Ababa University.
Analyzing 39 in-depth interviews from patients and community members, the students found a complex interplay of socio-cultural and economic factors.
Marriageability is a factor in hiding a woman’s mental illness, Baul and Ghebrehiwet say, along with the constraints of traditional gender roles and marriage dynamics. “We found mental illness didn’t preclude women from still having to maintain their household responsibilities,” Ghebrehiwet says. The way stigma extended to families, they say, was also affected by the gender of the person with a mental illness.
The ability to go to Butajira’s hospital for mental health care is also affected by gender, they say, both in having money to pay for care and because of women needing to be escorted around town.
Baul says women were also more likely to go to traditional care first because of how limited resources make them more dependent on their families. “We noticed that also delays the process until she shows very explicit schizophrenic symptoms that are not safe for the family or herself,” Baul says, “and then she’s taken to formal medical care.”
Another major factor, they say, is the danger of sexual violence faced by women. Baul says women with symptoms of schizophrenia would sometimes be hidden at home, or even restrained there. “We realized it’s for their own safety. It’s not necessarily that they want to hide the woman because they don’t want her to go out and get treatment, it’s because it’s safer for her to stay home. That was eye-opening.”
Ghebrehiwet and Baul say they found a myriad of other factors tied to diagnosis, from age to religion to the stressors of poverty. Their analysis is ongoing, but they say the final product will inform both research and healthcare in Butajira, and hopefully narrow gender disparities in diagnosis and mental health care.
Another key role of this study, they say, is helping to recognize how diagnostic strategies need to adapt to different cultures. “We don’t know if some of these clinical batteries are appropriate to use in Ethiopia because we’re not sure how they translate,” Baul says.
Ghebrehiwet says issues can be as simple as vocabulary. “The word ‘schizophrenia’ doesn’t exist in Amharic,” the official language of Ethiopia, she says, “so when we were reading transcripts we’d see ‘crazy’ or ‘mad’ or ‘their head is not right’—”
“—‘They’re possessed by evil spirits,’” finishes Baul. “Even ‘depression’ doesn’t mean the same thing in Amharic, so it’s very difficult as physicians to say, ‘Are you depressed?’ If they don’t have the same language, how are you supposed to use the same scales?”
They say these questions will be part of the larger project in Butajira going forward. Meanwhile, Ghebrehiwet and Baul, who both graduate in January, will continue to work as researchers in the Department of Psychiatry at BMC.
For Baul, who worked in a lab researching schizophrenia before coming to SPH, a research trajectory like this was the plan all along. Ghebrehiwet, on the other hand, says she came to SPH thinking research wasn’t for her. “I wanted to be in the community working face-to-face with individuals,” she says. Instead, she was drawn to the project because of her own cultural background. Her parents are from the neighboring country of Eritrea, which she says shares many cultural aspects with Ethiopia. “When we were reading the transcripts and coding the data, there was a lot of cultural nuance to it that I felt like I could pick up on.”
She says the experience has changed the way she thinks about research. “I’ve come to understand my potential role in it, and I’ve also come to understand how I can still be very connected to my cultural community through research,” she says. “I’ve changed my future plans altogether, so I’m grateful for that.”
At BMC, the researchers say they will be working mainly on US-based studies—less of a shift than it may seem. Global health “is a great way of understanding the immigrant population here,” Baul says, pointing to the influences a culture can have on even the descendants of immigrants.
“Because of where we’re located and who BMC serves, it is so relevant to remember that global health work is not just ‘over there’,” Ghebrehiwet says. “Global is local.”