An exploratory study assessing psychological distress of indigents in Burkina Faso: a step forward in understanding mental health needs in West Africa

The World Health Organization defines mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” [1]. Promoting mental health is increasingly becoming a global public health issue, partly because a large number of people worldwide are unable to live in a healthy mental state. Indeed, it is estimated that mental and substance disorders represent the fifth leading cause of global disability-adjusted life years (7.4%), and the leading cause of years lost due to disability (22.9%) [2]. Furthermore, in some low and middle-income countries, between 70% and 90% of mentally ill individuals have no access to care [3]. Addressing this gap in access to services and providing adequate treatment to individuals suffering from mental health disorders in resource-limited settings have recently been recognized as global health priorities [4].

The literature on social determinants of health indicates that living in chronic poverty is associated with a higher risk of developing various psychopathologies [5–7]. Evidence suggests that some indicators of poverty (i.e., poor or inexistent access to education, food insecurity, and living in an unstable environment) are linked to the risk of developing common mental disorders across settings, while other indicators show inconsistent results, partly because they are highly dependent on social, political, and cultural contexts [8, 9, 10]. The lack of empirical studies on mental health in low-income countries limits the current understanding of the mechanisms underlying the relationships between poverty, poor living conditions, and mental health outcomes in specific contexts.

For the current study we focused on Burkina Faso, one of the poorest countries in the world, with 73% of the population living in rural settings where food security and access to water, electricity, schooling, and healthcare - including mental health care - are reduced [11]. Rural communities depend largely on agriculture and farming to meet their needs [12]. In these areas, traditional gender roles prevail, with women constituting a socio-economically vulnerable group, particularly the elderly or widowed [13].

It is estimated that 40.1% of Burkina Faso’s population lives below the national poverty line [14] and that around 9% of the population lives below the extreme poverty line (annual income of less than 100 US$) and are identified as indigents [15, 16]. In the past decade, indigents have been identified in rural Burkina Faso through a community-based approach [17–19] in which various health professionals and community authorities were interviewed to choose criteria for an indigent selection process. Poor mental health and the presence of psychopathologies were unanimously recognized as being important indicators of vulnerability for indigence [20]. Despite this community insight, no previous empirical studies in West Africa have investigated mental health indicators among indigents [21], even though they are a group with specific health needs and less access to health care than the general population [18, 22, 23].

Besides the absence of evidence on indigents’ mental health, little is known about psychological distress in Burkina Faso. Only a few studies have been conducted in the capital city among clinical populations affected by various conditions such as HIV [24], dementia [25], depressive disorders [26–29], and transitory psychotic disorders [30]. These studies inform on the prevalence of specific conditions but provide little information on the development of pathologies and the influence of poverty and living conditions on psychological distress.

As Ouédraogo and colleagues [31] have pointed out, people seeking help from psychiatric facilities are those for whom traditional medicine has not worked and who have developed a chronic or recurrent condition (transitory psychotic disorder, schizophrenia, or major depressive disorder). They are thus not representative of the overall mental health needs of the general population, who are more likely to consult traditional healers due to greater compatibility with their beliefs [32]. Not only does the modern medical system not correspond to local conceptions of mental illness, but services also remain poorly accessible outside of urban settings [33].

We found only two studies conducted in Burkina Faso with a focus on a non-clinical sub-population. Both highlight that poverty and poor living conditions are linked to the risk of experiencing psychological distress. The qualitative study by Nanama and Frongillo [34] conducted in a rural area in the north of the country showed how food insecurity could be related to a high level of psychological distress and to certain anxious, depressive, and somatic symptoms. The study by Duthé and colleagues [35], conducted in the peripheral neighbourhoods of Ouagadougou, found that chronic illnesses or handicaps, extreme poverty, and food insecurity predicted the risk of developing a depressive disorder among their participants.

This exploratory study was a first attempt to document the mental health profile of the poorest in rural Burkina Faso, a very vulnerable sub-population likely to experience mental health distress. Indeed, our participants reported a high proportion of anxious and depressive symptoms, with 40.2% having experienced 10 symptoms or more in the past month. Given that there is no validated tool for the context with a predetermined clinical cut-off, we decided that reporting 10 out of a total of 14 symptoms was an indicator of psychopathology, an assumption that would need to be investigated in future studies.

Our results yielded higher proportions than did previous studies conducted in Burkina Faso. For instance, in their recent study on the prevalence of major depressive episodes in populations living in poor neighbourhoods nearby Ouagadougou, Duthé and colleagues [35] found that 9.0% of their sample (n = 2187) reported feeling depressed, sad, or empty, and 7.2% reported having lost interest or pleasure in doing things they usually enjoyed during the past two weeks. While it may not be surprising that people living in extreme poverty conditions in rural settings would report more symptoms than the general population, our results are still alarmingly high. Furthermore, when compared to data from the World Health Survey [39], participants in our sample reported worse perceived general health status, and greater levels of insomnia, sadness, and worries, both in the general population and in the poorest quintile.

Predictors of psychological distress in our study included being a single woman, being illiterate, being elderly, having a poor to average perceived health status, having no income, and having begged for food in the past month. This result is consistent with previous findings in Burkina Faso. In qualitative studies, Roth [40, 41] noted that elders in an urban setting are particularly vulnerable to isolation because of the intergenerational contract that puts the burden of the care of elders on children’s shoulders; our results showed this also seemed to apply in rural settings. Given difficult living conditions and rapid social changes, it appears elders are becoming more numerous and more dependent on their children, who unfortunately are often unable to take care of their aging parents [42]. Other studies in Burkina Faso have identified elders as a population incurring several risks, such as not having their basic needs fulfilled [43], being vulnerable and needing particular help and support [13, 22], experiencing psychological distress and depressive symptoms [43], and being marginalized due to their increasing psychological distress and diminished functioning, which can be related to shame for family members [44].

In her studies, Roth [40, 41] also pointed out that getting older is experienced differently by men and women in traditional settings because they do not carry the same roles and expectations from their entourage, which could lead to different levels of psychological distress. Our results confirmed this observation, as not only were the indigent individuals, as identified by the community-based approach, mainly women (67%), but these women were also more prone to report a high level of distress as compared to men, making them a vulnerable sub-group among the most vulnerable.

Similarly, lack of income and experiencing difficulty accessing food has been reported by Duthé and colleagues [35] as significantly associated with depressive symptoms in Ouagadougou. Nanama and Frongillo [34] found, in a rural setting in Burkina Faso, that food insecurity was an important vulnerability factor associated with anxious, depressive, and somatic symptoms. Duthé and colleagues also found that poor health status predicted the risk of developing depressive symptoms [35], and a qualitative study conducted with indigents and their relatives showed that poor health status was an indicator of extreme vulnerability, even among the least poor households identified as worst-off in rural settings [22].

A large proportion (25.5%) of our respondents reported at least one psychotic symptom, and 65.5% reported having had these symptoms for many years. It is important, however, to point out that the high proportion of psychotic symptoms must be interpreted with caution and within a culturally sensitive framework. The way individuals express distress varies across cultures [45, 46], rendering irrelevant the use of tools or concepts developed in the West to understand mental health needs in a different setting [37, 47, 48]. In fact, many of our respondents refused to answer the questions on psychotic symptoms out of fear of being accused of witchcraft, a socially shared conception of something that, by Western standards, would be considered psychotic/dissociative manifestations [32, 49, 50]. It is thus possible that some individuals did not report these symptoms to avoid stigmatization [51, 52]. It is also possible that other individuals reported psychotic symptoms which are understood by them and their relatives as socially accepted idioms of distress linked to spirit possession [50].

In terms of help-seeking behaviours, our results showed that one-third of respondents who reported any symptom did not seek help or talk to anyone about it. Those who were in poor health, needed to beg for food, and/or had no income were more at risk of not talking to anyone about their symptoms. This may have been because most of our respondents were socially isolated, making it harder for them to seek help. Also, a very small proportion (0.7% for psychotic symptoms and 1.7% for anxious or depressive symptom) did seek help within the formal medical system. Clearly, then, the medical system does not constitute a resource for psychological or mental support for these respondents, while it does for physical health issues. Indeed, between 48.8% and 77.8% of indigents with physical health issues had consulted the modern medical system for curative care [53]. Various factors may explain this discrepancy, including financial barriers, geographical barriers, stigma, lack of mental health literacy, or lack of knowledge about available psychiatric services - factors that are also linked to a lack of trained human resources and to a lack of funding [51, 52, 54–56].

Surprisingly, our respondents also did not appear to have sought the help of traditional healers, who are thought to engage in healing rituals and techniques that fit better with socially shared conceptions of mental health and mental illness [31, 32] than do psychiatric facilities or medical structures. It seems that, in both cases, financial costs and stigma may act as important barriers to care. It is also conceivable that, without these barriers, people experiencing psychotic symptoms would be more inclined to consult a traditional healer due to better compatibility with their beliefs [57]. However, that might not be the case for anxious and depressive symptoms, which might not be understood as “craziness” or spirit possession [32, 49].

In this study, the first to examine mental health outcomes among an indigent population in West Africa, we found that most respondents were reporting psychological distress as well as anxious and depressive symptoms. We consider the absence of help-seeking behaviours directed towards formal or informal resources to be a critical finding, especially since this was also observed among people who had been experiencing psychotic symptoms for many years. Our results highlight the importance of increasing access to mental healthcare in rural areas of the country. We believe future interventions and policies should be adapted to address this vulnerable sub-population, which has specific health needs and is more socially isolated. Services should also be planned according to certain characteristics, such as gender and age, which seem to have a major impact on the way psychological distress is experienced.