C O U N T R Y R E P O R T

Developing a culturally appropriate mental health care servicefor SamoaMatamua Iokapeta Sina Enoka1 PGDipNursMentH, Aliilelei Tenari1 PGDipNursMentH,Tupou Sili1 PGDipNursMentH, Latama Peteru1 PGDipNursMentH, Pisaina Tago1 PGDipNursMentH &Ilse Blignault2 PhD

1 Mental Health Unit, Samoan National Health Services, Apia, Samoa

2 Black Dog Institute and School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia

Keywordsculture, family nursing, mental health services,Pacific Islands, Samoa

CorrespondenceIlse Blignault PhD, Black Dog Institute, Hospital

Road, Prince of Wales Hospital, Randwick, NSW

2031, Australia.

Tel: +61 2 9382 4530

Fax: +61 2 9382 8208

Email: i.blignault@unsw.edu.au

Received 9 January 2011

Accepted 9 April 2012

DOI:10.1111/j.1758-5872.2012.00201.x

AbstractMental Health Care Services are part of the National Health Services forSamoa. Their function is to provide mental health care services to thepopulation of Samoa, which numbers 180,000 people. However, likemany other countries in the Pacific region, mental health is considered alow priority. The mental health budget allocation barely covers the opera-tion of mental health care services. More broadly, there is a lack of politicalawareness about mental health care services and mental health rarelybecomes an issue of deliberation in the political arena. This article outlinesthe recent development of mental health care services in Samoa, includingthe Mental Health Policy 2006 and Mental Health Act 2007. It tells thestory of the successful integration of aiga (family) as an active partner inthe provision of care, and the development of the Aiga model utilizingSamoan cultural values to promote culturally appropriate family-focusedcommunity mental health care for Samoa. Mental Health Care Servicestoday encompass both clinical and family-focused community mentalhealth care services. The work is largely nurse-led. Much has beenachieved over the past 25 years. Increased recognition by government andincreased resourcing are necessary to meet the future health care needs ofthe Samoan people.

Background

Samoa is a south-sea tropical country consisting of 10islands, four of which are inhabited. The total popu-lation is 180,000 people mostly living on Upolu Islandwhere the capital, Apia, is located. Samoa is classifiedas lower-middle income country (World Health Orga-nization, 2011). The health care system has two com-ponents: the Ministry of Health and the NationalHealth Service (NHS). The Ministry’s role is regula-tory, monitoring and policy development, while theNHS provides health care services to meet the needs ofthe country.

Samoans have a holistic understanding of healthin common with other Pacific peoples (Ministry ofHealth, 2008). Physical, mental, social and spiritualhealth are considered indivisible (Tamasese et al.,2005; Hope and Enoka, 2009). Mental wellbeing is

grounded in the aiga (family) and community (Gov-ernment of Samoa, 2006).

History of mental health care

In the early days, people with “madness and violence”were housed in prison. They were judged by theirrudeness, loud antisocial behavior and filthy obsceni-ties. Treatment was mainly custodial, psychotropicmedications were rare and families never visited. Thefamilies believed that they suffered a form of ma’iSamoa, ma’i aitu (demoniac illness) and required treat-ment with traditional medicines made from concoc-tions of leaves and earth for relief and recovery.

Common psychotropic drugs became available inthe 70s, initially antianxiety drugs and later chlorpro-mazine. In 1970, a new ward for people with mental

bs_bs_banner

Offi cial journal of thePacifi c Rim College of Psychiatrists

Asia-Pacific Psychiatry ISSN 1758-5864

1Copyright © 2012 Blackwell Publishing Asia Pty Ltd

disorders was built. The location was highly inappro-priate as it stood on top of the valley behind the mainhospital and posed a risk for patients and staff. Thisindicated the thinking about care for people withmental disorders: families were fearful and neglectfulof their relatives while the government did not recog-nize these citizens and accorded a very low priority totheir health care needs. There were no trained mentalhealth care workers to provide professional care.Accommodated in this small, isolated building formany years, the patients were both stigmatized andinstitutionalized.

Time for change

In the mid-1980s, a new way of thinking emerged; areminder that one worked yesterday (past) for today(now) and today for tomorrow (future) encouraged areturn to the roots. Questions were asked: “Why thereare so many people clustered in this most inappropri-ate place, living like untrained animals without familysupport and visitation?” “What is happening to thetraditional Samoan family roles (nafa o aiga)?” “Whereare the values of the Samoan culture which gives thecountry the most treasured hospitable warmth andfriendly people?” These questions guided major inno-vation, using the Samoan culture as it is rooted in theaiga as the focus of mental health care delivery.

The aiga: A partnership model of mentalhealth care

The final model was informed by qualitative researchundertaken by the first author (Enoka, 2001) whomade home visits to the families of all 26 patients inthe mental ward. The number of people in each familyvaried from six to 10, mostly head of family (matai),wife (faletua or tausi) and siblings (tamaiti) or extendedfamily members. Duration of the visits varied, depend-ing on the length of deliberations and the familyresponse to the discussions. The strength of Samoanculture was reflected in the use complimentary greet-ings and other cultural etiquette and protocols. Thelanguage spoken inspired compassion and respect andallowed the family to express their feelings and sharetheir honest thoughts about their institutionalizedrelative and the aiga conference outcome.

Drawing on the research findings, Aiga – A Part-nership in Care through Continuous Collaborationwas established and implemented as the community-

based and family-focused model of mental health careservice delivery for Samoa. The Aiga model works inthree phases. Phase 1 includes the cultural approachbetween the mental health nurse and the family:entering the home; shaking hands; and taking a seatand listening to the host’s greetings, usually the headof the family at this point. This phase will take time asit involves getting to know the family and trying tounderstand their thinking, attitudes and actionstowards their sick relative and the total familyresponse towards accepting the person. The nurseexplains the client’s illness and his or her behavior andthe treatment involved, and counsels the familytowards collaborating with the client in his or hertreatment. The nurse also collaborates with the clientin obtaining ongoing support from and for the family;whatever assistance they require. Listening is the mostsignificant aspect at this phase as it allows the nurse toempathize with the family and the client.

Phase 2 includes “storytelling”. The family tellstheir story in their own words and the nurse allowstheir expressions of the story to become a reality. Thenurse listens attentively to the context of the story andpays close attention to the full story, developing anunderstanding of the family’s beliefs and values andtheir preference for treatment modalities. Some fami-lies will go to great lengths in telling their story andcan be quite exhausting; the nurse continues toencourage them to get to the crux of the issues. Thestory is then analyzed and put into clear perspective sothat the family is able to recognize their worth incontributing to the client’s mental health care andtreatment, and to help them understand their ownperspectives on mental health care.

Phase 3 allows the family to take the lead indetermining what could be the problem and what todo about it. They can identify and help look for treat-ment that they think is appropriate or they can referthem to the Mental Health Unit for further assess-ment. The family is comfortable in taking care of theirrelative and is concerned about their mental health.Family members have a practical understanding of themental disorder, diagnosis and treatment and are sup-portive of the sick person. The nurse in her role ofwealth maker (faioa), that is health as the best wealth,continues to support the family and provide necessarytreatment for the client.

According to the Samoa Nurses Association (citedin Hope and Enoka, 2009) the move from institutionalto community-based care has brought about manybenefits. These include better recovery due to earlyimproved communication between the family andnurses, greater medication compliance, more tailored

Mental health care service for Samoa M.I.S. Enoka et al.

2 Copyright © 2012 Blackwell Publishing Asia Pty Ltd

treatment, and less disruption to interpersonal rela-tionships and regular activities. This approach alsomaintains the dignity and human rights of people withmental disorders.

Mental health workforce, organizationand financing

In order to provide specialized staff for the new modelof care, mental health and mental illness studies wereintroduced into the undergraduate nursing program atthe National University of Samoa in 1993. Commu-nity nurses in the field received three weeks in-servicetraining in mental health in 1998/99. A PostgraduateDiploma of Nursing in Mental Health was run once in2004. There were six graduates, three of whom arenow working in the Mental Health Unit, which islocated in the Ministry of Health compound that alsoincludes the Tupua Tamasese Meaole Hospital.

Mental Health Unit staff are accountable to theManager of Clinical Health Services for the delivery ofclinical services and to the Manager of Nursing andIntegrated Community Health Services for nursing-related matters. While the Unit is headed by a part-time psychiatrist most of the work is nurse-led. Theposition of Chief Mental Health Officer (not restrictedto a doctor) is filled by the psychiatrist or by one of thenurses if he/she is out of country.

Mental Health Care Services have both a clinicalcomponent (including holistic assessment, manage-ment, security, seclusion and rehabilitation) and afamily-focused community component. The MentalHealth Act 2007 incorporates two types of treatmentorder: an Inpatient Treatment Order and a Commu-nity Treatment Order. Whichever is executed dependson the mental status examination of the client andtheir general behavior. The Mental Health Unit alsoreceives voluntary admissions and provides outpatienttreatment.

After discharge, patients are followed up daily forthe first week, then fortnightly, then monthly. Thosewho live far away are followed up by the local com-munity nurse who reports back to the Mental HealthUnit. The mental health nurses visit all islands on aquarterly basis. In the villages, community nurses arethe first point of contact for patients and their families.If a person shows signs of mental illness, advice issought by phone from the Mental Health Unit. Diffi-cult and violent patients are taken to the MentalHealth Unit or the prison where the mental healthnurses providing a visiting service. Disagreementsbetween the family and nurses about management are

resolved by discussion and negotiation. The familyplays a major role in rehabilitation, encouraging theirrecovering relative in activities of daily living, employ-ment and education.

A National Mental Health Policy was officiallyapproved in June 2006, following consultation withkey stakeholders and the general public. It envisions“a multi-sectoral approach which provides qualitycare that is accessible to all people” (Government ofSamoa, 2006, p. 3). However, the budget allocation formental health barely covers operation of the existinglimited government services.

Conclusion

Over the past 25 years, Samoa has moved away froma standalone mental institution to a system wherefamilies and nurses share responsibility for the careand treatment of people with mental disorders in thecommunity. Despite shortages in the professionalmental health workforce, funding limitations, poorfacilities and a lack of political awareness, a great dealhas been achieved. Increased recognition by govern-ment and increased resourcing are necessary to meetthe health care needs of the Samoan people in thefuture.

Importantly, the transformation in mental healthpractice described has been informed by local researchand, in involving family, builds on the strengths of theSamoan culture. Similar culturally based approachesto mental health research and service developmenthave been effective with Maori and Samoan commu-nities in New Zealand (Tamasese et al., 2005; McClin-tock et al., 2012). This way of working may haverelevance for other Pacific Island and Indigenouspeoples.

Acknowledgments

This paper formed the basis of a presentation to the 15thWorld Congress of Psychiatry in Buenos Aires, Argentina,18–22 September 2011. We acknowledge the support ofthe Black Dog Institute. We also acknowledge the contri-butions of Dr Ian Parkin to the achievements describedabove, including discussions about the new mentalhealth policy and act and ongoing staff development.

References

Enoka M.I. (2001) Weaving mental health care inSamoa (O la’u tala). Pac Health Dialogue. 8(1),238–239.

M.I.S. Enoka et al. Mental health care service for Samoa

3Copyright © 2012 Blackwell Publishing Asia Pty Ltd

Government of Samoa (2006) Samoa Mental HealthPolicy. Apia, Samoa.

Hope E.F., Enoka M.I. (2009) Youth and Mental Healthin Samoa: A Situational Analysis. Foundation of thePeoples of the South Pacific International, Suva, Fiji.

McClintock K., Mellsop G., Moeke-Maxwell T., MerryS. (2012) Powhiri process in mental health research.Int J Soc Psychiatry. 58(1), 96–97.

Ministry of Health (2008) Pacific Peoples and MentalHealth: A Paper for the Pacific Health and DisabilityAction Plan Review. Wellington, New Zealand.

Tamasese K., Peteru C., Waldegrave C., Bush A. (2005)Ole taeao afua, the new morning: a qualitativeinvestigation into Samoan perspectives on mentalhealth and culturally appropriate services. Aust NZ JPsychiatry. 39(4), 300–309.

World Health Organization (2011) Mental Health Atlas2011. World Health Organization, Geneva.

Mental health care service for Samoa M.I.S. Enoka et al.

4 Copyright © 2012 Blackwell Publishing Asia Pty Ltd