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Developing a culturally appropriate mental health care service for Samoa

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    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 4530Fax: +61 2 9382 8208Email:

    Received 9 January 2011

    Accepted 9 April 2012


    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.

    BackgroundSamoa 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 Ministrys 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 violencewere 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 maiSamoa, mai 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_bannerOf cial journal of thePaci 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 hosts 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 clients 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 familys 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 clients 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 ofclinica