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A Community-Based Mental Health Intervention: Promoting Mental Health Services in Rwanda

  • Donatilla Mukamana
  • Lisa Lopez LeversEmail author
  • Kenya Johns
  • Darius Gishoma
  • Yvonne Kayiteshonga
  • Achour Ait Mohand
Living reference work entry

Abstract

The major purpose of this chapter is to identify and describe community-based mental health interventions in Rwanda and to illuminate their evolution and current function in preventing and treating mental health problems, while promoting healing and restorative mental health practices, especially in light of the 1994 Genocide. The chapter provides an introduction to health and mental health care in Rwanda along with offering historical and contextual perspectives of mental health services there, including discussions of Indigenous and Western medical approaches. The genocide is addressed by discussing its psychosocial implications and the emergence of trauma- and genocide-related mental health problems. Issues pertaining to the aftermath of the genocide are explicated as they relate to the following contemporary areas: the lived experiences of survivors; the increase in psychosocial, psychiatric, and substance abuse problems; and the special needs and concerns of women. The final section of the chapter details the emergence of post-genocide mental health responses, delineating the following distinct eras: the period immediately following the genocide, 1994–1997, and the assistance of international NGOs; the first decade post-genocide, during which mental health care services were reestablished, continued developing, and were integrated into the larger health care sector; the second decade after the genocide, in which community-based mental health interventions flourished; and the growing recognition of the need for specialized services and genocide-specific psychotherapeutic responses, as well as for establishing sufficient education and training for local mental health professionals. The chapter concludes with a recap of major points, emphasizing lessons learned and progress made.

References

  1. Abbott P, Rwirahira J. Millennium development goals: Rwanda country report. Kigali: United Nations Development Programme; 2010.Google Scholar
  2. Banyanga Jd’A, Björkqvist K, Österman K. Trauma inflicted by genocide: experiences of the Rwandan diaspora in Finland. Cogent Psychol. 2017;4(1):1–12. Retrieved from https://www.tandfonline.com/doi/pdf/10.1080/23311908.2017.1333244?needAccess=true
  3. Baro F. Mental health care for all. World Health. 1990 March, p. 26–7.Google Scholar
  4. Boris NW, Brown LA, Thurman TR, Rice JC, Snider LM, Ntaganira J, Nyirazinyoye LN. Depressive symptoms in youth heads of household in Rwanda: correlates and implications for intervention. Arch Pediatr Adolesc Med. 2008;162(9):836–43.PubMedCrossRefGoogle Scholar
  5. Bryant-Davis T, Ullman SE, Tsong Y, Tillman S, Smith K. Struggling to survive: sexual assault, poverty, and mental health outcomes of African American women. Am J Orthopsychiatry. 2010;80(1):61–70.  https://doi.org/10.1111/j.1939-0025.2010.01007.x.PubMedCrossRefGoogle Scholar
  6. Bryant-Davis T, Ullman SE, Tsong Y, Gobin R. Surviving the storm: the role of social support and religious coping in sexual assault recovery of African American women. Violence Against Women. 2011;17(12): 1601–18.  https://doi.org/10.1177/1077801211436138.PubMedCrossRefGoogle Scholar
  7. Budeli M, Vambe B. The Rwandan genocide: A legal analysis. African Identities, 2010;8(4):409–424.CrossRefGoogle Scholar
  8. Byanafashe D, Rutayisire P. History of Rwanda: from the beginning to the end of the twentieth century. Kigali: National Unity and Reconciliation Commission Under the supervision of National Unity and Reconciliation Commission; 2016. Retrieved from http://www.nurc.gov.rw/index.php?id=70&no_cache=1&tx_drblob_pi1%5BdownloadUid%5D=86
  9. Clifford C, Slavery SM. Rape as a weapon of war and it’s long-term effects on victims and society. In 7th Global conference violence and the contexts of hostility. 2008, May. Retrieved from https://www.peacewomen.org/sites/default/files/vaw_rapeasaweaponofwar_stopmodernslavery_may2008_0.pdf
  10. Cohen MH, Fabri M, Cai X, Shi Q, Hoover DR, Binagwaho A, Culhane MA, Mukanyonga H, Karegeya DK, Anastos K. Prevalence and predictors of posttraumatic stress disorder and depression in HIV-infected and at-risk Rwandan women. J Women’s Health. 2009;18(11):1783–91.CrossRefGoogle Scholar
  11. Condo J, Mugeni C, Naughton B, Hall K, Tuazon MA, Omwega A, Nwaigwe F, Drobac P, Hyder Z, Ngabo F, Binagwaho A. Rwanda’s evolving community health worker system: a qualitative assessment of client and provider perspectives. Hum Resour Health. 2014. Retrieved from https://human-resources-health.biomedcentral.com/track/pdf/10.1186/1478-4491-12-71
  12. Cooper-Knock SJ. Gender, politics, and parliament in Rwanda. openDemocracy: free thinking for the world. 2016, 26 February. Retrieved from https://www.opendemocracy.net/westminster/sarah-jane-cooper-knock/gender-politics-and-parliament-in-rwanda
  13. Finnoff CR. Gendered vulnerabilities after genocide: three essays on post-conflict Rwanda. Open Access Dissertations. 277. 2010. https://scholarworks.umass.edu/open_access_dissertations/277
  14. Freedman SW, Weinstein HM, Longman T. The teaching of history of Rwanda: a participatory approach. Berkeley: Human Rights Center, University of California, Berkeley; 2006. Retrieved from https://www.law.berkeley.edu/files/HRC/Rwanda_resource_book_for_teachers_version_10._rwandan_history_book.pdf
  15. Freedman SW, Weinstein HM, Murphy KL, Longman T. Teaching history after identity-based conflicts: the Rwanda experience. Comp Educ Rev. 2008;52(4): 663–90.CrossRefGoogle Scholar
  16. Freedman SW, Weinstein HM, Murphy KL, Longman T. Teaching history in post-genocide Rwanda. In: Straus S, Waldorf L, editors. Remaking Rwanda: state building and human rights after mass violence. Madison: The University of Wisconsin Press; 2011. p. 297–315.Google Scholar
  17. Galtung J. Violence, peace, and peace research. J Peace Res. 1969;6(3):167–91.CrossRefGoogle Scholar
  18. Gatarayiha F, Baro F, Wagenfeld MO, Stockman R. The development of mental health services in sub-Saharan Africa: the case of Rwanda. J Sociol Soc Welf. 1991; 18:25.Google Scholar
  19. Green LL. Sexual violence and genocide against Tutsi women. 2002. Retrieved from http://academic.udayton.edu/race/06hrights/georegions/africa/Rwanda01.htm
  20. Heim L, Schaal S. Rates and predictors of mental stress in Rwanda: Investigating the impact of gender, persecution,readiness to reconcile and religiosity via a structural equation model. International Journal of Mental Health Systems. 2014;8(37). Retrieved from https://www.researchgate.net/publication/274452019_Rates_and_predictors_of_mental_stress_in_Rwanda_Investigating_the_impact_of_gender_persecution_readiness_to_reconcile_and_religiosity_via_a_structural_equation_model
  21. Hilhorst D, Van Leeuwen M. Emergency and development: the case of Imidugudu, villagization in Rwanda. J Refug Stud. 2000;13(3):264–80.CrossRefGoogle Scholar
  22. Human Rights Watch. Shattered lives. 1996. Retrieved from https://www.hrw.org/reports/1996/Rwanda.htm
  23. Ilibagiza I. Left to tell: discovering God amidst the Rwandan holocaust. New York: Hay House, Inc.; 2006/2014.Google Scholar
  24. Jones A. Gender and genocide in Rwanda. J Genocide Res. 2002;4(1):65–94.CrossRefGoogle Scholar
  25. Kalra N. Burden of disease data help to illuminate new policy priorities in Rwanda. Institute for Health Metrics and Evaluation; 2018. Retrieved from http://www.healthdata.org/acting-data/burden-disease-data-help-illuminate-new-policy-priorities-rwanda
  26. Kantengwa O. How motherhood triumphs over trauma among mothers with children from genocidal rape in Rwanda. J Soc Polit Psychol. 2014;2(1).  https://doi.org/10.5964/jspp.v2i1.334. Retrieved from https://jspp.psychopen.eu/article/view/334/htmlCrossRefGoogle Scholar
  27. Kanyangara P, Rimé B, Philippot P, Yzerbyt V. Collective rituals, emotional climate and intergroup perception: participation in “Gacaca” tribunals and assimilation of the Rwandan genocide. J Soc Issues. 2007;63(2): 387–403. Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.379.9995&rep=rep1&type=pdf
  28. Kanyoni M, Gishoma D, Ndahindwa V. Prevalence of psychoactive substance use among youth in Rwanda. BMC Res Notes. 2015;8(1):190.PubMedPubMedCentralCrossRefGoogle Scholar
  29. Karangwa C. Validating traditional knowledge: Rwanda. In: Examples of the development of pharmaceutical products from medicinal plants, vol. 10. n.d. p. 127–34. Retrieved from http://tcdc2.undp.org/GSSDAcademy/SIE/Docs/Vol10/V10_S3_ValidKnowledge.pdf
  30. Keienburg S, Masakarasi G. Sexualised violence: opting for life [Online]. 2012. Retrieved from https://www.dandc.eu/en/article/sevota-supporting-children-rape-and-their-mothers-18-years-after-rwandas-genocide
  31. Kolassa I-T, Ertl V, Eckart C, Glöckner F, Kolassa S, Papassotiropoulos A, de Quervain, DJ-F, Elbert T. Association study of trauma load and SLC6A4 promoter polymorphism in posttraumatic stress disorder: evidence from survivors of the Rwandan genocide. J Clin Psychiatry. 2010;71:543–7. Retrieved from http://kops.uni-konstanz.de/bitstream/handle/123456789/13420/Kolassa_etal_2010-2.pdf?sequence=1&isAllowed=y
  32. Levers LL. Samples of indigenous healing: the path of good medicine. Int J Disabil Dev Educ. 2006a;53: 479–88.CrossRefGoogle Scholar
  33. Levers LL. Traditional healing as indigenous knowledge: its relevance to HIV/AIDS in southern Africa and the implications for counselors. J Psychol Afr. 2006b; 16(1):87–100.CrossRefGoogle Scholar
  34. Levers LL. Introduction to understanding trauma. In: Levers LL, editor. Counseling survivors of trauma: theories and interventions. New York: Springer; 2012.CrossRefGoogle Scholar
  35. Levers LL, Maki DR. African indigenous healing, cosmology, and existential implications: toward a philosophy of ethnorehabilitation. Rehabil Educ. 1995;9(2): 127–45.Google Scholar
  36. Levers LL, Kamanzi D, Mukamana D, Pells K, Bhusumane DB. Addressing urgent community mental health needs in Rwanda: culturally sensitive training interventions. J Psychol Afr. 2006;16(2):261–72.CrossRefGoogle Scholar
  37. Levers LL, Radomsky L, Shefer T. Voices of African traditional healers: cultural context and implications for the practice of counselling in sub-Saharan Africa. J Psychol Afr. 2009;19(4):497–502.CrossRefGoogle Scholar
  38. Lorch D. Ndera Journal; Minds in retreat from the madness of Rwanda. NY Times. 1994, 7 November. Retrieved from https://www.nytimes.com/1994/11/07/world/ndera-journal-minds-in-retreat-from-the-madness-of-rwanda.html
  39. Mamdani M. When victims become killers. Princeton: Princeton University Press; 2001.CrossRefGoogle Scholar
  40. Ministry of Health, Republic of Rwanda. Health sector policy. 2005. Retrieved from https://www.uhc2030.org/fileadmin/uploads/ihp/Documents/Country_Pages/Rwanda/HealthSectorPolicy.pdf
  41. Ministry of Health, Republic of Rwanda. National mental health policy in Rwanda. 2010. Retrieved from http://www.moh.gov.rw/fileadmin/templates/Docs/Posted-National-Mental-health-Policy-1.pdf
  42. Ministry of Health, Republic of Rwanda. Health sector policy. 2015a. Retrieved from http://www.moh.gov.rw/fileadmin/templates/policies/Health_Sector_Policy___19th_January_2015.pdf
  43. Ministry of Health, Republic of Rwanda. Third strategic plan: July 2012–June 2018 (MTR, HSSP3). 2015b. Retrieved from http://www.moh.gov.rw/fileadmin/templates/Docs/HSSP_III_FINAL_VERSION.pdf
  44. Ministry of Local Government (MINALOC), Republic of Rwanda. Decentralization implementation plan (DIP) 2011–2015. Kigali: Author; 2011. Retrieved from http://minaloc.gov.rw/fileadmin/documents/Minaloc_Documents/DIP_3rd_Phase_Draft_14.3.11_final_version.pdf
  45. Mujawayo E, Belhaddad S. Survivantes: Rwanda – Histoire d’un génocide. La Tour d’Aigues: Editions de l’Aube; 2004.Google Scholar
  46. Mujawayo E, Belhaddad S, Veil S. Survivantes: Rwanda, dix ans après le génocide. La Tour d’Aigues: Aube; 2004.Google Scholar
  47. Mukamana D, Brysiewicz P. The lived experience of genocide rape survivors in Rwanda. J Nurs Scholarsh. 2008;40(4):379–84.PubMedCrossRefGoogle Scholar
  48. Mukamana D, Collins A, Rosa WE. Genocide rape trauma: a conceptual framework for understanding the psychological suffering of Rwandan survivors. Res Theory Nurs Pract. 2018;32(2):125–43.PubMedCrossRefGoogle Scholar
  49. Munyandamutsa N, Nkubamugisha PM, Gex-Fabry M, Eytan A. Mental and physical health in Rwanda 14 years after the genocide. Soc Psychiatry Psychiatr Epidemiol. 2012;47(11):1753–61.PubMedCrossRefGoogle Scholar
  50. Mushimijimana D. Rwanda: traditional medicine to be regulated better. Rwanda Focus. 2016, 15 May. Retrieved from https://allafrica.com/stories/201605160646.html
  51. National Institute of Statistics of Rwanda (NISR). Size of the resident population. 2018. Retrieved from http://www.statistics.gov.rw/publication/size-resident-population
  52. National Institute of Statistics of Rwanda (NISR) [Rwanda], Ministry of Health (MOH) [Rwanda], & ICF International. Rwanda demographic and health survey (RDHS) 2014–15 key findings. Rockville: NISR, MOH, and ICF International; 2015. Retrieved from https://www.dhsprogram.com/pubs/pdf/SR229/SR229.pdf
  53. Nations Encyclopedia. Rwanda. 2018. Retrieved from https://www.nationsencyclopedia.com/economies/Africa/Rwanda.html
  54. Nyirandagijimana B, Edwards JK, Venables E, Ali E, Rusangwa C, Mukasakindi H, Borg R, Fabien M Tharcisse M, Nshimyiryo A, Park PH, Raviola GH, Smith SL. Closing the gap: decentralising mental health care to primary care centres in one rural district of Rwanda. Public Health Action. 2017;7(3):231–6. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5676999/pdf/i2220-8372-7-3-231.pdfPubMedPubMedCentralCrossRefGoogle Scholar
  55. Panda P, Agarwal B. Marital violence, human development and women’s property status in India. World Dev. 2005;33(5):823–50.CrossRefGoogle Scholar
  56. Prunier G, editor. The Rwanda crisis 1959–1994: history of a genocide. London: Hurst Publishers; 1995.Google Scholar
  57. Reid-Cunningham AR. Rape as a weapon of genocide. Genocide Stud Prev Int J. 2008;3(3):article 4. Retrieved from https://scholarcommons.usf.edu/cgi/viewcontent.cgi?article=1160&context=gsp
  58. Rugege S. Women and poverty in Rwanda: the respective roles of courts and policy. Paper no. 1. Oxford: Oxford Human Rights Hub; 2015.Google Scholar
  59. Rugema L, Mogren I, Ntaganira J, Krantz G. Traumatic episodes and mental health effects in young men and women in Rwanda, 17 years after the genocide. BMJ Open. 2015;5(6):e006778. Retrieved from https://bmjopen.bmj.com/content/5/6/e006778.longPubMedPubMedCentralCrossRefGoogle Scholar
  60. Rwanda Biomedical Center, Ministry of Health. Mental health statistics 2008–2013. Mental Health Division. Kigali: Author; 2014.Google Scholar
  61. Rwanda Biomedical Center, Ministry of Health. Addressing mental health challenges in Rwanda. Outlook. 2018, p. 26–7. Retrieved from http://rbc.gov.rw/fileadmin/user_upload/bulletin/2018/Health%20Outlook%20Magazine%20-%20Issue%20009.pdf
  62. Ryan S. The dilemmas of post-identity organizing: unmaking feminist ties in southern Rwanda. Women Lang. 2011;34:61–78.Google Scholar
  63. Schaal S, Weierstall R, Dusingizemungu JP, Elbert T. Mental health 15 years after the killings in Rwanda: imprisoned perpetrators of the genocide against the Tutsi versus a community sample of survivors. J Trauma Stress. 2012;25(4):446–53.  https://doi.org/10.1002/jts.21728.PubMedCrossRefGoogle Scholar
  64. Sebera F, Nyiramazaire H. Prévalence de l’épilepsie au Rwanda: Connaissance, perception, vécu et attitudes de la population et des professionnels de la santé. Kigali: Ministry of Health; 2005.Google Scholar
  65. Survivors Fund (SURF). Restorative justice: healing wounds and repairing lives: advancing the human rights of survivors of genocide in Rwanda. 2012. Retrieved from https://3l8c4w1xeg053utxpp3we7qc-wpengine.netdna-ssl.com/wp-content/uploads/2011/08/SURF-Restorative-Justice-Exhibition-lowres.pdf
  66. United Nations International Children’s Emergency Fund (UNICEF). UNICEF annual report 1997. Geneva: Author; 1997. Retrieved from https://www.unicef.org/ar97/
  67. United Nations Rwanda. Hunger and poverty. 2014. Retrieved from http://www.rw.one.un.org/mdg/mdg1
  68. University of Pennsylvania. Rwanda – history. East Africa living encyclopedia. 2018. Retrieved from https://www.africa.upenn.edu/NEH/rwhistory.htm
  69. World Economic Forum. 5 things to know about Rwanda’s economy. 2016. Retrieved from https://www.weforum.org/agenda/2016/04/5-things-to-know-about-rwanda-s-economy/
  70. World Health Organization. Social determinants of health. Geneva, Switzerland: Author. 2014. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/112828/9789241506809_eng.pdf;jsessionid=F5F537084ACBC231769EA34B5AEE70D6?sequence=1
  71. Yanagizawa-Drott D. Propaganda and conflict: evidence from the Rwandan genocide. Q J Econ. 2014.  https://doi.org/10.1093/qje/qju020. Retrieved from https://dash.harvard.edu/bitstream/handle/1/13457754/RwandaDYD.pdf?sequence=1CrossRefGoogle Scholar
  72. Zegeye A. Methodological problems to the understanding of the Rwandan genocide. Afr Identities. 2010;8(4): 309–16.CrossRefGoogle Scholar
  73. Zraly M, Rubin-Smith J, Betancourt T. Primary mental health care for survivors of collective sexual violence in Rwanda. Glob Public Health. 2011;6(3):257–70.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Donatilla Mukamana
    • 1
  • Lisa Lopez Levers
    • 2
    Email author
  • Kenya Johns
    • 3
  • Darius Gishoma
    • 4
  • Yvonne Kayiteshonga
    • 5
  • Achour Ait Mohand
    • 6
  1. 1.University of RwandaKigaliRwanda
  2. 2.Department of Educational Foundations and LeadershipDuquesne UniversityPittsburghUSA
  3. 3.Duquesne UniversityPittsburghUSA
  4. 4.Mental Health Department, College of Medicine and Health SciencesUniversity of RwandaKigaliRwanda
  5. 5.Mental Health DivisionRwanda Biomedical CenterKigaliRwanda
  6. 6.Ministry of Health, Mental Health DivisionRwanda Biomedical CenterKigaliRwanda

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