Abstract
Background: Occupational therapists provide vocational rehabilitation to mental health service users enabling them to purposefully and meaningfully engage in work. A vocational rehabilitation practice framework to guide occupational therapists working in mental healthcare settings is absent in Namibia.
Objectives: The study explored contextual factors to consider in developing vocational rehabilitation practice framework from the views of mental health service users and their primary caregivers.
Method: A qualitative collective case study design situated within an interpretivist paradigm was employed. Seven focus group discussions and 23 in-depth individual interviews were conducted with service users and primary caregivers purposively selected from two study sites where vocational rehabilitation service is provided. An inductive thematic analysis was conducted utilising ATLAS.ti.
Results: Three themes emerged: (1) service users want to and need to work, and have the rights to equitable work opportunities; (2) obtaining and sustaining work is difficult because of stigma and discrimination; (3) collaborative action is needed to create equitable work opportunities.
Conclusion: Occupational therapists should embrace an advocacy role to improve equitable work opportunities for chronic mental illness service users, and collaboration with employers and family members is crucial to achieve vocational rehabilitation outcomes.
Contribution: The study contributes to the field of mental disability and informs vocational rehabilitation strategies for mental health service users.
Keywords: chronic mental illness; work opportunities; self-employment; stigma; collaborative action.
Introduction
Background
Evidence shows that persons with chronic mental illness wish to work despite limitations because of illness and stigma (Swart & Buys 2014). Vocational rehabilitation plays a crucial role in enabling mental health service users to return to work or to carry on work (Lloyd 2010). Occupational therapists use various intervention strategies to help mental health service users regain their ability to work. In Namibia, there is no occupational therapy vocational rehabilitation practice framework to guide occupational therapists when providing vocational rehabilitation services to mental health service users. In the absence of such a framework, consistency of intervention across mental health care settings is uncertain, available evidence is not generated from local context and there is no assurance about the appropriateness of interventions (Chimara et al. 2024). Therefore, this study explored the views of mental health service users and their primary caregivers on contextual factors that should be considered for the vocational rehabilitation of service users with chronic mental illness. The study contributed to phase II of the four-phased doctoral study for the primary author (M.C.) who is developing an occupational therapy vocational rehabilitation practice framework for mental health service users in Namibia.
Work-related challenges that persons with chronic mental illness face can be categorised as societal, workplace-based, personal and internal (Auerbach & Richardson 2005). Societal challenges include the availability and implementation of vocational rehabilitation policy, vocational rehabilitation intervention strategies, physical and financial vocational rehabilitation resources, and individual vocational rehabilitation human resources (Auerbach & Richardson 2005). On the other hand, workplace-based challenges include dealing with stigma in the workplace, unethical workplace practices, insufficient workplace support, and conflicts with co-workers and supervisors (Auerbach & Richardson 2005). On the other hand, cultural and religious beliefs, social isolation, and relationship instability are some of the personal challenges that may interfere with work functioning for persons with chronic mental illness. Lastly, internal challenges relate to symptoms of mental illness, a person’s insight into mental illness, compliance to medication and anxiety related to work itself (Auerbach & Richardson 2005). Through vocational rehabilitation, which is a systematic process provided to working-age persons with health-related impairments or restrictions to improve work functioning, these work-related challenges faced by persons with chronic mental illness are mitigated (Swart & Buys 2014).
Mental health service users are seen by occupational therapists for vocational rehabilitation at two state mental healthcare facilities, namely Mental Health Care Centre (MHCC) at Windhoek Central Hospital in the capital city of Namibia, and at Ward 16 in Oshakati Intermediate Hospital which is located in the northern part of Namibia. Mental Health Care Centre has two sections such as forensic psychiatry and general psychiatry sections. Current vocational rehabilitation for service users in the forensic psychiatry section is centred around work projects. Service users engage in various work projects such as woodwork, car wash, leatherwork, gardening and working in a tuck-shop. These work tasks are therapeutically aligned to match the functional levels of the service users. On the other hand, vocational rehabilitation service in the general psychiatry side of MHCC largely focuses on assessment to identify the vocational rehabilitation needs of the service user, and to a lesser extent on providing prevocational skills training. At Ward 16 in Oshakati Intermediate Hospital, there were no vocational rehabilitation projects for service users at the time of data collection of this study, and only one occupational therapist was employed at that time.
A lack of awareness of mental illness and the stigmatisation of service users are quite apparent in Namibia, and this partly contributes to the current status of vocational rehabilitation (Chimara et al. 2024). Shifiona, Poggenpoel and Myburgh (2019) conducted a qualitative study to explore and describe the experiences of individuals living with chronic mental illness in northern Namibia. Their findings highlighted that there is a poor understanding of mental illness in the community, persons with chronic mental illness have to permanently fight stigma, and they have limited opportunities of getting a paid job. In northern Namibia, where the majority of the Oshiwambo-speaking people live, mental illness is associated with bewitchment (Shifiona et al. 2019). As a result, persons with chronic mental illness are often referred to traditional healers (‘Onganga’) for intervention (Shifiona et al. 2019). However, malpractices are rife where persons with chronic mental illness are reportedly bound on trees using chains which is a clear violation of human rights. In addition, this practice is misaligned with vocational rehabilitation principles (Shifiona et al. 2019).
Understanding the contextual factors that should be considered for vocational rehabilitation of service users with chronic mental illness is an important step in developing a practice framework. Service users and their families or primary caregivers are uniquely positioned to contribute to research endeavours seeking to understand contextual factors that should be considered for interventions affecting them. Contextual factors can be defined as ‘the underlying systems, culture and circumstances of the environment in which an intervention is implemented’ (Coles et al. 2020:1). Considering contextual factors helps to enhance understanding of what works for whom and in what settings (Coles et al. 2020). Thus, explicit contextual-relevant recommendations will be available and will minimise uncertainty on how to proceed with vocational rehabilitation interventions if contextual factors are explored (Chimara, Van Niekerk & Van Biljon 2022).
As already indicated above, there is absence of documented evidence on the contextual factors that should be considered for vocational rehabilitation of persons with chronic mental illness in Namibia. Persons with chronic mental illness and their primary caregivers are an important category of mental health stakeholders whose views on the vocational rehabilitation status quo need consideration by service providers, that is, occupational therapists. Therefore, this study aimed to explore context-specific factors that should be considered for vocational rehabilitation of service users with chronic mental illness from the perspectives of service users with chronic mental illness and their primary caregivers.
Occupational science and a decoloniality lens were the theoretical frameworks that guided our study. Occupational science is:
[A] basic science of the human as an occupational being, including the need for, and capacity to engage in and orchestrate daily occupations in the environment over the lifespan. (Kristensen & Petersen 2015:240)
The authors view work as an important occupation for mental health service users which influences their life satisfaction and recovery. Within the occupational science as a theoretical framework, the authors draw occupational justice concepts such as occupational apartheid, occupational deprivation, occupational marginalisation, occupational alienation, occupational imbalance and occupational inconsideration to aid our understanding of the contextual factors that should be considered for vocational rehabilitation for service users with chronic mental illness (Townsend 2004). As authors from the Global South, it was intentional to take a decoloniality gaze in this study taking into consideration that many occupational science terms are developed in the Global North (Ahmed-Landeryou 2024). Given that the authors are developing a vocational rehabilitation practice framework for service users in Namibia, a country located in the Global South, the authors critique the relevance of occupational science terms in the Global South.
Materials and methods
Research design and approach
A qualitative collective case study design within an interpretivist paradigm was employed. The cases were the two state mental healthcare facilities, whereas the unit of analysis was contextual factors that should be considered for vocational rehabilitation for service users with chronic mental illness who are seen at the two state mental healthcare facilities. The Standards for Reporting Qualitative Research (SRQR) guided the drafting of this manuscript (O’Brien et al. 2014).
Study context
The present study focused on two state mental healthcare facilities in Namibia, a southern African country with a population of about 3 million people of which 2838.71 per 100 000 population are estimated to be having mental illness (World Health Organization 2018). The first setting is the MHCC located in Windhoek, the capital city of Namibia. Mental Health Care Centre is a national referral unit where service users from all 14 administrative regions are referred to for mental healthcare services. Service users who receive care at MHCC are from both rural and urban settings. The second setting is Ward 16 at Oshakati Intermediate Hospital located in an urban setting in Oshakati town. Service users seen in Ward 16 are mainly from the northern administrative regions where about 60% of the Namibian population resides. However, the majority of the service users receiving care at Ward 16 are from the rural setting. Both study settings have occupational therapy departments where service users should receive vocational rehabilitation.
Study population
The study population comprised mental health service users receiving care at MHCC and Oshakati Intermediate Hospital, as well as their primary caregivers. In this study, mental health service user or service user refers to a person with chronic mental illness who receives care at a state mental healthcare facility. Chronic mental illness is defined as:
… [a] non-organic or personality disorder, for a period of two or more years of outpatient treatment or hospitalization in a mental health care facility, and disability criteria that includes impairment in work, mild impairment in basic needs and disturbing behaviour. (Bachrach 1988:384)
The definition of primary caregiver is an individual who is informally responsible for providing care to a mental health service user. Examples of primary caregivers include family members, relatives and friends. The target sample size was 64 participants, but a total of 79 participants were recruited, of which 49 were service users and 30 were primary caregivers. Participant demographic characteristics are presented under the results section.
Recruitment and sampling
A purposive sampling method was used to select service users who had been using mental healthcare services for a period of at least 2 years and their primary caregivers. Recruitment was processed through the two occupational therapy departments at two study settings for participants who met the inclusion criteria and were conveniently available for the study between January 2023 and July 2023. Inclusion criteria were that participants were between the ages of 18 and 64 years, that is, working age population, were mentally stable and were Namibian citizens. In addition, we ensured variation of our sample in terms of gender, urban versus rural, and diagnosis. Two research assistants, one in each study setting, helped with the recruitment process. A recruitment pamphlet, which highlighted the purpose of the study, criteria for participants that would qualify to partake in the study and how the participants would be involved, was used for inviting participants into the study. The contact details of service users, who were willing to participate, were recorded in the participant register kept at the occupational therapy department. The researchers asked service users who agreed to participate for contact details of their primary caregivers. Phone calls were made to primary caregivers explaining the details of the study. The researchers specifically invited primary caregivers who accompanied their family members to occupational therapy for vocational rehabilitation, and the details of those who showed interest were recorded in the participant register. Seventy-nine participants were recruited from the two study settings. A descriptive analysis of the study sample is presented in the results section.
Data collection methods and instruments
A total of eight focus group discussions and 23 individual interviews were conducted with service users and their primary caregivers using a semi-structured interview guide. Focus group discussions for service users were separate from primary caregivers. Individual interviews were conducted for participants who could not be part of the focus group discussions because of their personal schedules. The authors met to discuss and reach a consensus on the interview guide which was informed by a scoping review study on vocational rehabilitation of service users with chronic mental illness in low-income and middle-income countries (Chimara et al. 2022). The discussion questions were centred around service users’ experience as workers, vocational rehabilitation received at the hospital, ideal support needed for vocational rehabilitation, stakeholders in vocational rehabilitation, and recommendations for service providers in vocational rehabilitation. Data were collected from February to July 2023 in the two study settings. The first author (M.C.) conducted the interviews in English, whereas two research assistants conducted the interviews in local languages. Forward and backward translation was done for the interview guide and transcripts in local languages. All interviews and discussions were captured using a digital recorder.
Units of study and data processing
We developed a file identification system by allocating codes to each of the 31 transcripts. Our filing system allows for identification of the type of data collection used, the site where data were collected and the stakeholder category. All transcripts were cleaned and transferred to a qualitative data analysis software, ATLAS.ti. Inductive thematic analysis was conducted following the six steps suggested by Braun and Clarke (2006) concomitantly responding to the research question. Memoing of emerging ideas was performed by the first author who iteratively read through the transcripts. A total of 135 codes emerged through a repetitive process of discussing and renaming the codes among the four authors. The codes were reduced to categories and eventually to themes which provided insight on the contextual factors that should be considered for vocational rehabilitation of service users with chronic mental illness in Namibia.
Trustworthiness
Trustworthiness was established by maintaining the criteria set by Lincoln and Guba (Shenton 2004) which have the following aspects: credibility, authenticity, transferability, dependability and confirmability. Data were collected over a period of 6 months in the two settings using semi-structured interviews and focus group discussions thus establishing credibility. A detailed account of the research methodology ensures transferability, whereas an audit trail of the research process followed contributed to both confirmability and dependability of the findings.
Ethical considerations
Ethical clearance was obtained from the Health Research Ethics Committee of Stellenbosch University, with reference number S22/06/106. Permission to conduct the study was granted by the Ministry of Health and Social Services (Ref: 22/4/2/3). Institutional permissions were granted by the respective heads of Windhoek Central Hospital and Oshakati Intermediate Hospital. The researchers adhered to Beauchamp and Childress’ ethical principles of biomedical research in conjunction with the Belmont Report and the Declaration of Helsinki. Information pamphlets on the study were shared with the study participants. The purpose and details of the study were explained to the participants in a language accessible to them before they gave written consent to participate. Consent for audio recording of focus groups and interviews was also obtained. Audio data were stored in password-protected folders, whereas fieldnotes and printed interview transcripts were stored in a locked cabinet by the first author (M.C.).
Results
Study participants
A total of 79 individuals participated in the study through focus group discussions and individual interviews from the two research sites. Four focus group discussions were conducted with service users, whereas three focus group discussions were conducted with primary caregivers. All groups had all known genders and were mixed in terms of employment status, that is, employed and unemployed. Regarding individual interviews, a total of 23 individuals participated, of which 17 were service users and six were primary caregivers. Table 1 provides a summary of the study participants.
| TABLE 1: Summary of the study participants. |
Themes
Three themes covering 10 categories emerged, as illustrated in Table 2. The themes, categories and supporting quotes are presented in this section.
| TABLE 2: Themes, categories and supporting quotes. |
Theme 1
Mental health service users wish and need to work and have the right to equitable work opportunities.
Service users have the right to equitable work opportunities
The participants reported that service users have the right to work opportunities, their work choices should be respected, and there is a need for protection in the workplace. Service users should be viewed as any human being and should be accorded equitable work opportunities in the open labour market:
‘… we [service users] need that opportunity, that job opportunity that whenever they find a job somewhere, they must also employ as those that are suffering [from chronic mental illness].’ (12:36, 272 in P4JKBSUWhk, Participant 4, Service user)
‘I just want to add that they [service users] should get opportunities to do the work that they are capable of doing.’ (4:35, 159 in FGD4PCGOsk, Participant 3, Caregiver)
‘I just want to say people with mental illness need to be considered as people when it comes to work because it is very difficult for us to get jobs.’ (2:13, 13 in FGD2SUOsk, Participant 5, Service user)
Service users should be allowed to make work choices that are aligned with their interests. Some participants stressed the need for a law that protects service users in the workplace. They pointed out that service users’ voices should be heard by their employers as they express their challenges with regard to work and mental health. Also, some participants reported that many service users are not fairly remunerated for their work by their employers.
Service users need work to sustain themselves and their families, and want to improve their mental health
The study findings show that service users are motivated to work so that they can financially support themselves and their families, and that work improves their mental health. Work was reported as a source of income for service users, and it allows them to meet their basic needs and of their families. In addition, primary caregivers expressed that service users have responsibilities such as sending children to school, house maintenance and taking care of their parents, and hence they need work:
‘… they [service users] need to work because some of them have children maybe two or three, I cannot take care of them with my pension grant, they need to work so that they take care of their children just like how I took care of her. They really need jobs that’s why I am saying if there are opportunities they need to work.’ (5:4, 6 in FGD5PCGOsk, Participant 2, Caregiver)
‘We [service users] are just trying to earn for ourselves and also to support our children, like for me I have children and I am married.’ (1:17, 13 in FGD1SUOsk, Participant 1, Service user)
Other participants, who are service users, stated that they had to work because they also needed money for hospital visits as they stayed far away from hospitals that provide mental health services. Some primary caregivers reported that they observed service users getting better after securing employment. Service users themselves shared the same sentiments as their primary caregivers stating that they wanted to keep active through work to improve their mental health:
‘I have seen some of them [employers] have employed these people [service users], and from my observation they [service users] really get better.’ (4:32, 142 in FGD4PCGOsk, Participant 6, Caregiver)
Service users want and need training to gain work skills
The need for service users to gain work skills and entrepreneurship skills was reported by the participants. The participants believe that nowadays most jobs require qualifications and skills which the majority of service users lack. If service users gain work skills and qualifications, they will increase their chances of gaining employment. Therefore, it was suggested that work skills training should start while service users are admitted in the hospital:
‘… others have mentioned sewing but we also need to get training on how to do laundry, so that we can be the ones washing clothes and linen for other patients in hospitals. We just need to be shown how the machines operate and what we need to do so that maybe when we go back to our houses we will try to look for domestic work.’ (1:43, 44 in FGD1SUOsk, Participant 1, Service user)
It was further suggested by participants that the government should open vocational training schools for persons with disabilities where service users can be trained to gain work skills:
‘… the government should open a vocational school for people with disabilities and [for] people with mental illnesses.’ (3:39, 23 in FGD3SUOsk, Participant 3, Service user)
In terms of the type of work, the majority of participants mentioned skills-related or domestic skills-related jobs such as domestic work, gardening and crafts work. They also emphasised the need for entrepreneurship skills to help them start small businesses where they can either buy and sell goods or just sell products that they produce themselves. Vocational counselling was mentioned as a need for some service users in order to prepare them to enter the job market.
Service users want to be self-employed
Both service users and primary caregivers expressed the need for self-employment through income-generating projects especially in rural communities. The majority of participants mentioned gardening in particular as a realistic project for service users:
‘… start your own garden at home especially with fast vegetables like tomatoes, spinach, and cabbage, you can start your garden if you do not get a job. You have your garden at home and sell your food in your village to generate your own income … we can try to do something for ourselves not just wait to be employed.’ (1:1, 3 in FGD1SUOsk, Participant 1, Service user)
However, the lack of funding was identified as the biggest challenge for service users who wanted to start self-employment projects. It was, therefore, proposed that the government should assist with introducing these projects in the communities as well as assisting with funding for such projects:
‘But I think if the government has to get involved is maybe just through giving these people projects to generate their own income and they should be a system that request for feedback about the projects like how they are operating.’ (4:26, 103 in FGD4PCGOsk, Participant 1, Caregiver)
Theme 2
Obtaining and sustaining work is difficult because of stigma and discrimination.
Stigma and discrimination hinder access to formal and informal employment
Service users are stigmatised and discriminated against at home, in the community, and at work thus hampering their access to both formal and informal employment opportunities. At home, service users are excluded from family meetings or their contribution to family meetings is not taken seriously because their family members believe everything service users say or do is not valid or relevant:
‘Like in the community or even in our home, if there is maybe a meeting that I also attend and contribute to a discussion or so, people do not take my points as relevant because they think I am a ward 16 patient, I am mentally disturbed, so everything I say is not taken serious.’ (1:8, 7 in FGD1SUOsk, Participant 3, Service user)
‘Sometimes it’s even our family members that are causing these things because they stigmatize us a lot and they also do not even believe us, they think everything we say or do is useless.’ (2:23, 38 in FGD2SUOsk, Participant 2, Service user)
‘People see them [service users] as mad and useless, they think they cannot work because they have mental conditions.’ (6:6, 27 in FGD6PCGOsk, Participant 2, Caregiver)
In the community, service users reported that they were treated differently from other people by community members. Often, they were called by derogatory names such as ‘mad person’, ‘foolish people’, ‘abnormal’, ‘crazy’ or ‘ward 16 patient’. Some service users recounted that they found it difficult to start small businesses in the community because people incited each other not to buy their products simply because they were ‘ward 16 patients’ and the community believed that they were incapable of working because of mental illness. More so, service users reported that they did not receive loans from the banks to start small businesses because of their illness. Consequently, service users were demotivated to start small businesses in the community while others preferred to stay at home because of the stigma and discrimination that they experienced in the community. According to the participants, employers viewed service users as a risk to their companies, and they believed that employing them may result in low productivity and losses. Service users were reported as not being shortlisted for interviews once it was known that they had a mental illness:
‘Another thing that I have observed is discrimination especially when we are looking for a job especially in areas where people or the community knows us. For example, they will be like no this one is a ward 16 patient don’t take her let’s rather take this one.’ (3:7, 12 in FGD3SUOsk, Participant 1, Service user)
Thus, to increase their chances of gaining employment, some service users mentioned that they sought employment away from their communities where their mental health status was unknown.
Lack of support limits sustained employment
The participants revealed that service users who were employed found it difficult to keep their jobs because of a lack of support both in the workplace and at home. Service users feared being neglected, discriminated against and their contributions being ignored in the workplace and therefore rarely disclosed their illness as this might lead to their dismissal from work.
‘Some of us are working but we are living in a constant fear of losing our jobs anytime especially if the boss finds out about the condition [mental illness].’ (2:40, 46 in FGD2SUOsk, Participant 3, Service user)
‘I fell sick at work and when I called them to go start again they said they replaced me with someone and they will only call me if there’s an open vacancy again.’ (7:30, 179 in FGD7SUOsk, Participant 3, Service user)
A few service users who disclosed their illness at work mentioned experiencing a negative change in the way they were treated by their colleagues following the disclosure. Because of the stigma and discrimination in the workplace, some service users feared returning to work or considered resigning from their work.
‘My colleagues were just shocked when I went back to work and no one wanted to come closer to me even those who I used to joke with, they just started distancing themselves.’ (3:12, 12 in FGD3SUOsk, Participant 5, Service user)
Lastly, family members were reported as being unsupportive to service users, especially after losing their jobs leaving them in a catch-22 situation. Participants attributed the lack of support in the workplace to limited understanding of mental illness where some employers thought service users were unproductive and dangerous.
Theme 3
Collaborative action is needed to create equitable work opportunities.
Awareness raising is needed for equitable work opportunities
Participants stressed the need for raising awareness of mental illness as well as of the vocational rehabilitation services available to service users. Awareness raising should be aimed at employers and community members at large to reduce stigma. One recommendation put forward by participants was that occupational therapists should visit workplaces to educate workers and employers about mental illness and encourage employers to support service users in the workplace:
‘Okay this will now depend on your employer and colleagues, if they understand mental illness then it is not going to be a problem, it is only when they do not understand it.’ (2:6, 7 in FGD2SUOsk, Participant 2, Service user)
‘Is it not maybe possible for you guys [service providers] to take us to our workplaces and explain to our bosses what is happening, because it will be easy for us maybe they will understand you otherwise I don’t think there is anything that can be done.’ (3:25, 21 in FGD3SUOsk, Participant 5, Service user)
Another suggestion was that vocational trainers, also known as vocational education instructors, should receive training on mental health to improve their understanding of mental illness. Some service users were not aware of vocational rehabilitation and occupational therapy services available to them; therefore, they proposed the hospital to take a leading role in raising awareness of these services.
Government needs to play its part through different Ministries and programmes
Participants called for government action through the Ministry of Health and Social Services to provide vocational rehabilitation services for service users. They wish for hospital-based work projects which they can engage in while they are admitted to hospital:
‘Even here in the hospital there is supposed to be a rehabilitation for us [service users] but there is nothing, it has been 7 years now I am being seen in this hospital for several admissions but every time is just eating sleeping, eating sleeping and nothing is going on to further help us apart from the medications, and this is actually not enough, we need much more.’ (2:17, 15 in FGD2SUOsk, Participant 5, Service user)
‘Maybe the Ministry of Health [and Social Service] can also budget for rehabilitation because this concept is dead in the government.’ (2:49, 64 in FGD2SUOsk, Participant 5, Service user)
Some participants reported that they observed limited vocational rehabilitation resources in state mental health facilities and they suggested for involvement of hospital management in addressing this issue. A disparity in terms of vocational rehabilitation services provided at the two state mental health care settings was reported by service users who were once admitted to both facilities. In one setting, vocational rehabilitation services were reported as non-existent, whereas in another setting, service users engaged in work projects such as gardening, car-wash and leatherwork. A suggestion was made for the Ministry of Health and Social Services to collaborate with other Ministries such as the Ministry of Gender Equality, Poverty and Social Welfare in gathering resources for vocational rehabilitation of service users.
Family, community and employers needed as active role-players
The importance of support from family, community and employers was underscored by the participants. Whereas service users called for support from their families, primary caregivers mentioned that they were ready to help:
‘It starts from home our family members need to support us.’ (2:24, 38 in FGD2SUOsk, Participant 2, Service user)
A need for community support groups was suggested with some participants challenging the community to assist in seeking employment for service users:
‘Oh like for us in rural areas, people with small businesses can help employ these people [service users] like at our village.’ (4:31, 142 in FGD4PCGOsk, Participant 6, Caregiver)
‘There are charity organizations in Namibia which have been playing a role to eliminate different problems and they have succeeded, there are a lot of health organizations or programs we can even mention some of them.’ (4:34, 152 in FGD4PCGOsk, Participant 7, Caregiver)
‘It’s like we ourselves we have to support each other to do this and this so like tell each other what to do in groups, and divide work amongst ourselves like who and who are doing this and just support each other and even choose who can be a team leader.’ (8:41, 179 in FGD8SUOsk, Participant 3, Service user)
Participants think employers should create a supportive work environment and allocate time to service users for hospital visits. Hospital visits were described as a source of encouragement by the service users. As highlighted by one service user, one hospital visit per month is sufficient to ‘keep them going’ as they receive encouraging words from service providers. These encouraging words boost their confidence and motivation to keep working.
Service users want to manage their mental health
In the interest of achieving equitable work opportunities, service users realised the need to play their part in managing their mental health. Improving their self-care, taking their prescribed medication and understanding their mental conditions were highlighted as some of the important facets of managing one’s mental health:
‘I just want to say, us the patients we need to practice what we are being taught here in the hospital even when we go home, like if we have identified triggers for our illnesses then when you are discharged you should try to avoid those things so to avoid re-admissions.’ (13:26, 61 in P5SUOsk, Participant 5, Service user)
‘But what I can say is that everyone should be responsible for their own mental illnesses [mental health] yeah, to make sure they take care of themselves.’ (2:47, 64 in FGD2SUOsk, Participant 5, Service user)
On the other hand, alcohol and marijuana use was identified as one of the hindrances to effective work performance by service users. Participants reported that substance use contributed to frequent hospitalisation resulting in job loss. As such, reprioritising and focusing on what is important for ensuring continuous employment, including managing substance use were viewed as part of managing one’s mental health which are important roles for service users themselves:
‘We need to focus on the reality now because we are already in it, things like taking our medications serious, focusing on the good things and avoiding the triggers of our illnesses, stop the use of alcohol and dagga [marijuana].’ (2:34, 45 in FGD2SUOsk, Participant 1, Service user)
Discussion
The study findings reveal that despite a strong desire by mental health service users to acquire equitable work opportunities, obtaining and sustaining work is difficult mainly because of the stigma and discrimination they experience. Service users face stigma and discrimination at home, in the community and in the workplace. Collaborative action by various stakeholders such as the service users, family members, the community, employers and the government is needed to raise awareness of mental illness to create equitable work opportunities. In this section, we discuss these findings with emphasis on how they inform an occupational therapy vocational rehabilitation practice framework for mental health service users in Namibia.
Mental health service users wish and need to work, and have the right to equitable work opportunities
Service users wish and need to work in order to financially support themselves and their families. In Namibia where employment opportunities are limited due to high unemployment rate (Namibia Statistics Agency 2017), self employment was identified as a viable employment option for service users. Service users face intense competition for the limited formal employment opportunities available in the open labour market. Ostrow, Nemec and Smith (2019) acknowledge the importance of self-employment as an employment option for service users and this option is being under-utilised. However, self-employment option has some potential barriers including a lack of technical assistance, financial challenges, a lack of access to suitable training and a lack of mentorship (Ostrow et al. 2019). Also, the lack of entrepreneurial knowledge and skills among service users is a barrier to self-employment. Negative symptoms and long-term symptoms of some of the mental illnesses make it difficult to ensure sustained motivation, initiative and problem-solving, aspects that are integral in self-employment. Despite these potential barriers, the authors propose supported self-employment as a vocational rehabilitation strategy for service users in Namibia and in comparable settings in Africa.
Participants highlighted the need for training to gain vocational skills. It is known that some common mental conditions start early in adulthood before an individual acquires vocational skills to enter the job market. As a result, these service users lack some vocational skills and experience even when their condition stabilises. Conducting detailed work ability assessments and identifying potential vocational interest for such service users, performed in the hospital, are essential. This can be followed by identifying vocational training resources in the community and within the industry where service users can be enrolled to develop skills and gain the much-needed work experience.
The desire to be productive and to provide basic necessities for themselves and their families is engrained in all adult human beings, and mental health service users are no exception as evidenced by the findings of this study. For service users, work facilitates identity development and is a source of income to support themselves and their families (Swart & Buys 2014). Moreover, the structure in daily routines, being productive and the opportunity to be useful associated with work have the healing potential which is important for recovery (Fossey 2019). Therefore, loss of work, prolonged unemployment and exclusion from work for service users are detrimental to their health and well-being (Fossey 2019). To this end, service users have the right to equitable work opportunities as highlighted by several national and international legislation. For example, the World Health Organization Mental Health at Work Policy Brief (World Health Organization 2022:4) states: ‘access to decent and productive work, with fair pay in conditions of freedom, equity, security, and human dignity is the right of all men and women’. The Namibia Labour Act 11 of 2007(Labour Act 2007:15) states: ‘a person must not discriminate in any employment decision directly or indirectly on grounds of degree of physical or mental disability’.
Obtaining and sustaining work is difficult because of the stigma and discrimination
The findings are consistent with evidence in the literature which shows that stigma and discrimination are significant barriers to formal and informal employment for mental health service users. As highlighted by Fossey (2019), individuals with chronic mental illness are among the most marginalised ones in terms of employment patterns and economic status. Javed et al. (2021) identified three levels of stigma namely, intrapersonal stigma, interpersonal stigma and structural stigma. Intrapersonal stigma refers to self-stigma and internalisation of stigma by service users, whereas interpersonal stigma refers to ignorance, misinformation, prejudice and discriminatory behaviour (Javed et al. 2021). In the Namibian context, cultural beliefs play a role in interpersonal stigma and discrimination of service users. This is illustrated in a study by Bartholomew (2017:248) on conceptualising mental illness in Namibian Ovambo culture where mental illness is viewed as madness (eemwengu) and that mental illness is believed to come from ‘witching and curses’ or from ‘disconnecting from ancestors’. Discriminatory social structures and policies, as well as poor and inadequate quality of mental health services, attribute to structural stigma (Javed et al. 2021). Experiencing stigma and discrimination on all fronts is a challenge for vocational rehabilitation interventions such as supported employment or self-employment. Mental health literacy, education and awareness to service users, primary caregivers, service providers and employers are some of the measures to address stigma and improve vocational rehabilitation outcomes for individuals with chronic mental illness (World Health Organization 2022). More so, because stigma is culturally bound in the Namibian context, service providers should engage traditional leaders in their vocational rehabilitation strategies.
The lack of support for individuals with chronic mental illness to sustain employment can be explained using the Social Model of Disability which postulates that disability is a label imposed on individuals with impairments leading to isolation and exclusion from full participation in society (Haegele & Hodge 2016). Stigma and discrimination in the workplace, unfair dismissal from work and unsupportive family can be attributed to the perceptions of individuals with chronic mental illness as being less able to participate with members of the community (Haegele & Hodge 2016). Support for service users received from family members, friends and employers helps them to stay in employment (Shankar, Barlow & Khalema 2011). Regarding support for service users in the workplace, Shankar et al. (2011) recommend:
[T]he employer must know how to communicate with the employee, must recognize the signs of declining performance, must deal appropriately with behaviour and performance issues, and must provide timely feedback and reasonable work accommodation when needed. (p. 11)
It is evident that support for service users is crucial for sustaining employment; thus service providers should ensure that caregivers and employers are well equipped to support an employee who has chronic mental illness. Raising awareness of mental health issues through education could be a strategy to equip employers and caregivers with skills to support service users.
Collaborative action is needed to create equitable work opportunities
A lack of awareness of mental illness is one of the biggest barriers to employment for service users. In an effort to address unmet rehabilitation needs globally, the World Health Organization (WHO) Rehabilitation 2030 initiative calls for raising awareness among policymakers, civil society and private sector (Gimigliano & Negrini 2017). The importance of cooperative action between and within stakeholders is emphasised (Gimigliano & Negrini 2017). More so, the WHO Mental Health at Work Policy Brief identifies training to improve mental health literacy as an approach to protect and promote mental health at work (World Health Organization 2022). In the Namibian context, training to improve mental health literacy should be extended to family members and communities in general because of the extent of stigma and discrimination towards individuals with chronic mental illness.
Participants called for government action through the Ministry of Health and Social Service to provide vocational rehabilitation services to individuals with chronic mental illness. The state facilities providing vocational rehabilitation for service users in Namibia are limited to the MHCC and Oshakati Intermediate Hospital. In both settings, there are limited vocational rehabilitation human resources, facilities and materials (Chimara et al. 2024). As highlighted by service users at Oshakati Intermediate Hospital, they spend most of their time lying idle in the hospital wards resulting in them struggling to adjust to work demands after being discharged from the hospital. Therefore, vocational rehabilitation programmes should be an integral part of hospital-based intervention plans for service users admitted in all hospitals. There is a need for the government to create posts and recruit occupational therapists dedicated to vocational rehabilitation in these settings to meet the much-needed vocational rehabilitation for service users (Chimara et al. 2024). These occupational therapists should be capacitated to provide vocational rehabilitation services, conduct work visits and engage various stakeholders such as family members. In addition, vocational rehabilitation needs a multisectoral approach. As such, the Ministry of Health and Social Services should collaborate with other government ministries and agencies to provide opportunities for service users. Examples of government ministries to engage include the Ministry of Gender Equality, Poverty Eradication and Social Welfare, Ministry of Industrial Relations and Employment Creations, and Ministry of Urban-Rural Development.
Given our findings, a need for service providers to collaborate with family, community and employers in vocational rehabilitation of service users is apparent. Family support plays a significant role in vocational rehabilitation of service users with chronic mental illness. In light of the current universal drive to deinstitutionalise mental health services, family members and caregivers of service users are obliged to take a central role as primary carers (Ong, Fernandez & Lim 2021). Consequently, family members and primary caregivers are part of the intervention team and they need mental health literacy to effectively play their roles (Ong et al. 2021). A collective community support and skills development for service users through programmes focusing on issues such as coping skills, communication skills and entrepreneurship skills has the potential to improve vocational rehabilitation outcomes. Collaboration with employers for supported employment and reasonable accommodation is absolutely necessary.
Finally, service users wish to manage their mental health on their own. Evidence gathered by the WHO shows that individual interventions such as psychoeducation, stress management, coping skills training and leisure-based physical activity reduce emotional distress and improve work effectiveness (World Health Organization 2022). As reported by participants, substance use is high in Namibian communities, and some service users attributed job loss to alcohol use. Therefore, building the individual capacity for service users to manage their mental health and manage alcohol use should be prioritised in vocational rehabilitation.
Conclusion
Utilising focus group discussions and individual in-depth interviews allowed for a comprehensive exploration of contextual factors to be considered in the development of an occupational therapy vocational rehabilitation practice framework for service users with chronic mental illness in Namibia. The authors take note that despite service users’ willingness to work, the environment is unsupportive for this cause mainly because of the stigma and discrimination at work and in the community. Therefore, the study calls upon occupational therapists to take an advocacy role in protecting the rights of service users with chronic mental illness to have equitable work opportunities. This certainly requires occupational therapists to go beyond the hospital boundaries to reach out to various vocational rehabilitation stakeholders including employers and family members.
Despite several measures employed to enhance the trustworthiness of this study, the findings cannot be generalised. The methodology and study context for this article were described in detail such that the study can be repeated in similar low-income settings particularly in Africa.
Acknowledgements
The primary author would like to acknowledge the support received from Dr Matthew Chiwaridzo and Dr Nyaradzai Munambah. This article is partially based on the author, M.C.’s. dissertation entitled ‘Development of an occupational therapy vocational rehabilitation practice framework for service users with chronic mental illness in Namibia’ towards the degree of PhD in the Department of Occupational Therapy, Stellenbosch University, South Africa, with supervisors Lana van Niekerk, Fasloen Adams and Hester M. van Biljon.
Competing interests
The author reported that they received funding from African Collaborative Grant, the Elizabeth Casson Trust and Seed Corn grant which may be affected by the research reported in the enclosed publication. The author has disclosed those interests fully and has implemented an approved plan for managing any potential conflicts arising from their involvement. The terms of these funding arrangements have been reviewed and approved by the affiliated university in accordance with its policy on objectivity in research.
Authors’ contributions
Four authors contributed to this study. M.C. a Namibian occupational therapy educator, conducted the research in partial fulfilment of his doctorate degree. H.M.v.B. and F.A. are secondary supervisors, whereas L.v.N. is the primary supervisor. All four authors, M.C., H.M.v.B., F.A. and L.v.N. were involved in the conceptualisation of the study. M.C. led the fieldwork with support from research assistants, recruited participants and conducted in-depth interviews and focus group discussions. M.C. led the analysis and drafting of the manuscript with regular input from the rest of the team.
Funding information
The authors are highly grateful for three funding supports received for this study. The Africa Collaborative Grant covered travel and accommodation costs for primary author for face to face meetings and mentorship with supervisors at Stellenbosch University. The Elizabeth Casson Trust supported with PhD tuition fees for M.C., and the Seed Corn grant supported fieldwork costs for this study.
Data availability
The data that support the findings of this study are available on request from the corresponding author, M.C.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.
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