title: Conceptualizing and contextualizing functioning in people with severe mental disorders in rural Ethiopia: a qualitative study.
abstract: BACKGROUND
  The functional outcome of people with severe mental disorders (SMD) is purported to be better in low- and middle-income countries compared to high-income countries; however, cross-cultural measures of functioning may not capture adequately the relevant functional activities in rural, non-Western settings. This study aimed to gain in-depth understanding of day-to-day functioning in a rural Ethiopian setting and the functional impairments associated with SMD.
  
  
  METHODS
  A qualitative study was carried out in the Butajira area, south Ethiopia. In-depth interviews were conducted with people with SMD (n = 6), religious healers (n = 2) and psychiatric nurses (n = 2). Four focus group discussions were carried out with caregivers of people with SMD (n = 37) and one with project outreach workers (n = 5). A thematic analysis approach was used.
  
  
  RESULTS
  Participants emphasized that functional impairment in people with SMD arose not only because of the symptoms associated with the illness, but also due to poverty, social exclusion and lack of social support. Within this rural community, the ability to work productively, engage in family life, maintain self-care and fulfill social obligations were the most highly valued domains of functioning. A wide range of farming tasks were elaborated in detail and noted to be of varying levels of difficulty. Although many people with symptomatic SMD were reported to be able to carry out simple farming tasks, this was distinguished from effective farming. Gender differences were most apparent in the domains of work and family life. Impaired functioning was reported to have a critical immediate impact on survival and longer-term impacts on the lifetime opportunities of people with SMD, their caregivers and the younger generation within the family.
  
  
  CONCLUSIONS
  The study indicates that tackling social exclusion and poverty is needed alongside medical treatment through contextual community based rehabilitation programs. The gendering of functional roles and the complexity of work activities in this subsistence farming community lend support to arguments for locally contextualized measures of functioning in people with SMD.
authors.affiliation: School of Psychology, College of Education and Behavioral Studies, Addis Ababa University, P.O. BOX: 1176, Addis Ababa, Ethiopia. Kasshabmek@gmail.com.|PhD students, Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia. Kasshabmek@gmail.com.
authors.forename: Kassahun
authors.initials: K
authors.lastname: Habtamu
authors.affiliation: Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia. atalay.alem@gmail.com.
authors.forename: Atalay
authors.initials: A
authors.lastname: Alem
authors.affiliation: Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia. charlotte.hanlon@kcl.ac.uk.|Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK. charlotte.hanlon@kcl.ac.uk.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Hanlon
mesh_terms: D000203:Activities of Daily Living / Q000523:psychology*; D000328:Adult; D005002:Ethiopia / Q000453:epidemiology; D056344:Executive Function; D005260:Female; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000175:diagnosis / Q000453:epidemiology / Q000523:psychology; D008875:Middle Aged; D020380:Needs Assessment; D011569:Psychiatric Status Rating Scales; D036301:Qualitative Research; D012424:Rural Population; D012648:Self Care; D012944:Social Support