title: Psychosis and help-seeking behavior in rural KwaZulu Natal: unearthing local insights.
abstract: BACKGROUND
  Growing interest in strategies regarding early intervention for psychosis has led to a parallel interest in understanding help-seeking behavior, especially in low- and middle-income countries (LMICs). Nevertheless, few LMIC studies have examined individuals with psychosis in non-urban, non-hospital settings. Using the perspective of formal and informal community service providers, we aimed to uncover descriptions of people with psychosis in a rural South African community and illuminate the potential complexities of their help-seeking journeys.
  
  
  METHODS
  We conducted a qualitative study of 40 key informant interviews and seven focus groups with stakeholders (traditional leaders, traditional healers, religious leaders, health care nurses, heads of non-governmental organizations, schoolteachers, community caregivers) in a rural Zulu community (Vulindlela). Thematic analysis of the data was performed using the inductive analysis approach.
  
  
  RESULTS
  Interviewees discussed 32 individuals with probable psychosis in their community and provided rich descriptions of their symptoms. A complex picture of help-seeking behavior, primarily involving informal mental health service providers, emerged. Over half of the reported cases had no contact with formal health services in the course of their help-seeking journey; while more than two-thirds never attended a hospital and only 1 in 8 accessed a psychiatric hospital.
  
  
  CONCLUSIONS
  Our results highlight the important role of informal care providers in LMICs as well as the need for more research on mental illness and local providers in non-hospital contexts. Community stakeholders can contribute to a fuller understanding of these issues, thereby assisting in the creation of appropriate and effective mental health interventions for rural South African communities like Vulindlela.
authors.affiliation: Department of Psychiatry, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
authors.forename: Charlotte A
authors.initials: CA
authors.lastname: Labys
authors.affiliation: Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA ; New York State Psychiatric Institute, New York, USA.
authors.forename: Ezra
authors.initials: E
authors.lastname: Susser
authors.affiliation: Institute of Health Research, University of Exeter, Exeter, UK.
authors.forename: Jonathan K
authors.initials: JK
authors.lastname: Burns
keywords: Help-seeking; Psychosis; South Africa; Stakeholders; Treatment journeys