Improving mental health in Khayelitsha

Arriving in Cape Town via its main highway you can't fail to spot Khayelitsha. The informal township, reputed to be the largest and fastest growing in South Africa, runs parallel to the main artery leading into the city centre.

Driving along, a peri-urban sprawl stretches out – the looming presence of Table Mountain on the horizon to one side, the south Atlantic to the other. Expanding over 15 square miles, Khayelitsha is home to a population close to 1,000,000.

'On one level Khayelitsha is part of Cape Town; on another it seems a different world and a massive a community in its own right', Dr Sarah Halligan from our Department of Psychology tells me, fresh from her recent trip to the area. 'The first thing that's very striking is that this is not a small area. It's vast and it's a very, very substantial community', she explains.

Working with Stellenbosch to help children cope with trauma

Working with a team at Bath, including Dr Rachel Hiller and PhD candidate Victoria Williamson, Sarah is leading a collaborative project with our international partners at Stellenbosch University. Their focus is on improving responses to child trauma in the township. To date, their work has looked at this issue in the context of the UK. The comparison between the situation in Western Europe and that found in this township in the Western Cape could not be more significant.

Sarah's team is working with Professor Mark Tomlinson, Dr Jackie Stewart and their team, who are based in a specialist group focusing on maternal and child research in the Department of Psychology at Stellenbosch University.

Professor Tomlinson explained, 'These types of international collaborations are hugely valuable to improve our understanding of the similarities and differences between our countries, and specifically to learn lessons from each other about what works to improve child mental health in different contexts.'

Recent statistics tell a bleak story of Khayelitsha, which was first established in 1983 in the final contested days of apartheid. 33 years on, unemployment is widespread, in particular among the young; 74% of households have a monthly income of R3,200 (about £150); crime is endemic, notably violent crimes and sexual assaults; and the prevalence of HIV/AIDS is markedly high.

Compounding these issues are the massive mental health challenges faced by the children of Khayelitsha and their families. Many of them have experienced their own traumatic events and almost all will have witnessed others, ranging from the frequent and often serious road traffic accidents to violent crimes including physical/sexual assaults and murder.

Estimates suggest that up to 80% of children living in the area will have experienced some sort of trauma in their lives and all from a very young age. Sarah's work looks at children aged 6 to 16, for whom the long-term evidence is also stark: as a result of traumatic events they experience growing up, these children will go on to have poorer outcomes. This creates a vicious cycle of poverty and deprivation for areas like Khayelitsha.

Sarah and her team are collaborating with psychologist Professor Mark Tomlinson and his team at Stellenbosch to share learning in relation to child trauma and PTSD.

Their partnership began thanks to seed funding from our International Relations Office, which gave Sarah the opportunity to team up with Professor Tomlinson for three months last summer in South Africa.

Sarah explains: 'We got funding to get something started, which very quickly led to more funding from other sources. We've been building a good collaboration ever since.

'We've been bringing some of the work we've been carrying out in the UK and translating it into this new setting in South Africa, but the population is very different to the kind we'd normally see and they have very severe challenges. For someone working in childhood mental health and trauma, this represents both challenges and opportunities'.

Despite the many traumatic incidents which arise daily, the majority of Khayelitsha's inhabitants have no, or limited, access to mental health services. 'Mental health provision is not really there, and if it is, it isn't clear what the quality is or certainly whether families would even access it', she says.

Further challenges of access to healthcare

Work to date has focused on how parents can help children cope after trauma. Despite having only studied a small sample, early indications appear to confirm the team's estimates. They suggest that as much as 90% of children have experienced a trauma and that it is common for children to experience multiple traumas. These early findings also point to the much wider challenges in terms of access to healthcare.

'You have to realise that often the people of Khayelitsha are struggling to get access to physical healthcare for even the most serious of conditions, let alone about mental health provision. For some families, this means their child can't get access to a doctor. It becomes about a hierarchy of needs and sometimes these children are very badly injured or physically unwell.' Distance to services and travel costs are both prohibitive for families on the breadline, she explains.

Stage one of the project will be to work with Professor Tomlinson and the team from Stellenbosch to develop a much fuller picture about what's really happening in the area. They will then make recommendations for families, the community, healthcare professionals and, potentially, policy-makers in the country.

'Currently, we don't have much information about provisions or support for these very high-risk populations. Frankly, as it stands, parents are not clear on what to do and aren't coherent on what mental health services, if available, could provide. Just understanding more about what these children and their families are going through is a good first step. Longer term, you'd hope this would lead to better-targeted interventions.'

I finished by asking Sarah about her personal involvement in the study. 'I guess anyone who has any sort of compassion would want to help in this kind of situation, and as a psychologist, I can help improve mental wellbeing in these areas. If we can't stop adverse events happening at least we can better understand their impacts and generate evidence on which interventions could be based.'