1. Introduction

Mental health is a central component of total wellness; however, in many developing countries it doesn’t give attention for the expansion of mental health institutions like the hospitals and clinics expanded for the treatment of physical health problems. In Ethiopia mental health problems do not given due attention like other physical diseases ^[2]. The prevalence of mental illness in Ethiopia is reported as 15% for adults and 11% for children ^[3]. Other research finding also reported the same reports by the years 2000 to 2008, the rates augmented by 3% for adults and 4% for children. From this acceleration, among every five persons, at least one will be affected by mental illness at some stage in life ^[3].

A systematic review of 10 studies of children’s mental health problem in 6 countries of Sub-Saharan Africa indicated a prevalence rate of 14.3% ^[4]. A review of the European studies found that about 27% of adults were affected by at least one mental illness ^[5] and in other study a similar number of people in Europe suffer from mental health problems ^[6]. The prevalence rate for mental illness in Canada is approximately 20%; that is, about one in five Canadians will be affected by mental illness that range from mild to severe in their life time ^[7].

Mental health problem has impacts on socio-economic development of nations and on the in dividuals’quality of life. For instance, the WHO indicated that, about four out of six people suffers from some form of psychiatric illnesses ^[8]. Other research findings also indicated that mental health problem costs the global economy approximately US$44 billion per year ^[9]. The economic burden of mental illness in the United States was estimated at $317.6 billion and over £105.2 billion a year in England ^{[10, 11]}.

Mental illness covers 14% to the global burden of disease worldwide. World Health Organization ^[8] reported that, 154 million people globally suffered from depression, 25 million people from schizophrenia, 91 million people from alcohol use disorders, and 15 million from drug use disorders. Around 25% of individuals, in both developed and developing countries develop one or more mental or behavioral disorders at some stage in their life ^[8].

The impact of mental illness does not favor to color, race or ethnicity, social status and educational level of individuals. Even a relatively mild mental health problem ^[12] can cause social, emotional, or cognitive changes that in turn disrupt the whole social and vocational achievements that have major effect on the individual’s entire life journey. Several research findings revealed that, mental illness affect individuals at any stage of their life, ^[13] and these individual delays in seeking treatment for the problem as a result it may leads to poorer treatment outcomes ^[14].

Most people in Nigerian believe ^[15] that, mental illness is the result of afflictions caused by supernatural forces. Due to this perceived causes for the illness, the traditional medical practitioners and religious healers are the sole individuals to help the patients getting relief from the illness.

Many people tend to hide their maladaptive behaviors, emotional illnesses or psychological distress that requires modern mental health treatments. For instance, in the United Kingdom, around, 60- 70% of persons who experience clinically significant mental health problems have not been received any interventions ^[16]. In Canada, only 30% of people with mental health problems ever seek help and many delay seeking help until their condition becomes very severe ^[17].

Different literatures also indicate gender differences in help-seeking behavior among people with mental illness. Generally, females are more likely to seek help for their illness than males do ^[18]. In contradiction, another study by Boyd in rural Australia indicated that around 55.7% of participants reported that they would seek help if they suffered from mental health problems and gender differences were observed, such that males had higher preference indication for seeking help from psychologists than females do ^[19]; though the difference was not statistically significant.

In the present study more than 23 (90%) of the participants were perceived as the illness is not easily treatable by the modern professional mental and physical health care providers. As a result, most of them preferred to seek help from the God they believe on. Few individuals also preferred to go to the traditional healers who can prepare herbal medications, to the readers of the old medical books in the religious institutions and some individuals also go to the “Tenquai” or magicians who have special ability to know the cause of the illness and recommend possible treatment mechanisms for the illness.

Different researcher findings revealed that the perceived cause of mental illness influences patient’s treatment-seeking behavior ^{[19, 20]}. There are different models that provide explanations for the causes ^{[20, 21]} of mental illness and suggest their own recommendations about treatment approaches for the illness. The ‘Supernatural model’ attributes mental illness to evil spirits, magic, demons, and witchcraft. The ‘Psychosocial model’ attributes mental illness to different psychosocial factors such as environmental stressors or traumatic life experiences or substance abuse. The ‘Biomedical model’ attributes mental illness to biochemical abnormalities, brain injury or disease, genetic factors and problem in the neurotransmitters or brain chemical messengers ^{[20, 21]}. The attributed cause of mental illnesses is different across culture and place where individuals live in. For example, most people in Canada prefer psychosocial explanations to mental illness ^{[20, 21]} on the other hand; most health professionals in Nepal ^[22] and people in the United States attribute mental illness to the combinations of stressful life events and biological/genetic factors ^[23].

Attribution of mental illness to supernatural power is very common in different parts of the world. In Papua New Guinea in the South Pacific, devil spirits and supernatural forces are believed to be caused mental illness when an individual or a group has breaks social taboos and norms or disobeying culturally expected obligations of the society ^[24]. The majority of people who have mental illness in Malaysia attributed the illnesses to supernatural agents such as witchcraft and possession by evil spirits ^[25]. The same traditional beliefs are manifested in the Ethiopian people ^[25]. The supernatural powers are assumed to affect the state of individuals’ mind are widespread in all ethnic or religious groups in Ethiopia ^[26].

The same research result is found in the present study. Most participants in the Gebremenfes Kidus holy site attribute the mental illness to the supernatural powers and they prefer to treat the illness through religious healing techniques and other traditional herbal medications which is unique to the culture of that society. Most people in the holy site consider the illness is coming from the punishing hands of the God; as a result, it should be treated only by his hands again. They consider the illness is incurable by psychologists and other mental health professionals like that of other physical diseases.

Therefore, the rationales behind conducting this research is to collect primary data about the perceived causes of mental illness and the treatment preference from people who experienced the actual problem in the Gebremenfes Kidus holy water sit around Axum town. The researcher was observed many people in the Gebremenfes Kidus holy water for many years when they practice unbelievable and miracle religious healing practices and talking or shouting at the devil spirits who possessed them when they sprinkled by priests with the holy water. Having observed the religious healing practices, the researcher initiated to conduct a research on the perceived causes of mental illness and the treatment seeking behaviors in that particular culture and on those people who experienced the problem.

2. Methods and Design of the Study

A qualitative data were collected using case study method. In line with this method, a cross sectional research design was employed in order to make detail assessment about the perceived causes and treatment seeking behaviors from participants with different family backgrounds, socio-economic status, ages, sex and area of residence etc. at a time. A case study method helps to gather detail and in-depth information about participants’ perception, feelings and knowledge about the attributed causes of mental illness and its treatment practices. The cross sectional research design is also important for the reason that all participants who are with different family background, socio economic status, ages, sex, religion, etc. to involve in the research at a point in time.

The research was conducted in Gebremenfes Kidus holy water which is found around 8 K.ms far from Axum town. Axum is the place where ancient human civilization started in the horn of Africa. In the town there are different historical sites and human made observable heritages like palaces, ancient architectures and obelisks that are erected starting from long years ago in the history of ancient human civilization. Peoples of the town perform different cultural and religious healing practices to the treatment of illnesses. The most widely practiced approach to the treatment of mental illness in the town is sprinkling holy water, praying, fasting, using herbal medications, wearing amulet in the neck of the patient taking from readers of the old medical books.

In the Gebremenfes Kidus holy site, people who celebrate being in the place and number of people who presented for sprinkling by the holy water varies from day to day. For this reason, it is difficult to clearly state the number of patients who visit the holy site per day. However, in average 10 individuals who have mental health problems visit the holy place per day. The researcher takes 25 participants using available sampling technique with in 3 consecutive days. Having deal with these 25 participants, the researcher continued to conduct interviews with the participants for about 7 consecutive days. The number of days were scheduled by the researcher with full of reason to do so. By the orthodox Tewahdo religious principle, for any type of mental and physical health problem a patient is recommended to sprinkle by the holy water for about 7 consecutive days without any interruption. The 7 consecutive sprinkling days is called “Shuwae” by the religion language. This religious principle helps the researcher to collect detail and enough data from the participants. From this amount of patients the researcher conducted interviews for many times with all participants who visit the place for 7 consecutive days. In addition to the patients, normal individuals also visit the holy place for making pray and protect themselves from such kind of illnesses. However, the so called normal individuals were not included in the study.

In order to ensure better validity and reliability of data collecting instruments, the researcher adopted and modified some items ^[2] from the instruments used to assess the perceived causes of mental illness by Deribew and Shiferaw 2005 and some items from seeking professional psychological help scale ^[27] to assess the treatment seeking behavior of participants. The previous scales were intended to assess the perceived causes of mental illnesses and treatment seeking behaviors. However, the scales were not used as it is in the present research. It modified in the way that it is appropriate for interview without changing its original meaning of the scales. Few items were taken from the previous scales and the remaining interview questions were developed by the researcher.

Having adopted and developed the semi-structured interview questions, the researcher conducted the interview with the individuals who have mental health problems and their caregivers. However information collected from the key informants or caregivers was used as a supplementary or supportive to the idea of the individuals who have mental health problems. The data was collected from the patients within 7 consecutive days in the holy water site and in the journey to the holy site since, the holy site is 8 K.ms far from Axum town. The researcher gives no time limitation for each patient during the interview sessions in order to get complete picture of each participant about the perceived cause of the illness and the treatment seeking practices. The perceived causes of mental illness were firstly asked to each patient and followed by the treatment seeking behaviors.

Different independent and dependent variables were treated in the research among these;

Independent variables: perceived causes of mental illnesses and treatment seeking behaviors.

Dependent variables: mental illness and treatment seeking behaviors. Treatment seeking behavior is both independent and dependent variable in this study.

First and for most, the researcher asked the patients’ willingness to conduct interviews. Then after, the purpose of the interview is clearly stated to each participant before starting the interview sessions. Each participant knows the purpose of the study is just for the expansion of science and for the sake of recommending possible scientific treatment mechanisms to the illness. The researcher informed each participant have the right to stop the interview if it goes the relationship in the way they dislike it. Privacy and confidentiality of participants’ response remains among the interviewer and the participants in the interview sessions.

3. Results

Table 1. The Socio-demographic Information of Participants

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The above table revealed that, 11(44%) males and 14(56%) females were participated in the interview. The number of males and females is almost proportional. In addition to this, the number of participants between 15-30 age ranges was 10(40%) which consisted the 2^nd rank among the age intervals that indicates high prevalence of mental illness. The reason why individuals who are below the age of 15 do not included in this research was, peoples who are in the age between 1-15 are under the control of their parents. To conduct research up on this age group needs permission from participants’ parent. In addition to that, this age group is supposed to be more cognitively and behaviorally immature. Therefore, it is difficult to collect appropriate and valid information in the absence of their care providers. 13(52%) and 2(8%) are the number of individuals who are found in the age interval between 31-45 and 46-65 respectively. The age interval from 31 to 45 is the highest number of individuals who were affected by the mental illness in that particular place and the most prevalent age group visiting the holy place.

The other variable that must be considered in the research is the marital status of participants. The highest category or social status which was affected by the mental illness is those who were widowed or currently have not any marriage relationship for different reasons. The remaining married 7(28%) and single 5(20%) categories are the other social statuses that affected by mental illness following the widowed social category. The participants’ academic level is another variable that is analyzed in the above table. Individuals who were between grade 9 and 12 are the academic ranks in which highly affected by the illness and who visited i.e., 9(36%) the holy site with high prevalence in that particular place. The remaining academic levels of certificate and diploma holders as well as the academic grades from 1- 8 consisted the 2^nd and 3^rd rank i.e., 6(24%) and 5(20%) respectively were individuals affect by the illness and visit the holy water in that particular place. The least prevalence is 1(4%), it means a single individual who have first degree and above affects by the illness and visited that particular place per day. The remaining variable is the participants’ residence places. 16(64%) of participants come from the rural areas of around Axum town and the rest 9(36%) individuals come from Axum town. The number indicates that, most individuals who are from the rural districts use more such kind of treatment practices for mental health problems than the individuals who live in the town in that particular society.

The supernatural agents as perceived causes for mental illnesses

More than 21(84%) of participants in the interview attributed the mental illness to the supernatural agents like, curs when somebody violates the religious principles specially the one who violates the God’s commandments and other social taboos, supposed to affect by the mental illnesses. They also consider mental illness may be caused by devil practices of individuals who are missioners of devil spirits. They assume also as some persons have special abilities to harm others using their malicious power gained from devil spirits and religious education or training.

Most of the participants in the holy water also believed that, mental illness may be caused by when individuals move and work out of the proper time allowed to someone by that particular culture. In those particular societal beliefs, the mid day from around 7-8 pm and mid night from 6-9 am is the time when devils mostly move from place to place. At these particular periods, devils may harm the mental health of individuals who are found in the inappropriate time and place. “God gives men the day to work in and have pleasure; the night belongs to the devils!!” This is the idea taken from one participant during the interview session.

In addition to the above attributed causes of mental illnesses, some participants of the study also perceived mental illness as the result of when somebody walks around garbage dumps, ashes, walking along river banks and forests as well as walking around tombs. These particular places are considered as the potential areas to found devils that may affect the mental health of individuals.

As per the report of the participants, in the area there are certain social classes that are assumed to have special ability to harm the mental health of others. These marginalized social classes suspected of possessing the evil eyes or locally called “Buda”. Mainly these social classes are the members of the artesian classes like, the blacksmiths, goldsmiths, pottery makers and weavers. Such kinds of social classes in that particular place consider as they have special abilities to harm the mental health of others. This kind of special ability is presumed to be transferred from parent to children or hereditary.

Furthermore, in that particular place there are some individuals who seem religious men but really they are not religious. They specialize by the orthodox religious institutions to harm others. These individuals may harm others using their religious abilities on those who envy provoking persons. The envy of the religious persons “Debtera” may be provoked by the wealth of the affected persons, the religious person may be also jealousy at the good marriage relationship of the affected person he/she has with his/her wife or husband. The other reason is, the envy of the religious men may be provoked due to the attractive physical appearance of the affected person. Due to the above reasons, the one who seems religious person but not real religious man can affect the mental health of others. These religious individuals may also harm others by the order of other individuals who have not special ability to harm their enemy like the religious men. These individuals are called “Debtera” or “Metsihaf Gelach” by the local language of that particular society.

Generally, most participants of the study attributed the causes of the illness to the supernatural forces such as, possession by evil spirits, devil practices of individuals who presumed to have special abilities whether it gained though genetic inheritance or through religious education or trainings. Furthermore, most participants of the study make the socio-cultural and religious beliefs of that particular society responsible for the causes of mental illness.

The psycho-social factors as perceived causes of mental illnesses

In addition to the supernatural beliefs to the causes of mental illnesses, participants of the study also believe on the roles of the environmental and social stressors to the causes of mental health problems. 14(56%) of the participants agreed up on the traumatic life events, over thinking about daily life experiences, low social relationships, poverty and failure to achieve life goals are the perceived causes for the mental health problems. For you surprise as one participant reported that, “she is my previous wife makes me crazy who shows me not to finish what a good love I spent and enjoyed with her.” At that time his wife was not with him, she rejected him because he does not keep himself means that, he abuses drugs and alcohol while he was living with her. For this reason she made divorce with him at the expense of his interest.

The other responsible factor to the development of mental illness as per the report of some participants was inability to cope up with the challenges of daily lives and poverty. They consider the cause of the mental health problem as the result of over thinking about their future time; because they have limited economic resources to cover their expense in the future as their age increases. The over thinking disturbs their sleep and their life in general; and then this leads to severe mental health problems. One participant reported that, “life becomes challenging for me; when I strive to fill the missed one, other things do not wait me till I finish the unfinished one. In such moment, I need to escape somewhere else but, the parental responsibilities obligated me to stay there. Such circumstance makes me confused, tensed and even crazy”.

As two participants reported that, the onset for the mental illness was the unexpected death of their close relatives from the family. From that onwards, when they remember about their close relatives, they feel very gloomy and brokenhearted. Such kind of thinking disturbs the mental health of participants in their entire life time. They tried to forget many times to such kinds of obsession thinking but, it was not successful instead it leads them to the very severe mental health disturbances.

Generally, following to the supernatural agents of the causes of mental illness, the psycho-social factors attributes to the causes of mental illness by the participants who explained during the interview sessions. Most of the time participants’ belief on the supernatural cause of the illness over weighs to that of the psycho-social causes of the mental health problems. Most participants perceive the psycho-social factors play the second role following to the supernatural causes to the mental illnesses.

The Biochemical model as a perceived cause to the development of mental illness

Few individuals 6(24%) strongly believed on the causal roles of biochemical or genetic factors to the development of mental health problems. This amount of persons in the holy place reported that, “it is obvious to happen mental health problems on the children when there is problem in the parents during the stages in the life time because, the father harvested what he sowed in the ground”. This sentence was taken from one participant during the interview. Even though few participants believed on the biochemical model to the causes of mental illness, but they had negative attitude towards the effectiveness of the biomedical model to the treatment of mental health problems.

To sum up, whether somebody believes on the causes of supernatural agents, psycho-social or biochemical factors, it is the matter of his/her perception that affects his/her mental health outcome positively or negatively. The same is true for the effectiveness of the treatment practice to the illness. This is to mean that, the one who strongly believes on the particular treatment approach, the more effective and better treatment outcome of that particular treatment practice will be ^[28].

The supernatural agents as perceived causes for mental illnesses and its impact on the treatment seeking behaviors in the individual

Most participants who consider the causes of mental illness as the result of the supernatural powers, they also prefer to seek help from the supernatural agents. This is because most participants reported that, “He is the God makes us to have mental illness therefore, he is also the only one who have a divine power to cure us from the illness”. This is the word of the mass during the interview that is why they seek help from the kingdom of the God in the holy place of Gebremnfes Kidus holy water.

Since mental illness is attributed to the punishing hands of the God, therefore forgiveness for the mistakes of one’s deeds should be received from the hands of the God. This is to mean that, mental illness is perceived to be come when somebody disobeying to the God’s principle and violates other social taboos. Therefore, the only one who makes an excuse to the devil practices of such individuals is the God only. Most of the participants of the study strongly believed on this idea.

However, more than 14(56%) of participants also tried to seek help from the individuals who believed to have special power of knowing and prescribing traditional treatment practices to the mental illness. These special individuals believed to have special power of harming the mental health of others and to give or suggest treatment practice for the illness at the same time. As per the report of the participants, they tried to get help from such kinds of individuals for many times but, the treatment outcome was not as effective as they were expected; that is why they came to the holy place for better treatment of the illness.

There are special persons that prepare herbal medicine for harming the mental health of persons and at the same time they can also prepare herbal medications from forests’ leaf, root and team to the treatment of mental health problems. These individuals can prescribe doses of the herbal medications without any dose limitation for the illness. As some participants reported that, the dosage of the medication may intensify the illness and it also exposed them to other physical health problems like, liver damage, stomach ache, kidney disease, hypertension, and other related Cardio Vascular Diseases (CVD).

Some participants reported that, the illness was developed as a result of possession by the evil spirits for different reasons and in different occasions. For example, as one participant reported that, he was possessed by the evil spirit while keeping his crop production in the farmland at the mid night time. “The evil spirit called me by the name of my son in the mid night then I respond him immediately without any hesitation because, I consider him as my friend in our neighbor is calling me.” This sentence is taken word by word from one participant during the interview. The same is true for the other participant he possessed by the evil spirit while he going to church in the mid night. These are among the many perceived causal reasons for the illness by the participants during the interview sessions. Therefore, from their perception, the only appropriate treatment mechanism for the illness is the holy water sprinkling, fasting and praying being in the holy places.

The other impressive thing that two participants explained during the interview was, the mental health problem can be affected by some individuals who have special abilities to harm others. These individuals have a special social class in that particular society. The name given by the local language for such individuals is “Buda” or evil eye. Many traditional treatment practices were explained by the participants for those who called “Buda” or evil eye, but the holy water sprinkling is among the appropriate healing technique for such kind illness.

Furthermore, there are different treatment practices stated by the participants in that particular society. Among these, when the disease is thought to be caused by the evil eye or “Buda”, an attempt is made to identify the name of the “Buda”using smoke in the closed house. This action is thought to undo the attack of the sick person by the “Buda”. The first step among the healing ritual is making patient’s position very close to the smoke and then the priest or any other person repeatedly asking the patient to talk the name of the “Buda” or evil eye he/she possess him. Among the questions, who are you? This is the first question asked to the affected person. At this time, it is assumed to be the evil eye or “Buda” will expose him/herself through the mouth of the sick person with the evil eye’s tone or voice. Then, the next question followed, why you have taken possession of this person? And where did you encounter him? Will you please leave this sick person? If the response of the evil eye is “no” then the sprinkling and smoking continues until the evil eye or “Buda” agree to leave. What do you want? The usual response of the “Buda” or evil eye to the question is ashes or “Atela” (sediment of the local alcoholic beverage called “Tella”). Some of the ashes or “Atela” gives to the victim to eat. Finally, the so called “Buda” or evil eye assumed to leave his/her possession of the victim. At the end when the victim awakes, he/she can remember nothing about the healing rituals and becomes healthy.

There are religious individuals but not really religious men who have the ability to affect the mental health of others through the education and training gained from the religious institutions in that particular society. These individuals also have the ability to cure the illness through reading different old medical books and preparing amulets from what they have read. The amulet is prepared from, writings of old medical books or from the holy bible folded and cover by the animal skin and then the patient ordered to wear like other jewelries in his/her neck and hands. They also pray reading different books over a glass of water. The water is expected to heal the illness when a patient is sprinkling by it. Therefore, these special individuals or locally called “Debtera” have the ability to affect the mental health of others at the same time also have the ability give treatments for the illness.

There are persons who have malicious power or locally called “Tenquai” or magician to know the cause of mental illness and suggest better treatment mechanisms for the patients in that particular society. These individuals can also prepare medications from deferent herbs and other unknown ingredients. Five participants reported that, they visited many times to those individuals to have better treatment for the illnesses. However, the effectiveness of the prescribed herbal medications and other unknown ingredients were not as effective as they expected.

The persons who have malicious or magical power are different from the previously explained the so called “Debtera” or religious but not really religious men. The “Debter” is gained his special ability through religious education and training whereas, the “Tenquai” or magicians’ ability is gained from the unknown.

The psycho-social factors as perceived causes of mental illnesses and its perceived treatment seeking behaviors by the patients

As stated in the above psycho-social causal factors for mental illness, individuals who believe on these causal factors perceived their problems may be solved if there is good professional help in addition to the religious healing practices. More than 48% of participants reported that, the mental health problems can be solved if environmental stressors are avoided and if there is no anything that makes them to think more in their daily lives. Among the environmental factors that participants suggest for the recovery of their mental health are good family and marriage relationship, having enough economic resources, and good professional help to forget some traumatic life events and obsession thinking from their awareness.

The Biochemical model as perceived causes to the development of mental illness and the treatment seeking behavior of individuals who believe on this model

Even though few participants believed on the genetic factors for the development of mental illness, but they had negative attitude toward the effectiveness of the modern biochemical treatment approaches to the treatment of mental illnesses. As stated in the above biochemical causal factors to mental illness, “the father harvested what he sowed in the ground. Therefore, it is obvious to have mental health problem within the children if there were mental health problem with parents. Mental illness may not have any solution from the modern mental and physical health care providers but nothing is hidden from the sight of God, he may cure us from the illness one day using his divine power”. This idea is taken without any magnification or minimization from few participants during the interview.

Generally, in whatever model patients believe on, it is their matter of perception that directed them to find ways for the treatment of the illnesses. Therefore, there is no specific and better treatment approach to a particular mental illness. The treatment effectiveness depends on the weight given by the patients toward that particular treatment practice ^[28]. Furthermore, the choice of where to seek help is said to depend on the what is believed to be the causal factor of the illness ^[1]. Because mental illness is believed to be due super natural causes, a significant number of people with mental health problems tend to initially seek and to continue seeking traditional healers’ before visiting for the professional psychological services and the modern medical help ^[1]. As a result traditional healers find themselves shouldering a large burden of care of patients with mental health problems.

4. Discussions

The researcher assessed some perceived causal factors and treatment seeking behavior of individuals who have mental health problems. However, the research results in the present finding are very few just like taking a glass of water from an ocean. In Ethiopia there are lots of traditional, cultural, and religious beliefs as well as treatment practices of mental illness.

Even though few participants were believed on the psycho-social and biochemical models to the causes and treatment preferences of mental illnesses, the researcher can confidently conclude that, almost all of the participants firmly believed on the supernatural agents to the cause and treatment practices of mental illness. Most of the participants more or less tried the traditional and cultural treatment practices however, finally they decided to go and pray in the kingdom of the God. In previous studies of Papua New Guinea in the South Pacific, devil spirits and supernatural forces are believed to cause mental illness when an individual or a group has breaks social taboos and norms or disobeying to the culturally expected obligations of the society ^[24]. The majority of Malaysian people who have mental illness also attributed the mental illnesses to supernatural agents such as witchcraft and possession by evil spirits ^[26]. Other previous study conducted ^[2] in Ethiopia also revealed the same result about the attributed causal factors and help seeking behaviors of people with mental illness. The supernatural agents are attributed to affect the state of individuals’ mind are common in all ethnic or religious groups in Ethiopia ^[25]. In some Ugandan communities, treatment is mostly sought from traditional healers initially, whereas modern form of care is usually considered as a last option. The factors found to influence help seeking behavior within the community include: beliefs about the causes of mental illness and the people’s lack of awareness about the scientific cause and treatment approaches to the illness ^[1].

In the present study following to the supernatural powers, significant number of participants was believed on the psycho-social model to the causes of mental illness and needs help from professional mental health care providers. A study conducted in Ethiopia ^[26] majority of participants (over 87%) attributed the cause of mental illness to the psychosocial factors and the participants’ attitude toward seeking professional psychological help was positive. This belief goes with the scientific wisdom of the field, and education can enlighten people and aid in resisting more traditional and primitive notions about mental illness because the research was conducted on third year university students ^[25]. Generally, the more education a person has received, the more enlightened he or she would be with regard to ways of resolving problems, and the more likely they would be to seek help from professionals when faced with psychological problems ^[26].

For your surprise, few participants in the present study have strong beliefs on the biochemical model to the causes of mental illness. However, these participants had negative attitudes toward the effectiveness of the biochemical model to the treatment of mental health problems. However previous Studies indicate that, perceived causation of mental health problems influence help seeking behavior and the type of help that is sought ^[19]. A previous research result conducted ^[25] in Ethiopia on university students also revealed that most of the participants in the study attributed mental health problems to biogenetic factors and participants seeking help from professionals.

Studies in the Western world show that, mental illnesses are generally thought to be caused by psychosocial factors such as, environmental stressors and traumatic life experiences ^[29]. Biochemical and genetic inheritances are also recognized as causal factors to mental illness but, it is not equally important as environmental stressors ^{[29, 30]}. Most of the time, severe mental illnesses such as schizophrenia are more likely to be linked to genetic causal factors, compared to the common mental health problems, such as anxiety and depression ^{[29, 30]}.

To conclude, mental health is an integral part to the total well being of every person regardless of one’s age, sex, religion, social class, educational levels etc. In Ethiopia the area of mental health does not give due attention by the government and researchers. Having said this, the researcher indicates the government to give an attention to the area and suggest mental health researchers to conduct their research on the mental health beliefs and practices in Ethiopia in the future. The government of Ethiopia currently invested on the area of health intubations for the treatment of physical health problems. Just like that, on the area of mental health should also be invested whatever facilities and human development programs needed. This is because “there is no health without mental health!” ^[31].

There were different factors that might be negatively affected the research results. Among these, it would be better if more participants were involved in this research. That is because, the more participants were involved in the research finding, the more comprehensive and representative information would be collected during the interview. The main reason to delimit the number of participants to 25 individuals is, due to lack of money to afford daily fee for the data collectors. No one was helped the researcher through funding during the data collection time. For this reason, the researcher forced to delimit the study participants and study site in to one area. The other potential limitation of the study might be, few participants were not fully voluntary to disclose very detail information about the perceptions of the problem and treatment seeking practices tried before coming to the holy water. The reason for this may be, due to the cultural and religious beliefs of that particular society. These reasons might be affected the research result to some extent negatively.

The research result implied that; the concerned body should create awareness on the scientific cause and treatment mechanism of the illness on the society. The society has no any awareness about the scientific cause and modern treatment approaches to the illness. As a result, their mental health might be severely affected when delaying to receive treatment form the modern mental health care providers. Delays in seeking proper treatment are known to compromise the outcome of the care ^[1]. In addition to this, patients were taken herbal medications without any dose limitation and any scientific proof about the clinical effect and adverse effect of the medications. The drug prescription without any scientific ground might be affected the mental and physical health of individuals.

The research result also implies that, the different traditional healing techniques were not effective as patients expected to get relief from that particular healing practice in the first-second trial periods. Therefore, the participants’ perceptions and treatment practices might be changed to modern professional psychological help and medical treatment in the near future. That is because, it is natural to seek other options if first and second trial periods towards the solution of the problem were not successful.

5. Conclusions

Result of the present study revealed that, participants had negative attitude towards the modern psycho-social and biogenic models to the causes and treatment of mental illness and have positive attitude towards the supernatural agents for the cause and treatment of the illness. This shows that, most people have little knowledge about the scientific nature of the problem as well as its treatment mechanisms. Furthermore, mental health in Ethiopia needs further research in order to digging out the peculiar beliefs and practices made by the people towards the causes and treatment practices of mental illnesses. Most of the time, the Ethiopian people attribute mental health problems to supernatural powers. As a result, most people observed to seek help from the supernatural agents like, praying, fasting, holy water sprinkling, and consulting individuals who presumed to have special powers of healing mental health problems. These special persons are locally called, “Tenquai” or magicians, “Debtra” (persons who perform devil practices using their religious knowledge and training) and other special individuals who have the ability to prepare herbal medications without any scientific knowledge about the effect of the medications. Notable: “Debera” is defined as individuals who have special powers to affect and treat the mental health of others using their religious education or training. But, the religion does not allow those individuals to invest their knowledge on such kinds of devil practices.

Peoples’ belief determines the treatment seeking behaviors. However, when individuals seek help from other options, they strongly believe on the supernatural power to the cause and treatment of the illnesses. In contrast, few participants of the study believed on the biological or genetic factors to the cause of mental illness, but their attitudes toward the biochemical treatment of the illness were negative.

Based on the conclusions made in the above, the researcher indicated future directions particularly in the area of mental health.

•  The government should expand mental health institutions that work to educate the society about the nature and treatment mechanisms for the illness.

•  Mental health researchers should conduct further investigation in the area in order to digging out the untouched people’s belief about the illness.

•  Patients should carefully decide about the treatment practices before starting the particular traditional healing technique. This is because, the herbal medications taken without any dose limitation and scientific proof about the clinical and adverse effect of the medication upon the individuals’ mental and physical health. The unscientific prescription of the medications may expose individuals to other chronic mental and physical health problems.

•  The government should make liable to the individuals who prescribe herbal medications and other traditional healing practices for their action following the treatment practices.

•  Awareness creation programs should be conducted through governmental and non-governmental mass media, conferences, seminars, symposium, magazines and news papers about the scientific nature and treatment approaches to the illness on the society.

•  Policy makers in the area of health should take the result of this study as an input in the future.

Acknowledgments

First and for most I would like to express my heartfelt gratitude to the participants of the study for their generous cooperation and trust they had during the interview sessions. Secondly, I would like to say thanks for my family and friends who encouraged me to conduct this research through providing constructive suggestions and comments.

References

[1]	James R Nsereko, Dorothy Kizza, Fred Kigozi, Joshua Ssebunnya, Sheila Ndyanabangi, Alan J Flisher, Sara Cooper, MHaPP Research Programme Consortium. Stakeholder’s perceptions of help-seeking behavior among people with mental health problems in Uganda. International Journal of Mental Health Systems. 2011.
	In article
[2]	Deribew, A., &Shiferaw, Y. How are mental health problems perceived by a community in Agaro town? Ethiopian Journal of Health Development, Addis Ababahttps://www.ajol.info/index.php/ejhd/a. 19(2), 153-159. 2005.
	In article
[3]	Susuman, S. A. Mental health promotion in Ethiopia: Emerging issues faculty of natural sciences. University of the Western Cape Town, South frica. wmhconf2010.hhd.org/…/…2010
	In article
[4]	Cortina, M., Sodha, A., Fazel, M., &Ramchandani, P. Prevalence of child mental health problems in Sub-Saharan Africa: a systematic review. Archives of Pediatrics and Adolescent Medicine, 166(3), 276–281. 2012.
	In article		CrossRef PubMed
[5]	Organization for Economic Co-Operation and Development (OECD). Mental Health in OECD Countries. Policy Brief. Retrieved on 3/3/2013 from www.oecd.org/health/healthdata. 2008.
	In article
[6]	Wittchen, H. U., & Jacobi, F. Size and burden of mental disorders in Europe: a critical appraisal of 27 studies. European Neuro-psycho-pharmacology, 15(4), 357-376. 2005.
	In article		CrossRef PubMed
[7]	Jorm, A. F., Barney, L. J., Christensen, H., Highet, N. J., Kelly, C. M., & Kitchener, B. A. Research on mental health literacy: what we know and what we still need to know. Australian and New Zealand Journalof Psychiatry, 40(1), 3. 2006.
	In article		CrossRef PubMed
[8]	WHO. Book on mental health. Geneva: Human Rights and Legislation. 2002.
	In article
[9]	Human Resources and Training in Mental Health. Mental Health Policy and Service GuidelinePackage. https://www.who.int/mental_health/policy/Training_in_Mental_Health.pdf. 2006.
	In article
[10]	Kessler, R. C., Heeringa, S., Lakoma, M. D., Petukhova, M., Rupp, A. E., &Schoenbaum, M. Individual and societal effects of mental disorders on earnings in the United States: results from the national co-morbidity survey replication. The American Journal of Psychiatry, 165(6), 703-711. 2008
	In article		CrossRef PubMed
[11]	Centre for Mental Health. Economic and social costs of mental health problems in 2009/10. London: Centre for Mental Health. 2010.
	In article
[12]	Rickwood, D., Deane, F., Wilson, C., &Ciarrochi, J. Young people’s help-seeking for mental health problems. Australian e-Journal for the Advancement of Mental Health, 4(3), 1446-7984. 2005.
	In article		CrossRef
[13]	Patel, V., Flisher, A., Hetrik, S., &McGorry, P. Mental health of young people: a global public-health challenge. The Lancet, 369, 1302-1313. 2007.
	In article		CrossRef
[14]	Boyd, C., Hayes, L., Nurse, S., Aisbett, K., Francis, D., Newnham, K., & Sewell, J. Preferences and intention of rural adolescents toward seeking help for mental health problems. The International ElectronicJournal of Rural and Remote Health, 11, 1582. Available from: https://www.rrh.org.au. 2011.
	In article
[15]	Ganesh K. &Udoh J.Knowledge and Attitude of Mental Illness among General Public of Southern India. National Journal of Community Medicine. 2012.
	In article
[16]	Royal College of Psychiatrists. No health without public mental health: Position statement. 2010. Available at https://www.rcpsych.ac.uk.
	In article
[17]	Centre for Addiction and Mental Health. Challenges & choices: Finding mental health services in Ontario. 2003.
	In article
[18]	Ciarrochi, J., Wilson, C. J., Deane, F. P., &Rickwood, D. Do difficulties with emotions inhibit help seeking in adolescence? The role of age and emotional competence in predicting help-seeking intentions. Counseling Psychology Quarterly, 2003. 16, 103-120.
	In article		CrossRef
[19]	Clarke, J. Mad, bad and dangerous: the media and mental illness. Mental Health Practice, 7(10), 16-19.
	In article		CrossRef
[20]	Gureje, O. &Alem, A..Mental health policy development in Africa. Bulletin of the World Health Organization, 78(4) # World Health Organization. 2000.
	In article
[21]	Beverley, B., & Richard, C. (2007). Mental health literacy in Canada: phase one report mental health literacy project.Canadian Alliance on Mental Illness and Mental Health.
	In article
[22]	Shyangwa, P. M., Singh, S., &Khandelwal, S. K. Knowledge and attitude about mental illness among nursing staff. Journal of Nepal Medical Association, 42, 27-31. 2003.
	In article
[23]	Link, S..Public perception on mental illness: level, causes, dangerousness and social distance.American Journal of Public Health, 89(9), 7328-7333. 1999.
	In article		CrossRef
[24]	Koka, B. E., Deane, F. P., & Lambert, G. Health worker confidence in diagnosing and treating mental health problems in Papua New Guinea. South Pacific Journal of Psychology, 15(1), 29-42. 2004.
	In article
[25]	Yirgalem A. Perceived Causes of Mental Health Problems and Help-Seeking Behavior among University Students in Ethiopia. Springer Science+Business Media New York: 2013.
	In article
[26]	Razali,M., Khan, A., &Hasanah, I.. Belief in supernatural causes of mental illness among Malay patients: impact on treatment. ActaPsychiatricaScandinavica, 94(4), 229-233.
	In article		CrossRef PubMed
[27]	Ang, R. P., Lau, S., Tan, A.-G., & Lim, K. M. Refining the attitudes toward seeking professional psychological help scale: factorial invariance across two Asian samples. Measurement and Evaluation inCounseling and Development, 2007. 40(3), 130-141. https://mec.sagepub.com/.
	In article
[28]	Gubrrine K. Belief in supernatural causes of mental illness among Malay patients: impact on treatment. ActaPsychiatricaScandinavica, 2013. 94(4), 229-233.
	In article
[29]	Jhon G. Knowledge and Attitude of the kinondoni Community toward Mental Illness. Department of Nursing Science; Stellenbosch University, Tanzania. 2011.
	In article		PubMed
[30]	Jorm D, Recovery centers for people with severe mental illness: a survey of programs. Community Mental Health Journal. 2000.
	In article
[31]	WHO. No health without mental health: Position statement. 2012. Available at https://www.rcpsych.ac.uk.
	In article