Aitururu (Sadness): Variation of Idioms of Distress among the Iteso
Sam Emuria Ojikan Akoit
2020/HD03/20148U
A research proposal submitted to the School of Psychology in partial fulfilment of the
requirements for a Master of Science in Clinical Psychology of Makerere University
July, 2022
i
Declaration
I Sam Emuria Ojikan Akoit, declare that this research proposal titled Anxiety, depression
and coping strategies among mothers during postpartum period is my original work and has
never been submitted to Makerere University or any other institution of higher learning for
any award or grant.
Signature……………………………….
Date…………………………………….
ii
Approval
I certify that this research proposal titled Aitururu (Sadness): Variation of Idioms of
Distress among the Iteso by Sam Emuria Ojikan Akoit has been written under my
supervision.
Signature…………………………………….
Date……………………………………..
Dr. Roscoe Kasujja
Supervisor.
iii
Table of Contents
Declaration .................................................................................................................................. i
Approval ....................................................................................................................................ii
Chapter One ............................................................................................................................... 1
Introduction .................................................................................................................... 1
Background .................................................................................................................... 1
Statement of the Problem ............................................................................................... 3
Purpose........................................................................................................................... 5
Objectives of the Study .................................................................................................. 5
Research Questions ........................................................................................................ 5
Scope of the Study ......................................................................................................... 5
Significance of the Study ............................................................................................... 6
Chapter Two............................................................................................................................... 7
Introduction .................................................................................................................... 7
Idioms of Distress .......................................................................................................... 7
Cultural idioms of Distress ............................................................................................ 9
Clinical Utility of Idioms of Distress ........................................................................... 10
Chapter Three........................................................................................................................... 11
Introduction .................................................................................................................. 11
Study Area ................................................................................................................... 11
Design of the Research ................................................................................................ 11
Study and Target Population ........................................................................................ 11
Sampling technique and procedures ............................................................................ 12
Data Collection Methods ............................................................................................. 12
Data Collection Instruments ........................................................................................ 13
iv
Data Management ........................................................................................................ 13
Data Analysis ............................................................................................................... 13
Quality control issues ................................................................................................... 13
Ethical Issues ............................................................................................................... 13
Study Limitations ......................................................................................................... 14
Appendices ............................................................................................................................... 15
Appendix I: Consent Form (English version). ............................................................. 15
Appendix II: Interview Guide. .................................................................................... 17
Appendix III: Interview Schedule ................................................................................ 18
Appendix IV: Work Plan ............................................................................................. 22
References ................................................................................................................................ 23
1
Chapter One
Introduction
This chapter contains the; background, statement of the problem, theoretical
framework, objectives of the study, research questions, scope of the study and the
significance of the study. This chapter provides a justification for looking at variations in
expressions of sadness.
Background
Sadness is a common Problem, particularly for those suffering from depression,
which affects an estimated 300 million people worldwide (Patel et al. 2016). It represents the
second leading cause of disability, with an estimated global point prevalence of 4.7 percent,
and is the eleventh largest contributor to the global burden of disease (Ferrari et al., 2013).
Although more than 80 percent of the people with mental illness reside in low- and middleincome countries (LMIC) (Rathod et al., 2017), the diagnostic categories of depression and
its screening and measurement tools have been developed in high resource, Western cultural
contexts which means that most assessment for depression follows a totally foreign form
resulting in unclear or misleading observations or conclusions regarding diagnosis.
In the need to explore and incorporate local ways of how distress is understood and
expressed, Nichter (1981) coined the phrase „„idioms of distress.‟‟ which has mostly been
used by anthropologists to better understand the languages used by people of distinct sociocultural societies to describe suffering, pain, and illness (Jacob, 2019). Idioms of distress,
though rarely studied, have grown in prominence as a way to characterize interpersonal,
social, political, economic, and spiritual reasons for suffering, especially since their inclusion
in the most recent diagnostic and statistical manual (DSM-5) (Mendenhall et al., 2019).
2
Idioms of distress are the „„socially and culturally resonant means of experiencing and
expressing distress in local words,‟‟ and are often polysemic and dynamic in nature, with
continuous transformation due to historic and cultural processes (Nichter 2010). These idioms
of distress can be used to communicate internal states across a range of severity, from mild
distress to clinical psychiatric morbidity (Lewis-Ferna´ndez and Kirmayer 2019). Idioms of
distress are often correlated with psychiatric disorders, but also capture information and
heterogeneity beyond standard DSM/ICD diagnostic categories (Kohrt et al. 2014).
Cross-national epidemiologic research has revealed that mental diseases afflict people
all over the world and that people's perceptions of and responses to suffering differ, the
concept of idioms of distress has provided a mechanism to study culturally distinct types of
distress without having to categorize and reify them. This means that we can study how
people talk about and react when they are distressed in order to understand more about how
they feel (Kirmayer, 2001), (Kaiser & Jo Weaver, 2019).
There is an urgent need for culturally informed and locally valid approaches to mental
health evaluation and intervention all over the world, particularly among disadvantaged and
marginalized people. Such methods must be guided by a thorough understanding of locally
applicable idioms of distress and their determinants, including those triggered or intensified
by globalization (Gibson et al., 2019).
Aitururu is one of those Ateso idioms that the Iteso use whenever something sad
occurs resulting in perceived or real loss in any real-life situation. Since sadness is a key
ingredient in the criteria for diagnosing depression, more effort and attention should be given
to understand, and explain such idioms and their application in the expression of distress, and
intervention in the local context.
3
Although Uganda is one of the most ethnically diverse countries in the world,
research targeted at exploring how particular ethnic communities‟ express idioms of distress
is scanty, limiting mental health evaluation and utilization of therapies (Cork et al., 2019).
This research will target understanding how Aitururu (sadness) is applied as an idiom of
distress and how it can be expressed locally to explain distress as well as the variations in the
ways aitururu is implied in order to locally contextualize intervention among the Iteso.
Statement of the Problem
Most of the relocated during the 1987–1992 civil wars and after hostilities stopped in
Uganda, researchers found a high rate of mental health issues (distress), including depression,
anxiety, PTSD, hazardous alcohol use, and suicide. Health providers have prioritised
maternal mental health, yet government services are inadequate (Tol et al., 2018).
Recent findings indicated that at least 14 million Ugandans suffer a diagnosable
mental condition, with the rates of depression rising to 28.9% of the population after Covid19 Related lockdown (Logie et al., 2022).
Teso region is the second poorest part of the country due to a variety of issues,
including flooding, Lords Resistance Army raids, and Karimojong raids, which have all had
an impact on both the region's psychological and economic productivity (Rafa et al., 2022).
There has been little research in Uganda on the use of local idioms of distress in
health in the expression of distress. Because of this knowledge gap, Many Ugandans in
psychological distress do not obtain formal care; they instead find solace in social or religious
help from within their communities (Johnson et al., 2017).
Teso distress idioms aren't investigated. This research aims to improve mental health,
health-seeking, and therapy. Poor folks need specialised mental health treatment. Such
4
remedies must be customised to local idioms of suffering and their causes, namely global
power disparities and structural injustices (Gibson et al., 2019).
Theoretical framework
Theory can be defined as an objective, educated guess about a set of assumptions. On
the other hand, Creswell (2014) defined a theory as “a set of constructs interrelated and
formed into propositions or hypotheses to specify a relationship among variables”.
Constructivism theory was formulated by Jesse Delia 1976. The major assumption of the
theory is that people who are cognitively complex in their perception of others have a
communication advantage over those with less developed mental structures. These fortunate
individuals can produce sophisticated messages that have the best chance to achieve their
own goals. Griffin (2000) observes that constructs are the cognitive templates or stencils we
offer, to fit over reality to bring order out of chaos. The underlying argument of the social
constructionist theory of representation is predicated on the fact that meaning does not reside
or inhere in things in the world; rather, it is fixed socially, fixed in culture: thus, it is
constructed, it is produced. The foregoing implies that as human beings, we analyse activities
or events taking place in the society and interpret them, after which we will assign meaning
to them. The meaning we give to such things depends on how we perceive them. Thus, we
may perceive them to be bad or good. In any event, it is our perception that guides the
assignment of meaning. Constructivism theory centres on the categories of personality and
actions that we use to define the character of another person. The theory is very relevant to
the study at hand seeks to understand the way the people (maybe the Iteso) interpret and use
aitururu in various situations as an idiom of distress hence assigning it meaning consciously
or unconsciously.
5
Purpose
To explore variation in the use of sadness (aitururu) as an idiom of distress among the
Iteso and its influence on mental health seeking behavior.
Objectives of the Study
The general objective of this research is to explore what Iteso mean when they say Aitururu
and the various contexts in which aitururu is expressed.
1. To explore the meanings the Iteso attach to the usage of Aitururu (sadness) as an
idiom of distress.
2. To investigate other idioms used to express Aitururu
3. To explore contexts in which Aitururu is expressed.
4. To gather information about other cultural expressions in which aitururu my surface
Research Questions
1. What meanings do the Iteso attach when using the word Aitururu?
2. What other idioms are used to express Aitururu by the Iteso?
3. How do the Iteso express Aitururu?
4. What other cultural expressions may contain Aitururu among the Iteso?
Scope of the Study
The study will be conducted in the peri-urban area, particularly at Soroti city. Soroti is
the main town of the Teso region. It will seek information on the subjective opinions of the
subjects on aitururu and other idioms of distress, their application and contribution to
improvement in the understanding of distress, its symptoms, how people respond and healthseeking behavior in the case of community members. Idioms of distress are those ways in
which members of sociocultural groups convey affliction. The data collection will be carried
out for one month.
6
Significance of the Study
This will help to decrease language hurdles that could lead to misinterpretation; by
providing a better understanding of aitururu and its role in expressing distress among Ateso
speakers, This study will lead to a better comprehension of discomfort and, as a result,
improve health-seeking behaviour, because a better understanding and expression of
suffering leads to a desire to intervene.
The researcher believes that, like all other empirical research, the findings of this will
be utilized as a resource by future academicians who want to conduct similar research, may
be incorporated in other publications in terms of reference, updating, and providing
international understanding, as well as highlighting the utilization of aitururu in the daily life
of Ateso speakers. This will go a long way toward enriching the Ateso language in terms of
expressing distress and contextualizing interventions.
The results of the study will be documented and shared with the relevant stakeholders
once it is completed. Therefore, government, through its policymakers and implementers, can
use this data to navigate program interventions, track program progress, and inform
management of health – related issues that may develop in the near future.
7
Chapter Two
Introduction
This chapter will highlight the relevant findings of the different studies that have been
done globally, continentally, and around the country to underscore the importance of
understanding the role of idioms of distress in the contextualization of health care in Ugandan
setting.
Idioms of Distress
Idioms of distress are those ways in which members of sociocultural groups convey
affliction. Idioms vary across cultures, depending on the salient metaphors and popular
traditions that pattern the human biological capacity for experiencing distress, including
conditions that are sufficiently severe to meet criteria for psychiatric disorder (Hinton &
Lewis-Fernandez, 2010).
Idioms of distress are alternative modes of expressing distress and indicate
manifestations of distress in relation to personal and cultural meaning. Distress may arise out
of interpersonal conflicts, economic difficulties, and cultural conflicts. These have social
implications and are readily accepted by the family and society. Thus, alternative means of
expressing psychosocial distress are utilized. Expression through bodily distress and bodily
symptom or somatization is focused upon as an important idiom through which distress is
communicated. Idioms of distress are considered as adaptive responses in circumstances
where other modes of expression fail to communicate distress adequately or provide
appropriate coping strategies (Desai & Chaturvedi, 2017).
Hinton and Lewis-Fernandez (2010) noted that for depression measurement, the use
of idioms of distress in a given culture may indicate the markers of psychopathology in that
context. Idioms of distress can also indicate missing aspects of phenomenology, can refine or
8
expand psychiatric nosology, and detect the emergence of new forms of distress (LewisFerna´ndez and Kirmayer 2019). A growing body of evidence has demonstrated the
successful incorporation of idioms of distress into mental health assessment tools for greater
sensitization of psychiatric screening (Cork, Kaiser and White, 2019; Fabian et al. 2018).
Idioms of distress often present with a strong focus on somatization, it is also useful to
develop ethnophysiological models, described as „„the culturallyguided apperception of the
mind/body rather than actual biological differences‟‟ (Hinton and Hinton 2002). Combined
with ethnopsychology, the exploration of ethnophysiology and the perceived associations
with psychiatric disorders can construct more holistic narratives of idioms of distress, and
better inform culturally sensitive care provision.
There are many definitions of culture. A very general yet integrated definition
describes culture as “integrated patterns of learned beliefs and behaviour shared among
groups”(Kohls, 2001). In a similar fashion, Toffle, (2015) defines culture as “systems of
knowledge, concepts, rules and practices that are learned and transmitted across generations”.
She goes on to say that cultures are “open, dynamic systems that undergo continuous change
over time” and they caution against generalizing and stereotyping groups because individuals
today encounter various cultures and therefore develop their own identities based on their
experience. Race is a category culturally constructed that classifies humans by their
superficial physical characteristics. Toffle, (2015) states that race actually does not have a
biological definition but is considered important socially because it promotes “racial
ideologies, racism, discrimination and social exclusion”. Racial biases and racism in general
can cause misdiagnosis, increase psychiatric problems and promote bad outcomes of
treatment. Ethnicity is a group identity that is culturally constructed. It may be the result of a
common language, religion, history, or other shared aspects of a group. Toffle, (2015) points
out that culture, race and ethnicity have an effect on health disparities. This is because they
9
are connected to economic inequality, racism and discrimination. All of this analysis leads up
to
one
thing:
individuals
must
be
assessed
not
just
in
terms
of
their
medical/psychiatric/psychological/ complaints but within a framework that relates them to
their own cultural context so as to both diagnose and treat effectively. On the level of
communication, discovering something about how patients describe their illnesses, in their
own idioms of distress, unlocks some of the mystery of treatment (Toffle, 2015)
Cultural idioms of Distress
The concept of “cultural idioms of distress” was introduced to draw attention to the
fact that reports of bodily distress can serve a communicative function (Chaturvedi et al.,
1995) A study done in South India on Havik Brahmin women reported the modes of
expression as commensality, weight loss, fasting and poisoning, purity, obsession and
ambivalence, illness, external forces of disorder such as the evil eye and spirit possession,
and devotion (Nichter, 2010).
Cultural idioms of distress are often expressions that can express several problems.
The above example of a common expression “nerves” is useful to understand the concept. A
person having „nerves‟ could be suffering from anxiety, stress, pre-menstrual syndrome, too
much caffeine intake, etc. What this idiom does is express a common experience that people
from the same cultural group understand; it is an opportunity to share and sympathise without
knowing exactly what the problem is (Toffle, 2015).
Toffle, (2015) states that culture assists in diagnosis because it shapes “the experience and
expression of the symptoms, signs and behaviours that are criteria for diagnosis”. The idea of
“cultural idioms of distress” is presented as a description of suffering among people of the
same cultural group. Various “cultural idioms of distress” have been identified worldwide,
10
ranging from the „Susto‟ (Central America) to „Maladi Moun‟ (Haiti) which can be correlated
with various psychopathologies (Toffle, 2015).
Clinical Utility of Idioms of Distress
Idioms of distress matter, whether the goal is to provide culturally sensitive care or to
conduct an adequate ethnography of trauma-related disorders in a certain cultural context. For
example, if a clinician does not recognize complaints as culture-specific idioms (i.e., as
opening up a complex network of meanings or, in other words, as revealing a
hypersemiotized domain that links a complaint to multiple ontological zones), he or she may
not attain a level of understanding of the patient‟s life world critical to valid diagnostic
practice and consensual treatment negotiation (Hinton and Lewis-Fernandez, 2010).
11
Chapter Three
Introduction
This chapter will discuss the methods that will be employed to carry out the study at
different stages. It will also discuss the details of the study area, study design, target
population, eligibility criteria, sample size, sampling techniques and criteria, data collection
methods, data collection, management and analysis.
Study Area
The study will be conducted in the peri-urban area, particularly in Soroti city. Soroti is
the main town of the Teso region. Soroti District is bordered by Amuria District to the
north, Katakwi District to the east, Ngora District to the southeast, Serere District to the
south, and Kaberamaido District to the west. Soroti, the district headquarters is located
approximately 116 kilometres (72 mile), by road, northwest of Mbale, the nearest large city.
Design of the Research
A cross-sectional design will be used in this investigation. The study will use
qualitative methods and a phenomenological approach to fulfil the specific aims of the study.
A phenomenological approach will be used since the researcher will describe the lived
experiences in the variation of the use of sadness (aitururu) as an idiom of distress among the
Iteso. This design has strong philosophical underpinnings and typically involves conducting
interviews (Giorgi, 2012; Moustakas, 1994).
Study and Target Population
This study will be limited to participants who meet the pre-set eligibility criteria such
as the health workers, community members, community leaders and cultural elders.
Eligibility Criteria
For this study, the inclusion criteria will be as follows:
12

Participants above the age of 18 years

Participants who are Iteso

Participants that have lived in Teso for more than 5 years

Participants must have sufficient functioning to engage in rational thought and
emotion

Participants must be able to understand and interpret statements
Choosing a sample size
The actual sample size for the study will be 16 respondents with in Soroti city. The
respondents will be selected in line with the eligibility criteria.
Respondents
Number
1.
Mental Health workers
4
2.
Community leaders
4
3.
Cultural elders
4
4.
Ordinary community members
4
Total
16
Sampling technique and procedures
The multistage sampling will use purposive sampling to select the respondents from the
various clans and groups to participate in the study. All the participants will be chosen
purposely to participate basing the fact that they meet the criteria outlined.
Data Collection Methods
The researcher will use in-depth interviews to collect information from the
respondents after obtaining consent from them.
13
Data Collection Instruments
The researcher will use semi – structured interviews and key informants interviews to
collect data from the participant.
Data Management
The interview will be audio recorded and an Ateso native speaker who is fluent in
English will translate the interview guide and schedule during interviews and translate the
transcription of the audio recordings back to English. All responses will be read in detail and
coded. Content analysis will be used to create themes for each participant. Themes will be
discussed until consensus is reached.
Data Analysis
Both NVivo 10 qualitative data analysis software from QSR International and manual
methods will be used to conduct the analyses. Table format will be used to describe the
primary ideas that emerge.
Quality control issues
Data will be collected by a group of research assistants who will be first oriented and trained
on the purpose of the study and variables in the study, the components of the interviews and
data quality management. The pre-test of the tools will be done within Soroti district,
Uganda. This will give you a better idea of how much time each instrument will take to
administer.
Ethical Issues
The supervisor will be given a finished research proposal to approve. A letter of
introduction will be written and submitted to the Makerere University Research Ethics
Committee (MUREC) for ethical approval and authorization to perform the study. Prior to
14
taking part in the study, all participants will be requested to sign informed consent papers.
Participants' privacy will be protected, they will take part voluntarily.
Study Limitations
Travel obstacles, rejections, budgetary limits, and the fact that some participants are
extremely cautious with information may make finding information difficult.
15
Appendices
Appendix I: Consent Form (English version).
Consent to Participate in a Research Study
Study title: Aitururu (Sadness): Variation of Idioms of Distress among the Iteso
Introduction:
I am Akoit Emuria Ojikan Sam, a Student of MSc. Clinical Psychology. I am carrying out my
academic study on Aitururu: Variation of Idioms of distress in depression.
Purpose of the study:
To gather as much information as possible regarding Aitururu in the variation of idioms of
distress among the Iteso
Study procedure:
You will be expected to spare your valuable time for this study. The process will take 30 to
60 minutes. The procedure will involve data collection using face to face interview.
You will be asked questions on your lived experience with aitururu and that of the people
known to you in the community you live in. The interview and discussion will be audio
recorded.
Respect and confidentiality
The information collected will only be used for research purposes and no record of your
identity will be kept
Benefits
There are no financial benefits to you but the findings of the study will be available to
relevant stakeholders who may use them to bridge any found gaps thus further improving
quality of life. You are however free to participate or withdraw at any time without any
16
negative implications.
Contacts:
In case of any other information you want to know about the study/investigation, feel free to
call me on Tel:0782429753, 0703804204. Email: emuria.sam@gmail.com
Statement of consent:
I have fully understood the nature and purpose of this study on aitururu (sadness) in the
variation of idioms of distress among the Iteso and I voluntarily accept to participate.
Name
Signature
…………………………..
…………………………
Date
…………............
17
Appendix II: Interview Guide.
A: Background information
1.
Where do you live?
2.
What is your age?
3.
Are you married?
4.
Do you have children?
5.
Whom else do you live with?
B: Research Question One: What do the Iteso mean when they use the word aitururu in
various contexts?
a.
When you hear someone say aitururu what comes to your mind?
b.
Discuss some of the emotions that might accompany the thoughts in (a) above
c.
What are the likely impacts of these emotions on your psychological, social and
physical wellbeing?
C: Research Question Two: Which local idioms besides aitururu do the Iteso use to express
distress in depression?
a.
Which other words do people in your community use interchangeably with or mean
the same as aitururu?
b.
What do you feel emotionally, psychologically and physically when they mention
those words?
3.
Research Question: How does the community quantify or gauge the depth and
intensity of aitururu while referring to the severity of the condition it represents?
18
Appendix III: Interview Schedule
Interview Schedule for ____________________________________________
My name is ______________________________________________________________and
a student of ________________________________________________________________,
i thought it would be a good idea to interview you, so that I can collect better information
about my academic research of _________________________________________________
I would like to ask you some questions about _____________________________________
I hope to use this information to help __________________________________________
The interview should take about 10 minutes. Are you available to respond to some questions
at this time?
(Transition: Let me begin by asking you some questions about where you live and your
family)
A.
(Topic) General demographic information
1.
How long have you lived in soroti?
(Question 1. did not have to be asked because this information is on the Bio-Sheet)
a.
B.
Are you originally from Soroti?
What meanings do the Iteso attach when using Aitururu as an idiom of distress?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
19
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
C.
What other idioms are used to express Aitururu by the Iteso?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
D.
How do the Iteso express Aitururu (emotions and bodily gestures associated with
expression?)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
20
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
E.
What other expressions among the Iteso may contain aitururu?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
D.
when you have aitururu (sadness) do you ever think of getting some help, which type
and where do you go?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(Transition: Well, it has been a pleasure finding out more about you. Let me briefly
summarize the information that I have recorded during our interview.)
III
Closing
A.
(Summarize)
21
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
I appreciate the time you took for this interview. Is there anything else you think would be
helpful for me to know?
I should have all the information I need. Would it be alright to call you at any time if I have
any more questions?
Thanks again for your time.
22
Appendix IV: Work Plan
Time Lines
ACTIVITY
RESPONSIBLE Status
PERSONS
March 2021
Identification and
Researcher
Done
Done
engagement with the
research supervisor
March – April
Agreement on the research
Researcher and
2021
topic
supervisor
April – May
Review of relevant
Researcher
Done
2021
literature
June 2022
Drafting and submission of
Researcher and
Done
proposal for presentation at
supervisor
the Department of
Psychology
July 2022
Review of proposal as per
Researcher and
assessment
supervisor
Done
recommendations
March 2023
Submission of proposal to
Researcher and
Makerere University IRB
supervisor
Initial field visit to engage
Researcher
Done
Researcher
Not yet done
3rd visit for data collection
Researcher
Not yet done
May 2023
Data analysis and reporting
Researcher
Not yet done
June 2023
Dissertation
Researcher and
Not yet done
April 2023
done
the community at the
research site
April 2023
2nd field visit to engage key
informants
April 2023
April 2023
supervisor
23
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