"Blood is thicker than water" - experiences and perspectives of family caregivers of people living with severe mental illness at Holy Water traditional healing sites, Addis Ababa, Ethiopia.

Background: Family caregivers of people with severe mental illness (SMI) are the backbone of the mental health care system in resource-limited family centered cultural setting like Ethiopia. This exploratory qualitative study examines the experiences and perspectives of family caregivers at two Ethiopian Holy Water treatment sites for people with SMI in Addis Ababa, where a collaborative project exists between traditional healers and biomedical practitioners.

Methods: Eleven family caregivers at two Holy Water treatment sites in Addis Ababa, Ethiopia were interviewed in 2021, using a semi-structured interview guide. The transcribed material was analyzed using qualitative thematic analysis. Inclusion criteria for study participants were over 18 years of age, capacity to give informed consent, and has a family member with mental illness for whom the family caregiver has sought help at the Holy Water treatment sites and at the collaborative Clinic.

Results: Content analysis found seven notable themes: 1. Strong sense of obligation and responsibility and ongoing provision of care; 2. Caregiving puts a serious strain on caregivers' lives and established family roles; 3. Chronicity and persistence of illness take toll on family caregivers and networks of support; 4. Family caregivers appreciate the supportive religious setting and attendants at Holy Water treatment community; 5. Family caregivers develop a community of mutual support for each other; 6. Severe shortage and poor access to formal biomedical services and appreciation of the collaborative Clinic; 7. Burden, exhaustion, and loss of hope regarding the future.

Conclusion: The study shows that families in Ethiopia face a protracted and heavy caregiver burden in their caretaking duties, often in isolation, with a severe lack of formal biological treatment and psychosocial support. Informal assistance and mutual support form part of the culturally shaped support networks, but there are on-going challenges. Innovative programs with collaborative approach show some promise. More development of community mental health services and support are urgently needed.