Seeking Healing for a Mental Illness: Understanding the Care Experiences of Service Users at a Prayer Camp in Ghana.

Human rights abuses in mental health care are a global concern. Addressing the problem requires input from key stakeholders, particularly from people using mental health services. This study explored the experiences of persons with mental illness receiving care in a faith-based setting in Ghana. The study employed a qualitative design, with in-depth interviews (n = 23) and focus groups (n = 18 participants in 3 groups). The constant comparative method of analysis was used to identify themes in participants' descriptions of their experiences. The first three themes identified are consistent with human rights and coercion, and the last two themes related to service users' views on participation in spiritual practices. Themes included: decision-making around care; consent and efficacy of religious healing; experiences with chaining; views around biomedical treatment; participation in religious activities as part of healing and recognition of the need for spiritual healing. It was observed that participants with prior experience of psychiatric treatment were happy about the absence of chaining in psychiatric facilities but strongly disliked the side effects of medications. These findings underscore the need for faith-based institutions to provide care that is consistent with patient preferences, thereby helping to address the resultant human rights abuses.

Joining psychiatric care and faith healing in a prayer camp in Ghana: randomised trial.

BACKGROUND: Care of people with serious mental illness in prayer camps in low-income countries generates human rights concerns and ethical challenges for outcome researchers. Aims To ethically evaluate joining traditional faith healing with psychiatric care including medications (Clinical trials.gov identifier NCT02593734). METHOD: Residents of a Ghana prayer camp were randomly assigned to receive either indicated medication for schizophrenia or mood disorders along with usual prayer camp activities (prayers, chain restraints and fasting) (n = 71); or the prayer camp activities alone (n = 68). Masked psychologists assessed Brief Psychiatric Rating Scale (BPRS) outcomes at 2, 4 and 6 weeks. Researchers discouraged use of chaining, but chaining decisions remained under the control of prayer camp staff. RESULTS: Total BPRS symptoms were significantly lower in the experimental group (P = 0.003, effect size -0.48). There was no significant difference in days in chains. CONCLUSIONS: Joining psychiatric and prayer camp care brought symptom benefits but, in the short-run, did not significantly reduce days spent in chains. Declaration of interest None.

Key influences in the design and implementation of mental health information systems in Ghana and South Africa.

INTRODUCTION: Strengthening of mental health information systems (MHIS) is essential to monitor and evaluate mental health services in low and middle-income countries. While research exists assessing wider health management information systems, there is limited published evidence exploring the design and implementation of MHIS in these settings. This paper aims to identify and assess the key factors affecting the design and implementation of MHIS, as perceived by the key stakeholders in Ghana and South Africa. METHODS: We report findings from the Mental Health and Poverty Project, a 5-year research programme implemented within four African countries. The MHIS strengthening in South Africa and Ghana included two related components: intervention and research. The intervention component aimed to strengthen MHIS in the two countries, and the research component aimed to document interventions in each country, including the key influences. Data were collected using semi structured interviews with key stakeholders and reviews of key documents and secondary data from the improved MHIS. We analyzed the qualitative data using a framework approach. RESULTS: Key components of the MHIS intervention involved the introduction of a redesigned patient registration form, entry into computers for analysis every 2 months by clinical managerial staff, and utilization of data in hospital management meetings in three psychiatric hospitals in Ghana; and the introduction of a new set of mental health indicators and related forms and tally sheets at primary care clinics and district hospitals in five districts in the KwaZulu-Natal and Northern Cape provinces in South Africa. Overall, the key stakeholders perceived the MHIS strengthening as an effective intervention in both countries with an enhanced set of indicators in South Africa and introduction of a computerized system in Ghana. DISCUSSION: Influences on the design and implementation of MHIS interventions in Ghana and South Africa relate to resources, working approaches (including degree of consultations during the design stage and communication during implementation stage) and the low priority of mental health. Although the influencing factors represent similar categories, more influences were identified on MHIS implementation, compared with the design stage. Different influences appear to be related within, and across, the MHIS design and implementation and may reinforce or negate each other thus leading to the multiplier or minimization effects. The wider context, similar to other studies, is important in ensuring the success of such interventions. CONCLUSION: Future MHIS strengthening interventions can consider three policy implications which emerged from our analysis and experience: enhancing consultations during the intervention design, better consideration of implementation challenges during design, and better recognition of relations between different influences.

Developing mental health research in sub-Saharan Africa: capacity building in the AFFIRM project.

BACKGROUND: There remains a large disparity in the quantity, quality and impact of mental health research carried out in sub-Saharan Africa, relative to both the burden and the amount of research carried out in other regions. We lack evidence on the capacity-building activities that are effective in achieving desired aims and appropriate methodologies for evaluating success. METHODS: AFFIRM was an NIMH-funded hub project including a capacity-building program with three components open to participants across six countries: (a) fellowships for an M.Phil. program; (b) funding for Ph.D. students conducting research nested within AFFIRM trials; (c) short courses in specialist research skills. We present findings on progression and outputs from the M.Phil. and Ph.D. programs, self-perceived impact of short courses, qualitative data on student experience, and reflections on experiences and lessons learnt from AFFIRM consortium members. RESULTS: AFFIRM delivered funded research training opportunities to 25 mental health professionals, 90 researchers and five Ph.D. students across 6 countries over a period of 5 years. A number of challenges were identified and suggestions for improving the capacity-building activities explored. CONCLUSIONS: Having protected time for research is a barrier to carrying out research activities for busy clinicians. Funders could support sustainability of capacity-building initiatives through funds for travel and study leave. Adoption of a train-the-trainers model for specialist skills training and strategies for improving the rigor of evaluation of capacity-building activities should be considered.

Generating evidence to narrow the treatment gap for mental disorders in sub-Saharan Africa: rationale, overview and methods of AFFIRM.

There is limited evidence on the acceptability, feasibility and cost-effectiveness of task-sharing interventions to narrow the treatment gap for mental disorders in sub-Saharan Africa. The purpose of this article is to describe the rationale, aims and methods of the Africa Focus on Intervention Research for Mental health (AFFIRM) collaborative research hub. AFFIRM is investigating strategies for narrowing the treatment gap for mental disorders in sub-Saharan Africa in four areas. First, it is assessing the feasibility, acceptability and cost-effectiveness of task-sharing interventions by conducting randomised controlled trials in Ethiopia and South Africa. The AFFIRM Task-sharing for the Care of Severe mental disorders (TaSCS) trial in Ethiopia aims to determine the acceptability, affordability, effectiveness and sustainability of mental health care for people with severe mental disorder delivered by trained and supervised non-specialist, primary health care workers compared with an existing psychiatric nurse-led service. The AFFIRM trial in South Africa aims to determine the cost-effectiveness of a task-sharing counselling intervention for maternal depression, delivered by non-specialist community health workers, and to examine factors influencing the implementation of the intervention and future scale up. Second, AFFIRM is building individual and institutional capacity for intervention research in sub-Saharan Africa by providing fellowship and mentorship programmes for candidates in Ethiopia, Ghana, Malawi, Uganda and Zimbabwe. Each year five Fellowships are awarded (one to each country) to attend the MPhil in Public Mental Health, a joint postgraduate programme at the University of Cape Town and Stellenbosch University. AFFIRM also offers short courses in intervention research, and supports PhD students attached to the trials in Ethiopia and South Africa. Third, AFFIRM is collaborating with other regional National Institute of Mental Health funded hubs in Latin America, sub-Saharan Africa and south Asia, by designing and executing shared research projects related to task-sharing and narrowing the treatment gap. Finally, it is establishing a network of collaboration between researchers, non-governmental organisations and government agencies that facilitates the translation of research knowledge into policy and practice. This article describes the developmental process of this multi-site approach, and provides a narrative of challenges and opportunities that have arisen during the early phases. Crucial to the long-term sustainability of this work is the nurturing and sustaining of partnerships between African mental health researchers, policy makers, practitioners and international collaborators.

A situation analysis of mental health services and legislation in Ghana: challenges for transformation.

OBJECTIVE: To conduct a situation analysis of the status of mental health care in Ghana and to propose options for scaling up the provision of mental health care. METHOD: A survey of the existing mental health system in Ghana was conducted using the WHO Assessment Instrument for Mental Health Systems. Documentary analysis was undertaken of mental health legislation, utilizing the WHO Legislation checklists. Semi-structured interviews and focus group discussions were conducted with a broad range of mental health stakeholders (n=122) at the national, regional and district levels. RESULTS: There are shortfalls in the provision of mental health care including insufficient numbers of mental health professionals, aging infrastructure, widespread stigma, inadequate funding and an inequitable geographical distribution of services. CONCLUSION: Community-based services need to be delivered in the primary care setting to provide accessible and humane mental health care. There is an urgent need for legislation reform, to improve mental health care delivery and protect human rights.

Scaling up community-based services and improving quality of care in the state psychiatric hospitals: the way forward for Ghana.

OBJECTIVE: This paper aims to explore the options available for developing community-based care and improving the quality of care in psychiatric hospitals in Ghana. METHOD: Semi-structured interviews (SSIs) and focus group discussions (FGDs) were conducted: with a cross-section of stakeholders including health professionals, researchers, policy makers, politicians, users and carers. The SSIs and FGDs were recorded digitally and transcribed verbatim. Apriori and emergent themes were coded and analysed with NVivo version 7.0, using a framework analysis. RESULTS: Psychiatric hospitals in Ghana have a mean bed occupancy rate of 155%. Most respondents were of the view that the state psychiatric hospitals were very congested, substantially compromising quality of care. They also noted that the community psychiatric system was lacking human and material resources. Suggestions for addressing these difficulties included committing adequate resources to community psychiatric services, using psychiatric hospitals only as referral facilities, relapse prevention programmes, strengthening psychosocial services, adopting more precise diagnoses and the development of a policy on long-stay patients. CONCLUSION: There is an urgent need to build a credible system of community-based care and improve the quality of care in psychiatric hospitals in Ghana.

A situation analysis of mental health services and legislation in Ghana: challenges for transformation

Objective: To conduct a situation analysis of the status of mental health care in Ghana and to propose options for scaling up the provision of mental health care. Method: A survey of the existing mental health system in Ghana was conducted using the WHO Assessment Instrument for Mental Health Systems. Documentary analysis was undertaken of mental health legislation; utilizing the WHO Legislation checklists. Semi-structured interviews and focus group discussions were conducted with a broad range of mental health stakeholders (n=122) at the national; regional and district levels. Results: There are shortfalls in the provision of mental health care including insufficient numbers of mental health professionals; aging infrastructure; widespread stigma; inadequate funding and an inequitable geographical distribution of services. Conclusion: Community-based services need to be delivered in the primary care setting to provide accessible and humane mental health care. There is an urgent need for legislation reform; to improve mental health care delivery and protect human rights

Scaling up community-based services and improving quality of care in the state psychiatric hospitals: the way forward for Ghana

Objective: This paper aims to explore the options available for developing community-based care and improving the quality of care in psychiatric hospitals in Ghana. Method: Semi-structured interviews (SSIs) and focus group discussions (FGDs) were conducted with a cross-section of stakeholders including health professionals; researchers; policy makers; politicians; users and carers. The SSIs and FGDs were recorded digitally and transcribed verbatim. Apriori and emergent themes were coded and analysed with NVivo version 7.0; using a framework analysis. Results: Psychiatric hospitals in Ghana have a mean bed occupancy rate of 155. Most respondents were of the view that the state psychiatric hospitals were very congested; substantially compromising quality of care. They also noted that the community psychiatric system was lacking human and material resources. Suggestions for addressing these difficulties included committing adequate resources to community psychiatric services; using psychiatric hospitals only as referral facilities; relapse prevention programmes; strengthening psychosocial services; adopting more precise diagnoses and the development of a policy on long-stay patients. Conclusion: There is an urgent need to build a credible system of community-based care and improve the quality of care in psychiatric hospitals in Ghana

The effect of social change on causal beliefs of mental disorders and treatment preferences in Ghana.

The present study investigated the associations between social change, personality, causal beliefs and treatment style and goal preferences of 375 Ghanaian teachers. The index of social change (ISC) was conceptualized as the average percentile rank of a person's income, education and acculturation. The self-report measures (greatly modified after two pilot studies) were subscales of the SuinnLew Acculturation Scale, the Depressive Experiences Questionnaire (dependency), the Sociotropy-Autonomy Scale (autonomy), the Symptom Checklist '90 (paranoid ideation), the Spheres of Control Scale, and the Cognitive Somatic Anxiety Questionnaire. Respondents also completed a questionnaire on causal beliefs and treatment preferences pertaining to mental disorders. Results indicated that beliefs and treatment preferences were affected by the index of social change (ISC) and were specific to type of disorder. High ISC teachers endorsed significantly higher ratings on belief in an internal cause for Depression and Dependent Personality Disorder, and indicated greater preference for participation in treatment than lower ISC teachers. Contrary to prediction, lower ISC teachers indicated a greater preference for greater individual goals in treatment for depression and schizophrenia. High ISC teachers also reported greater perception of interpersonal control and emotional support, less dependency and less interpersonal sensitivity than lower ISC teachers. Little support was found for the commonly observed somatization of distress among non-Western peoples.