Combining mHealth Technology and Pharmacotherapy to Improve Mental Health Outcomes and Reduce Human Rights Abuses in West Africa: Intervention Field Trial.

Background: In West Africa, healers greatly outnumber trained mental health professionals. People with serious mental illness (SMI) are often seen by healers in "prayer camps" where they may also experience human rights abuses. We developed "M&M," an 8-week-long dual-pronged intervention involving (1) a smartphone-delivered toolkit designed to expose healers to brief psychosocial interventions and encourage them to preserve human rights (M-Healer app), and (2) a visiting nurse who provides medications to their patients (Mobile Nurse). Objective: We examined the feasibility, acceptability, safety, and preliminary effectiveness of the M&M intervention in real-world prayer camp settings. Methods: We conducted a single-arm field trial of M&M with people with SMI and healers at a prayer camp in Ghana. Healers were provided smartphones with M-Healer installed and were trained by practice facilitators to use the digital toolkit. In parallel, a study nurse visited their prayer camp to administer medications to their patients. Clinical assessors administered study measures to participants with SMI at pretreatment (baseline), midtreatment (4 weeks) and post treatment (8 weeks). Results: Seventeen participants were enrolled and most (n=15, 88.3%) were retained. Participants had an average age of 44.3 (SD 13.9) years and 59% (n=10) of them were male. Fourteen (82%) participants had a diagnosis of schizophrenia and 2 (18%) were diagnosed with bipolar disorder. Four healers were trained to use M-Healer. On average, they self-initiated app use 31.9 (SD 28.9) times per week. Healers watched an average of 19.1 (SD 21.2) videos, responded to 1.5 (SD 2.4) prompts, and used the app for 5.3 (SD 2.7) days weekly. Pre-post analyses revealed a significant and clinically meaningful reduction in psychiatric symptom severity (Brief Psychiatric Rating Scale score range 52.3 to 30.9; Brief Symptom Inventory score range 76.4 to 27.9), psychological distress (Talbieh Brief Distress Inventory score range 37.7 to 16.9), shame (Other as Shamer Scale score range 41.9 to 28.5), and stigma (Brief Internalized Stigma of Mental Illness Scale score range 11.8 to 10.3). We recorded a significant reduction in days chained (1.6 to 0.5) and a promising trend for reduction in the days of forced fasting (2.6 to 0.0, P=.06). We did not identify significant pre-post changes in patient-reported working alliance with healers (Working Alliance Inventory), depressive symptom severity (Patient Health Questionnaire-9), quality of life (Lehman Quality of Life Interview for the Mentally Ill), beliefs about medication (Beliefs about Medications Questionnaire-General Harm subscale), or other human rights abuses. No major side effects, health and safety violations, or serious adverse events occurred over the course of the trial. Conclusions: The M&M intervention proved to be feasible, acceptable, safe, and clinically promising. Preliminary findings suggest that the M-Healer toolkit may have shifted healers' behaviors at the prayer camp so that they commit fewer human rights abuses.

Corrigendum: Perinatal autopsy in Ghana: healthcare workers knowledge and attitude.

[This corrects the article DOI: 10.3389/fgwh.2022.1021474.].

Perinatal autopsy in Ghana: Healthcare workers knowledge and attitude.

Background: Perinatal mortality refers to stillbirths and early neonatal deaths. Stillbirth, the death of a foetus from 28 weeks or with a birth weight below 1,000 g, and early neonatal deaths, the death of a new-born within 24 h of delivery, are among the most distressing global health problems, with approximately 2 million stillbirths occurring annually. Although a post-mortem examination of the stillborn baby is essential for understanding and learning the cause of stillbirth, many couples decline the procedure. Sub-Saharan Africa has one of the highest stillbirth rates in the world, yet there is a dearth of studies on post-mortem uptake from the region. Aim: To explore healthcare professionals' views and perceptions of perinatal autopsy in Ghana. Methods: Mixed-method approach consisted of semi-structured interviews and an electronic cross-sectional survey to evaluate the views and perceptions of healthcare professionals at Korle-Bu Teaching Hospital on autopsy for stillbirths and early neonatal deaths. Descriptive quantitative data were summarised in frequencies and percentages, and statistical results and descriptions were tabulated and coded in terms of types of barriers. For the qualitative aspect, the audio-taped interviews were transcribed, themes generated, and direct quotes and descriptions were coded for all knowledge, beliefs, attitudes and practices concerning the barriers and facilitators for post-mortem. Results: Ninety-nine healthcare professionals participated. No participant had formal training regarding counselling for perinatal autopsy and 40% had " no idea " who is responsible for counselling and obtaining consent for a perinatal autopsy. Forty-four percent (44%) of the participants knew of only the "Conventional/ Full" autopsy and <4% were aware of less invasive methods of performing an autopsy. Qualitative data showed healthcare worker influence, religious and financial considerations impede the implementation of perinatal autopsies. Despite the low uptake of perinatal autopsies, interviews from healthcare workers suggest acceptance rates would improve if parents knew about different options, especially less invasive procedures. Conclusion: At Ghana's largest referral centre, perinatal autopsy counselling and uptake are at extremely low levels. Most healthcare professionals have little knowledge, skills, and capacity to advise parents regarding perinatal autopsies. Training is needed to update the workforce on recommended perinatal autopsy practices.

A Digital Toolkit (M-Healer) to Improve Care and Reduce Human Rights Abuses Against People With Mental Illness in West Africa: User-Centered Design, Development, and Usability Study.

BACKGROUND: The resources of West African mental health care systems are severely constrained, which contributes to significant unmet mental health needs. Consequently, people with psychiatric conditions often receive care from traditional and faith healers. Healers may use practices that constitute human rights violations, such as flogging, caging, forced fasting, and chaining. OBJECTIVE: The aim of this study is to partner with healers in Ghana to develop a smartphone toolkit designed to support the dissemination of evidence-based psychosocial interventions and the strengthening of human rights awareness in the healer community. METHODS: We conducted on-site observations and qualitative interviews with healers, a group co-design session, content development and prototype system build-out, and usability testing. RESULTS: A total of 18 healers completed individual interviews. Participants reported on their understanding of the causes and treatments of mental illnesses. They identified situations in which they elect to use mechanical restraints and other coercive practices. Participants described an openness to using a smartphone-based app to help introduce them to alternative practices. A total of 12 healers participated in the co-design session. Of the 12 participants, 8 (67%) reported having a smartphone. Participants reported that they preferred spiritual guidance but that it was acceptable that M-Healer would provide mostly nonspiritual content. They provided suggestions for who should be depicted as the toolkit protagonist and ranked their preferred content delivery modality in the following order: live-action video, animated video, comic strip, and still images with text. Participants viewed mood board prototypes and rated their preferred visual design in the following order: religious theme, nature motif, community or medical, and Ghanaian culture. The content was organized into modules, including an introduction to the system, brief mental health interventions, verbal de-escalation strategies, guided relaxation techniques, and human rights training. Each module contained several scripted digital animation videos, with audio narration in English or Twi. The module menu was represented by touchscreen icons and a single word or phrase to maximize accessibility to users with limited literacy. In total, 12 participants completed the M-Healer usability testing. Participants commented that they liked the look and functionality of the app and understood the content. The participants reported that the information and displays were clear. They successfully navigated the app but identified several areas where usability could be enhanced. Posttesting usability measures indicated that participants found M-Healer to be feasible, acceptable, and usable. CONCLUSIONS: This study is the first to develop a digital mental health toolkit for healers in West Africa. Engaging healers in user-centered development produced an accessible and acceptable resource. Future field testing will determine whether M-Healer can improve healer practices and reduce human rights abuses.

Emotion Norms, Display Rules, and Regulation in the Akan Society of Ghana: An Exploration Using Proverbs.

Proverbs are widely used by the Akan of West Africa. The current study thematically analyzed an Akan proverb compendium for proverbs containing emotion references. Of the identified proverbs, a focus on negative emotions was most typical. Emotion-focused proverbs highlighted four emotion regulation strategies: change in cognition, response modulation, situation modification, and situation selection. A subset of proverbs addressed emotion display rules restricting the expression of emotions such as pride, and emotional contagion associated with emotions such as shame. Additional themes including: social context influences on the expression and experience of emotion; expectations of emotion limits; as well as the nature of emotions were present in the proverb collection. In general, Akan emotion-related proverbs stress individual-level responsibility for affect regulation in interpersonal interactions and societal contexts.