Innovation summary

Sierra Leone, like many other low-income countries, experiences poor mental health awareness and minimal engagement with any formal mental health services that are available. At the same time, as many as 90% of those with mental health problems attend traditional healers and religious leaders for treatment1 – a practice that predates colonial rule – demonstrating a highly utilized parallel system of care. While this may in part be due to the lack of community-based health services2, it is primarily due to cultural beliefs that emphasize spiritual causation, a lack of mental health knowledge, and poor awareness surrounding mental health and the existence of formal services (which are still quite new in Sierra Leone)3.

This innovation aimed to increase mental health service utilization and reduce the maltreatment of people with mental health problems by promoting mental health awareness and facilitating community engagement. To achieve this, the program delivered 3-day Community Mental Health Forums in each district of Sierra Leone over two years. The Community Forums were designed to facilitate a two-way approach that encouraged open dialogue, active listening, understanding, and shared learning between all of the relevant stakeholders, including clinicians, traditional healers, and religious leaders. The aim was to provide an opportunity for consensus on the relative merits of both systems of care, and to facilitate a collaborative approach that promotes the best outcomes for people affected by mental health difficulties. 

 

Impact summary

  • Community Mental Health Forums were delivered in all 14 districts of Sierra Leone to a total of 1271 community stakeholders
  • There was a measurable increase in awareness and openness to other methods of treatment and care
  • The intervention was cost-effective at €20 EUR ($22 USD) per direct beneficiary

 

"Through the referral pathway we can explore a number of options, we can have the traditional option, the spiritual option and also invite the mental health nurse. So we have been using [since the community forums] the two prong approach... spiritual leaders may combine with modern medicine."

- Traditional healer

 

"When we came for the workshop [community forum], the son of one of my brothers was mentally ill. Each time the illness used to set in we would get him and beat him. But after the workshop I would not let the others or anyone beat him."

- Religious leader

Innovation details

In 2010, the WHO identified Sierra Leone as a priority nation for the piloting of its Mental Health Gap Action Programme (mhGAP)4,5. As a result, mental health activities within Sierra Leone increased6. Enabling Access to Mental Health in Sierra Leone (EAMH-SL) – a European Commission-funded project designed to meet mental health needs in Sierra Leone – built upon this opportunity, incorporating the evidence base and guidance set out by mhGAP into its overall objectives, content, and design. The project was implemented under the supervision of CBM International and Global Initiative on Psychiatry (GIP), and was designed to strengthen the national mental health system and to improve capacity​6.

In line with mhGAP, EAMH-SL had three components:

  • Capacity building for service delivery at district and primary level by introducing a mental health nurse diploma course and strengthening systems, including medication supply and clinical supervision
  • Development of a national mental health coalition to provide advocacy and peer support
  • A national community mental health engagement and awareness raising programme

Each component was implemented by a different in-country partner. The community engagement and awareness programme (Community Mental Health Forum) was implemented by The Community Association for Psychosocial Services (CAPS) - a local NGO that provides community sensitisation through mental health screening and counselling.

In 2014 and 2015 under the supervision of EAMH-SL, CAPS delivered three-day Community Mental Health Forums across all fourteen districts of Sierra Leone. The content and structure of these Forums was developed during the course of a workshop, which included representatives of the traditional leadership structures. The Forums were primarily aimed at those working as informal and traditional providers of care such as traditional healers and religious leaders, and were facilitated by mental health nurses in the District where they are based.

The Forums content included:

  • Exploring local understandings of mental distress, illness and healing by facilitating open discussion
  • Raising awareness through the provision of basic mhGAP training, including role-plays and basic education surrounding mental illness, assessment, treatment and available services
  • Reaching agreement on complimentary roles in supporting community members with mental health difficulties, referral procedures and collaborative care

A human rights based approach formed the basis of all content. Team building and mutual learning were promoted by using a two-way approach and encouraging open and honest dialogue.

Goals of the Community Mental Health Forums 

The programme aimed to achieve the following goals through community engagement, active participation, and open dialogue:

  • Engage with communities to share understandings of issues related to mental health
  • Strengthen the relationship between trained mental health nurses and the communities they serve
  • Increase mental health awareness and sensitisation, particularly among informal care providers (traditional healers, traditional leaders and religious leaders)
  • Strengthen a well-defined mental health referral mechanism to improve access to and utilisation of services
  • Encourage positive changes in the way people with mental health problems are treated within and by their communities by addressing negative myths and beliefs to reduce the stigma surrounding mental ill health

Cultural Considerations

Awareness-raising interventions focused on knowledge, attitudes, and practice are common ways to address issues such as stigma, human rights violations, and service utilisation. However, these interventions are often implemented using a 'top-down' approach that can be viewed as patronising and insensitive to the cultural context. Although culture is usually acknowledged, it is rarely systematically recognised as central to these interventions. In line with this, to ensure cultural responsiveness and lay the foundation for long-term relationship building, the mental health nurses were involved throughout the development, implementation, and evaluation of this intervention. The Forums focused on open dialogue and shared learning, role plays and debate as a way of encouraging this. 

Key drivers

Previous Success
The Forums were part of a wider body of work and depended upon the successful achievement of other components (system strengthening, capacity building, and advocacy) of the EAMH-SL project. For example, District Mental Health Units with trained (diploma) Mental Health Nurses in each district ensured a focal point person and site for referral.

Local Support Structures
The National Mental Health Steering Committee and Mental Health Coalition provide a higher level support structure that strengthens the overall position of mental health in the country.

The Global Health Agenda
The increased prominence of mental health in global health and development increases the prioritisation of mental health, financial resource availability for local programming, and technical resources of high quality and local utility (e.g. mhGAP).

Stakeholder Engagement
Community stakeholders showed a real eagerness to participate when initially approached, and during the forums themselves.

Challenges

Ebola
The 2014 Ebola Outbreak significantly disrupted the roll-out of the Forums, as it was dangerous, and for some time prohibited, to travel to many parts of the country.

Infrastructure
Poor national infrastructure made the logistics of organising visits to remote areas complex, time-consuming, and expensive.

Multi-partner collaboration
While collaborating with multiple partners improves buy-in and richness of dialogue, it increases complexity of organisation, and can result in tensions related to resource allocation.

Time and Resources
Resources tend to be limited to brief programme cycles, which makes planning to systematically scale-up innovation over a longer time frame challenging.

Health information systems
Weak health information systems meant that data collected was insufficient to demonstrate the impact beyond qualitative methods.

Continuation

At the programme level, because the mental health nurse posted to each District facilitated the Forum in that District, this relationship should continue, promoting ongoing collaboration across traditional and formal health sectors. In addition, the EAMH-SL programme promoted District Mental Health Units, the level of governance through which most decisions are now made.

The research component of this innovation makes numerous recommendations for such programmes and further research. These recommendations will be of benefit to future programmes in similar contexts with similar aims.

 

Partners

Evaluation methods

CBM International and a mental health researcher from The Centre for Global Health at Trinity College Dublin systematically evaluated this innovation. The evaluation aimed to:

  • Explore the experiences and perceptions of programme stakeholders in order to determine programme outcomes
  • Identify the factors that facilitated and prohibited the desired outcomes of this programme
  • Ascertain what (if anything) needs to change for such programmes to be successful and any barriers to be overcome

Semi-structured interviews with mental health nurses who facilitated the Forum in their district and focus group discussions (FGDs) with Forum attendees were conducted. Qualitative data collection took place over a three month period, between April-June 2016. The total number of participants from both semi-structured interviews (Forum facilitators) and FGDs (Forum attendees) was sixty-two. Data analysis focused on outcomes associated with the Community Mental Health Forums and, perhaps more importantly, identifying the factors (barriers and facilitators) that influenced program success.

Cost of implementation

This work was subsumed into the wider Enabling Access to Mental Health in Sierra Leone project, making it difficult to extract only the costs of the Forums.

A conservative (high) estimate for the total cost of the work related to the Forums, over 2 years, was approximately €25,000 EUR ($27,200 USD). This means that each 3-day Forum cost €1,785 EUR ($1,945 USD) on average (including all administrative and personnel costs), or €20 EUR ($22 USD) per direct beneficiary.

Impact details

The programme had a wide impact, as those who attended the Forums reported changed behaviour such as referral of patients to appropriate services, and reduction of human rights abuse in traditional practice.

When analysing the data from this study, various topics arose that related to a physical outcome or action, such as an increase in referrals by Forum attendees to District Mental Health Units/Nurses. Prior to the Forums most DMHUs had received no referrals. These outcomes and actions were observed and corroborated by the majority of participants and in some incidences the researchers.

Programme aims and corresponding outcomes 

Increase mental health awareness and sensitisation
A significant increase in awareness was perceived to have taken place by all stakeholders.

Address negative myths and beliefs
Beliefs and perceptions surrounding mental health causality and treatment was achieved with varying levels of confirmation and closely linked with an increase in awareness.

Reduce maltreatment/Promote human rights
A positive change in the treatment of people with mental health problems was self-reported although this only applies to those who attended the forums/participated in the research.

Reduce stigma surrounding mental health
Negative myths and beliefs had changed, however stigmatisation is ongoing.

Encourage community mental health engagement
Those who attended the Forums appeared to be actively engaging in mental health advocacy and other activities.

Relationship building/Collaboration
All stakeholders reported that due to the Forums, relationships had been developed, over 50% reported being eager and willing to work collaboratively with the mental health nurses if they were not already doing so.

Increase service utilisation
A well-defined mental health referral mechanism is now in use. Each mental health nurse is now receiving referrals.

 

The Evaluation Report (see Resources section) has further details on the study and programme outcomes.

References

  1. Yoldi, O., Sierra Leone Trapped in the Shadows of the Mind. Refugee Transitions 2012. 26: p. 60-65.
  2. Esliker, R., Mental Health in Sierra Leone: Beliefs, Myths and Truth. Unpublished (available online at http://universityofmakeni.com/wordpress/wp-content/uploads/Mental-Illness-Sierra-Leone.pdf), 2015.
  3. Abdulmalik, J., et al., The Mental Health Leadership and Advocacy Program (mhLAP): a pioneering response to the neglect of mental health in Anglophone West Africa. International journal of mental health systems, 2014. 8(1): p. 1.
  4. WHO, mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: mental health Gap Action Programme (mhGAP). 2010: Geneva: World Health Organization.
  5. WHO, Mental Health Gap Action Programme: scaling up care for mental, neurological, and substance use disorders. 2008: WHO Press.
  6. WHO, WHO proMIND: profiles on mental health in development: Sierra Leone. Geneva: WHO, 2012.

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