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 capacity6.
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
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.