SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA PATHWAYS TO PSYCHIATRIC CARE PRIOR TO PRESENTING AT A PUBLIC PYCHIATRIC HOSPITAL: A CROSS SECTIONAL STUDY OF MENTAL HEALTH PATIENTS AT PANTANG PSYCHIATRIC HOSPITAL BY SIDUA HOR (10508172) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH JULY, 2015 i DECLARATION I, Sidua Hor hereby declare that apart from reference to other people’s work, which I have duly acknowledged, this dissertation is a result of my own independent work. I further declare that this dissertation has not been submitted for award of any degree in this institution and other universities elsewhere. SIDUA HOR DATE……………………………. STUDENT ……………………………… Dr. ABDALLAH IBRAHIM DATE…24 July, 2015…………. SUPERVISOR ii DEDICATION I dedicate this work to God my maker, my wife and son, Rachel Aku Batini and Kevin Kanwei Batini, my siblings, Aisha Batini and Balu Batini. iii ACKNOWLEGEMENT My deep Appreciation goes to my supervisor Dr. Abdallah Ibrahim for his supervision, guidance and encouragement during this work. I am also grateful to Dr. Irene Agyapong and Dr. Patricia Akweongo for their advice. I wish to also express my sincere appreciation to Anna Bledsoe of New York University, Afia Konadu Owusu-Kwarteng and Caleb Tekper for helping me to collect data for this study. Also, I am very grateful to the clinical staff of the psychiatric OPD of Pantang Psychiatric Hospital for their support during the data collection. I am deeply grateful to Toni Godi for his guidance in the statistical analysis. Finally, I wish to express my profound appreciation to all the academic staff of the Health Policy, Planning and Management (HPPM) department for the training and mentoring they gave me. iv TABLE OF CONTENTS DECLARATION ........................................................................................................... I DEDICATION .............................................................................................................. II ACKNOWLEGEMENT .............................................................................................. III LIST OF TABLES .................................................................................................... VIII LIST OF FIGURES .................................................................................................... IX LIST OF ACRONYMS ................................................................................................ X DEFINITIONS OF TERMS ....................................................................................... XI ABSTRACT ............................................................................................................... XII CHAPTER ONE ............................................................................................................ 1 1.1 INTRODUCTION ................................................................................................... 1 1.2 Background ..................................................................................................... 1 1.3 Problem Statement ........................................................................................... 3 1.4 Justification ..................................................................................................... 4 1.5 Objectives of Study .......................................................................................... 6 1.6 Conceptual Framework .................................................................................... 7 CHAPTER TWO ........................................................................................................... 8 2.0 LITERATURE REVIEW ................................................................................. 8 2.1 Introduction ..................................................................................................... 8 2.2 Gaps between Need and Treatment for Mental Health Patients in Africa .......... 9 2.3 The Influence of religious beliefs on health seeking behavior ......................... 10 v 2.4 Pathways to psychiatric care .......................................................................... 11 2.5 Triggers for Help Seeking and Entry into the Mental Health System. ............. 16 CHAPTER THREE ..................................................................................................... 17 3.0 METHODOLOGY ................................................................................................ 17 3.1 Introduction ................................................................................................... 17 3.2 Type of study ................................................................................................. 17 3.3 Study Design ................................................................................................. 17 3.4 Study location/area ........................................................................................ 18 3.5 Variables ........................................................................................................ 18 3.6 Study Population ............................................................................................ 19 3.7 Sample size of the study ................................................................................. 19 3.8 Sampling procedure / method ......................................................................... 20 3.9 Data collection and analysis ........................................................................... 21 3.10 Quality Control ............................................................................................ 22 3.11 Ethical Consideration/Issues ........................................................................ 23 CHAPTER FOUR ........................................................................................................ 24 4.0 RESULTS .............................................................................................................. 24 4.1 Introduction ................................................................................................... 24 4.2 Sample Characteristics ................................................................................... 24 4.3 Patient diagnosis and where they sought help ................................................. 28 4.4 Proportion of study participants who sought health elsewhere prior to reporting at Pantang Psychiatric Hospital ............................................................................ 29 vi 4.5 First Pathway to care (The first place patients contacted for help) .................. 30 4.6 Second Pathway to care (The second place patients contacted for help) .......... 31 4.7 Third Pathway to care (The third place patient contacted for help) ................. 33 4.8 Delays in seeking care .................................................................................... 33 4.9 Association between socio demographic factors and patient pathways to care 35 4.10 Reasons for seeking care from the various pathway contacts to psychiatric care ............................................................................................................................ 37 4.11: Treatment received at psychiatric and general hospital ................................ 40 4.12: Patients Satisfaction with Providers (Pathways) .......................................... 41 CHAPTURE FIVE....................................................................................................... 42 5.0 DISCUSSION OF FINDINGS .............................................................................. 42 5.1 Introduction ................................................................................................... 42 5.2 Proportion of Patients who sought help elsewhere prior to reporting at Pantang. ............................................................................................................................ 42 5.3 Pathways to Psychiatric Care ......................................................................... 43 5.4 Delay in seeking psychiatric care ................................................................... 46 5.5 Association between socio-demographic factors and patients pathways .......... 47 5.6 Reasons for seeking help from unorthodox and unorthodox providers ............ 48 5.7 Type of treatment received and feedback on satisfaction ................................ 50 CHAPTER SIX ............................................................................................................ 53 6.0 CONCLUSIONS AND RECOMMENTDATIONS ........................................ 53 5.1 Conclusions ................................................................................................... 53 vii 5.2 Recommendations .......................................................................................... 54 5.3 Limitations of the Study ................................................................................. 55 REFERENCES ............................................................................................................ 57 APPENDICES ............................................................................................................. 60 APPENDIX A: INFORMED CONCERN FORM ...................................................... 60 viii LIST OF TABLES Table 4.1: Socio-demographic characteristics of study subjects ............................... 26 Table 4.2: Patient diagnosis and where they sought help .......................................... 29 Table 4.3: First pathway (The first place patients contacted for help) ....................... 31 Table 4.4: Second pathway (The second place patients contacted for help) .............. 32 Table 4.5: Third pathway (The third place patient contacted for help) ...................... 34 Table 4.6: Association between socio demographic factors and health pathways of patients .................................................................................................................... 36 Table 4.7: Reasons for the various pathways patients took in search for a solution for their sickness ........................................................................................................... 37 Table 4.8: Summary of the various treatments patients received at non-orthodox health pathways. ...................................................................................................... 39 Table 4.9: Treatment received at psychiatric and general hospital ............................ 40 Table 4.10: Patients Satisfaction with Providers (Pathways) .................................... 41 ix LIST OF FIGURES Figure 4.1: Proportion of patients who Sought help elsewhere prior to reporting at Pantang Psychiatric Hospital ................................................................................... 30 Figure 4.2: Patient pathways and distribution regarding where help was sought. ...... 35 x LIST OF ACRONYMS AIDS Acquired Immune Deficiency Virus ART Anti-Retroviral Treatment FEP First Episode of Psychosis HIV Human Immune Virus OPD Out Patient Department SD Standard Deviation WHO World Health Organization xi DEFINITIONS OF TERMS Pathway: This refers to the sequence of contacts patients or their families use to seek care. Care giver: People who provide care for the mental health patients Care Pathway Contact: The individual, agency, or service provider with whom the patient came into contact with on the pathway to mental health care. Close-end question: A question which can be answered with a simple ―yes‖ or or ― no‖, or with a specific piece of information. Open-end question: A question which cannot be answered with a simple ―yes‖ or or ― no‖, or with a specific piece of information, and which gives the person answering the question a scope to give the Information that seems to them to be appropriate. Significant others: Relatives and friends who take care of patients and make key decisions on behalf of a patient. Node: The point of contacts on individuals’ pathways to care. xii ABSTRACT Background: In Ghana, about 2.4 million people suffer from mental health illness and only 67,780 (2.8%) received treatment in 2011. The pathway to seek for care by patients who experience first episode of mental health illness may determine how early or late they receive the needed treatment. This study has been conducted to study help-seeking patterns in patients with psychiatric illness, the pathways they traversed to reach psychiatric services, and to understand the factors that influence the patient’s help-seeking pathways. Methods: An institutional-based cross-sectional study was conducted at Pantang Psychiatric Hospital in Accra. It involved 115 patients aged between 18 and 82 years. Only patients’ relatives or care givers between 18 and 70 years were interviewed. The study adopted the World Health Organization’s (WHO) health encounter form to collect information about patient’s pathway contacts to psychiatric care. Results: The study subjects consisted of 50.4% males and 49.6% females. At the early onset of illness, 23.5% contacted religious or traditional healers, 28.1% went to a general hospital and 50.4% had a direct pathway to a psychiatric hospital. In a chi-square analysis of association, marital status (P = 0.001) and employment (P = 0.004) are significantly associated with patient pathways to psychiatric care. Conclusion: Patients used four types of pathways to psychiatric care namely;(1) direct pathway to a psychiatric hospital, (2) transition from religious or traditional healers to psychiatric hospitals, (3) transition from general hospital to psychiatric hospital and (4) upon onset of illness directly to unorthodox providers to general hospital and to psychiatric hospital. 1 CHAPTER ONE 1.1 Introduction In this chapter, the background to the study is discussed in perspectives that highlights the contextual issues information the study. It underscores the importance of early treatment for mental health conditions, and discusses some of the factors that influence the health seeking behavior of mental health patients. Also, it provides a brief comparative overview of the funding situation of mental health services in developing and developed countries, and provides an indication of the proportion of mental health patients in Ghana who are in need of skilled care. Besides, the problem statement is discussed with a transition into the justification of the study, the study objectives and the conceptual framework. 1.2 Background Seeking timely treatment at the early onset of mental health disorders is vital because early intervention is crucial to restoring the mental as well the physical and social health of an individual (Girma &Tesfaye, 2011).Studies have documented the relationship between mental disorders and the risk of physical illness, including those suggesting that mental disorders increase the risk of physical illness and vice versa (Girma & Tesfaye, 2011). People who develop mental health problems sometimes delay in seeking treatment at a mental health facility, or fail to seek treatment from such a facility at all, and this risk compromising appropriate care significantly (Nsereko et al., 2011). A study conducted in Uganda in East Africa provides evidence suggesting factors such as fear of being diagnosed as suffering from mental illness, mistrust towards mental health 2 system, and lack of confidence in health professionals make people hesitant to seek professional help (Sundh & Roslund, 2012). The study also showed that seeking treatment appears to be related to the individual’s perception of the severity of the illness. Those who perceive the illness to be severe being more inclined to seek help. The study further indicated that the choice of where to seek help often depends on what the individual or his or her family believes to be the causal factor of the illness (Sundh & Roslund,2012). Since mental health illness in Africa is often believed to be due to super natural causes, a significant number of people with mental health problems tend to initially seek and to continue seeking traditional healers’ services after western medical care (Nsereko et al., 2011). In Ethiopia, mental illness is the leading non-communicable disorder in terms of burden, with schizophrenia and depression included in the top ten most burdensome conditions, out-ranking HIV/AIDS (Bifftu & Dachew, 2014). In least developed countries, including Ghana, the mental health sector is one of the lowest health priorities (Offori-Atta et al, 2010). In fact 62% of developing countries spend less than 1% of total health budgets on mental health and 16% of developed countries (WHO, 2003). Read and Ofori-Atta (2010) noted that with the relative absence of community care, institutionalized care remains the norm for many of those with mental health problems in low-income countries. They acknowledged that in countries such as Ghana, many of those in need of treatment do not receive the requisite psychiatric services at all, but seek the care of informal community mental health services such as traditional and faith healers and family members who offer a varying quality of service and level of efficacy. In Africa therefore, as in other regions 3 of the world, the deficit is not in the evidence for interventions to address mental health problems, but in the resources and political will that can make these interventions available to those who need them (Read et al., 2010). In another study , it was noted that there were an estimated 2.4 million people with mental health problems in Ghana of which 67,780 (2.8%) received treatment in 2011 (Roberts et. al., 2014)In Ghana, there is an informal sector of mental health services provided by faith-based and traditional healers. Despite reports of human rights abuses by these healers, these avenues of treatment are still very popular. This is because it is believed that mental illness is usually caused by evil spirits. In fact it claimed that the belief in unknown evil forces makes families to seek help and relief from churches, prayer camps and shrines all over Ghana for help and relief (Sundh & Roslund,2012.) 1.3 Problem Statement Research findings show that delays in the treatment of the first episode of psychosis result in poor clinical and functional outcome, and that it may be possible to reduce the duration of this delay (Norman & Malla, 2001; Melle et al., 2004; Marshall et al. 2005; Perkins et al., 2005). Marshal et al (2005) state that delay in treatment leads to lower overall functioning, more severe positive and negative symptoms, lower quality of life, and a reduced likelihood of achieving remission (Marshall et al., 2005). This is in addition to poor response to psychiatric treatment (Perkins et al., 2005). In Ghana, many individuals seek unorthodox psychiatric care through faith-based and traditional healers for common mental disorders such as anxiety and mood disorders (Offori-Atta et al, 2010; 13:99-109). Research findings show that in developing 4 countries, including Ghana, many of those in need of psychiatric treatment do not reach psychiatric services at all, but seek the care of these informal community mental health services (Bifftu & Dachew, 2014). This is reflected in the low numbers of people with common mental disorders who utilize mental health services. In some cases, people with mental disorders visit other places to seek for help prior to reporting at mental hospitals. Thus, a substantial amount of time is lost before the initiation of treatment at mental illness facilities, resulting in poor response to psychiatric treatment and, consequently, lowers quality of life (Bifftu & Dachew, 2014). 1.4 Justification An understanding of the patterns of treatment seeking behavior ,the associated factors for mental illness and early intervention is critical to restoring the mental as well as the physical and the social health of an individual (Girma & Tesfaye, 2011).There are several variables that impact pathways to care, including the help-seeking behavior of the patient and family members. Other key variables are the accessibility to health services, and identification of, and response to, symptoms of early psychosis by each contact on the pathway (Anderson, Fuhrer, & Malla, 2010). Crucial factors include not only the patient's or family's knowledge and recognition of the mental disorder, but also the accessibility and availability of a helping agency in the community. Moreover, both socio-economically and psychosocial factors, such as the financial situation of the family, and social stigma, are also important( Toshiyku . et al., 2006) In 2006, the World Health Organization estimated that of the 21.6 million people living in Ghana, 650,000 were suffering from a severe mental disorder; a further 5 2,166,000 suffer from a moderate to mild mental disorder. Yet statistics from the Ghana health information system at that time showed a nationwide treatment rate of 32,283 people. This is a treatment gap of 98% of the total population expected to be suffering from mental health disorders (WHO, 2007). Doku and Awakame (2012) estimate that approximately 240,000 people suffer from severe mental disorders in Ghana and 2,400,000 suffer from a form of mental disorder (Doku & Awakame, 2012). Though studies that examined the associated factors of poor mental health within African countries are limited in number, research has consistently shown that lower socio-economic status, less education and gender are factors associated with poor mental health (Sipma et. al, 2013) In Ghana, there has been limited research on the pathways to psychiatric care, yet knowledge of such pathways and of the factors that influence them is crucial not only for education and sensitization of the public on the ramifications of unorthodox pathways to psychiatric care, but also on how mental health services should be delivered. Previous studies show that inadequate funding for mental healthcare has compromised effective service delivery particularly on geographical coverage, and lack of regional and district management structures for mental health with multiple adverse consequences including limited systems for planning, monitoring, service and quality improvement (Roberts et al, 2014). With the passage of the Ghana Mental Health Bill into law in 2012 which calls for regulation of the non-public psychiatric facilities, information on the pathways to psychiatric care will be vital for policy makers in the health sector to design mental health interventions to improve knowledge, attitudes and practices for individuals 6 with mental illness toward seeking treatment from mental health facilities promptly. In this regard, this study seeks to contribute to research efforts in Ghana and provide useful information on pathways to psychiatric care for policy elites, development partners of the Government of Ghana and the larger Ghanaian society, especially the family unit for early treatment of mental health patients and improved mental health care in general. 1.5 Objectives of Study General Objective To explore factors that influence mental healthcare seeking pathways prior to presenting at a public psychiatric hospital. Specific Objectives To determine the proportion of mental health patients who sought help (care) elsewhere prior to reporting at Pantang Psychiatric Hospital To document the healthcare providers (formal and informal) whom patients first contact about their symptoms and their subsequent pathway to psychiatric care. To identify factors that influence the mental health patient’s pathways to psychiatric care prior to reporting at Pantang Psychiatric Hospital. To find out the reasons why patients seek help from the various health care providers they contact. 7 1.6 Conceptual Framework The conceptual framework above illustrates how personal characteristics, social and economic factors influence patients pathways to care. For the purpose of this study, the outcome variable is Pathway to care (places patients sought help prior to presenting at Pantang).The independent variables are: age, sex, marital status, religion, educational status, employment status, and place of residence. The plane lines indicate direct movement of patient at the onset of mental health sickness to psychiatric hospital, faith based healers, traditional healers and general hospital. The broken lines symbolize indirect pathway to psychiatric care. The light plane lines from the socio-demographic factors that touches the other plane lines shows the influence of patient socio-demographic factors on patients’ pathways to care. Onset of Mental Health Condition Socio-demographic factors Age; Sex; Marital Status; Religion; Income; Employment Status; Education; Place of residence ; Educational Status Traditional Healers Psychiatric Hospital Faith-based healers General Hospital /Clinic 8 CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 Introduction The World Health Organization (WHO) estimates that approximately one in four people globally suffer from some form of mental health disorder, which makes it a leading cause of disability around the globe(WHO 2007). Poor mental health increases a person’s susceptibility to both infectious and chronic diseases and accounts for more than 30% of years of life lost worldwide (WHO 2007). According to the WHO, mental health disorders made up 12% of global disease in 2000. That figure is expected to rise to 15% in 2020, when unipolar depression is predicted to become the second most disabling health condition in the world (currently it is ranked at fourth) (Doku & Awakame, 2012). Poor mental health disorders are the leading cause of disability worldwide, with considerable negative impacts, particularly in low-income countries (WHO, 2001). Nevertheless, empirical evidence on its national prevalence in low-income countries, particularly in Africa, is limited (Sipsma et al., 2013). Mental health is increasingly becoming recognized by the public health community as critical to good health (CDC, 2011). An estimated 26% of Americans aged 18 years and older suffer from a diagnosable mental health disorder in a given year. The estimated lifetime prevalence of any mental health disorder among the U.S. adult population is 46% (CDC, 2011). Over time, private health providers, including those in the business of informal care are increasingly offering mental health services. No local studies have offered an 9 explanation for this growth. In their study of service use, charge and access to mental healthcare in a private Kenyan setting, Menil et al.(2011) revealed that though no studies within the African region provided explanation for the growth of private providers of mental healthcare, evidence from rapidly developing countries in Asia suggests that, on the demand-side, service users prefer non-state provision because they perceive the non-state sector as having more flexible access, shorter waiting times, greater confidentiality, and greater sensitivity to their needs (Menil et al., 2014). 2.2 Gaps between Need and Treatment for Mental Health Patients in Africa In Africa, the gap between need and treatment for mental disorders is wide, and private and informal providers are increasingly offering services (Fournier, Olivia A, 2011).Research Studies have shown that only 50% of countries in Africa have a mental health policy, and most of the existing policies are outdated ((Fournier, Olivia A, 2011). In addition, there are limited skilled personnel for mental health care in Africa, and research finding indicate that about 90% of African countries have less than one psychiatrist per 100,000 people, with 70% of the countries allocating less than 1% of the total health budget to mental health. Furthermore, less than 60% of African countries have community mental healthcare, while 40%are focused on psychiatric hospitals (Fournier, 2011). The picture at the national level in Ghana is glaring. As noted above, the WHO estimates 650,000 Ghanaians suffer from severe mental health conditions and that 2.17 million more are suffering from moderate to mild mental disorders with a treatment gap of 98% of the affected population (Bark, Nyarko & Klecha, 2010). 10 An overview of the mental health system in 2011 revealed serious weaknesses in mental health services in Ghana, which include insufficient in-patient facilities in the regions and districts, overcrowding in some of the inpatient facilities and deficiency in the management of substance abuse outside psychiatric institutions (Roberts et al ,2014). The study further noted that low level of community based rehabilitation facilities was putting burden on families who had to travel long distances in search of treatment (Roberts et al ,2014).Economic factors are also central to choice in healthcare, with traditional medicine highlighted as the only alternative, affordable option for the poorer part of Ghana’s population (Sundh and Roslund n.d.) 2.3 The Influence of religious beliefs on health seeking behavior Existing literature suggests that individuals with mental health problems will usually seek healthcare from faith–based or traditional healing centers before seeking help at a mental health facility because of beliefs that associate mental health problems with spiritual causes (Sipsma et al., 2013). In fact research has shown that in Africa, the consultation of traditional and religious healers in the pathway to mental health care is as a result of the conceptualization about the nature and origin of mental illness by African society (Sipsma et al., 2013). Generally, diseases are regarded as spiritual phenomena determined by the interaction of vital forces including deities, ancestral spirits, living beings, animals, and objects (Sipsma et al., 2013). In Ethiopia, the common belief about the causes of mental illness is spiritual possession (Girma & Tesfaye, 2011). In Ghana, the mentally ill are sometimes chained to trees, exposed to the sun and rain, deprived of food and/or water, or flogged in an attempt to exorcise demons, supposed to be the cause of their illness ( 11 Asare et. al., 2013). These practices constitutes gross human rights violations and have yet to be addressed as there are insufficient laws governing mental healthcare outside of psychiatric hospitals. Nonetheless, seeing a faith healer is seemingly less stigmatizing than visiting a psychiatric hospital ( Asare et. al., 2013). A mentally ill person is usually shown some sympathy from the community if they attend therapy sessions with a traditional healer, while less empathy is shown to those who visit a mental hospital (Roberts et. al., 2013). The Executives of Mind Freedom, a national nongovernmental organization in Ghana encourage a balance between faith healing and physical treatment when necessary, agreeing that seeing a traditional or faith healer brings fewer stigmas and is often more accessible and convenient transport wise (Fournier, 2011). As a result, the average pattern for Ghanaians involves utilizing traditional care first, after which they might attend a psychiatric hospital if the problem is not ―cured‖. Twenty to thirty percent (20-30%) of the Accra Psychiatric Hospital’s patients try spiritual or traditional healing before a family member or the court brings them to the psychiatric hospital (Roberts Et. al., 2013). About 20% of patients use faith healing after leaving the hospital for spiritual reinforcement (Roberts et. al., 2013) 2.4 Pathways to psychiatric care Pathways to care are defined as ―the sequence of contacts with individuals and organizations prompted by the distressed person’s efforts and those of his or her significant others, to seek help‖ (Rogler & Cortes, 1993). Anderson and her colleagues (2010) defined the term Care Pathway Contact as the individual, agency, or service provider with whom the patient came into contact on the pathway to mental healthcare. The First Contact refers to the care pathway contact from which help was 12 first sought after the onset of psychotic symptoms. According to the study, this is of interest because it is a marker of how patients and family members initiate help- seeking, and highlights the care pathway contacts who could be targeted for early intervention (Anderson, at. al., 2010). Also, epidemiological studies in China have reported that approximately three- quarters of patients took an indirect pathway to care and that only 5.5% of patients made their first contact with a psychiatric service , while the vast majority of patients first visited local tertiary general hospitals or local secondary general hospitals (Nsereko et al., 2011) . The direct pathway was the third most common pathway after tertiary general hospitals and secondary general hospitals pathways. However, only 9.6% of patients were diagnosed with mental health disorders, 73.2% did not receive an accurate diagnosis (e.g. normal or no abnormal findings were observed). Of the patients who first sought help from a psychiatric hospital, only 55.6% received a professional diagnosis and finally reached a mental health professional because of the poor treatment or high-cost medical care. The suggestion to first seek care most often came from the individuals themselves, followed by family members, relatives/ friends and colleagues. The vast majority of patients and their family members had poor knowledge of mental illness, which may be one of the reasons that patients with mental illness often diverge from multifarious care facilities (Zhang et al. 2013). Another study in Nigeria to assess the pathways to mental schizophrenia showed that majority of patients consulted spiritual or traditional healers as the first contact in the process of seeking care for the illness (Adeosun et al., 2013b). Psychiatrists were the first contact for 17.4% of patients, while 13.8% had previously consulted a non- 13 psychiatric physician or General Practitioner. The study also revealed that less than a quarter of patients had sought help from both traditional and spiritual healers at one point of time during the course of the illness, 42.8% from spiritual healers alone, and 11.6% from traditional healers alone. The delay between the onset of psychosis and contact with the first was shorter in patients that resorted to non-orthodox treatment. The first non-physician contact was consulted within an average of 4 weeks after the onset of psychotic symptoms, whereas the first physician contact was made about 17 weeks after the onset of symptoms. There was significantly greater delay in initiating physician contact as compared with non-physician contact. Those who first consulted general practitioners made an average number of 0.98 care contacts before presenting to mental health professionals, while those whose first contact was traditional or religious healers consulted an average of 5.74 care providers before presenting to mental health professionals. The predominant reason accounting for the choice of spiritual and traditional healers rather than orthodox mental health service providers was the belief that the illness was spiritual or supernatural in origin (Adeosun et al., 2013b). In a systematic review conducted by Anderson et al (2010) in developed countries, 20 studies examined the first contact on the pathway to care, with one study presenting data from two different countries. The first contact for the largest proportion of patients was a physician in 13 of 21 studies. Three additional studies found that a similar proportion of patients used a physician or emergency services as the first contact, three studies found that the majority used emergency services, and two found that majority of patients made first contact with a non-physician. When they examined the findings by region, all of the eight European studies found that a 14 physician was the first contact for the largest proportion of patients. By contrast, none of the five North American studies found that a physician was the first contact for the largest proportion of patients, with two studies finding that the largest proportion of patients used emergency services, and three found that approximately equal proportions used a physician or emergency services (Anderson et. al., 2010). In South Western Ethiopia, a hospital based study on the patterns of treatment seeking behavior for mental illnesses revealed that respondents went to the mental hospital for treatment of mental illness after a mean of 231.6 weeks. More than half of the patients sought traditional treatment from either a religious healer or a herbalist, before they went to the hospital (Girma & Tesfaye, 2011). The majority of patients attended the mental hospital as their second or third order treatment location (Girma & Tesfaye, 2011). Over time, it has been observed that care pathways are not random happenings, but are influenced by social, cultural, and health service factors (Singh & Grange, 2006). According to Singh and Grange (2006), pathways to care encompass not only the help-seeking behavior of the patient and his or her family members, but also the accessibility to health services and the identification of, and response to, the symptoms of early psychosis by each contact on the pathway (Singh & Grange, 2006). Therefore, for a country such as Ghana to effectively plan psychiatric health services, an understanding of the help-seeking behaviors of patients with mental illness is vital. Studies show that having an exact knowledge of the patient’s help-seeking pathways 15 is key in providing early interventions and supplying specialized and focused healthcare in diverse situations (Zhang et al., 2013). Evidence shows that delay in the commencement of treatment, after the onset of schizophrenia disease, may be related to the pathways patients take before receiving mental healthcare (Adeosun et al., 2013b). Also, knowledge of information about the pattern and correlates of pathways to mental care of patients with schizophrenia, may inform interventions that could make it possible for mental health patients to get to mental health professionals much earlier, thereby reducing the duration of untreated psychosis (Adeosun et al., 2013b). The emphasis on early detection and reduction of treatment delay in first-episode psychosis (FEP) has led to an interest in the modes and routes by which patients experiencing psychotic symptoms access help (Haider et. al,2009). Estimates of time between onset of psychosis and initiation of treatment – duration of untreated psychosis - is estimated to be 22 weeks to over 150 weeks. There are variable predictors of treatment delay in psychosis (Haider A. et al,2009).According to some studies, positive symptoms of psychosis (hostility) predicted short delay while negative symptoms predicted longer delays (Girma & Tefaye,2011). However, other studies fail to confirm this association (Haider et. al, 2009). According to some studies, social participation (social network outside family, employment) predicted shorter delay, and other impacting factors, including substance use, homelessness and contact with law, propensity to seek help, service accessibility and stigma have also been reported (Haider et. al,2009). 16 2.5 Triggers for Help Seeking and Entry into the Mental Health System. When people with episodes of mental conditions seek psychiatric help, they do so based on triggers. Research has shown that family members consistently reported consulting with a network of relatives, friends and religious leaders before seeking psychiatric help only as a last resort or based on the recommendation of others in their social network (Corcoran et al., 2007). Similarly, a qualitative study conducted in Uganda, revealed that some patients and their care-takers considered going to a health facility only as a last resort when no improvement is realized, or when the condition is believed to be getting worse (Nsereko et al., 2011) .Aside the influence of the family, studies show that family members reported seeking help from mental health professionals when behaviors became more alarming, particularly when it is frequently in the context of overt psychotic symptoms such as yelling at family members or reports of hearing voices (Corcoran et al., 2007). Also, a general hospital- based study on the pathway to psychiatric care in urban north China, showed that of the patients who first sought help from psychiatry hospital, 55.6% received a professional diagnosis and finally reached the mental health hospital because of the poor treatment or high cost medical care (Zhang et al., 2013). Another hospital based study in south western Ethiopia indicated that persons with somatic symptoms may present to the primary care early in the course and may then get referred for psychiatric assessment (Girma and Tesfaye, 2011). 17 CHAPTER THREE 3.0 METHODOLOGY 3.1 Introduction This capture explains the study design, study location, the variables, outcome of interest and the study population. Also, the sample size of the study and how it is obtained is explained. In addition, the sampling procedure, data collection and analysis, quality control and ethical considerations are explained. 3.2 Type of study This research is a quantitative study with incorporation of some qualitative dimensions to investigate the pathways to psychiatric care prior to reporting at a public mental health Hospital. In this regard, both quantitative and qualitative methods were applied to explore the pathways nodes of mental health patients. Quantitative research is about explaining phenomena by collecting numerical data that are analyzed using mathematically based methods (Aliaga & Gunderson (2000). 3.3 Study Design This is an institutional based cross-sectional study that entailed analysis of primary data. For the purpose of this study, a person with mental illness is defined as any patient who received any psychiatric diagnosis after being evaluated by mental health professional. 18 3.4 Study location/area The Study was conducted at Pantang Psychiatric Hospital. The Pantang Psychiatric Hospital, the largest (acreage wise) of the three psychiatric hospitals, was commissioned in the rural Pantang Village in the Greater Accra Region in 1975 in order to reduce the congestion at the Accra Psychiatric Hospital. It was planned to be a regional psychiatric hospital with a 500 bed capacity, but in addition to the original psychiatric services, the hospital now offers primary health care, reproductive and child health services and, under the National Health Insurance Scheme, HIV counseling, screening, and ART (anti-retroviral treatment) services. The psychiatric services are free by description, but similar to the Accra Psychiatric Hospital, Pantang asks patients to pay a small fee for their folders and medication if they can afford it. Nurses, nursing students, Health Assistant Training School students, and Community Health Mental Officers also gain clinical psychiatric experience at the Pantang Hospital (Roberts al, 2013). 3.5 Variables The outcome of interest, also known as the dependent variable in this study, is places patients sought help prior to reporting at Pantang Hospital. In this study the term Care Pathway Contact is defined as the individual, agency, or service provider with whom the patient came into contact on the pathway to mental health care. The First Contact refers to the care pathway con- tact from whom patient first sought help after onset of symptoms of a mental health condition. This is of interest because it gives an indication of the places mental health patients and their families seek help. Also, it provides useful information about care pathway contacts that could be targeted for early interventions (Anderson at. al., 2010). 19 The predicator variables, also referred to as the independent variables in this study, are the potential correlates or factors that may influence the patient pathway to psychiatric care. They are presented on the below. Outcome variable Exposure variables Places patients sought help Age Sex Marital status Religion Ethnicity Regions/Place of residence Education Employment status 3.6 Study Population The Significant others (Family members, relatives or friends) who accompany patients to the OPD of Pantang Psychiatric hospital are those interviewed, and all those included in this study are adult (18 -70 years) care givers who accompanied the patient to the psychiatric OPD ( Out Patient Department) of Pantang psychiatric hospital. Any patient who was not accompanied by someone was excluded. Also, any relative or caregiver who accompanied a patient to the OPD but was below 18 years was not included. Furthermore, all those ineligible participants who did not give consent to participate in the research were excluded. 3.7 Sample size of the study The sample size was determined using the formula below: no = (Zα/2) 2 P (1-P)/ e2 , Gleeson et al. (1993) 20 n = Based sample size N = Total proportion of mental health patients who received psychiatric treatment in Ghana = 67,780 {2.8%} (Robert et al., 2013) P = estimated prevalence in population as a decimal: 0.028 e = Margin of error around P, expressed as a decimal: 0.05 for 5% Z = Critical value for 95% (1.96) confidence level Using the above values for the parameters, the minimum Sample size (n) for the study is 41. To increase the reliability of the estimate, the researcher decided to interview 120 participants. Due to time limitation however, only 115 participants were interviewed over a two weeks period. 3.8 Sampling procedure / method Subjects Selection criteria Systematic sampling technique was used to select the study participants at the psychiatric OPD (Out Patients Department) at Pantang mental health hospital. With a population of 1,917 (Monthly average OPD attendance at Pantang Psychiatric Hospital), the average OPD attendance in two weeks (the period in which data collection was done) is 959 patients. The sampling interval (7) was obtained by dividing the two weeks average OPD attendance by the desired sample size (120). The starting point was determined randomly by tossing a fair dice. The study participants were relatives or care givers who accompany their patients to the Pantang Psychiatric hospital and this included the relatives of both old and new patients who have been assessed and confirmed by a mental health specialist to have a mental health condition. 21 3.9 Data collection and analysis The study adopted the method developed for the World Health Organization multicenter pathway study (Goldberg DP and Huxley P, 1980), but with a shorter period (two weeks) in this study. A semi-structured questionnaire (A data collection tool containing both closed and open ended questions) based on an encounter form developed in the WHO collaborative study was administered to 115 study participants (relatives of patients). The encounter form was modified slightly to reflect the context in Ghana. Specifically the form was used to record patients demographic data, places they sought help prior to presenting at Pantang psychiatric hospital, those who made the decision regarding patients pathways, the main problems they presented, their diagnosis, the source and type of care received before reporting at Pantang Psychiatric hospital, and the length of time between the occurrence of their mental health problems and their contact with professional careers. The length of time at each step of care was recorded. Face-to-face interviews were conducted with relatives of patients at the psychiatric OPD after having their consent, and each interview lasted about 15 minutes. The open-ended questions in the encounter form made it possible to probe deep into some of the issues about the patients’ pathways to care and made it possible to capture a range of opinions from the participants. The completed semi-structured questionnaires were coded and entered into Microsoft excel, cleaned up and exported onto Stata version 12 for analysis. Summary statistics and correlational analysis were used for this study and the results presented in the form of tables and charts. To determine the factors that influence patient’s pathways to psychiatric care, a chi-square test of association between each of the potential socio- demographic factors and of patient health seeking pathways is applied. From the analysis, all those variables (socio-demographic and other factors) with a p-values 22 ≤ 0.005 are considered as having an association with the identified pathways to psychiatric care. To determine the pathways that expedite or delay receipt of specialist Psychiatric care, the time to reporting at Pantang was recoded as a binary data; delayed or not delayed. All those who reported at Pantang in less than one month after first onset of symptoms were considered as not delayed. All those who reported one month after onset of symptoms have been categorized as delayed. Some of the open ended questions such as treatment received at various pathways were also coded and analyzed using summary statistics. The other open ended questions were analyzed using the thematic approach. This is a method of qualitative data analysis that moves beyond counting explicit words or phrases and focuses on identifying and describing both the implicit and explicit ideas within a data, that is, themes. Codes are then developed to represent the identified themes for later analysis. 3.10 Quality Control The data collection tool was pretested, reviewed and finalized. Two first degree holders in social science and one with a Master’s in Public Health supported the lead researcher in the data collection. The lead researcher trained them on how to administer the data collection tool correctly. They were taken through all the questions on the data collection tool, and all terminologies clearly explained to ensure that each person in the data collection team had the same understanding of all the questions in the tools and how to administer it. During the two weeks data collection period, completed questionnaires were reviewed at the close of each day to ensure completeness and accuracy of information. 23 3.11 Ethical Consideration/Issues Before commencement of data collection, ethical approval for the study was sought from Ghana Health Service (GHS) ethical review board. Secondly, copy of the ethical approval from the GHS was submitted to the authorities of Pantang Psychiatric Hospital, who in turn issued a letter of approval for the study to be conducted at the hospital. All participants or respondents gave their verbal consent or endorse a consent form before interviews. In addition, the purpose and objectives of the study was explained to all the study participants and they were informed that their participation in this study was voluntary and that they could decline to answer any question if they felt uncomfortable to do so. The study participants were informed of their right to discontinue from participating in this study at any time if they wanted to. They were also informed that they will not gain any direct benefit from this study but it will contribute to knowledge and suggest ways of improving the care of mental health patients. The methods and procedure for study was explained to the study participants and that their involvement in this study will not in any way negatively affect the services they receive from the Pantang Psychiatric Hospital, except that they may be inconvenienced by spending their time to respond to questions, and the difficulty of providing answers to some of the questions that border on personal information. In addition, study participants were informed that every piece of information they provided will be known to the lead researcher or a member of the data collection team only and meant purposely for this study. If in the course of answering the questions they decide not to continue, they were free to do so and their information destroyed and omitted from this study. They were also informed that such a decision will not affect them in any way. 24 CHAPTER FOUR 4.0 RESULTS 4.1 Introduction In this capture, the results of the study are presented and analyzed. The results covers the sample characteristics, study participants pathways to care ,the number of contacts made before seeking care from a psychiatric facility, those who made the decision about participants health pathways to care, and delays in seeking psychiatric care. Also, the association between patient demographic characteristics are analyzed with a highlight on socio-demographic factors that have a significant association with study participant’s pathways to care and those that have no significant association. Furthermore, the diagnosis of the study participants are presented and categorized according to where patients with a particular diseases sought help. Finally, the kind of treatment study participants received from the various health pathways contacts they made, their satisfaction on the treatments received are also presented. 4.2 Sample Characteristics A total of 115 relatives or care givers patients participated in the study. Of this number, 58 (50.4%) are males and 57 (49.6%) are females. The mean age (SD) of the participants is 37.3 (± 14.4). Over one quarter 45 (39.1%) of the participants have basic education with 29 (25.3%) and 27 (23.5%) of them attaining secondary and tertiary education respectively. However, 14 (12.2%) of the study subjects have no formal education. Most 66 (57.4%) of the participants are single or never married and 28 (24.4%) of them are married. The remaining proportion comprise of those separated, devoiced or widowed. Majority 100 (87%) of the study participants are 25 Christians, as those who share the Islam faith constitute 13 (11.3%) and 2 (1.8) % of them are in the traditional African religion and others. Almost the same proportion 45 (39.1%) of the participants are engaged in self-employment activities relative to those that are unemployed 46 (40%); and less than a quarter 14 (12.2%) of them are in public service. Slightly above a quarter 28 (24.4%) of the patients live within 0-20 km from Pantang and majority 47 (40.8%) reside at places within 25-49 km from Pantang. Those who live in communities over 100 km from Pantang constitute 28 (24.4%) of the study sample. The ethnic distribution of the participants are Akans 41 (35.6%), Ewe 31 (27%), Ga-Adangme 22 (19.1%) and others 21 (18.3) which comprise Chamba, Wangara, Kasena, Wala, Gonja, Guan, foreigners (Nigerians) and Fulani. Table 4.1 below provides detail information on the sample Characteristics. 26 Table 4.1: Socio-demographic characteristics of study subjects Characteristic Frequency (%) Age 18-19 20 – 29 30 – 39 40 – 49 50 – 59 60+ Total Mean ± SD 6 (5.2) 34 (29.6) 33 (28.6) 20 (17.4) 12 (10.4) 10 (8.7) 115 (100%) 37.3 ± 14.6 Sex Male Female Total 58 (50.4) 57 (49.6) 115 (100%) Educational level No formal education Basic ( Primary/JHS) Secondary (SHS/Vocational) Tertiary Total 14 (12.2) 45 (39.1) 29 (25.2) 27 (23.5) 115 (100%) 27 Marital Status Single/Never married Married Widowed Divorced Separated 66 (57.4) 28 (24.4) 7 (6.1) 8 ( 7) 6 (5.2) Total Religion Christian Islam Traditionalist Others 115 (100%) 100 (87) 13 (11.3) 1 ( 0.9) 1 (0.9) Total Occupation Unemployed Self-employed Public servant Retired Other 115 (100%) 46 (40) 45 (39.1) 14 (12.2) 3 (2.6) 7 (6.1) Total 115 (100%) 28 Distance to Pantang Psychiatric Hospital (Km) 0 – 24 25 – 49 50 – 99 100+ Total 28(24.4%) 47(40.8) 12(10.4) 28(24.4) 115 (100%) Ethnicity Akan Ewe Ga-Adangme Others 41 (35.6) 31 (27) 22 (19.1) 21 (18.3) Total 115 (100.0) 4.3 Patient diagnosis and where they sought help Schizophrenia 36 (31.3%), psychotic disorder 27 (23.5%) and depression 13 (11.3%) are the common diagnosis among the study subjects. Other diagnoses (Bipolar Affective Disorder, Mood Disorder, Seizure Disorder, Substance Abuse and others) have been recorded but their proportions { 9 (7.8%), 5 (4.3%), 6 (5.2), 5 (4.3%), & 9 (7.8%)} respectively are relatively not very significant in this study. Less than half 27 (17.4%) of the patients sought help unorthodox (Religious or Traditional) healers. Also, only 30 (26.1%) of the participants attended general health facilities for help. More than half 58 (50.4%) of the patients sought help from a psychiatric hospital. The disaggregation is shown on table 4.2 below. 29 Table 4.2: Patient diagnosis and where they sought help Diagnosis Religious/ Traditional Healer Freq.(%) General Medical Service Freq.(%) Psychiatric Service Freq.(%) Total Freq.(%) Bipolar Affective Disorder 4 (44.4) 0 5 (55.6) 9 (100.0) Depression 0 5 (38.5) 8 (61.8) 13(100.0) Mood Disorder 1(20.0) 2 (40.0) 2(40.0) 5(100.0) Psychotic Disorder 4(14.8) 8(29.6) 15(55.6) 27(100.0) Schizophrenia 11(30.6)) 7(19.4) 18(50.0) 36(100.0) Seizure Disorder 2( 33.3) 2( 33.3) 2(33.0) 6(100.0) Substance Abuse 3(30.0) 2(20.0) 5(50.0) 10(100.00 Others Total 2(22.2) 27 (17.4%) 4((44.4) 30 (26.1%) 3(33.3.) 58 (50.4%) 9(100.0) 4.4 Proportion of study participants who sought health elsewhere prior to reporting at Pantang Psychiatric Hospital As seen in figure one below, those who sought help elsewhere (including other psychiatric facilities) prior to reporting at Pantang since the onset of the first episode of their mental health conditions are more than half the total number of the study subjects relative to those who made Pantang their first place of contact when they first experience symptoms of mental illness. 30 Figure 4.1: Proportion of patients who Sought help elsewhere prior to reporting at Pantang Psychiatric Hospital 63.5 36.5 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 Yes No (%) Yes No 4.5 First Pathway to care (The first place patients contacted for help) Information from the study sample (115) on their first pathway to care show an even distribution between those who sought help from a psychiatric hospital and those who sought help from other places. Specifically, 58 (50.5%) of the patients sought help from a psychiatric hospital as religious or traditional healers and general hospital each has a share of 27 (23.5 %.). The decision regarding where patients sought help first was made by patients’ relatives or friends 107 (93%). 31 Table 4.3: First pathway (The first place patients contacted for help) Characteristics Frequency (%) First place of contact Religious/Traditional healer Community nurse Medical Practitioner General hospital Psychiatric service 27 (23.5) 2 (1.7) 1 (0.9) 27 (23.5) 58 (50.5) Decider of first contact Patient him/herself Relatives/friends Workmates/colleagues Others 5 (4.4) 107 (93.0) 1 (0.9) 1 (0.9) Delay between symptoms and first pathway Immediately Delayed 87 (75.6) 28 (24.4) Total 115 (100.0) 4.6 Second Pathway to care (The second place patients contacted for help) For the patients who did not seek psychiatric help at their first place of care, and proceeded to a second place (pathway) to seek help, 51 (68.9%) of them visited a psychiatric hospital and 15 (20.3%) sought help from a traditional or religious healer. 32 Similar to the first pathway, those who decided where patients should seek help on their second pathway are relatives and friends 62 (90%). Table 4.4: Second pathway (The second place patients contacted for help) Characteristics Frequency (%) Second place of contact Religious/Traditional healer Medical Practitioner General hospital Psychiatric service 15 (20.3) 1 (1.4) 7 (9.5) 51 (68.9) Decider of second place of contact Patient him/herself Relatives/friends Workmates/colleagues Others 1 (1.4) 62 (83.8) 3 (4.1) 4 (5.4) 4 (4.1) Delay between first and second pathway No delay Up to 1 year Up to 5 years >5 years 18 (24.3) 27 (36.5) 18 (24.3) 11 (14.9) Total 74 (100.0) 33 4.7 Third Pathway to care (The third place patient contacted for help) Furthermore, the 30 patients who did not seek psychiatric care at their second contact (Pathway) proceeded to a third place in search for a solution to their mental health condition, the decision was made by patient’s relatives or friends 27 (90.0). Of the thirty (30) who went to a third place for help, 26 (86.7%) of them sought psychiatric services, 2(6.7%) went to general hospital, 1 (3.3) sought help from a community nurse and 3.3 % of them sought help from religious or traditional healer. 4.8 Delays in seeking care Majority of the patients sought help immediately at the onset of first episode of illness and 28 (24.4%) of them delayed. Between the first and second pathways, only 18 (24.3%) sought help immediately, 27 (36.5%) of the patients delayed up to one year before seeking care, 18 (24.3%) delayed up 5 years before seeking help and about 11 (15%) delayed beyond five years. Majority 28 (93.3) of the patients delayed before seeking care at the third place where they sought care. Figure 4.2 and tables, and 4.5 provides details on the pathway information. 34 Table 4.5: Third pathway (The third place patient contacted for help) Characteristics Frequency (%) Third place of contact Religious/Traditional healer Community nurse General hospital Psychiatric service 1 (3.3) 1 (3.3) 2 (6.7) 26 (86.7) Decider of third place of contact Patient him/herself Relatives/friends Workmates/colleagues Others 1 (3.3) 27 (90.0) 1 (3.3) 1 (3.3) Period between second and third contacts No delay Delayed 2 (6.7) 28 ( 93.3) Total 30 (100.0) 35 Figure 4.2: Patient pathways and distribution regarding where help was sought. 4.9 Association between socio demographic factors and patient pathways to care Table 4.7 below shows the associations between patient demographic characteristics and patients health pathways (place patient sought help). From the analysis, only marital status and employment have significant associations with the patients’ health pathways, with p-values of 0.001 and 0.004 respectively. Age (P = 0.744), Sex (P = 0.795), Educational level (p = 0.877) Religion (P = 0.351), Distance to hospital (P = 0.105) and Ethnicity (p = 0.727) are not significantly associated with patients’ health pathways in this study. 36 Table 4.6: Association between socio demographic factors and health pathways of patients Characteristic Religious/ Traditional Healer General Medical Services Psychiatric Service Total Statistic P-value Age 18 - 19 20 – 29 30 – 39 40 – 49 50 – 59 60+ 2 (33.3) 9 (26.5) 8(24.2) 5(25.0) 3(25.0) 60 1(16.6) 11(32.4) 8(24.2) 3(15.0) 3(25.0) 4(40.) 3(50..0) 14(41.2) 17(51.5) 12(60.0) 6(50.0) 6(60.0) 6(100.0) 34(100.0) 33(100.0) 20(100.0) 1(100.0) 10(100.) 0.744 Sex Male Female 15(25.8) 12(21.1) 14(24.1) 16(28.1) 29(50.0) 29(50.8) 58(100.0) 57(100.0) 0.795 Educational level No formal education Basic ( Primary/JHS) Secondary (SHS/Vocational) Tertiary 2(14.3) 13(28.8) 6(20.6) 6(22.2) 5(35.7) 9(20.0) 8(27.6) 8(29.6) 7(50.0) 23(51.1) 15(51.7) 13(48.2 14(100.0) 45(100.0) 29(100.0) 27(100.0) 0.877 Marital Status Single/Never married Married Widowed Divorced Separated 22(33.3) 0 0 3(37.5) 2(33.3) 16(24.4) 12(42.8) 1(14.3) 1(12.5) 0 28(42.4) 16(57.1) 6(85.7) 4(50.0) 4(66.7) 66(100.0) 28(100.0) 7(100.0) 8(100.0) 6(100.0) 0.001 Religion Christian Islam Traditionalist Others 25(25.0) 1(7.7) 1(100.0) 0 27(27.0) 3(23.1) 0 0 48(48.0) 9(69.2) 0 1(100.0) 100(100.0) 13(100.00) 1(100.0) 100(100.0) 0.351 Occupation Unemployed Self-employed Public servant Retired Other 12(26.1) 9(20.0) 6(42.8) 0 0 5(10.8) 14(31.1) 6(42.8) 1(33.3) 4(57.1) 29(63.0) 22(48.8) 2(14.3) 2(66.7) 3(42.8 46(100.0) 45(100.0) 14(100.0) 3(100.0) 7(100.0) 0.004 Distance to Hospital(km) 0 – 24 25 – 49 50 – 99 100+ 4(14.3) 11(23.4) 6(50.0) 6(21.4) 5(17.8) 12(25.5) 4(33.3) 9(32.1) 19(67.8) 24(51.1) 2(16.7) 13(46.4) 28(100.0) 47(100.0) 12(100.0) 28(100.0) 0.105 Ethnicity Akan Ewe Ga-Adangme Others 9(21.9) 6(19.4) 7(31.8) 5(23.8) 12(29.3) 7(22.6) 4(18.3) 7(33.3) 20(48.8) 18(58.1) 11(50.0) 9(42.8) 41(100.0) 31(100.0) 22(100.0) 21(100.0) 0.727 Total 37 4.10 Reasons for seeking care from the various pathway contacts to psychiatric care The open ended questions in the data collection tool made it possible to further probe some of the issues regarding patient’s pathway to care. In particular, the relatives of patients were asked where patients sought help, why they chose to seek help from a particular pathway contact, the treatment received, whether they were satisfied with the treatment, and why. This made it possible for relatives of patients and their care givers to share their experiences, feelings, frustrations and lessons learnt in search for cure or treatment for their patients. Tables 4.8 and 4.9 below provides information on the reasons why the mental health patients chose each pathway and the kind of treatment they received from the various health providers they contacted. Table 4.7: Reasons for the various pathways patients took in search for a solution for their sickness Reasons Religious/T raditional Healer General Medical care Psychiatric hospital Total To seek psychiatric/mental care 0 7 63 70 Pantang is the right place to treat patient 0 0 22 22 To seek medical care 0 31 39 70 For proximity and convenience 1 0 3 4 Because sickness is caused by witchcraft or evil spirits 19 0 0 19 To seek spiritual healing 16 0 0 16 For prayers and spiritual deliverance 3 0 0 3 For supernatural healing 5 0 0 5 Total 44 38 127 210 P⃰articipants sought help from multiple places and gave multiple reasons for contacting those the different providers. 38 From Table 4.8 below, the patients who ever contacted a religious or traditional healers, 19 of them said their main reason for doing so because their sickness is caused by witch craft of evil spirits, while 16 of them also seek their reason for seeking help from a religious or a traditional healer was to seek spiritual healing. In addition, 5 of the respondents said the patients contacted religious or traditional healer for supernatural healing while 3 respondents gave spiritual deliverance as the reason why they contacted an unorthodox provider. Only one responded said proximity and convenience were the reasons why the patient contacted a religious or traditional health. Of the participants said the main reason the patients reported at a Psychiatric Hospital was to seek psychiatric or mental health care, while seven patients reported at a general hospital to seek same care. Another 22 or the participants said reported at Pantang Psychiatric hospital because it is right place a mental health patient care get the needed treatment and only one person said the patient went to a general hospital because he felt it was the right place to get the requisite treatment. For patients who sought care from a general hospital, 31 of them said their reason for report there was to seek medical help, while another 7 said their main reason for reporting at a general hospital was to Psychiatric care. Similarly, multiple reasons were given by those who attended a Psychiatric Hospital. While 63 of them said their main reason for seeking help from a Psychiatric Hospital was to seek Psychiatric care, 22 patients said they reported at Pantang Psychiatrist Hospital because it was the right place to seek help. 39 Table 4.8: Summary of the various treatments patients received at non-orthodox health pathways. Category Subcategory Treatments patient received. Prayer Camp/Church Prayers Fasting/ Deliverance Smeared anointing oil on the body Received prayers and completed dry fasting for three days ( 68) Patient was given spiritual bath and prayers (57). Patient received spiritual bath and prayers only (19) Prayer and fasting was done for patient (31) Prayed for and relatives told to take him to Pantang (18) Smeared anointing oil on his body and prayed for (101) Prayers and anointing oil smeared on patient (6) Traditional Healer Spiritual bath Patient was giving a substance to bath to cleanse his body and mind (71) Patient was given a spiritual bath and prayers (97) Traditional Healer Herbal and concoctions Received herbal treatment and other concoctions (34) Treated with herbal medication only(85) Wrote verses from the Holy Quran with ink and washed off for patient to drink and wash his face (60) Patient given concoction to drink (80) R⃰espondent questionnaire numbers are indicated in brackets. 40 4.11: Treatment received at psychiatric and general hospital For those who went to psychiatric or general hospital, they all received standard medical treatment, usually in the form of diagnosis, administration of medicines (tablets and injections) and counselling where necessary. The treatments patients received various orthodox places are summarized below. Respondent questionnaire numbers are indicated in brackets. Table 4.9: Treatment received at psychiatric and general hospital General Hospital/ Psychiatric Hospital Treatment received Patient was assessed , admitted and put on medication (46) Patient was admitted and given injection and pills for three weeks (78) Patient was injected and given tablets (86) Injection and pills were administered to patient (106) Drugs was administered to patient (51) Injection and pills were given to patient (109) ⃰ Respondent interview questionnaire numbers are indicated in brackets 41 4.12: Patients Satisfaction with Providers (Pathways) The satisfaction patients received on their pathways varied across board. Of the 27 patients who sought help from a religious or traditional healer, 18 (13.9%) of them said they were not satisfied with the outcome of treatment they received from those places. However, 45 (73.7%) out of the 58 patients who sought help from psychiatric hospitals said they were satisfied with the results of the care and treatment given them. Remarkably, 20 (37.7%) of the 27 patients who sought help from general hospital also said they were not satisfied with the outcome of treatment received at the facilities. Table 4.10: Patients Satisfaction with Providers (Pathways) First pathway Response Religious/ Traditional Healer Community Nurse Medical Practitioner General Hospital Psychiatric facility Total (%) Satisfied 9 (14.5) 1 (1.64) 0 7 (11.5) 45 (73.7) 62 (53.9) Not satisfied 18 (13.9) 1 (1.9) 1 (1.9) 20 (37.7) 13 (24.5) 53 ( 46.1) Total (%) 27 (23.5) 2 (1.7) 1 (1.9) 27 (23.5) 58 (50.3) 115 (100) 42 CHAPTURE FIVE 5.0 DISCUSSION OF FINDINGS 5.1 Introduction In this capture, the results of the study are discussed. Discussion takes into account the key findings of the study, with an analysis of trends, variations, dichotomies and the context in relation to the variables examined. This section also highlights the key findings of the study, compared and contrasted with that of similar studies done elsewhere. Specifically, the proportion of patients who sought help elsewhere prior to reporting at Pantang Psychiatric hospital is discussed, the various pathways taken by patients to seek psychiatric care, delays associated with each pathway, the socio- demographic factors associated with patients’ pathways to care, the reasons why the patients sought help from orthodox and unorthodox places, the type of treatment patients received at these places and the satisfaction of patients with regards to the treatment they received from the pathways they took. The conclusions, recommendations, and limitations of the study, as well as suggestions for future research are also discussed. 5.2 Proportion of Patients who sought help elsewhere prior to reporting at Pantang. This is an institutional based cross-sectional study with a sample size of 115 comprising 50.4% males and 49.6% females. The mean age (SD) is 37.3 (± 14.6). Of the 115 participants, 63.5% sought help elsewhere prior to reporting at Pantang psychiatric hospital while 36.5% made Pantang their first place of contact. The 63.5% who sought help elsewhere before reporting at Pantang psychiatric hospital sought treatment from general medical facilities, prayer camps, churches and African 43 traditional and spiritual healers. While some of the patients had sought treatment from unorthodox providers before reporting at Pantang psychiatric hospital, it is important to note that some of them had received some form of professional psychiatric help from some general hospitals were efforts are being made to integrate mental healthcare services. Also, some of the patients who sought help at Accra psychiatric hospital stopped going there for help but rather decided to seek help from Pantang psychiatric hospital. Accounts from some of the patients reveal abuses and poor conditions such as overcrowding, and starvation of patients at the Accra psychiatric hospital. Schizophrenia is the common diagnosis among the study sample and psychiatric hospital is the first place of contact for half (50.0%) of them, whilst 23.5% and 28.1 % sought help from religious or traditional healers and general hospital services respectively. This is markedly different from what was observed in a previous study in Nigeria in which majority (69%) of the schizophrenia patients consulted spiritual or traditional healers as their first place of contact in the process of seeking care for the illness and that psychiatrists were the first contact for 17.4% of the patients(Adeosun et al., 2013b). 5.3 Pathways to Psychiatric Care The general findings on patients first contact to care is markedly different from other studies done in Nigeria and Ethiopia but similar to that of Cantabria in Spain. Contrary to the findings in Nigeria and Ethiopia, only 23.3% of the sample in this sought help from religious or traditional healer on their first pathway. The study in Nigeria however reported non physicians (traditional and religious healers) were the first point of contact for majority of patients with schizophrenia (Adeosun et al., 44 2013b). A similar trend was observed in Ethiopia and China where over a half of the patients in the Ethiopia study sought traditional treatment from either a religious healer (30.2%) or a herbalist (20.1%) before reporting at the hospital (Girma & Tesfaye 2011), and in China about three-quarters of the patients sought help elsewhere before seeking orthodox to care ( p < 0.0001). Also, the findings did not confirm the Cantabria study in Spain that showed that majority of the sample established first contact with both the general practitioner (54 %) and the hospital doctor (26 %) and from there directly proceed to the psychiatric services ( Vazquez- Barquero, et al., 1993). In contrast, this study found that 50.4 % of the sampled proceeded directly from onset of mental illness to the mental hospital for psychiatric care and 28.8% established contacts with a general hospital from where they were either referred to a psychiatric hospital, or treated and allowed to go back home and initiate either a non-orthodox or psychiatric care based on the decision of their relatives or friends if the patient’s condition did not improve. Differences in local contexts and that of individual socio-demographic variables might account for the variations in patients’ pathway trends in this study compared to those conducted in China, Ethiopia, Nigeria and Spain (Vazquez-Barquero, et al., 1993. Furthermore, the proportion of the sample that sought help elsewhere, including other mental health services prior to reporting at Pantang Psychiatric hospital is 63.5% compared to those who establish direct contact (26.5%) with the facility. This brings to light a very important issue about affordability and access to mental health care. Currently, mental health patients are not exempt from paying the subscription fee of the National Health Insurance scheme (NHIS). This means that mental health patients will have to make out of pocket payment to access the needed 45 health services and giving that Pantang psychiatric hospital is much better in terms of facilities and care, patients who come from families with financial means tend to seek care at Pantang while the poor ones do so at Accra psychiatric hospital. This might be one of the reasons why half of the participants in this study sought help from Pantang as their first pathway contact. It is possible the reverse might be the case if the same or a similar study is conducted at Accra psychiatric hospital. As shown in figure 4.2, over a quarter of the patients previously had two previous consultations with orthodox or non-orthodox caregivers before reaching a psychiatric facility. In western India, a similar observation was made in a study that show that averagely, patients made three previous consultations before reaching a psychiatric facility (Dave, 2014).Consistent with expectations, the number of patients who made contacts with religious and traditional healers as well as general hospital dropped in favor of psychiatric hospitals as patients transitioned from first contact, to second and third. This is consistent with previous studies in which more patients with non- psychiatric first contacts made contacts with psychiatric services as they proceeded to a second and third pathway contact (Bhui,et.al., 2014). In this study, patients made similar multiple consultations with various practitioners and switching between them. Also, patterns emerged showing that patients largely consulted each practitioner independently and switched among them but most of them eventually shift to psychiatrists and stay with them. This shows a positive trend towards acceptance and efficacy of psychiatric treatment /facilities (Dave, 2014). 46 5.4 Delay in seeking psychiatric care Previous studies in Japan noted two types of delay in reaching psychiatric care. The study described the first type of delay as the delay between the onset of an episode of a mental health condition and the contact with the first care provider, and the second type being the type of delay caused by contacting a care provider who is not a mental health professional (Fujisawa et al., 2008). This delay is due to the time that it takes care providers to recognize a patient's problem or discover that their treatment of that problem was not successful, which then trigger’s them to refer the patient to a mental health professional(Fujisawa et al., 2008).These two types of delays were observed in this study as patients proceeded from their first contact to the second and third in search for a solution to their problem. In particular, those who sought help from religious or traditional healers as their first contact may proceed to a general hospital and then to a psychiatric hospital. As observed in this study, 24.4% of the patients delayed in making their first contact with care providers from the onset of symptoms. During the transition from first, second to third care providers (pathways), 36%, 24.3% and 14.9% of the patients delayed up to one year, up five years and over fivers years respectively. These long delays may be attributed to the time spent at prayer camps, traditional healers and switching from one non psychiatric provider to the other. Studies in Nigeria indicated that referral delays is associated with the duration of untreated psychosis , and that there is the possibility of reducing the delay in accessing orthodox mental health service when orthodox mental health professionals are liaised with traditional healers (Adeosun et al., 2013a). Perhaps, the government of Ghana, particularly the ministry of health and Ghana health service might need to consider identifying unorthodox mental health care providers and formalize their 47 working relationship with public psychiatric healthcare providers to reduce the delays noted in this study. 5.5 Association between socio-demographic factors and patients pathways When mental sickness sets in, patients and their families take a number of pathways in search for treatment or cure. Their decision to seek care from one pathway or the other is mostly affected by some factors. One important factor that has been noted to be associated with healthcare decision making is socioeconomic status (Tabi, et al, 2006). Also higher education is noted to be associated with positive attitude towards a person with mental health condition (Barke et al, 2010). In this study, marital status is significantly associated with patient’s pathway to care (P = 0.001). Also a significant association between employment status and pathway to care has been observed (p = 0.004. Other studies have shown that mental health patients are vulnerable and have a high risk of being unemployed and very susceptible to impoverishment due to the challenges they face in securing or maintaining work or their income. (Paper et al., 2012). Given the strong association between pathway to care and employment and marital status, it will be helpful to address the issues of stigmatization of mental health patients, access to the needed healthcare facilities and enabling public education. I has been suggested that public intervention to address social exclusion, discrimination and social protection and improved access to essential basic amenities can contribute to social equity and inclusion for mental health condition(Paper et al., 2012) 48 5.6 Reasons for seeking help from unorthodox and unorthodox providers The findings in this study reveal that significant others (relatives and friends of caregivers of patients) are the main decision makers regarding where patients sought help at each stage of the pathway. They make decisions on behalf of the patients based on their understanding and conceptualization of the nature of the patient’s sickness and beliefs about what cause the sickness. On the contrary, a study in China finds that 80% of the patients made the decision themselves or from their immediate members and 18.5% of the decisions infrequently made by other relatives and friends(Zhang et al., 2013). In this study, those who sought help from psychiatric hospital, 63% of them said their main reason was to seek mental health care while another 22% said they had prior knowledge that Pantang is a the right place to get the needed care for the patient. For example, the respondent in questionnaire number 13 said: ―We brought him to Pantang to seek Psychiatric help to cure his condition so that he will behave normal. Some of the relatives of patients are aware that about the right place to seek help when some develops an episode of mental health condition. Respondent number 14 also said: ―we know that Pantang hospital is the facility that can give him the needed help‖. Furthermore, respondent number 41 said: ―Pantang hospital has a track record of helping people with similar health condition, so we brought him here to treat his condition‖. Those who patronized the services of the religious or traditional healers, 19% of them said they decided to go there because the sickness that has afflicted their patient is caused by witchcraft and evil spirits. An additional 16% also said they their reason for 49 contacting a religious of traditional healer was to seek spiritual healing. For instance respondent number 34 said: ―The mother believed it is a spiritual illness and that patient he needed prayers and spiritual deliverance‖. Some of the relatives of patients believed their patients will be healed if only they are delivered from the attack of evil spirits and witches. Respondent number 38 said: ―I took my patient to prayer camp to seek spiritual help to deliver patient from the attack of witches‖. For one of the respondents, even though he took his brother to Pantang for psychiatric care and that it is the right thing to do, the wellbeing or recuperation of his patient depends on what God does when the psychiatric doctor and the nursed have finish with their treatment. He said: ―Doctors treat but is it God who heals. That is why I took him to a church to pray for God to heal him as he takes his treatment”. These findings are consistent with a previous study in Uganda in which researchers explored how people diagnosed with depression conceptualize their condition and how their conceptualization shaped their efforts to seek help. The authors documented stories of participants detailing the role of significant others regarding illness definition, treatment choices and how the beliefs of patients significant others influenced the definition of illness and that of appropriate therapy. In fact almost all the respondents agreed that cultural perceptions’ of mental disorders as supernatural, ―spiritual‖ illnesses or a product of ―evil forces are widespread within Ugandan society (Neema, 2007).The findings in this study also supports Anderson’s (1968) model of health care utilization in which category one of the model states that ―an individual is more or less likely to use health services based on demographics, 50 position within the social structure, and beliefs of health services benefits, and that an individual who believes health services are useful for treatment will likely utilize those services‖ (Wolinsky, 1988b). 5.7 Type of treatment received and feedback on satisfaction While professional medical treatment in the form of diagnosis, consultation and administration of medicine in the form of injections and pills were received by patients who contacted psychiatric and general hospital, the experience of those who sought help from religious and traditional healers is different. At the prayer camps, patients, and in some instances their relatives were made to fast for a number of days deemed appropriated by the pastor. Anointing oil was smeared on their body and long prayers sessions were held for the patient by the pastor and his team of ―prayer warriors‖ to cast out demons and the spirit believed to be the cause of the sickness. The accounts of those who visited traditional healers include drinking herbal preparations, concoctions and burning incense to cleanse the patient. Given that Ghana is a religious country with high level of superstitious believes, it not surprising that mental health patient sought help from these places. What is of concern is how long they stay there, they kind treatment they received, the conditions at such places and importantly, whether that is the kind of treatment required for the mental health conditions patients present. In this study, evidences abound that spiritual and traditional healers are not the right places to treat mental health patients. Of the 27 patients who sought care from religious or traditional healers, only 9 said they were satisfied with the outcome but the remaining 18 of them said they were not satisfied because the treatment did not help the patients. Respondent number 80 said: 51 ―the concoction didn’t help him stop using the substance even though the traditional healer claimed it would‖. In some instances, the patient condition gets worse. This was what respondent number 70 said: ―The prayer camp did patient at all. In fact his condition deteriorated at that place‖. Also, some of the unorthodox providers extorted money from the patients and relatives. ―Respondent number 97 narrated his experience as follows: ―Patient was not cured and at a point, we realized the traditional healer was just deceiving us for our money‖. Conversely, 45 of the patients who sought help from psychiatric hospital said they were satisfied and 13 of them said they were not satisfied. For example, respondent 108 said: ―I am not a medical doctor but I can see that he is well now because he does not talk to himself again‖. Some said the treatment their patients received at the psychiatric hospital improved patient health condition. Respondent (no.74) said: ―Patient sleeps well and behaves normally once he takes his medication correctly‖. For the 13 study subjects who said they were not satisfied with the treatment patients received at Psychiatric hospital, their disaffections has nothing to do with the treatment patients received at Pantang Psychiatric hospital, but that of Accra psychiatric hospital. They mentioned over crowing, hunger and beating of patients as some of the reasons why they had to take patients from that facility to Pantang. For instance, respondent number 86 said: 52 ―Patient was not well taken care of while on admission. She was naked and would not take her medication. The healthcare givers at the facility did not do much to help her get her cloths on or take her medicine”. Some care givers were angry about the manner their patients were treated at Accra psychiatric hospital. Respondent number 87 said: ―Patient condition got worse; he was beaten by the nurses at the facility that facility (Accra Psychiatric hospital)‖. 53 CHAPTER SIX 6.0 CONCLUSIONS AND RECOMMENTDATIONS 5.1 Conclusions Majority of patients who report at Pantang psychiatric hospital had previous sought help from a religious or traditional provider and a general hospital From this study, four key pathways to psychiatric care have been identified. The first pathway is the direct pathway to a public psychiatric hospital at the onset of a mental health condition. The second pathway is the transition of patients from religious and traditional healers to psychiatric hospital. The third pathway is referrals from general hospitals to a public psychiatric hospital. The fourth pathway is the long pathway; that is the transition of mental patients from tradition or religious healers to a general hospital (or vice versa) to public psychiatric facility. Secondly, about half of the people with mental health conditions who live in urban cities or towns that have mental health hospitals first seek help from public psychiatric hospitals while the remaining 50% percent take other pathways before finally arriving at a psychiatric hospital. This is because findings from this study show that majority of the participants live in Accra and around Accra even though there hail from different parts of the country and their proximity to Pantang psychiatric hospital leverage their geographical access to the facility compared to their colleagues in distant towns and villages. Furthermore, the ethnic distribution of the participants highlights the important role of geographical access to healthcare. The predominant ethnic groups in the study sample are Akans, Ewes, Ga-Adangms and Krobos.Very few ethnic groups from the northern part of Ghana were recorded in this study. This 54 does not in any way suggest that the predominant ethnic groups in this study are more predisposed to developing mental health conditions, but may be due to their proximity to the facility. The accounts of patients who first sought help from religious and prayers camps suggest that patients who patronize their services experience no healing but rather their condition get worse or remain same. This implies that mental health patients who contact unorthodox places for help do not only risk wasting their limited resources on these so called healers but risk having their conditions deteriorated. 5.2 Recommendations 1. Community mental health services should be developed and expanded to improved access to mental health care services in all the ten administrative regions of Ghana. 2. The ministry of health should give priority to mental health care services by increasing the budgetary allocation to the mental health care subsector in the national health budget 3. The Ministry of Health and Ghana Health Service should recognize the role of unorthodox mental healthcare providers and put in place appropriate measures to ensure that their activities are integrated into the formal mental healthcare services to make it possible for them to play a referral role. 4. Public education on mental healthcare should be initiated and the role of community based organizations such as NGOs, churches, mosques and community health volunteers will key in making it a success in educating communities on the importance of early treatment at psychiatric facilities. 55 5. Ghana health service to should pay close attention to the living conditions of the inmate’s patients at Accra psychiatric hospital by addressing over crowing and poor feeding. 5.3 Limitations of the Study Due to limited financial resources and time, this study was limited to only Pantang psychiatric hospital. It is possible the findings of this study might have been different if other psychiatric hospitals in Ghana where included. Secondly, a sample size of 115 is too small to get the bigger of picture of the health seeking pathways mental health patients in Ghana. As a result, the findings of this study cannot be generalized. Finally, the decision to include both old patients (patients who had already reported at Pantang before the study) might have resulted in a recall biases since some of the patients had their first episodes of mental illness in over twenty (20) years. With this length of time, it is possible the care givers of the study participants (Patients) might change over time and the therefore, the information they provided about patients pathways to care inaccurate or very limited. Future Research Giving that majority of those who attend the Pantang psychiatric hospital are perceived to be relatively better off economically compared to patients at Accra psychiatric hospital and other public psychiatric hospitals, it is possible that the economic characteristics of the patients at these other psychiatric facilities in Accra and elsewhere could produce a significantly different results if this study was to be extended to those psychiatric facilities. Therefore, it will useful for any future 56 pathway study of mental health patients in Ghana to include the other psychiatric facilities in the country. Furthermore, any furthermore study of pathways to psychiatric care in Ghana should consider a larger sample size so as to make the findings generalizable. 57 REFERENCES Adeosun, Increase Ibukun, Abosede Adekeji Adegbohun, Tomilola Adejoke Adewumi, and Oyetayo O Jeje. 2013a. ―The Pathways to the First Contact with Mental Health Services among Patients with Schizophrenia in Lagos , Nigeria.‖ 2013. ———. 2013b. ―The Pathways to the First Contact with Mental Health Services among Patients with Schizophrenia in Lagos, Nigeria.‖ Schizophrenia research and treatment 2013: 769161. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3893872&tool=pmce ntrez&rendertype=abstract. Anderson, K K, R Fuhrer, and a K Malla. 2010. ―The Pathways to Mental Health Care of First-Episode Psychosis Patients: A Systematic Review.‖ Psychological medicine 40(10): 1585–97. http://www.ncbi.nlm.nih.gov/pubmed/20236571 (November 23, 2014). Bhui, Kamaldeep, Simone Ullrich, and Jeremy W Coid. 2014. ―Which Pathways to Psychiatric Care Lead to Earlier Treatment and a Shorter Duration of First- Episode Psychosis⃰?‖ BMC Psychiatry 14(1): 1–11. BMC Psychiatry. Bifftu, Berhanu Boru, and Berihun Assefa Dachew. 2014. ―Perceived Stigma and Associated Factors among People with Schizophrenia at Amanuel Mental Specialized Hospital , Addis Ababa , Ethiopia⃰: A Cross-Sectional Institution Based Study.‖ 2014. Centers for Disease Control and Prevention. Public Health Action Plan to Integrate Mental Health Promotion and Mental Illness Prevention with Chronic Disease Prevention, 2011–2015. Atlanta: U.S. Department of Health and Human Services; 2011. Corcoran, Cheryl et al. 2007. ―Original Article Trajectory to a First Episode of Psychosis⃰: A Qualitative Research Study with Families.‖ : 308–15. 58 Dave, Kamlesh R. 2014. ―Pathways to Psychiatric Care – A Study from Tertiary Level General Hospital of Western India.‖ 24: 411–14. Doku, V C K, and J Awakame. 2012. ―IMPLEMENTING THE MENTAL HEALTH ACT IN GHANA⃰: ANY CHALLENGES AHEAD⃰?‖ 46(4). Dr.Robers, Mark , Prof. Asare, Joseph B, Mogan, Caroline, Dr. Adjase, Emmanuel, Dr.Osei, Akwesi. 2013. ―T He Mental Health System in Ghana.‖ Fournier, Olivia A, University of Califonia. 2011. ―eScholarship Provides Open Access, Scholarly Publishing Services to the University of California and Delivers a Dynamic Research Platform to Scholars Worldwide.‖ Fujisawa, Daisuke et al. 2008. ―International Journal of Mental Pathway to Psychiatric Care in Japan⃰: A Multicenter Observational Study.‖ 9: 1–9. Girma, Eshetu, and Markos Tesfaye. 2011. ―Patterns of Treatment Seeking Behavior for Mental Illnesses in Southwest Ethiopia⃰: A Hospital Based Study.‖ BMC Psychiatry 11(1): 138. http://www.biomedcentral.com/1471-244X/11/138. Illness, Mental. 2011. ―For More Information , Contact National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention 4770 Buford Highway , NE , Mailstop K-67 Atlanta , GA 30341- 3717 Available at Www.cdc.gov/mentalhealth.‖ Jl, Vazquez-barquero, Herrera Castanedo S, Artal Ja, and Cuesta Nunez J. 1993. ―Pathways to Psychiatric Care Ill Cantabria.‖ : 229–34. Menil, Victoria Pattison De, Martin Knapp, David Mcdaid, and Frank Gitau Njenga. 2014. ―Service Use , Charge , and Access to Mental Healthcare in a Private Kenyan Inpatient Setting⃰: The Effects of Insurance.‖ 9(3): 1–7. Nsereko, James R et al. 2011. ―Stakeholder ’ S Perceptions of Help-Seeking Behaviour among People with Mental Health Problems in Uganda.‖ 59 International Journal of Mental Health Systems 5(1): 5. http://www.ijmhs.com/content/5/1/5. Paper, Background et al. 2012. ―AN OVERVIEW OF VULNERABILITIES AND RISK FACTORS Risks to Mental Health⃰: An Overview of Vulnerabilities and Risk Factors Background Paper by WHO Secretariat for the Development of a Comprehensive Mental Health Action Plan.‖ ―Pathway to Psychiatric Care in Bali.‖ Read, U M, C Lund, Programme Consortium, and Angela Ofori-atta. 2010. ―A Situation Analysis of Mental Health Services and Legislation in Ghana⃰: Challenges for Correspondence⃰:‖ : 99–108. Roberts, Mark, Caroline Mogan, and Joseph B Asare. 2014. ―An Overview of Ghana ’ S Mental Health System⃰: Results from an Assessment Using the World Health Organization ’ S Assessment Instrument for Mental Health Systems ( WHO- AIMS ).‖ 8(1): 1–13. Sipsma, Heather et al. 2013. ―Poor Mental Health in Ghana⃰: Who Is at Risk⃰?‖ BMC Public Health 13(1): 1. BMC Public Health. Sundh, Linda, and Rebecca Roslund. ―From Evil Spirits to Extra Affection.‖ WHO. 2007. ―No Title Ghana, A Very Progressive Mental Health Law.‖ 7. World Health Organization: Mental Health: New Understanding, New Hope. In World Health Report. Edited by World Health Organization; 2001 [http://www.who.int/whr/2001/en/whr01_en.pdf]. Zhang, Weijun et al. 2013. ―Pathways to Psychiatric Care in Urban North China: A General Hospital Based Study.‖ International journal of mental health systems 7(1): 22. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3852166&tool=pmce ntrez&rendertype=abstract (November 23, 2014). 60 APPENDICES Appendix A: Informed Concern Form Introduction Thank you for your time. My name is Sidua Hor, a student of School of Public Health, University of Ghana. I am carrying out a research in this health facility on pathways to Psychiatric care. I would be grateful if you could be one of my participants. Kindly read (or have it read to you) the information provided in this paper for details about your participation. This form details the purpose of this study, a description of the involvement required and your rights as a participant. The purpose of this study is to determine the pathways to psychiatric care prior to presenting at a psychiatric hospital, and to determine the factors that influence the decision making process regarding where to seek help. Benefits of the research This study will not offer you any direct or immediate benefits following your participation. However, the study will help us suggest ways of improving the care of mental health patients. These benefits will include the following: To better understand the places patients with mental health conditions initially seek help prior to admission at Pantang, and why they delay in seeking early treatment at mental health hospital. To identify significant components that could help health sector policy makers in Ghana design future interventions to improve early treatment of mental health conditions in Ghana. 61 The methods that will be used to meet this purpose include: One-on-one interviews Focus group discussions with health care providers You are encouraged to ask questions or raise concerns at any time about the nature of the study or the methods I am using. Study Procedure I have a set of questions I will like to ask you for very short answers. It will take about twenty minutes to complete. You may simply say Yes or No, or choose among a number of suggestions I will read to you. Risks and Discomfort Your participation in this study will not in any way negatively affect the services you receive from this hospital. You will however be inconvenienced by spending your time to respond to my questions, and the difficulty of providing answers to some of the questions that may border around personal information. Confidentiality I am not recording your name. Every piece of information you give me will be known to me only and meant purposely for this study. The completed questionnaire will be stored in my personal electronic folder and protected with a password. Your name will not be mentioned anywhere in connection with this information when compiling and analyzing the set of data collected, or publishing any report emanating from this study. 62 Voluntary Participation and Withdrawal Your decision to participate in this study is purely voluntary. If you don’t feel like answering a particular question, you are free not to. If in the course of answering the questions you decide not to continue, you are also free to do so. Then we will stop the interaction. But this decision will not affect you in any way. In the event you choose to withdraw from this study, all information you provide will be destroyed and omitted from the final paper. Insights gathered by you and other participants will be used in writing a research report which will be presented to the School of Public Health, University Ghana, in partial fulfillment of the requirement for the award of Masters of Public Health Degree. Though direct quotes from you may be used in the paper, your name and other identifying information will be kept anonymous. Contact If you have questions regarding this study, or clarification on any aspect of your participation, kindly contact the following persons: Dr. Abdallah Ibrahim, Academic Supervisor ( 0266 450012) Ms. Hannah Frimpong, GHS/ERC Administrator ( 0243235225/0507041223) My personal mobile number is 020 7708938 63 PARTICIPANT’S CONSENT I have read (or it has been read to me) all the details about my participation in this study. I have understood everything and cleared my mind of all doubts by asking questions for clarification. I have not denied myself of any right by taking part in this study. I willingly volunteer to be a participant in your study as indicated by my signature/thumbprint below or verbal consent: Signature Thumbprint ……………………………… Appendix B: Date Collection Tool Name of Facility: …………………………………………………. Date of Interview: ……………………………………………… ID of interviewee……………………………………………….. Name of Interviewer: …………………………………………………. SOCIO-DEMOGRAPHIC DATA No. code tick the appropri ate box 1 Sex? Sex Male 1 Female 2 2 What was your age (as at your last birthday) age 3 What is your highest educational level completed edu no formal 0 basic(primary/JHS) 1 secondary(SHS/vocational) 2 Tertiary 3 64 4 What is your marital status? mstatus single/never married 1 Married 2 Widowed 3 Divorced 4 Separated 5 co-habitating 6 5 What is your religion? religion Christian 1 Islam 2 Traditionalist 3 other (specify)…………………………………………… 4 6 What is your occupation? occupation Unemployed 0 self-employed (petty trade, private business, artisans, etc) 1 public servant 2 Retired 3 Other (Specify)…………………………………….. 4 7 Name of village/town/city where patient lives Health seeking behaviors What was the first symptom developed by the patient………………………………… How long ago? (Number of months/weeks)………………………… State your diagnosis………………………………………….. Decision to first seek help Did you seek help elsewhere before coming to Pantang Psychiatric Hospital?1 = Yes 2 = No Who was first seen? 65 0 = Religious /Native healer 1= community nurse 2= medical practitioner 3= general hospital 4= psychiatric service 5 = not known How long ago (Number of months) …………………………………….. Who initiated the first contact? 0 = patient himself/herself 1= relative/friends 2 = neighbor’s 3= workmates/colleagues 4= employer 5= police 6= medical practitioner 7= other (specify) What symptoms caused decision to seek care? (Specify)……………………………… ………………………………………………………………………………………… What were the reason for seeking help from that place?.................................... ………………………………………………………………………………………… What treatment was offered?............................................ ………………………………………………………………………………………… 66 Where you satisfied with the treatment your patient received at that place? 1 = yes 2= No Give reasons for your answer…………………………………………………. ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………… THE FIRST REFERAL Who was seen next? 0 = Religious /Native healer 1= community nurse 2= medical practitioner 3= general hospital 4= psychiatric service 5 = not known How long ago ( How many months)…………………………………. Decision taken by whom 0 = patient himself/herself 1= relative/friends 2 = neighbor’s 3= workmates/colleagues 4= employer 67 5= police 6= medical practitioner 7= other (specify) What symptoms caused decision to seek care? (Specify)……………… What were the reason for seeking help from that place?............................................ What treatment was offered?............................................... …………………………………………………………………… Where you satisfied with the treatment your patient received at that place? 1 = yes 2= No Give reasons for your answer……………………………………………. SECOND REFERAL Who was seen Next? 0 = Religious /Native healer1= community nurse 2= medical practitioner 3= general hospital 4= psychiatric service 5 = not known How long ago ( Number of months/weeks) …………………………………….. Who initiated the first contact? 0 = patient himself/herself 1= relative/friends 2 = neighbor’s 3= workmates/colleagues 68 4= employer 5= police 6= medical practitioner 7= other (specify) What symptoms caused decision to seek care? (Specify)………………… What were the reason for seeking help from that place?....................................... What treatment was offered?............................... Where you satisfied with the treatment your patient received at that place? 1 = yes 2= No Give reasons for your answer……………………………… THIRD REFERAL Who was seen next? 0 = Religious /Native healer 1= community nurse 2= medical practitioner 3= general hospital 4= psychiatric service 5 = not known How long ago ( Number of months/weeks)? …………………………………….. Who initiated the first contact? 0 = patient himself/herself 69 1= relative/friends 2 = neighbor’s 3= workmates/colleagues 4= employer 5= police 6= medical practitioner 7= other (specify) What symptoms caused decision to seek care? (Specify)…………………………… What were the reason for seeking help from that place?.......................... .......................................................................................................................................... .............................................................. What treatment was offered?.................................. ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………….. Where you satisfied with the treatment your patient received at that place? 1 = yes 2= No Give reasons for your answer………………………………