Tipo de violencia emocional: “me duele el corazón, el alma”

7.7.1 Strengths

There were two strengths to the present study. The first strength is the use of a cluster randomised controlled trial as the study design. The design strengthened the methodological base of the study in several ways. Randomisation of participants into intervention and control clusters was conducted by the Principal Supervisor of the study without the involvement of the student researcher, preventing the introduction of bias in the randomisation process by the student. Again, because randomisation took place at the district rather than the individual level, it allowed us to physically separate the intervention and control groups, thus maintaining the integrity of the study. Furthermore, physical separation of the groups was beneficial because it prevented the contamination effect that could occur if participants from the intervention group communicated with the control group about the training programme, which had the potential to affect the outcomes of the study.

The second strength was the use of andragogy as the theoretical underpinning of the study. As an educational intervention for adults, andragogy was a suitable match for the intervention because it provided guiding principles to enhance the learning process of assembly members. It provided a guide to conduct activities at every stage; before the commencement of the learning process, during the learning process, and closure of the learning process. Andragogy provided a straightforward approach to facilitating the programme that yielded improvement in knowledge about and attitudes toward people with mental disorders. In addition, incorporation of a culturally-sensitive, problem- solving Story-bridge approach in the programme aligned well with the guiding principles of andragogy. The Story-bridge approach encouraged open and healthy discussion among participants, including drawing on their own life experiences, all of which is consistent with dealing with important issues in a Ghanaian community and family context. The

discussions brought forth different perspectives on issues addressed, enhancing the learning process of participants.

7.7.2 Limitations

The present study has six limitations. The first and most important was the high rate of attrition at follow-up. Overall 19% of participants had withdrawn at follow-up, the majority from the control group. The attrition resulted in a reduced sample size and missing data at follow-up. This limitation may have made it harder to detect significant differences in study outcomes. The attrition rate may be reduced in a future study by providing reimbursement to participants to compensate for their time and inconvenience in taking part in the study (Polacsek, Boardman, & McCann, 2016). However, reimbursement should be appropriate to the study setting, nature and level of participation in order not to be considered excessive inducement or coercion and, hence, unethical (Polacsek et al., 2016).

The second limitation was the duration of the training programme. The three-hour duration of the intervention curtailed a fuller discussion of some issues that were raised. Although discussions were facilitated to ensure various views were heard, the inability of some participants to express their perspectives was noted, and as a consequence, some important perspectives may inadvertently have been missed. Two strategies are feasible to extend the duration of the programme in a future study; a session encompassing an entire day or, alternatively, two half-day sessions completed on separate days. In light of the geographical spread of participants, an entire day’s programme may be more feasible, where participants could be provided with overnight accommodation; thus, avoiding the inconvenience of travelling on separate days.

The third limitation of the study was methodological shortcomings. Ideally, in conducting a cluster randomised controlled trial and process evaluation, including assessing treatment fidelity, different personnel should handle various aspects of the design to avoid bias in the entire process. However, as this study was conducted within a Ph.D. project timeframe, it was constrained by time, personnel and financial resources. Consequently, I recruited the participants, collected data at both time-points, delivered the programme and conducted the process evaluation. These activities allowed me to know which allocation group participants belonged to, and this might have had an influence on

participants’ responses and could be interpreted as introducing bias into the process. That notwithstanding, several strategies were implemented to minimise this limitation. Randomisation of the districts was done solely by the Principal Supervisor of the study to avoid the influence of the student researcher. Research protocols were adhered to maintain the treatment fidelity of the study. Participants were also assured of their anonymity to encourage them to be comfortable with and freely share their responses. Regular Skype meetings and emails exchanges with the supervisors of the study was done to ensure that research protocols were being followed and unexpected methodological issues were addressed. In a future similar research, additional researchers should be involved to take up different roles in the study.

Another methodological shortcoming was the use of telephone calls to collect data at follow-up. At baseline, questionnaires were handed out to the participants to complete. However, at follow-up, the process took longer than expected mainly because it was difficult to meet face-to-face with all participants. In addition, travel time between communities and unanticipated difficulties, such as bad road surfaces, faulty vehicles and participants’ inability to keep appointments, limited the number of questionnaires handed out daily. These factors adversely affected the timelines for follow-up data collection. Hence, telephone calls were used, with items in the questionnaire being read aloud and responded to by telephone. This method of data collection might have affected participants’ responses to the questionnaire. However, the anonymity of the calls may have helped overcome any feeling of uneasiness in directly responding to the questionnaire. To minimise adverse effects of this process, participants were encouraged to put their telephone on speaker, or if they preferred, have earpieces connected to their telephones. They were encouraged to ask for items to be repeated as often as they wanted. Finally, I did my best to read the items slowly, loudly and clearly to avoid any misinterpretation and repeated questions where necessary.

A final methodological shortcoming was the two-stage approach to data collection in the process evaluation. Quantitative data were collected immediately after the training programme, while qualitative data were collected at 12-week follow-up. Even though it was more practicable to collect quantitative data at that time, this may not have given participants sufficient time to reflect on the programme. In contrast, the qualitative data collection time-point gave participants more time to review the programme. The process

evaluation was comprehensive, and because of the mixed methods approach to this evaluation, this gave participants ample opportunity to comment about issues relating to the conduct and content of the intervention. In a future study, consideration should be given to collecting process evaluation data at the follow-up data collection time-point, thus allowing participants more time to reflect on the programme.

The fourth limitation was, by focusing on the assembly member population, which is largely male-dominated, this resulted in fewer female participants in the study. The fifth limitation was the voluntariness of participation in the qualitative interviews of the process evaluation and its findings, as participants may have felt compelled to provide favourable comments about the programme. The final limitation was the lack of involvement of a person with a mental disorder and his/her family representative. It was explained earlier that sharing of personal experiences of family members with mental disorders by the participants and I might have positively influenced participants’ attitudes. Involvement of a person with a mental disorder and a family representative to share their personal experiences would also have been valuable in contributing this unique perspective to the discussion. The interaction of a person with a mental disorder, his/her family representative and the participants might have provided a compelling reason for participants to positively change their attitudes towards people with mental disorders and their family members.