Tipo de violencia psicológica: “no te voy a dejar en paz”

There are four main recommendations of the study: improving the content and outcomes of the mental health literacy programme, improve community mental health literacy, mental health education in district assemblies, and research for change in the mental health system.

7.8.1 Improving the content and outcomes of the programme

In future intervention research to improve mental health literacy and reduce stigma towards people with mental disorders, researchers may consider a combination of education and contact components as part of the intervention. There are suggestions that a combination of education and contact elements in an intervention would be effective in improving mental health literacy and reducing stigma and social distance (Morgan et al.,

2018). It is important to improve people’s knowledge about mental disorders so that they can recognise a person with a mental disorder and mental health crisis and arrange timely and appropriate responses. However, public stigma hinders timely and appropriate responses. Therefore, it would be useful to engage people in a programme that not only improves their knowledge but also helps them to deal with and decrease stigma for better outcomes. In this instance, the programme could include direct social interaction with a trained speaker with lived experience of mental disorder supported by an enthusiastic facilitator to guide the content and delivery of the programme (Corrigan et al., 2014b; Knaak et al., 2014).

Another recommendation to improve the content and outcomes of the programme is to extend its duration and to allow a longer follow-up period. Extending the duration would have two distinct benefits. First, there would be enough time to allow most participants to share their perspectives on issues, which may, in turn, influence and strengthen the positive attitudes created. Second, extending the duration of the programme would create an opportunity to include more discussion/activities. For example, activities that would help participants such as assembly members to develop proactive strategies for dealing with people with mental health issues, such as supporting community mental health literacy programmes or addressing human rights abuses of people with mental disorders in traditional and spiritual centres.

A final recommendation is the need to modify the vignette to suit the Ghanaian context. The Delphi technique84 is a valuable method that could be adopted to help improve the cultural appropriateness of the vignette. It is also recommended that the videos used in the programme should be situated within a Ghanaian context so that participants can relate better to them and have a wider understanding of the issues being portrayed.

7.8.2 Improve community mental health literacy

The mental health literacy programme, based on a problem-solving Story-bridge approach, underpinned by andragogy, is recommended for use as an effective approach to improve community mental health literacy. There are other community leaders such as Unit committee members, sub-chiefs and some respected individuals who could be

84 _{“The Delphi method provides expert consensus on what constitutes best practice in scenarios that cannot be feasibly or ethically}

trained on knowledge about, and attitude towards people with mental disorders through this approach. In addition, specific target groups identifiable within the community, such as people with lived experience of mental disorder and their families, teachers, social workers, primary health care workers, students and media personnel, could also be involved in such programmes (Corrigan et al., 2014b; Dalky, 2012). A community resource such as the ‘information centre’ could also be used to disseminate mental health information in the communities. Furthermore, community-wide mental health education programmes could be introduced using mental health professionals assisted by mobile video vans85 to improve community mental health literacy. Overall, the impact of such initiatives could, in the long-term, result in a reduced desire for social distance and discrimination, increase positive attitudes and better outcomes for people with mental disorders and their families.

7.8.3 Mental health education policy in district assemblies

All district assembly members in Ghana have a responsibility and commitment to manage and improve their local environments and this includes responsibilities related to mental health. However, lack of knowledge and stigma have meant that mental health issues may be relegated to the background in favour of physical health responsibilities. As evidenced in the present study, the programme has benefits that could be sustained by district assemblies. By instituting a mental health education policy that requires all assembly members to undertake training at the commencement of their term in office, their knowledge of mental health and disorders would be greatly improved. In effect, mental health issues would be given the necessary attention by assembly members, who would now have a better understanding of the issues and actions needed to deal with them. Furthermore, over time, mental health literacy among other community leaders would improve, and they could encourage positive and help-seeking attitudes for people with mental disorders and their families.

7.8.4 Research for change in the mental health system

Finally, recommendations are made for future research that may have the potential to bring change to the mental health system in Ghana. Although the programme had positive

effects on assembly members’ knowledge about and attitudes toward people with mental disorders, further research is needed. More research is required to assess the effectiveness of the programme with a larger group, over a wider geographical area, and with a longer follow-up period than the present study. A larger group should increase the statistical power of the analyses and make it easier to detect the effects of the programme. In addition, because most current assembly members are male, future research should consider providing equal opportunities for female community leaders, such as sub-chiefs, unit committee members or female leaders from churches, to participate. This is very important considering the effects mental disorders have on females and in light of their crucial role as primary caregivers in supporting family members with mental disorder. In addition, a booster session or refresher course with an extra timepoint for follow-up data collection could also be incorporated into the programme. The booster session would allow participants to examine their understanding and application of acquired knowledge and help reinforce positive attitudes toward people with mental disorder and their families. The additional data collection time-point would also help strengthen the overall rigour of the study. Furthermore, future research should consider the possibility of including individuals with mental disorders and their family representatives in the programme. This would address the limitation mentioned earlier and provide unique perspectives of the lived experience of mental disorder.