Poor mental health in Ghana: who is at risk?

Approximately one of every four people suffer from poor mental health, making it a leading cause of disability around the globe [1]. Poor mental health increases susceptibility to both infectious and chronic diseases and accounts for more than 30% of years of life lost worldwide [1, 2]. Additionally, the negative economic impact of mental health issues is considerable [3], particularly in low-income countries where key risk factors including poverty, underemployment and unemployment, political instability, and HIV/AIDS are most prevalent.

Nevertheless, empirical evidence on national prevalence of poor mental health in low-income countries, particularly in Africa, is limited. Although several studies have been conducted in African countries, most have used small, specialized populations including people living in rural settings [4–6], pregnant women [7], and hospitalized patients [8, 9] and thus lack national generalizability. Due in large part to the diversity of populations examined and methods used, prevalence estimates of poor mental health have varied widely, ranging from 4% to 65% [4–15]. The Nigerian Survey of Mental Health and Well-Being (NSMHW) is the only survey from the World Health Organization’s Mental Health Survey Initiative that was conducted in a low-income African country [16]. These data, however, are not nationally representative and were collected nearly a decade ago, limiting their usefulness for estimating contemporary estimates of poor mental health.

Although research that examines correlates of poor mental health within African countries are limited in number, findings consistently indicate that lower socioeconomic status, less education, and female gender are risk factors for poorer mental health [6–9, 12, 13, 15]. Based on this evidence, researchers and policy makers are now calling for empirical investigations of the association between empowerment and poor mental health among women. Although this link has been suggested by a few small studies in Africa [7, 11–13], a more thorough understanding of this association may provide avenues for interventions.

In this study, we sought to estimate the national prevalence of poor mental health in Ghana, a low-income country in West Africa, and to explore its correlates on a national level. Additionally, we aimed to examine associations between empowerment and poor mental health among women. Ghana is particularly relevant to this discourse as country leadership is poised to make substantial improvements in mental health services since the recent passing of their Mental Health Bill, which calls for better integration of mental health into the Ghanaian National Health Services (Mental Health Act 846 of 2012). Consequently, current epidemiological data on mental health and its correlates may be useful in understanding the scope of the problem in Ghana and for targeting particular subgroups for interventions.

Our findings indicate that the prevalence of reported psychological distress is substantial among both men and women in Ghana, but is higher among women. Nearly 20% of the sample had moderate or severe psychological distress, an estimate higher than that found among South African (16%) [20] and Australian (11%) adults [24]. Our findings are consistent with literature supporting women’s vulnerability to poor mental health [14, 25], but this is the first study to our knowledge that has been conducted among a large, nationally representative sample in a low-income country on the African continent. Our results also suggest that women who are disempowered and lack control in the context of intimate relationships may be particularly vulnerable to psychological distress. Although small studies from several African countries have suggested an association between empowerment and mental health [10–13], our study is the first to explore multiple measures of empowerment, using a nationally representative sample of women.

Overall, the prevalence of psychological distress differed by gender, marital status, education, wealth, region, health and religion, but not by age or urban/rural location. These results are consistent with other studies that demonstrate higher rates of poor mental health among women and those with lower education [12, 13]. The literature, however, is less consistent on the associations between marital status and poor mental health [4–7, 9]. In high income countries, for instance, females who have never been married often demonstrate greater risk for poor mental health than females who are married [26]. In low income countries, however, this association may be reversed. Given the dependence of women on men in these settings for income, we hypothesize that marriage can bring with it substantial disempowerment and lack of control, which we found to increase risk for psychological distress. As a result, in these contexts, never having been married may in fact be protective [4, 6, 10, 11, 25]. Future research should explore measures of empowerment among women who have never been married to more clearly understand the mechanisms linking mental health and marital status.Our analysis of women in relationships suggests that empowerment is particularly important for women’s psychological health in Ghana and possibly in other low-income African countries. All of the components of women’s empowerment, including attitudes about their roles in decision-making, attitudes towards intimate partner violence, partner control, and experiences of abuse, were strongly associated with worse mental health and present opportunities for intervention. Interventions may focus on preventing experiences of intimate partner violence among women and decreasing the acceptance of such behavior [27, 28]. They may also aim to decrease the effects of intimate partner violence on women’s mental health by ensuring and building adequate social support for her if physical and/or psychological abuse persists [29, 30]. Interventions may also aim to target men in an effort to reshape their views on physical and psychological abuse [31]. More intervention studies, however, are needed in low income settings; our research suggests that interventions targeting multiple components of empowerment will have potentially greater effects than those targeting fewer aspects of women’s empowerment.

Our findings have implications for policy at the national level for Ghana and possibly for other low-income African countries as well. First, given the high prevalence of psychological distress among the population, a greater portion of national healthcare budgets should be allocated to mental health. Second, because poor mental health is associated with several negative outcomes, including a reduced ability to pursue educational and employment opportunities, efforts to improve access to treatment and reduce the stigma associated with poor mental health are essential. Fundamental to addressing the high need for mental health services is integrating mental health care into primary care. This calls for approaches such as task shifting and expanded community-based mental health. Prioritizing mental health services and rehabilitation is particularly relevant in Ghana, where a new mental health bill has been passed and where they are currently developing approaches to deploy university graduates in psychology to fulfill their national service obligation as community mental health workers. This with the expansion of brief assessment units in the psychiatric hospitals and new psychiatric wings in regional hospitals are planned to strengthen access to needed services.

Although our study has several strengths, including the use of nationally representative data, it does have limitations. All data were self-reported and due to resource constraints could not be corroborated by clinical interviews or additional sources; nevertheless, this method is the standard approach for measuring mental health and sociodemographic characteristics in population-based surveys and was used consistently across the sample. Wealth is particularly difficult to measure in Ghana as much is generated from the informal sector. Furthermore, our measure of mental health does not indicate whether or not the respondent has a clinically significant impairment. Previous literature [17], however, suggests a high correlation between the K10 and clinical mental health disorders (anxiety, affective, substance use, or personality disorders); among people with a K10 of 26 or above, at least 75% can be expected to have a clinically significant mental disorder. There still exists, however, the potential for misclassification. Additionally, our analysis examining empowerment only studies women who have been involved in romantic relationships in the past 12 months. Future research should improve methodology and measures to examine this construct among women outside of romantic relationships. Last, the cross-sectional nature of the analysis limits our ability to understand the temporal sequence between mental health and empowerment. The study does, however, identify a population who is suffering and should be targeted by interventions. It also highlights the importance of gender in low income countries as a critical public health issue.

The prevalence of psychological distress is high among both men and women in Ghana. Women who are disempowered in the context of intimate relationships may be particularly vulnerable to psychological distress. This is the first study conducted among a large, nationally representative sample in a low-income country on the African continent, and our results suggest that findings from other contexts may not be generalizable to lower income African populations. Future studies should continue exploring risk factors for poor mental health among low-income African countries, and prevention and treatment should be delivered accordingly. Mental health services should be prioritized at the national level.