COMMUNICATION STRATEGYON STIGMA REDUCTION &

DISCRIMINATION AGAINST

PERSONS WITH MENTAL ILLNESS IN GHANA

MENTAL HEALTH AUTHORITY 2018

Copyright @ Mental Health Authority

2018

Production of the Mental Health Authority of the

Ministry of Health, Ghana

2018

ISBN:

Contact:

The Mental Health Authority

LG DTD 20035

10 Tripoli (Adjei Tsuru) Street

East Legon, Accra

GH POST ADDRESS

GPS: GA-334-2821

Tel: +233 30 3964878

Email: info@mhaghana.com

Website: www.mhaghana.com

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ACKNOWLEDGEMENTSAppreciation goes to the under-listed officers for their roles in developing this guideline:

Technical Team Members1. Dr. Akwasi Osei Chief Executive (MHA)2. Dr. Caroline Amissah Deputy Chief Executive (MHA)3. Mr. Kofi Adusei Ministry of Health (MOH)4. Mr. Prince Adomako Ministry of Health (MOH)5. Mr. Kwaku Brobbey Head of Communications (MHA)6. Mr. Etornam Gblende Greater Accra Regional Mental Health Co-ordinator7. Dr. Albert Eshun Lecturer - University of Professional Studies (Media Critic)8. Mr. Yaw Agyei-Wiredu Director, Finance(MHA)9. Mr. Joseph Narnor ORAKLE (Consultant)10. Mr. Emmanuel Yuon ORAKLE (Consultant)11. Mrs. Priscilla E. Tawiah Deputy Director, Community Care(MHA)

TABLE OF CONTENTS

1.0 Introduction ..................................................... 12.0 Brief background ..................................................... 23.0 Burden of Mental Illnesses ........................................ 24.0 Burden of stigma ..................................................... 45.0 Problem statement ..................................................... 46.0 Aim ............................................................................... 57.0 Objectives .................................................................. 58.0 Methodology ..................................................... 68.1 Baseline study ..................................................... 68.2 Target Segmentation ........................................ 78.3 Target Audience Clusters: ........................................ 79.0 Proposed BCC Model in the stigma reduction strategy 810.0 The Communication Strategy ........................... 1110.1 The Creative Strategy ........................................ 1211.0 Proposed Activities & Tactics ........................... 1312.0 Initial Creative Guidelines ........................................ 1313.0 Outcomes .................................................................. 1514.0 Implementation plan and timelines.......................... 1615.0 Monitoring and evaluation ........................................ 1916.0 Conclusion and Next steps ........................................ 1916.1 The Communication Mandatories ........................... 1916.2 Key Triggers for Success ........................................ 2017.0 Budget .................................................................. 2117.1 Budget Summary ..................................................... 2618.0 Sample Concepts ..................................................... 27

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PREFACEThe Mental Health Authority, the body mandated to oversee mental health service delivery in Ghana, is bent on ensuring greater success in mental health recovery for persons with mental illness in the country. To achieve this, the Authority recognizes the need to take strategic steps to eliminate or minimize stigmatization and discrimination against such persons. The Mental Health Act 2012 (Act 846) in Section 3 (g) enjoins that the Authority works to ensure and guarantee the fundamental human rights of persons with mental disorder against discrimination and stigmatization.

Stigmatizing against the person with mental illness is a daily occurrence in Ghana. Stigma occurs when an individual is disqualified from full social acceptance because of possession of an attribute that is deeply discrediting. Discrimination, according to the Cambridge advanced learner’s dictionary, is to treat a person or particular group of people differently, especially in a worse way from the way in which you treat other people, because of their skin colour, sex, religion etc.

Stigma contributes to what a WHO fact sheet identified as the hidden burden of mental illness. Stigma and labeling have generally been described as one of the main obstacles to the course of recovery from most mental health conditions. Ultimately, stigma and discrimination impede social integration, interfere with performance of social roles, diminish quality of life and prevent timely access to treatment. This effectively creates a vicious cycle of social disadvantage and disability.

The nation will require a Behavioural Change Communication (BCC) strategy to address the challenge of stigma and discrimination against persons with mental illness in Ghana.

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BCC is the strategic use of communication to promote positive health outcomes, based on proven theories and models of behavior change. It employs a systematic process beginning with formative research and behavior analysis, followed by communication planning, implementation, monitoring and evaluation. Audiences are carefully segmented, messages and materials are pre-tested, and mass media, which include radio, television, billboards, print material, internet, interpersonal channels, such as group presentations and community mobilization are used to achieve defined behavioral objectives.

This behavioral change strategic document on stigma reduction seeks to eliminate or reduce the levels of discrimination and stigmatization by:

• Causing a change in the general attitude of Ghanaians towards people living with mental illnesses and • Providing an educational platform that will dispel the myths surrounding mental illness and create an atmosphere that supports the individuals and their recovery.

The Mental Health Authority is of the conviction that the full implementation of this behavioral change strategic document will provide persons with mental illness in Ghana tools to cope with the “invisible” barrier to social inclusion – self-stigma.

DR AKWASI OSEIChief Executive

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1.0 INTRODUCTION

Mental health is a state of well-being in which the individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully and is able to make contribution to his or her community (WHO 2015). Mental illnesses on the other hand, are health conditions involving changes in thinking, emotions or behavior (or combinations of these). Mental illnesses are associated with distress and or problems functioning in social, work or family activities (APA 2015).

Stigma is a Greek word that in its origin refers to a tag or marking or tattoo that is cut or burnt into the skin of criminals, slaves, traitors in order to visibly identify them as blemish or morally polluted persons. These individuals are to be avoided particularly in public places (Goffman 1963).

Stigma is a “collection of negative attitudes, beliefs, thoughts, and behaviors that influence the individual, or the general public, to fear, reject, avoid, being prejudiced, and discriminate” against those with mental disorders (Gary, 2005, p. 980). It occurs when an individual is disqualified from full social acceptance because of possessing of an attribute that is deeply discrediting (Goffman 1989). Stigma in the form of social distancing is observed when people are unwilling to associate with a person with mental illness. Being discriminated against has a huge impact on self-esteem and confidence. This can increase isolation from society and reinforce feelings of exclusion and social withdrawal.

Stigma is most often associated with discrimination. This is

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an action or practice that excludes disadvantages or merely differentiates between individuals or groups of individuals on the basis of some ascribed or perceived trait. Discrimination and stigma have been linked to ignorance. Many studies show the majority of the public have limited, nonfactual knowledge and misconceptions of mental illness. Many people with mental health problems experience discrimination when applying for jobs, looking for accommodation or accessing other basic social services.

2.0 BRIEF BACKGROUND

In Ghana, data on mental health stigma and discrimination is not readily available. It is however generally accepted that stigma and discrimination against those living with mental illness is widespread. The phenomenon reaches into our educational institutions, workplaces, homes, health facilities, the media and even churches/mosques. Inadequate knowledge, socio-cultural practices, superstitious beliefs, misconceptions and myths surrounding mental illnesses contribute to stigma and discrimination against persons with mental illnesses.

3.0 BURDEN OF MENTAL ILLNESSES

According to the WHO, mental illness will by 2020 become the second largest non-communicable disease in the world with as many as 121 million people suffering from anxiety and stress related problems. Mental health in our part of the world is largely plagued by myths and perceptions. These myths and perceptions have always played on our minds and inform policy

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decisions particularly on issues of mental health. Societies with such cultural inclinations tend not to empathize with the mentally ill and therefore stigmatize and marginalize them. This has contributed to the obvious neglect that mental health suffers in our developing nations.

► One in every four persons will suffer mental illness at some point in his or her life.► Research from around the world shows that 40% of all persons attending health clinics have some form of mental illness most often unknown to them.► 16-20% of women who give birth in developing countries experience maternal depression. (NIMH,2009).► Young people are at particular risk, half of all lifetime mental disorders start by aged 14 (NIMH, 2009) .► By 2020 mental health conditions will account for 15% of the global disease burden. Yet mental health is severely underfunded. Currently, on average low-income countries allocate only 0.5% of their total health budgets to mental health, and lower middle income allocate 1.9%.► In 2011, WHO research showed that 2.8 million of people living in Ghana had varied forms of mental disorders. ► Recent and past media reports on suicides, spousal killings, etc., attest to the problems of mental health conditions not previously known.

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4.0 BURDEN OF STIGMA

Stigma contributes to what a WHO fact sheet identified as the hidden burden of mental illness. Stigma and labeling may also affect the course of recovery. Mental disorders account for at least 160 million lost years of healthy life, of which about 30% could be averted with existing interventions. Stigma and discrimination make it difficult for treated persons with mental illness to reintegrate into the community. People, who lived with psychiatric stigma and its consequences, often experience suffering that is devastating, and life-limiting. Stigma and discrimination prevent people with mental illness from obtaining the basic family and community care that others enjoy. They impede social integration, interfere with performance of social roles, diminish quality of life, and prevent timely access to treatment, effectively creating a vicious cycle of social disadvantage and disability.

5.0 PROBLEM STATEMENT

Stigma has been noted to be one of the major obstacles to recovery, treatment and societal acceptance for persons living with mental illness. People with mental health problems experience many different types of stigma and discrimination that affect all aspects of their lives. There is therefore an urgent need to address this problem of stigma against people with mental illness, so they can live their lives to the fullest and as integral members of society. The MHA, therefore, intends to launch a nationwide BCC strategy to deal with the challenge in collaboration key stakeholders.

7.0 OBJECTIVES

1. To reduce stigma against persons with mental illness by: • 80% amongst our internal publics within twelve months after the adoption of the document for implementation. • 40% over baseline of the population by 2020.2. Over 70% of the target groups exhibit knowledge on basic facts and information on mental illnesses .3. Change negative perceptions and attitudes amongst internal publics by 100% and 50% over baseline amongst external publics by 2020.4. To lobby stakeholders including policy makers in support of mental health issues .5. Over 50% of patients discharged are accepted by their families.6. To build collateral trust and confidence in MHA as the chief advocate for mental health in Ghana.

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6.0 AIM

To address stigma and discrimination against persons with mental illnesses in Ghana, using Behavioral Change Communication (BCC) strategies.

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8.0 METHODOLOGY

The objective of the programme is to reduce the impact of stigma and discrimination amongst the general population and health workers. This will be done through mass media campaigns, interpersonal communications and capacity building. Consequently, the following activities will be carried out:1. Development of draft messages • Jingles, pictorials, audio-visuals, etc.2. Pre-testing of messages.3. Finalization of developed audio-visual messages.4. Roll out the messages which involve mass and interpersonal media approaches.

8.1 Baseline studyDue to the relative scarcity of data on mental health in Ghana and as part of implementation procedures, there will be a need to conduct a baseline study. The campaign will adopt a mixed method of research, i.e., quantitative and qualitative approaches to establish the baseline. This will be done through stakeholder and focus group interviews and structured conversations. The data gathered will then be analyzed using common structural features. The outcome from this initial work will form the baseline study.

Some of the key activities will include the following:• Development of data collection tools• Documentation (literature review)• Conduct focus group discussions • Stakeholder and key informant interviews• Data analysis

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• Report writing and dissemination .

8.2 Target Segmentation 1. Persons with mental illness a. Vagrants b. Clients seeking clinical services and those on admission in the general hospitals c. Clients in homes, offices, workplaces and communities, etc. 2. Domestic caregivers a) Guardians b) Relatives.3. Health personnel a) Clinics and hospitals.4. Employers a) MMDAs5. The community and general Ghanaian.

8.3 Target Audience Clusters: 1. Persons living in Ghana They live within households, towns, cities and communities where the stigma against persons with mental illness occurs on a daily basis .2. Opinion formers/leaders with some influence in communities. For example, Traditional leaders, Land lords/ladies, etc.3. Employers and corporate

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organizations.4. Caregivers in the Health Sector - Clinics and Hospitals.5. Political leadership – The President, Ministers of State, MPs, MMDCEs, Assembly men and women.6. Faith-based organizations.7. Traditional and faith-based healers in mental health.8. Educational Institutions (basic to tertiary) and Educationists/Teachers.9. Media Actors.10. Development Partners.11. CSOs.

9.0 PROPOSED BCC MODEL IN THE STIGMA REDUCTION STRATEGY

Generally, there are a number of models utilized in BCC. The employment of a specific model is dictated by the anticipated goals and objectives on one hand and the level of the stigma with respect to the target audience clusters on the other hand. In working towards achieving optimum behavior change, we will employ the Stages of Change model as below.

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Six stages that individuals go through when changing behaviour

The diagram above shows six stages an individual may have to go through in order to effect a change in behavior as demonstrated by Grimley, 1997 (75) and Prochaska 1992 (148). In Ghana, it is widely believed that most people are at the pre-contemplation stage with regards to behavioral change on stigma and discrimination. This is as a result of the high levels of unawareness of the phenomenon and how it affects the lives of people against whom such acts are perpetrated. The project is to work to ensure that Ghanaians move from a stage of unawareness to action, where stigmatization of persons with mental illness will be reduced or stopped altogether. This situation will have to be sustained as portrayed by the last step in the chain.

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10 processes that help predict and motivate individual movement across stages.

Awareness creation

Advocacy

Evidence-based demonstrations

and peer services

Continuous and consistent

predictable quality service

This model adopts strategies including awareness creation (mental health literacy campaigns), advocacy, evidence-based demonstrations and peer services, legislative and policy interventions. The awareness creation step within the model is one of the most common approaches to stigma reduction interventions, as it provides the opportunity to counter one of the most important causes of stigma –lack of knowledge or misconceptions about persons with mental illnesses. This will be supported by evidence-based demonstrations and peer services, policy/legislative interventions, and continuous and consistent predictable quality service.

10.0 THE COMMUNICATION STRATEGY

The proposed nationwide campaign will look at the problem from several perspectives: • The general Ghanaian populace who perpetrate stigma against persons living with mental illness (Persons Living with Mental Illness).• From the view point of the mentally ill persons themselves who suffer from the stigma and finally• Healthcare providers, facilities or organizations which operate within the mental health sector.

The overall strategy will hinge on the following road map:• Execute launch events (in phases) to introduce the campaign to the Ghanaian public and facilitate adoption of the campaign message.• Roll out a 360-degree Media campaign over a one-year period to generate awareness.• Build and enhance message visibility .• Promote and entrench the Stigmatization Unique Selling Point.• Take full advantage of New Media as a key primary channel for engaging with core target groups.• Engage all key stakeholders and actors within the sector to ensure a synchronized and sector-wide approach to the campaign.

The strategy is to connect emotionally with the identified target groups, shine the light on the stigma and begin generating conversations about it and how to solve it together as a nation. An emotionally connected and well-informed Ghanaian is more likely to act positively towards persons with mental illness.

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10.1 The Creative StrategyInnovation, repetition and visibility of messages are usually the only measures of success in mass messaging projects of this nature. For behavioral change to happen, mass messaging needs to be linked to tangible and specific calls to action that are real and meaningful to the target. The strategy therefore is to stick to the three cardinal rules in message engineering: • Difference • Emotion • Simplicity

These will help generate ideas that: • Break through media clutter and grab target audience attention.• Deliver precise targeting of fragmented audiences.• Deliver precise targeting of fragmented audiences.• Efficient media management skills using a network of associates.• Events co-ordination solutions that guarantee target buy- in on a sustainable basis.• Message pre-testing, monitoring and evaluation.• Impactful advertising to firmly position the message in the hearts and minds of the target group.

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11.0 PROPOSED ACTIVITIES & TACTICS

1. Effective Event Launches – especially in Accra, Kumasi and all regional capitals to be followed by: •Junior and Senior High Schools sensitization tours. •Tertiary campus outreach in collaboration with the various student bodies. •Regional, District and Community durbars and engagements •Faith-based group engagements. •Specialized events including outreach and livelihood empowerment. •Various trainings, peer services and club formations 2. New Media Channels to trigger awareness in more interactive ways and to encourage and facilitate feedback from target.3. On-going public relations and other related activities to entrench positioning of core stigma related messages.4. Short videos for social media, documentaries, TV and Radio adverts/ jingles, etc. 5. Press Ads and pull-outs, Large format Billboards, crawlers (strategically located in targeted places), New Media Platforms (dedicated Websites, Facebook, Twitter, Instagram, etc.).6. Below-the-line support activities, Event Activations and Sponsorships, Regional/ District Level Road Shows, Radio/TV appearances, Brochures, Fliers, Street Banners, Posters, and Ongoing Press Relations/Editorial rolled out in the mainstream media as hard news and human-interest stories on TV, Radio, Press, etc.

12.0 INITIAL CREATIVE GUIDELINES

Our initial creative direction is inspired by ONE BIG IDEA - “Stand with me”. Some of the proposed messages include:

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• Show concern when your friend needs help. Don’t discrimination.• There is hope never give up. Don’t stigmatize.• Mental illness is treatable.• Stamp out the stigma against mental illness.• You are not ALONE!• I deserve your love, say no to discrimination/stigmatization. • Love yourself, mental illness is not a permanent condition.• It’s OK to talk about mental illness.• There is no shame in seeking help for mental illness.• Mental sickness is not a choice, show you care!• Stigma erodes self-confidence, support me! • Feeling depressed? Dial 0800-678-678 for a free & confidential chat.• Know your mental status today. Dial 0800-678-678 for a free & confidential chat.• A Mental Patient is not a Criminal. Show your compassion.• Compassion works like magic for the Mentally ill.• Do you need urgent help on how to cope with Stress? Help is available – Free & Confidential.• Don’t keep it buried inside. Help is only a call awayThe above will all be supported by comprehensively tested and effective messaging training.

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13.0 OUTCOMES

• 80% of the stigma reduced amongst our internal publics within six months .• Stigma reduction of 40% over baseline of the population by 2020.• Over 70% of the target groups exhibit knowledge on basic facts and information on mental illnesses .• Changed negative perceptions and attitudes amongst internal publics by 100% and 50% over baseline amongst external publics by 2020.• Complete buy-in from stakeholders including policy makers of mental health issues.• Over 50% of patients discharged are accepted by their families.• Improved public confidence and trust in MHA as the chief advocate for mental health in Ghana.

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15.0 MONITORING AND EVALUATION

First of all, the project plans will be monitored as well as the input, output and impact. Consequently, indicators will be developed which will be used for the monitoring. The monitoring will take place throughout the project life, starting from the inception, midterm, and terminal. Reports will be produced and disseminated.

16.0 CONCLUSION AND NEXT STEPS

16.1 The Communication Mandatories• Integrated communications and message awareness through-the-line.• Point of Contact presence and visibility – events and activations.• Compelling online presence – website, social media channels.• A strategy for countering negative claims by potential detractors.• Innovative media solutions.• A toll-free number to encourage a dialogue and feedback.• Effective PR solutions.• Positive tone of advertising and advocacy - credible, trustworthy, friendly, supportive.• Encourage and promote dialogue with stakeholder base in Ghana.

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16.2 Key Triggers for Success• Engagement with core target groups through relevant media and events.• Clearly articulated benefits to society.• Consistent, single-minded publicity.• Consistent and predictable quality service and message display.• Proximity and availability of contact points – e.g., confidential hotline.• Motivated event teams, responsive to target needs.• Implement reward mechanisms.• Appropriate budget levels to support the campaign.

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17.1 Budget Summary

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18.0 SAMPLE CONCEPTS

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