Lupine Publishers | Scholarly Journal Of Psychology And Behavioral Sciences
Abstract
Sustainable development denotes the
development of nations in ways that are not restrictive for future generations
in their efforts to meet their own needs. Without healthy human beings,
sustainable development cannot be successfully carried out or assessed as a
goal. For this reason, health, which forms the third arm of sustainable
development goals have received much attention across nations. In Ghana,
however, the aspect of health which has not received as much attention lies in
the area of mental health. This paper addresses how mental health care and
access in Ghana can be improved through the use of applied science and
technology. Specifically, recommendations are made about the prospects that
telepsychology and mental health mobile apps hold for applications in Ghana.
This concept is introduced in the paper by reviewing telemental health
practices and the use of mobile mental health apps in more advanced countries
like the United States and Britain. The paper addresses how these two concepts
can be introduced in Ghana, and guided by the experiences of other African
countries, the potential associated challenges of implementation are also
discussed. The paper ends with recommendations on how to overcome these
challenges and makes note of the impossibility of fully achieving sustainable
development goals for health when Ghana’s mental health care system remains in
such dire states.
Keywords:Sustainable development; Ghana; Mental health;
Telepsychology; Mental health mobile apps
Introduction
In September 2015, 194 countries adopted
the sustainable development goals spearheaded by the United Nations. These 17
goals officially came into effect in January 2016 with the ultimate aim of a
higher quality of life for all (“The Sustainable Development Agenda,” n.d.).
Sustainable development can be defined as development that meets the needs of
the present without compromising the ability of future generations to meet
their own needs. Sustainable development implies development and growth in
conscious ways that do not cause havoc for future generations. Human beings are
the central reason for the need for sustainable development and at the same
time, without humans, the agenda for sustainable development cannot be
realized. Health and wellbeing comprise the third arm of the United Nations’
sustainable development goals.
The goals of sustainable development cannot be achieved when there is a high
prevalence of encumbering illnesses (Von Schirnding & Mulholland [1]).
Health is a significant contributor to, and an indicator of, sustainable
development and its wide-reaching impact on people, societies, countries,
economies and such goals as the sustainable development goals have corralled
attention to this integral area. In doing so, there is an aspect of health that
has not gained as much attention as the physical health related issues in Ghana
and this lies in the area of mental health. Mental health can be defined as a
state of well-being in which every 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 a contribution to his or her community (“WHO |
Mental health: a state of well-being”, 2017). It comprises an individual’s
psychological, emotional, and social being with impacts on the way one thinks,
feels and acts. The state of an individual’s mental health affects how stress
is handled, how relationships are managed, and the decisions that one makes.
Just like physical health, mental health is important in every phase of life,
from childhood to adulthood. In childhood for example, mental health plays a
role in the bond between parents and their children. It helps set a solid
foundation for life. During adolescence, mental health plays an integral role
in the way the adolescent develops a sense of morality, and in adulthood,
mental health plays a significant role in the way work, family and intimate
relationships develop and evolve. In a pandemic such is currently being
experienced with the coronavirus, its associated distresses of grief, social
isolation, fear, panic and pre-existing mental health conditions mandate the
pursuit of mental health can be ameliorative.
Problems with mental health can come in mild, moderate or severe forms. They
can impact how one deals with mandatory social isolation or social distancing
during a pandemic. They can impact a child’s understanding of social cues, for
example, as can be the case with Autism Spectrum Disorders. Issues with mental
health can influence the way the student is able to take in, process and
understand information as can be the case with learning disorders. In the case
of the new mother, problems with mental health can impact the way she is able
take care of her child as can be the case with post-partum depression. Early detection
and intervention tend to yield better outcomes for individuals with mental
health disorders. In Ghana, however, access to mental health care and mental
health professionals are severely lacking. According to the World Health
Organization’s situational analysis report on Ghana, there is a mental health
treatment gap of 98% in Ghana, meaning that only 2 out of every 100 Ghanaians
with mental health issues will get the care they need. Advancements in
technology have played a crucial role in the evolution of health care treatment
and prevention. From electronic medical record keeping systems to portable
diagnostic devices, health care systems are making use of technological
advancements that bring about more efficiency. Diagnostic devices are being
produced to be more sensitive in ways that can lead to early diagnosis and now,
because of technology, healthcare devices are being made in sophisticated ways
that allow for transfer and use in countries and areas that do not have easy
access to such mechanisms. The impact that technology has had on medical
science has been enormous and continues to evolve daily. In the field of
psychology, technology has had impacts although not as great as that of the
field of medicine. During a pandemic such as the world is currently facing with
the coronavirus, many occupational fields, not just medical or psychological
are turning to technology to provide care and services. Ghana can explore ways
that technology can positively influence mental health care and access. This paper
explores a few of these ways.
Methodology
The methodology for this research paper
involved a review of the telepsychology practices and mobile mental health app
use in advanced countries, particularly the United States and the United
Kingdom. The APA and BPS telepsychology guidelines were reviewed in addition to
the United Kingdom’s National Health Service digital library for mobile mental
health apps and the APA’s mobile mental health app evaluation model. These
countries were selected based on the major advances they have made with regard
to regulating the use of telepsychology practice and mobile mental health apps.
A literature review was also conducted on the application of telepsychology and
mental health mobile apps in other African countries. This review was conducted
mainly to balance the opportunities of telepsychology and mobile mental health
apps observed in the advanced countries like the United States and United
Kingdom with the potential real-life implementation challenges that have been
discovered in similar cultural contexts.
Review of Telepsychology
and Mental Health Mobile Apps
The trends of telepsychology and mental
health mobile apps in more advanced countries can serve as learning
opportunities for Ghana’s mental health system. The following sub-sections
discusses some of these opportunities and makes suggestions for implementation
[2-4].
Telepsychology and mental
health care access
Telepsychology can be defined as the
provision of psychological services using telecommunication technologies.
Psychological services provided with such a modality can be in lieu of or in
addition to traditional therapy or treatment. With telecommunication mechanisms
like e-mail, texting, mobile apps and videoconferencing, mental health services
can be provided without the need for inperson interactions. Telepsychology
presents as a unique option for patients who are not ambulatory or for people
and families who are unable to travel to the psychologist’s office to access
services. For individuals whose diagnoses (such as agoraphobia or the fear of
social situations) prevent them from leaving the house to get to the
psychologist, telepsychology presents as an opportunity to begin the process of
treatment that would eventually help them overcome their fear and potentially
transfer to in-person treatment. The practice of some form of telepsychology or
online counseling is not a novel concept in Ghana or abroad. Telepsychology has
been around since the launch of the internet in 1972 (Alleman [2]). Currently,
psychologists worldwide perform or have performed some sort of online
counseling or telepsychology. In 2008, a survey conducted by the American
Psychological Association revealed that 87 percent of psychologists provide
mental health care services via telepsychology (American Psychological
Association, 2009). The prevalence of this practice has led to the formulation
of practice guidelines in some developed countries like the United States,
Britain, and Canada. Mental health care access is an area in Ghana’s mental
health care system that requires major development. With the exception of the
popular, major psychiatric hospitals in the country, it can be difficult for
the average Ghanaian to know where to go to in order to seek mental health care
especially one that is not located in a psychiatric hospital. In recent years,
the Ministry of Health has made provisions to allow for the placement of
clinical psychologists in its hospitals. However, mental health care access
continues to be a problem because of location, insufficient numbers of clinical
psychologists and stigma among other reasons. Today, one is more likely to gain
access to a clinical psychologist in the nation’s capital of Greater Accra than
in any of the other regions of Ghana. This problem is worsened by reported
estimates from Osei [3], the former Chief Psychiatrist of the Accra Psychiatric
Hospital of a doctor-patient ratio of 1:1.7 million in the mental health sector
(Awaf [4]). Stigma can be a deterrent when it comes to seeking mental health
care even among people who have relatively easy access to these services. With
clinical psychology facilities sometimes being housed in places like the Accra
Psychiatric Hospital, individuals may be afraid to seek out these services for
fear of being perceived as ‘mad’. In cases like these, the practice of
telepsychology holds the potential for ameliorating such problems by
abbreviating the distance between the prospective patient and psychologist, for
allowing easy access to psychologists and for reducing the potential stigma of
accessing the psychologist in a setting that could potentially be stigmatizing.
Development of telepsychology
guidelines and opportunities for ghana
In 2013, the American Psychological
Association (APA) released their guidelines for the practice of telepsychology.
Prior to that in September 2009, the British Psychological Society (BPS)
released its second edition of regulations concerning the provision of
psychological services via the internet and other nondirect means (Professional
Practice Board [5]). The formation of these guidelines was a response to the
increasing rate of the use of telecommunication strategies among its
psychologists. While the APA and BPS recognized the potential for
telepsychology to increase access to psychological services, it also recognized
the need for the formal regulation of tele psychological practices because of
the potential challenges it presented. It is possible for Ghana to take a cue
from these guidelines in order to pre-empt any potential challenges, and to
keep itself from being reactive when tele psychological services rise to the
capacities experienced in more developed countries. The formulation of such a
guideline for Ghana’s psychologists will also serve as a mechanism to permit
the use of such a service delivery mechanism as a solution to Ghana’s mental
health care access problems [6]. For the APA (and BPS), core issues identified
in their guidelines for telepsychology include the competence of the
psychologist in providing tele psychological services and the importance of the
need for the psychologist to be well-versed in the use of the telecommunication
technologies as well as the awareness of the potential impact of such a
modality on clients/patients, supervisees and other relevant stakeholders
(“Guidelines for the Practice of Telepsychology”, 2013). There is a vast array
of choices when it comes to telecommunication technologies today and it is
important for the psychologist using such modalities to be knowledgeable about
their chosen systems of communication especially where issues of privacy and
confidentiality are concerned. Given the sensitivity of information that is
shared in the client-psychologist relationship, the potential fears of stigma
as well as the consequences of client-psychologist privileged information
becoming public knowledge, it is important for the psychologist to be
thoroughly knowledgeable about their telecommunication mechanisms and its
privacy/confidentiality limitations in order to select systems that provide the
most privacy/ confidentiality possible and to communicate any such limitations
to the patient/client as sanctioned by psychological practice.
The upholding of the standards of care in
the delivery of telepsychology services was also an important issue in the
development of the APA and BPS telepsychology guidelines. By these, the
guidelines reinforced the importance of translating the same ethical and
professional practices of in-person services to telepsychology. While
telecommunication technologies have the potential of connecting the patient to
the psychologist, it also has the potential of creating a disconnect in the
patient-psychologist therapeutic relationship. The patient/client who ‘sees’
the psychologist via a telecommunication device may not feel as close to the
psychologist as the patient/client who does so face-to-face or in-person. In
the patient- psychologist relationship, trust and the feeling of safety are
important, and these tend to be more easily developed through in-person
interactions.
For this reason, the APA and BPS
telepsychology guidelines advise that psychologists choose telecommunication
systems that do not negatively impact the development of a good
patientpsychologist therapeutic relationship. In the spirit of upholding the
ethical and professional standards of practice, it is also important that the
psychologist assesses the effectiveness of telepsychology modalities to meet
the needs of the client. While mental health care access can be a problem,
telepsychology should be an option which not only connects the patient to the
psychologist but which also does so in a way that ensures the patient is
receiving optimal ethical and professional standards of care. Ethical and
professional standards of care cannot be sacrificed on the altar of mental
health care access. Sometimes, the severity of a mental health issue is such
that an in-person service is required, and treatment cannot ethically be
provided via the practice of telepsychology.
An area of focus that the APA guidelines
concentrated on and which might potentially require some significant adaptation
for Ghana as compared to the other identified core areas lies in the area of
psychological testing. Psychological testing is equivalent to the laboratory
testing that is performed in the medical sciences in that it is also needed for
aiding in diagnoses formation and the assessment of the current functioning of
the patient. While there are online psychological testing options, most tests
are designed for in- person interactions allowing for the observed behaviors of
patients/clients during the testing process to serve as important information
in the testing process. For example, if a cognitive test is being conducted on
a child who ends up scoring above average, it is also important to note if the
child was attentive during the testing process or if the child had difficulty
staying seated. It is important to note if the child was able to follow social
cues or the child answered questions while staring out a window without making
eye contact with the psychologist. While testing via videoconferencing can
provide such information, it can be difficult to ascertain what part the
videoconferencing in itself contributes to the behaviors witnessed in the
patient/client during the testing process. Psychological testing in Ghana
already possesses issues given the fact that the available testing tools are
designed for a foreign population. This can create issues regarding validity
and reliability of tests results for the Ghanaian cultural context without the
additional variable of a telecommunication system of testing. Still, with the
goal of the maintenance of ethical and professional standards of practice,
guidelines can be formulated that ensures integrity of practice and the
provision of appropriate care while trying to solve the problem of mental
health care access.
Mobile apps and mental health
care access
Mobile applications serve as mechanisms
through which the problem of mental health care access can also be solved or
improved upon. A mobile application or mobile app is an application software
that is designed to run on mobile devices such as smart phones or tablets. With
advances in technology, it is more common now to find individuals using smart
phones which come with the capability of having apps such as those for emails,
social media, messaging, shopping, gaming, and other areas of interest. Today,
some smart phones have already built-in mobile apps that are geared towards
health. Some apps for example allow people to track their food and water
intake, physical activity and even stress levels. There are mental health apps
(also known as mHealth apps) too that, for example, provide support for
teenagers struggling with depression like the Code Blue app and apps that guide
people through breathing exercises for stress management like the Breathe2Relax
app. Some of these mental health apps are also interactive, combining
therapeutic techniques with real life experts like the Lantern app. Other apps
that can be used in addition to real life treatment include mobile applications
such as the PTSD Coach, Self-Help for Anxiety Management (SAM) and Optimism
apps which allow people to track their symptoms over time while providing
psychological tools (“Top 10 Mental Health Apps”).
As already discussed, the problem of mental health care access in Ghana is
impacted by the lack of clinical psychologists in the country, the physical
distance between the patient and psychologist as well as the inability of
people to know where and how to contact a psychologist, especially one that is
not located in a psychiatric hospital setting. While accessing mental health
services in a psychiatric hospital setting is not a problem in itself, there
can be a hesitancy to access services in such locations because of the potential
stigma of being perceived as ‘mad.’ Mobile applications have been used as a
bridge to mental health care access problems in countries like the United
States and Britain. mHealth apps can be designed where people in Ghana have a
way of accessing available clinical psychologists and facilities by location
and specialty. These apps can have built in the ability of also getting in
touch with or communicating with a psychologist to begin treatment. Such an app
also has the potential of regulating professional psychology practice in the
country if the app only includes psychologists and facilities in the country
which are actively licensed. When a psychologist or facility ceases to maintain
active licensure, measures can be put in place to withdraw inclusion in the app
or deactivate visibility and access to such psychologists and facilities. With
such an app approved by the Ghana Psychological Council, psychologists will
want to ensure active licensure of themselves and their facilities while
potential patients are assured of getting access to qualified and approved
professionals and facilities. Such an app which provides information on the
psychologist, location and specialty will also serve as important data for
developing the profession in the country. For example, if the app indicates the
need for more psychologists who work with geriatric populations, geriatric
training programs can be developed to cater for the mental health needs of such
a population in the country. In mental health treatment, clinicians sometimes
make use of group therapy to help support individuals who struggle through the
same symptoms or problems. For example, group therapy can be used with
individuals struggling with substance use, individuals who have gone through
grief and loss, and individuals who struggle with depression and anxiety. This
group treatment modality allows individuals to receive support from others who
experience the same problems they go through and whom can empathize with their
struggle. It also presents with opportunities for these individuals to hold
each other accountable to treatment goals and to have a sense of purpose
through their ability to contribute to the lives of others like themselves who
are hurting thus raising self-esteem. There are apps that Ghana can adapt or
develop that provide the platform to offer group therapy with a trained
therapist. Such an app can be helpful for communal support through mental
health struggles without some of the potential reservation and risks to
confidentiality that the typical face-to-face group therapy presents.
In the traditional face-to-face group
therapy setting, there are times when an individual or groups of individuals
may not be as open or as vocal in ways that allow them to contribute to and
benefit from group treatment. When the option of such an app is available, this
can allow those who would likely be more hesitant and withdrawn to be more
vocal and open. In addition to the group therapy module, mental health mobile
apps present as a good opportunity for complementing in-person treatment or the
practice of telepsychology. mHealth apps can provide supportive services to
patients and clients between sessions that help facilitate treatment. The
individual who is seeing a psychologist for anxiety related problems, for
example, can have an app that provides resources for coping such as breathing
exercises.
According to Henderson et al. [7] , one
factor that affects the seeking out of mental health services includes lack of
knowledge to identify features of mental illnesses. It is possible for people
with mental health problems to experience difficulties that they either do not
understand or which they brush aside. Sometimes the responsibilities of daily
life can prevent one from attending to mental health problems until symptoms
reach a point where they become severe enough to require psychiatric
hospitalization or attempts are made to commit suicide. There is a great need
for Ghanaians to be educated on mental health and through psychoeducation,
convey the importance of seeking help while normalizing mental health help
seeking behaviours to that of physical health seeking behaviors. When people
are made to conceptualize seeking mental health help the same way they would
seek medical help, fears associated with mental health stigma can be reduced
and we could possibly see a decline in suicide behaviors. Mental health apps
that are geared towards psychoeducation can be useful in Ghana’s fight for
mental health education, access, and care. Such mental health apps can include
screening for mental health issues which would have the potential for making on
the spot referral recommendation when applicable. For example, an individual
experiencing symptom of depression can take a questionnaire on the mHealth app
that indicates their level of depression (whether mild, moderate, or severe)
and makes recommendations to see a psychologist.
Development of mhealth apps and
opportunities for ghana
The American Psychological Association
has developed an app evaluation model in response to the increasing use of
mHealth technologies. This decision to develop the evaluation model was also a
response to questions received from mental health care professionals concerning
the efficacy and risks of these mobile mental health apps. It appears the expanding
use of mobile mental health apps was such that the development of the
evaluation model was a better alternative to running every available app
through an approval process and advertising those as APA-approved. In contrast
to the stance taken by the American Psychological Association, the United
Kingdom’s National Health Service has included in its digital library, a list
of mhealth apps with indications of which apps have been approved and which
apps are in the process of being tested by NHS. There are legitimate concerns
regarding the increasing number of mHealth apps and the associated tendency for
people to self-diagnose or use such mechanisms in lieu of the necessary
professional care. The increased access to the internet in general has come with
the tendency for people to look up the symptoms they experience -whether
physical or behavioral- in order to figure out what is wrong with them. The
enormous and varied number of mHealth apps only provides more avenues for
potential selfdiagnoses and misuse.
It is for this reason that Ghana’s Psychological Council could combine the
strategies used by both the APA and UK’s NHS to formulate an evaluation model
that is used to recommend apps for the public. With such a mechanism in place,
mHealth apps can be reviewed and regulated by the appropriate professional
national body from the very onset. Also, mHealth app developers can begin the
app development process keeping in mind that the final product would have to go
through an approval process before being used by the public. The Ghana
Psychological Council or Association bodies can themselves develop approved
apps for its professionals and countrymen and women as well. The apps that are
locally developed would have to be suited to the Ghanaian context and take into
consideration some of the cultural and unique expressions of mental health
problems among Ghanaians, for example, the commonality of somatization of some
mental health problems.
Finding and
Recommendation
Telepsychology and mental health mobile
apps hold unique opportunities for improving mental health care and access in
Ghana when adopted. Like most opportunities, these two concepts present with
challenges that will be discussed in the sections to follow with
recommendations on how to overcome these obstacles in order to improve mental
health care and access. When mental health care and access is improved upon,
the nation’s sustainable development goals for health can make gains towards a
more complete picture of fulfillment. Ghana’s sustainable development goals for
health cannot be entirely met if its mental health care problems persist.
Human health resources
Telepsychology and mobile apps provide
potential solutions to mental health care problems in Ghana, but certain issues
currently impede its implementation. These issues are not unlike the issues
discovered in an analysis of tele mental health in South Africa (Jefee-Bahloul
et al., [8] ). Just like in South Africa, Ghana does not have sufficient human health
resources. As already discussed, there aren’t enough mental health
professionals to meet the current demand in the nation. For this reason, there
is the need for mental health or psychology training up to the highest level
possible in the country. There is also the need for the profession to be
properly supported by the government in order to keep from deterring other
professional aspirants from the field of mental health care or psychology.
Infrastructure
An obvious potential limitation also lies
in the requirements of technical and administrative support that the proposed
technology mechanisms require. The use of telepsychology mandates adequate
bandwidths that might not be available or which may be too expensive to
acquire. Also, while messaging apps like WhatsApp and Skype can be used for
telepsychology, these also require adequate amounts of data which could be
relatively expensive when used at the levels that would be required for
appropriate treatment. Again, should the problem of expense be addressed,
another potential problem arises in the requirement of stable network
connectivity which is not always the case in Ghana.
Political will
Until the year 2012 when Ghana’s mental
health bill was passed, the country operated under a mental health law that was
put into effect in 1972. Although Ghana made tremendous strides with the
passing of the 2012 mental health act, five years later, the Legislative
Instruments which will serve to assist the implementation of the bill is yet to
be passed (Boateng [5]). Improvement in mental health care and access through
recommendations of modalities like telepsychology and the use of mental health
mobile apps would also only be more successful with government or political
backing. Without support from Ghana’s government to improve upon mental health
care, Ghana will likely continue to lag behind when it comes to attaining the
advances that have been seen in the more developed countries with mental health
care practice [9-11].
Conclusion
Sustainable development is development
that meets the needs of the present without compromising the ability of future
generations to meet their own needs. The health of human beings plays a central
role in the fulfillment of sustainable development goals both as enactors and
indicators of sustainable development. Health forms the third arm of the United
Nation’s sustainable development goals and has received great attention given
its implications not just on sustainable development goals but to the lives of
families, societies and economies. In meeting sustainable development goals for
health, mental health has not received as much attention although it holds just
as much significance in attaining sustainable development goals for health.
Mental health can have just as significant an impact on families, societies and
economies. An individual with a healthy body but an unhealthy mind can be just
as incapable of functioning as an individual with a healthy mind but an
unhealthy body. Telepsychology and mobile mental health apps present as great
opportunities for mitigating mental health care access problems in Ghana.
During and outside of pandemic realities, these technologies can serve as means
of connecting the potential patient to the psychologist, discovering options
for mental health care, regulating the practice of psychotherapy in the
country, and providing psychoeducation and complementary resources to
treatment. With continuing growth in Ghana’s telecommunication technologies and
support for the work of mental health professionals, the discussed challenges
can be overcome and Ghana can make its way toward greater mental health care
access, and ultimately, the achievement of its sustainable development goals
for health.
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