Factors influencing the career choice and retention of community mental health workers in Ghana

Reasons for choosing a career in mental health

Respondents were given four choice options: 1) job prospects within mental health,
2) I just wanted to work with mental health patients, 3) I got into mental health
accidentally and 4)I have a family member or friend with a mental problem and was
touched by their plight and an “other” category where they could specify additional
reasons. A comparison of the reasons why the CMHWs chose to work in mental health
was made using cross tabulation. The results of this analysis showed there was as
a statistically significant association between the CMHW type and the reasons they
chose to work in mental health as shown in Figure 3.

Figure 3. Percentages of the CMHWs groups and the reasons they chose to work in mental health
(df?=?8, P value?=0.00).

Figure 3 suggests that significantly more CMHOs choose to work in mental health because of
the job prospects (32.4%) compared to both CPOs (5.3%) and CPNs (12.7%). Furthermore,
no CMHO got into the mental health profession accidentally. Around a third of all
CMHWs said they just wanted to work in mental health with fairly similar proportions
from the different CMHW types in this group. However, a higher proportion of CPOs
(31.6%) chose to work in mental health because they had a family member or friend
with mental health problems compared with CMHOs (14.9%) or CPNs (2.8%).

Other reasons given by the CMHWs for choosing a career in mental health can be grouped
under three themes, namely: touched by the plight of mental health patients, developed
an interest in mental health after undertaking an attachment in a psychiatric hospital
and desire to learn more about mental health. Some of the reasons under the various
themes are as summarized in Table 2.

Table 2. Other reasons why CMHWs chose careers in mental health

Concerns about the state of mental healthcare in Ghana

Overall, 89.2% and 97.3%, respectively, of CMHOs expressed concern about the state
of mental healthcare in Ghana before and after they began to work in mental health.
For CPOs, it was 89.5% and 100%, respectively, whilst 88.7% and 97.2%, respectively,
for CPNs expressed concerns about the state of mental healthcare before and after
they began to work in mental health. Figure 4 shows the specific concerns expressed by the different CMHWs.

Figure 4. Percentage of the different CMHWs who expressed specific concerns about the state
of mental healthcare in Ghana.

Respondents were given a number of optional responses and asked to tick all those
that applied. They were also given the opportunity to add additional concerns. The
majority of CMHWs expressed concern about the lack of an appropriate mental health
infrastructure followed by the lack of family support for patients and then the lack
of community and social support. The other concerns identified by the community mental
health workers included the following: stigmatization of mentally ill clients, lack
of motivation and support for mental health professionals, cost of some psychotropic
drugs and lack of knowledge about appropriate place to get mental health services.

Impact of stigma, risk and other factors on the mental health workforce

A five-point Likert scale was used to assess respondents’ perception as to whether
there is stigma associated with working in mental health, the extent to which they
are affected by this stigma and the extent to which it might have caused them to consider
leaving their job. Almost all the CMHWs (163 (99.4%)) reported that they believed
there is stigma associated with working in mental health. The CMHWs were also asked
if they had been impacted negatively by the stigma associated with working in mental
health and if they had considered leaving the mental health profession because of
this stigma. The results are as summarized in Figure 5.

Figure 5. Percentages of CMHWs who expressed concerns about the risk associated with working
in mental health and those who had considered leaving the mental healthcare profession
because of concerns about stigma.

However, only 35 (42.5%) of CMHOs, 10 (52.6%) of CPOs and 53 (60.6%) of CPNs reported
they have been negatively impacted by the stigma in mental health. Furthermore, only
12 (16.2%) of CMHOs, 1 (5.3%) CPO and 20 (28.2%) of CPNs reported they had considered
leaving the mental health profession because of the stigma. On the other hand, all
the psychiatrists believed that all CMHWs are affected by stigma although only four
(36.4%) of the psychiatrists said they knew some CMHWs who had considered leaving
the mental health profession because of stigma. Again, 16 (55.2%) health policy coordinators
were of the opinion that CMHWs are affected by stigma with 12 (41.4%) of them reporting
that they knew of some CMHWs who had considered leaving the mental health profession
because of stigma.

The CMHWs were also asked if they had concerns about the risk associated with working
in mental health and if they had considered leaving the mental health profession because
of this risk. The results are as summarized in Figure 6.

Figure 6. Percentages of CMHWs who expressed concerns about the risk associated with working
in mental health and those who had considered leaving the mental healthcare profession
because of concerns about risk.

On the other hand, all the 11 psychiatrists believed that CMHWs are affected by the
risk of working in mental health, although only 6 (54.5%) of the psychiatrists said
they knew of CMHWs who had considered leaving the profession because of concerns about
risk. Furthermore, 26 (89.7%) health policy coordinators also believed that CMHWs
are affected by risk but only 3 (10.3%) said they knew of some CMHWs who had considered
leaving the mental profession because of concerns about risk.

Overall, 61 (37.2%) of the CMHWs reported that they have considered leaving the mental
health profession for other reasons other than stigma and risk including the following:
the lack of support, respect and recognition from healthcare managers, lack of opportunities
for professional development and poor conditions of service including low salaries,
lack of office and personal accommodation and lack of risk allowance and transportation
as well as poor relationships with other healthcare workers including psychiatrists
and district medical officers. One CMHO wrote, “I have worked for two years and have
still not received any salary”. One CPO also wrote, “There is no motivation and I
have had to use my own means of transport and resources to deliver services without
any vehicle maintenance allowance being paid to me”. Another CPO wrote, “there is
conflict between me and the medical officer in my hospital”. Similarly, one of the
CPNs wrote, “there is poor relationship between the psychiatrist and community psychiatric
nurses”. Another CPN also wrote, “The mental health profession is neglected by the
health authorities and is not given the necessary logistics and assistance to aid
its workforce”. Similarly, seven (63.6%) of the psychiatrists said they also knew
of some community mental health workers who had considered leaving the mental health
profession for other reasons including low salaries, lack of adequate protection against
risk and lack of opportunities for career progression, in-service training and further
education. Furthermore, 11 (37.9%) health policy coordinators said they knew of some
CMHWs who had considered leaving the mental health profession for other reasons including
the lack of motivation, low salaries and after getting opportunities to enrol in other
health training institutions.

Support from district health management teams and conditions of services

The CMHWs were asked to indicate on a five-point Likert scale the extent to which
they felt supported by the DHMTs in which they work. Overall, only 35.6% of CMHOs,
47.4% of CPOs and 45.1% of CPNs reported they feel supported by their DHMTs. A chi-square
test for independence indicated no significant association between the CMHW types
and the response regarding support from the DHMT (P?=?0.41). In contrast, five (45.5%) psychiatrists said the DHMTs support CMHWs to
some extent, four (36.4%) said they support them only to a limited extent whilst two
(18.2%) said the DHMT do not support the CMHWs at all. However, all the health policy
coordinators and implementers believed that the CMHWs feel supported by the DHMTs
although to varying extents, including 12 (41.4%) who said they support them to a
limited extent, 9 (31%) who said they support them to some extent and 8 (27.6%) who
said they absolutely support them.

Only 5 (6.8%) of CMHOs, 7 (36.8%) of CPOs and 15 (21.1%) of CPNs thought they receive
adequate remuneration for the work they do. Consistent with this, 33 (43.2%) CMHOs,
7 (36.8%) CPOs and 37 (52.1%) CPNs said they will probably leave the mental health
profession if they find a better paying job in other sectors of the economy. Overall,
162 (98.8%) of the mental health workers reported that they believed the district
health management teams could do more to support their work. The CMHWs identified
several incentives and support that they could get from the DHMT to enhance their
work including the provision of transportation and other logistics such as umbrellas,
rain coats and public address systems for community outreach work, office and personal
accommodation, regular supply of medication, security for staff visiting patients
in their homes and payment of risk allowance; giving similar recognition to mental
health as is given to physical health and integration of mental health into public
health activities; and regular in-service training and supervision as well as better
infrastructure for mental healthcare. Overall, seven (63.6%) of the psychiatristscompared
to five (17.2%) of the health policy coordinators reported that they do not think
CMHWs receive adequate pay and incentives for the work they do in their districts.
Also, all the 11(100%) psychiatrists compared to 24 (82.8%) of the health policy coordinators
were of the opinion that if the CMHWs got better paid jobs in other sectors of the
economy, they will leave their current jobs. Incentive packages identified by the
psychiatrists which could enhance the work of the CMHWs included the following: transportation,
enhanced pay, office and residential accommodation, risk allowance, early retirement,
improved work environment, recognition for human resource development, monetary incentives,
early promotion, free utility services and accommodation and they should be treated
like all other healthcare professionals. Similarly, health policy coordinators identified
incentive packages which they think could enhance the work of the CMHWs including
the following: means of transportation, opportunities for career progression and further
training, enhanced supervision, enhanced salaries, office and residential accommodation,
free utility services, risk allowance and early promotion. One district director of
health wrote, “Salary should be one step ahead of those in equivalent ranks in other
health professions”.