These observations suggest that the voice-hearing experiences of people with serious psychotic disorder are shaped by local culture. These differences may have clinical implications.

BackgroundWhilst there have been several studies exploring retention in health workers, little is known about health workers engaged in the provision of mental health services and the factors that affect their recruitment and retention.AimsThe objective of this research was to examine the views of stakeholders about the factors which influence career choices and retention of community mental health workers (CMHWs) in Ghana.MethodsWe administered three separate, self-administered, semi-structured questionnaires to 11 psychiatrists, 29 health policy directors and 164 CMHWs across Ghana, including 71 (43.3%) community psychiatric nurses (CPNs), 19 (11.6%) clinical psychiatric officers (CPOs) and 74 (45.1%) community mental health officers (CMHOs).ResultsOverall, 34 (20.7%) of all CMHWs chose to work in mental health because of the job prospects in mental healthcare. Overall, 12 (16.2%) CMHOs, 1 (5.3%) CPO and 20 (28.2%) CPNs reported they had considered leaving the mental health profession because of the stigma, with 4 (36.4%) psychiatrists and 12 (41.4%) health policy coordinators also reporting that they knew some CMHWs who had considered leaving the mental health profession because of stigma. Similarly, 16 (21.6%) CMHOs, 4 (22.1%) CPOs and 38 (53.5%) CPNs said they had considered leaving the mental health profession because of concerns about risk. Furthermore, 6 (54.5%) psychiatrists and 3 (10.3%) health policy directors said they knew some CMHWs who had considered leaving the mental health profession because of concerns about risk. Overall, 61 (37.2%) of 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 inter-professional relationships.ConclusionsSeveral factors affect the recruitment and retention of CMHWs in Ghana, including the prospects of easy employment, stigma, risk, lack of opportunities for career progression and low salaries.

BackgroundBecause of the absence of adequate numbers of psychiatrists, the bulk of mental health care at the community level in Ghana is provided by community mental health workers (CMHWs).ObjectiveTo examine the role and scope of practice of CMHWs in Ghana from their own perspectives and to make recommendations to improve the care they provide.DesignWe conducted a cross-sectional survey of 164 CMHWs from all the 10 administrative regions of Ghana, comprising 71 (43.3%) community psychiatric nurses (CPNs), 19 (11.6%) clinical psychiatric officers (CPOs), and 74 (45.1%) community mental health officers (CMHOs).ResultsOverall, only 39 (23.8%) CMHWs worked closely with psychiatrists, 64 (39%) worked closely with social workers, 46 (28%) worked closely with psychologists and 13 (7.9%) worked closely with occupational therapists. A lower proportion of CMHOs worked closely with psychiatrists, psychologists, and social workers compared with CPOs and CPNs. There was no significant difference in the proportion of the different CMHW types who expressed confidence in their ability to diagnose any of the commonly named mental health conditions except personality disorders. However, a lower proportion of CMHOs than CPOs and CPNs expressed confidence in their ability to treat all the disorders. The CMHWs ranked schizophrenia as the most frequently treated mental health condition and there was no statistically significant difference in the reported frequency with which the three groups of CMHWs treated any of the mental health conditions.ConclusionsMental health policy makers and coordinators need to thoroughly review the training curriculum and also evaluate the job descriptions of all CMHWs in Ghana to ensure that they are consistent with the demands and health-care needs of patients they care for in their communities. For example, as CMHOs and CPNs prescribe medication even though they are not expected to do so, it may be worth exploring the merits of including the prescription of common psychotropic medication in their training curriculum and job descriptions.

This study compares 20 subjects, in each of three different settings, with serious psychotic disorder (they meet inclusion criteria for schizophrenia) who hear voices, and compares their voice-hearing experience. We find that while there is much that is similar, there are notable differences in the kinds of voices that people seem to experience. In a California sample, people were more likely to describe their voices as intrusive unreal thoughts; in the South Indian sample, they were more likely to describe them as providing useful guidance; and in our West African sample, they were more likely to describe them as morally good and causally powerful. What we think we may be observing is that people who fall ill with serious psychotic disorder pay selective attention to a constant stream of many different auditory and quasi-auditory events because of different "cultural invitations"-variations in ways of thinking about minds, persons, spirits and so forth. Such a process is consistent with processes described in the cognitive psychology and psychiatric anthropology literature, but not yet described or understood with respect to cultural variations in auditory hallucinations. We call this process "social kindling."