Child mental health in Sierra Leone: a survey and exploratory qualitative study
Sustainable Development Goals: 3
- SDG 3 - Good Health and Well-Being
The study explores the prevalence and causes of mental illness amongst children in Sierra Leone. It applies the results to recommend changes in mental healthcare for children who have lived in regions of conflict.
This study complements the growing amount of research on the psychosocial impact of war on children in Sierra Leone by examining local perceptions of child mental health, formal and informal care systems, help-seeking behaviour and stigma.
The study combined: (1) a nationwide survey of mental health care providers, with (2) exploratory qualitative research among service users and providers and other stakeholders concerned with child and adolescent mental health, with a particular emphasis on local explanations and stigma.
Formal mental health care services are extremely limited resulting in an estimated treatment gap of over 99.8 %. Local explanations of child mental health problems in Sierra Leone are commonly spiritual or supernatural in nature, and associated with help-seeking from traditional healers or religious institutions. There is a considerable amount of stigma related to mental disorders, which affects children, their caregivers and service providers, and may lead to discrimination and abuse.
Child and Adolescent Mental Health (CAMH) care development in Sierra Leone should cater to the long-term structural effects of war-violence and an Ebola epidemic. Priorities for development include: (1) the strengthening of legal structures and the development of relevant policies that strengthen the health system and specifically include children and adolescents, (2) a clearer local distinction between children with psychiatric, neurological, developmental or psychosocial problems and subsequent channelling into appropriate services (3) supplementary CAMH training for a range of professionals working with children across various sectors, (4) specialist training in CAMH, (5) integration of CAMH care into primary health care, education and the social welfare system, (6) further research on local explanations of child mental disorders and the effect they have on the well-being of the child, and (7) a careful consideration of the role of religious healers as care providers.
Recent years have seen an increasing awareness of the impact of child mental health problems on the global burden of disease [1–3]. This is particularly true for low and middle income countries (LMICs), where children and adolescents constitute a high proportion of the overall population . Children in low-resource settings are often disproportionally affected by risk factors such as violence, poverty, malnutrition and ill-health. Exposure to these multiple and often cumulative risks can have lasting effects on their development, mental health and psychosocial wellbeing, including a higher life-long risk of mental health problems [4–6]. Despite the vast needs in LMICs, child and adolescent mental health care is an often neglected area [1–3, 7]. In humanitarian settings, which disproportionately affect LMICs, mental health and psychosocial support programs are becoming a standard part of humanitarian interventions, but there remains a large gap between popular interventions and knowledge on effective practices .
In this study we examine the particular situation of child and adolescent mental health (CAMH) care in the post-conflict setting of Sierra Leone. The study was undertaken before the ebola virus disease (EVD) Outbreak of 2014/2015 and the situation on the ground will have changed in some respects. Nonetheless, we believe the findings of this study are important to take into account both for the longer term EVD outbreak response and continued attention to long-term mental health consequences of the conflict.
Situated on the west coast of Africa, Sierra Leone is bordered on the north by Guinea and on the south by Liberia. Its estimated population is approximately 6 million . Sierra Leone gained its independence from Britain in 1961. From 1991 to 2002 the country experienced a brutal armed conflict, which left approximately 70,000 people killed and about half of its population displaced . Human rights atrocities included the amputation of limbs, and the systematic sexual abuse of women and girls . Nearly 7000 children are believed to have been recruited as child soldiers . The conflict severely damaged the country’s infrastructure: health facilities were destroyed and many health professionals fled the country .
The 2010–2015 National Health Sector Strategic Plan of the Government of Sierra Leone paints a rather grim picture of the general maternal and child health status of the country before the EVD outbreak, including high maternal, infant and under-five mortality rates and high incidences of malaria, malnourishment and stunting of growth . To tackle the many health issues, the President of Sierra Leone launched an ambitious free healthcare initiative in 2010 for pregnant women, breastfeeding mothers and all children younger than 5 years. While the programme resulted in increased healthcare use, it also revealed weak components in the health care system such as a lack of medication, diagnostic services, electricity, running water and transportation . The EVD outbreak exposed the weak health systems to the outside world . The epidemic resulted in a major setback in maternal and child health, due to the partial closure of health facilities, fear among the population to use health facilities, and the suspension of vaccination campaigns resulting in the emergence of old diseases such as measles [17–19].
The status of mental health care in Sierra Leone 10 years after the ending of the conflict was described by Shackman and Price . They point out that at the end of the war, mental health and psychosocial support interventions focused on reconciliation, child soldier reintegration and trauma-related counselling. Many services were provided by international non-governmental organisations (NGOs), most of which left the country after completing their projects. In recent years there has been an increased local interest in the development of mental health care services in Sierra Leone. The Mental Health Coalition of Sierra Leone was initiated in 2011, bringing together national and international stakeholders in mental health . The Mental Health Policy enacted in 2012 offers a framework for the development of mental health systems in the country . Belfer identifies the development of CAMH policy as a key to the establishment of child and adolescent mental health care services . The decision to design an addendum to the Mental Health Policy for Child & Adolescent Mental Health (with corresponding guidelines for delivery of care) in the Mental Health Strategic Plan 2014–2018  can therefore be seen as a step in the right direction. References made to mental health in other documents recently released by the Government of Sierra Leone [24, 25] seem to indicate an increased awareness about mental health among law and policy makers. This may pave the way to the development of specific policy for CAMH care in Sierra Leone. At the time of our survey, the country had one retired psychiatrist, one clinical psychologist in private practice and four psychiatric nurses (one expatriate). Degree courses in psychiatry, psychology and mental health social work were unavailable  and there was no specialist training in CAMH. The Mental Health Strategic Plan 2014–2018 outlines strategies for the development or revision of mental health curriculum for all levels of training in health and social work, and mentions CAMH as a specific topic to be included . In 2012, with help from international donors, the College of Medicine and Allied Health Sciences launched a certificate and diploma course in mental health nursing. Since the completion of our survey, 22 nurses were trained and subsequently employed in district hospitals across the country. Despite these developments, a WHO Consultation Meeting in Freetown in 2015 concluded that the country was not sufficiently prepared to deal with the psychosocial effects of the EVD outbreak and that the international response again tended to focus on short-term solutions rather than on sustainable development of a mental healthcare system .
A concise review of recent (January 2000–October 2015) literature on child mental health in Sierra Leone (see Additional file 1) shows that 26 out of 42 studies are exclusively on children associated with the armed forces [29–54], while another 14 included or exclusively studied the larger population of children affected by the armed conflict [55–68]. The studies include unique longitudinal research of the mental health outcomes of children associated with and/or affected by the war by Betancourt et al. [29–34, 49–51, 56, 57, 61–66, 69]. There are many valuable lessons to be learned from these studies of child mental health in Sierra Leone in the context of war, which included the linguistic and cultural adaptation of relevant assessment tools, and the development of a promising low-cost intervention to improve youth mental health and (school) functioning in war-affected youth. We identified two studies published on child mental health topics not related to the conflict [70, 71] and one prevalence study on the mental health and psychosocial needs of children with and without parental support in the eastern part of Sierra Leone . Five to six years after the conflict, this study found an extremely high prevalence of mental disorders among the children (8–20 years), e.g. Major Depressive Disorder (80 %), PTSD (76.5 %) and conduct disorder (20.2 %). The symptoms experienced by these children severely impaired their social and educational capacities. Although the study has some methodological limitations, its outcomes do highlight the need for research on child and adolescent mental health in Sierra Leone.
The overall aim of this study was to identify potential barriers and opportunities for the development of CAMH care in Sierra Leone. In particular, we were interested in (a) providing an overview of current systems of child mental health care; (b) make a preliminary inventory of local explanations related to child mental health; and (c) explore how these explanations affect help-seeking patterns, and how they relate to stigma.
The WHO proMIND profile on Sierra Leone  identifies stigma as a major issue affecting mental health in Sierra Leone. Brief surveys done by an international NGO showed that most inhabitants of local communities believed mentally ill people to be evil, violent, lazy, stupid, unable to marry or have children, and unfit to vote . In Sierra Leone society, children hold the lowest social status and their main role is to serve the household and be obedient to fathers and elders in general . Therefore, behavioural and emotional deviance is likely to be less tolerated in children than in adults. This can result in an even greater stigma affecting children with mental health problems . Although our study did not have stigma as its main focus, we did find it helpful to look at the many references to stigma in the light of Mukolo’s suggested framework of stigma experience in child mental disorders . Mukolo’s framework describes the interrelated constructs of (1) dimensions (stereotypes, discrimination and devaluation), (2) context (self, general and public) and (3) targets (child, family/associates and service) of stigma.
For this study, we combined a nationwide survey of mental health care providers with exploratory qualitative research among service users and providers and other stakeholders concerned with child and adolescent mental health. Data collection took place between April 2012 and May 2013.
For the survey we included all Mental Health Care (MHC) Providers identified by and/or involved with the Mental Health Coalition of Sierra Leone in March 2012 (n = 13). An MHC Provider could be a single counsellor in private practice or an organisation with multiple staff members. For the exploratory qualitative study we used non-probabilistic sampling methods, with an emphasis on purposive sampling . We used the first author’s extensive knowledge of the country and her close relationships with many key stakeholders in mental health to identify the most relevant informants in the field of CAMH. We selected informants from all four provinces in Sierra Leone. To find informants we used contact details as provided in a database of the Mental Health Coalition and/or asked local MHC Providers that were visited to assist with identification (e.g. “Can you introduce us to two local pastors or traditional healers who are known to be working with people/children with mental disorders?”). The Government-supported Christian primary and Muslim secondary schools in the Northern Province were identified by MHC Providers, while the schools in Freetown (Western Area) were identified by the first author, selecting a Government school and a Government-supported, NGO-monitored school. Purposive sampling was also used to assure gender balance. Convenience sampling was occasionally used when choices were refined based on accessibility (e.g. the possibility of being introduced through a trusted person), availability at the time of visit, or practical considerations (e.g. travel time). In an iterative process, the sample was adjusted over time: some sub-groups were reduced as less in-depth information was retrieved from them (e.g. health care providers and teachers), while others were added (e.g. parents of children with intellectual disabilities). (Head) teachers from the two government-supported schools for children with special needs were included. All informants were met at their home or place of work. All interviewed parents were living in Freetown and approached through/interviewed at the School for Special Needs (n = 4) and the Epilepsy Association of Sierra Leone (n = 1). Participants in the Group Interview were recruited voluntarily at a training session of the Mental Health Coalition in Freetown. The group included 3 MHC providers who also participated in the survey and a Traditional Healer who had facilitated visits to other healers. Table 1 gives an overview of the final qualitative research sample.
For the survey we used a questionnaire (see Additional file 2) which was an adapted version of tools provided in a WHO–UNHCR toolkit for the assessment of mental health and psychosocial needs and resources in humanitarian settings . Data were retrieved personally by the first author (n = 11) or electronically (n = 2). Case-load information was where possible gathered through treatment records. For the qualitative research we combined semi-structured questionnaires (see Additional files 3, 4, 5, 6, 7 and 8), which were again mostly adapted versions of tools provided in the above mentioned WHO–UNHCR toolkit , with open interviews and a group interview. For the Group Interview we used a structured list of questions on CAMH related topics, drawn up by three of the authors (see Additional file 9). When opportunities occurred, respondents were asked about local expressions for CAMH problems in the Krio language. The interviews were conducted by the first author in Krio or English. One traditional healer had a limited understanding of Krio, so her granddaughter assisted with translation. Notes were taken during the interview in English and Krio and subsequently written out, mostly in English, and where relevant (e.g. expressions) in Krio. Outcomes of the group interview were recorded by the Interviewer (first author) on a flip chart and by a note-taker on a laptop.