'They know what is best for their own lives'

Walking into a small paediatric ward on my recent research visit to rural Ghana (Navrongo), in a typically British manner I asked the nurse about her day. She answered that it was quiet as it was not market day. Why is market day the busiest, I asked? She explained that mothers and children are more likely to hitch a lift to the hospital on the way to the markets.

This was a hard reality to grasp. How long did some families have to wait until they found transport to take their ill child to receive medical attention? This got me thinking about the physical 'opportunity' component in Susan Michie's COM-B model of health behaviour. Something as fundamental as not having transport to a medical centre will be a big contributor to a child's health. Any health psychologist needs to be aware of such factors, but this really brought home the value of immersing myself in the local context.

Fortunately for me, I had the opportunity to stay for 10 days at the Navrongo Health Research Centre, Health and Demographic Surveillance Site, and in Ghana for a total of three weeks. Navrongo is a rural community situated in the Upper East Region of north Ghana, bordering Burkina Faso. Communities in Navrongo mainly earn a living through subsistence farming, which is greatly affected by the hot and humid climate.

During my visit, I learnt howreligion is central to the lives of people in Ghana, and I was honoured to be invited to the Methodist Church Annual Senate to listen to my colleague Dr Engelbert Nonterah engage the community in a discussion on the role of nutrition in non-communicable diseases. In the most down-to-earth but clinically-informed way, Engelbert intrigued the audience with context-specific and realistic nutritious advice. This was the first time that a medical doctor had been invited to the Annual Senate, and everyone agreed this was a great platform to engage the community in improving their health.  

Bringing a health psychology perspective to the situation, I reflected that social cohesion within the church could have a key role in improving community health, potentially tapping into important concepts such as social norms, peer support, self-efficacy (either individual or community) and other aspects of social learning theory.

Community engagement

Community engagement is core to the work of Dr Engelbert and the Navrongo Health Research Centre. The research centre has imbedded itself within the community to achieve an extraordinary trusting relationship between researchers and local people. Research findings frequently translate into Ghanaian national policy, which brings about structural change in the country. Furthermore, the research teams place value on the community's research contribution and believe it is essential to inform each person in the Health Demographic Surveillance System (HDSS) about their individual health results; 'they are people, not guinea pigs', explained the HDSS head of department.

Additionally, the research centre encourages community ownership by inviting volunteer health informants in the villages to report significant events to the research team. The Navrongo Health Research Centre demonstrates that empowering participants to have an active role in the research can encourage a sense of control over their health and wellbeing. It's crucial to truly value and invest in the people that we want to involve in our studies.  

I also witnessed the negative consequences of not considering the health context, mainly in the activities of external donors. The Ghanaian Government make little contribution towards funding health research, and therefore Ghana Health Research Centres are dependent upon external donors. It was made clear to me that it is common practice for external donors to arrive and pitch their own research agenda, and the Ghanaian research teams agree to become partners as a matter of research centre survival. This often means that the Ghanaian research centres are conducting research designed by Europeans and Americans from halfway across the world, on topics they know are not the priorities for the community.

Often, external donors are not considering where they are conducting their research, and promote interventions and build facilities that are inappropriate and unsustainable. When the funding inevitably ceases, the intervention suddenly stops and the community are back to square one. I saw infrastructure financially supported by internationally-renowned NGOs now unusable due to the lack of sustainable maintenance. I heard stories from women bewildered by the sudden termination of nutrition support for their children. This made me question how much the external donors consider the repercussions and consequences of their short-term contribution on the communities. Increasingly research projects co-design with local PIs, but co-design with the local service users would be even more useful. They know what is best for their own lives.

Delving below the surface

At a qualitative workshop, we analysed focus group data about maternal and child nutrition, as part of University of Southampton programme. INPreP aims to identify two context specific nutritional interventions, to improve maternal and child nutrition in communities in Ghana, Burkina Faso and South Africa. In relation to the wider project, this qualitative study provides an opportunity for local men and women to identify key maternal and child health and nutrition concerns in their locations, and suggest potential interventions.

In the workshop, I found that even as a trainee health psychologist I could draw on my skills and knowledge when interpreting the qualitative data. Psychological concepts related to the influence of social networks, perceived locus of control, and community values appeared to be important factors in mothers' and children's perceived nutrition status. Again, the key theme emerged that the local people have ideas for solutions. This is not necessarily a novel finding, but acknowledging this within intervention-planning – by taking the community's contributions and suggestions on board to tailor the intervention to the local context and needs – can only result in better outcomes.

I was in Ghana a mere three weeks… certainly not enough time to delve below the surface of the complex interplay of factors contributing to community health. However, I could see how my Stage 2 Health Psychology training could have real potential to improve the lives of people in low and middle income countries by properly understanding the values of communities, as informed by any number of useful psychological theories and models. My experience in Ghana taught me that although I will adopt a psychological perspective, I will need to be mindful of the values and beliefs of the local people and research teams. As a recently-enrolled health psychology Stage 2 trainee working with communities in Africa and international partners, I'll take this lesson forward to support global health solutions.

-        Daniella Watson MSc MBPsS is a Senior Research Assistant & PhD student & Health Psychologist Trainee

Global Health Research Institue, Human Development and Health Academic Unit, University of Southampton

[email protected]

@Daniellawatson_

Acknowledgements

"Thank you to the Navrongo Health Research Centre for hosting, INPreP colleagues at the workshop, and to one of my PhD supervisors, psychologist Prof Mary Barker, for leading the qualitative research from the bottom-up.

I would like to acknowledge the work by Ama de-Graft Atkins and colleagues on Health Psychology in Ghana, and I look forward to following their progress in making the subject and training more culturally appropriate."