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Discov Ment Health
Discov Ment Health
Discover Mental Health
2731-4383
Springer International Publishing Cham

39251546
89
10.1007/s44192-024-00089-y
Research
Creating communities that care: social representation of mental health in two urban poor communities in Ghana
Agyei Francis fagyei@uhas.edu.gh

1
de-Graft Aikins Ama 23
Osei-Tutu Annabella 4
Annor Francis 5
1 https://ror.org/054tfvs49 grid.449729.5 0000 0004 7707 5975 Fred N. Binka School of Public Health, University of Health and Allied Sciences, Ho, Ghana
2 https://ror.org/02jx3x895 grid.83440.3b 0000 0001 2190 1201 Institute of Advanced Studies (IAS), University College London (UCL), London, UK
3 https://ror.org/01r22mr83 grid.8652.9 0000 0004 1937 1485 Regional Institute of Population Studies (RIPS), University of Ghana, Accra, Ghana
4 https://ror.org/01r22mr83 grid.8652.9 0000 0004 1937 1485 Department of Psychology, University of Ghana, Accra, Ghana
5 https://ror.org/0492nfe34 grid.413081.f 0000 0001 2322 8567 Directorate of Research, Innovation and Consultancy, University of Cape Coast, Cape Coast, Ghana
9 9 2024
9 9 2024
12 2024
4 1 3318 1 2024
28 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Building caring communities is fundamental to achieving a community-based approach to mental health. Understanding how communities perceive mental illness provides critical insight into fostering mental health awareness and care. We explored the perceptions of mental illness among members of two urban poor communities in Accra, Ghana. Qualitative data were collected from 77 participants through key informant interviews, focus group discussions, and situated conversations. Using theory-driven thematic analysis based on social representations theory, findings revealed cognitive-emotional representations of mental illness. The communities demonstrated high awareness of the multilevel factors contributing to mental illness risk and experiences, drawing on five sources of knowledge: embodied, common sense, medical, cultural, and religious. Mental illness representations informed the classification and legitimization of mental illness based on the severity of conditions and the identity of sufferers. These findings provide valuable insights for planning community mental health interventions that address both social and institutional care needs.

Keywords

Social representations
Mental illness
Poor communities
Caring communities
issue-copyright-statement© Springer Nature Switzerland AG 2024
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pmcIntroduction

Resource-poor communities are disproportionately affected by the global burden of mental illness due to several social and structural stressors that compromise well-being [1, 2]. Mental health systems within these communities are poorly funded, resulting in significant treatment gaps [3, 4]. Mainstream institutionalized mental health approach has been inadequate in addressing mental health challenges in such communities [5]. In Ghana, research highlights a high prevalence of both severe and common mental disorders in resource-poor communities [6, 7]. Formal responses to mental health problems, both at the national and community level, are weak and underfunded, creating huge treatment gaps [8, 9]. There have been calls for critical approaches that focus on building the mental health competences of resource-poor communities [10, 11]. A key aspect of building mental health competence involves understanding local mental health knowledge within such communities [12].

We explored how members of resource-poor urban communities in Ghana perceive and make sense of mental illness both broadly as a concept and in terms of specific disorders common within their communities, and how they respond to mental illness. The study was conducted in two urban poor communities in Accra, Jamestown and Usshertown, often referred to collectively as Ga-Mashie. The primary sources of livelihood in these communities are fishing for men and fish mongering for women, with other economic activities such as petty trading, food vending, hairdressing, carpentry, and butchery also being common. These communities face significant socioeconomic challenges, with an average annual income of less than GH₵600 (approximately USD 42) [43]. High unemployment rates and limited access to healthcare and education further exacerbate these issues. Public infrastructure and social amenities, such as playgrounds and parks, are inadequate [13]. The management of solid and liquid waste is poor, with the few existing drains chronically clogged with plastic and other waste [14, 43]. Longitudinal social psychological research in these communities over the past decade has shown a high prevalence of chronic physical and mental health disorders, as well as high levels of mental illness stigma [13, 15, 16]. The drivers of poor mental health in Ga-Mashie are both material and symbolic, encompassing unemployment, poverty, powerlessness, and frustration [15, 16]. These characteristics make Jamestown and Usshertown an ideal context for exploring the realities and opportunities for enhancing mental health competence in poor communities within the Ghanaian context.

Conceptual framework and literature review

We used the social representation theory as a framework. Social representation theory, developed by Serge Moscovici, refers to the system of values, ideas, metaphors, beliefs, and practices that are shared among members of a group and that contribute to the establishment of social norms [44, 45]. It provides insights into how everyday knowledge and common sense shape the way people perceive and engage with the world, guiding their attitudes and behaviours [44]. This theory is particularly useful for understanding how communities conceptualize and respond to mental health issues, as it highlights the role of socio-cultural factors in shaping perceptions and practices related to mental health [21].

We operationalized social representation as practical social knowledge that guides attitudes and behaviours [17]. Representations as practical social knowledge provides insights into practical mental health knowledge and helps understand the socio-cultural factors that drive poor mental health, undermine effective responses, and how the impact might be predicted and addressed timely [18]. Conceptualizing social representations as practical social knowledge [21], we explored the content, source, and functions of mental illness representations within the communities. Regarding the content of representations, we assessed what community members know and how they make sense of mental illness broadly and specific disorders prevalent within the communities. Existing studies report poor mental health knowledge in poor communities, reflected in largely negative perceptions about mental illness [22–25]. For the sources of representations, we analysed where community members draw their mental health knowledge from, using cognitive polyphasia as an analytical tool to explore the heterogeneity of knowledge stocks.

Previous research has shown that social representations can be a double-edged sword. On one hand, poor communities have developed coping strategies and resources to deal with their stress-laden realities in the absence of expert information and state support for mental health promotion [19]. Social representations provide practical and symbolic resources that equip local communities to cope with their social realities. On the other hand, local knowledge can also be detrimental to the well-being of community members, as ideological mechanisms may conspire to undermine optimal mental health [20]. There is a need for a constructive dialogue between local mental health knowledge and expert mental health knowledge as a necessary precondition for transforming mental health in communities [18].

Existing studies suggest that community members mainly draw on common sense in understanding mental illness, reflected in lay descriptions of symptomatology and classifications of disorders [22, 25]. De-Graft Aikins (2012) showed how cognitive and emotional processes underpin representations of unfamiliar health conditions, informing categorization and stigmatization based on strangeness and severity [21]. Emotions are fundamental in forming representations and constitute valid knowledge that informs how communities think, reflect, and act [21]. A cognitive-emotional process of representations informs the othering of individuals with health conditions perceived as threatening and fearful [21].

Regarding the functions of representations, we assessed everyday practices and how communities respond to the social realities of mental disorders. Some previous studies have reported that mental health representations shape classifications and categorizations of mental disorders [26, 27]. Foster (2001) reported that undergraduate students in London clustered all mental disorders together based on unpredictability and violence, while differentiating between severe (e.g., schizophrenia, manic depression) and less severe (e.g., anxiety and depression) forms based on normality, severity, temporality, and curability [26]. Morant (2006) reported that community-based mental health professionals in the UK understood mental disorders through medical and functional representations, with the coexistence of otherness and sameness in their perceptions [27].

De-Graft Aikins (2015) observed that mental illness representations inform the differentiation and legitimization of disorders. Synthesizing evidence from Ghana, Kenya, Uganda, and Britain, she noted that disorders like depression and neurosis are classified as mild, while psychosis and schizophrenia are seen as severe [18]. Severe disorders were deemed illegitimate, carrying a high risk of destitution, while medium-severity disorders (e.g., postpartum depression) had conditional legitimacy and medium risk, and least severe disorders (e.g., dementia) had unconditional legitimacy and lower risk [18].

Mathias et al. (2018) provided insight into strengthening community mental health competence through safe social spaces. In resource-poor communities in India, safe social spaces allowed the development and incorporation of new mental health knowledge within existing frameworks [11]. Informal community conversations about mental health promoted knowledge sharing through non-hierarchical means, integrating biomedical mental health knowledge into local systems [11, 21].

Previous studies have predominantly examined mental health through a predominantly Western or expert-driven lens, often neglecting the local cultural contexts and everyday knowledge systems prevalent in resource-poor communities. For instance, while research has documented the prevalence of mental health issues and evaluated institutional responses, it frequently overlooks how community members’ own understanding and social representations of mental illness influence their perceptions and behaviours. Existing studies do not address the double-edged nature of social representations, which can both support and hinder mental health outcomes depending on their content and function. Additionally, the lack of focus on how cognitive and emotional processes contribute to mental health knowledge within these communities leaves a gap in understanding how local perceptions and stigmas shape mental health practices and interventions.

This study aims to address the inadequacies of previous research by providing a comprehensive understanding of how mental illness is perceived and managed in poor urban communities, offering practical insights for developing culturally sensitive and effective community-based mental health interventions. The objectives of this study were to: (i) explore how members of Jamestown and Usshertown communities perceive and make sense of mental illness broadly and specific mental disorders, (ii) identify the sources of their knowledge and perceptions of mental disorders, and (iii) identify how their knowledge and perceptions influence how they respond to mental illness, to inform the development of community-based mental health interventions that are culturally sensitive and effective.

Methods

Study design and data collection

Qualitative data was gathered using individual interviews (n = 17), focus group discussions (FGDs, n = 50) and situated conversations (n = 10). The individual interviews were conducted among key informants who were purposively selected, based on the practical and theoretical relevance of their identities to mental health within the communities. They included local community leaders, biomedical practitioners (community mental health nurse and over-the-counter medicine seller), faith-based healers (traditional priestess and prophet), herbal and traditional medicine practitioners, leaders of social groups, individuals with history of mental illness, and family caregivers.

The inclusion criteria were individuals above the age of 18 years, who are residents within the selected communities. The FGDs were held with conveniently selected community members and other identified social groups such as members of self-help group, male-only groups, and female-only groups within both communities. The situated conversations were opportunistic engagements with some of the community members during the fieldwork. These conversations were usually impromptu, informal, and unstructured short conversations that was held, as and when the opportunity presented itself, sometimes with one person, and other times with groups of two or three members.

Sample questions used in the interview guide included; what do you understand by mental illness?, What are the common mental health problems you have observed in this community? What do you know about these mental disorders? Where do you get members of this community get these knowledge from? How do people treat or relate to mentally ill patients and their caregivers within this community? These questions and their probes were designed to elicit content, sources and functions of the participants' mental health knowledge.

Ethics approval and consent to participate

This study was conducted in accordance with ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. Ethical clearance was obtained from the Ethics Committee for Humanities of the University of Ghana (ECH:010/18–19). Informed consent was obtained from all participants either orally or in writing, ensuring their voluntary participation. Privacy and confidentiality were strictly maintained throughout the study.

Study participants

A total of 77 participants were involved in the study (see Table 1). More than half were females (61%), majority were Ga-Adangme (77.9%), and their educational levels were low.Table 1 Sociodemographic profiles of survey respondents

Characteristics	Categories	f (%)	
Community	Jamestown	44 (57.1)	
	Usshertown	33 (42.9)	
Gender	Male	30 (39.0)	
	Female	47 (61.0)	
Ethnicity	Ga-Adangme	60 (77.9)	
	Akan	12 (15.6)	
	Ewe	5 (6.5)	
Age	20–29 years	9 (11.7)	
	30–39 years	26 (37.8)	
	40–49 years	11 (14.3)	
	50–59 years	17 (22.1)	
	60 + years	14 (18.2)	
Key informants	Lay community members	33 (42.9)	
	Self-help group members	27 (35.1)	
	Biomedical mental health practitioners	4 (5.2)	
	Traditional and faith-based practitioners	4 (5.2)	
	Caregivers	4 (5.2)	
	Patients with history of mental	3 (3.9)	
	Local community leaders	2 (2.6)	
Educational level	No education	35 (45.5)	
	Basic/Middle School	30 (39.0)	
	Secondary/SHS	5 (6.5)	
	Tertiary	7 (9.1)	

Data analysis

Thematic analysis was used, following the steps outlined by Attride-Stirling (2001), integrating it within social representation theory. The first stage involved the development of a coding framework to guide the coding of the transcripts. The second stage of the analysis involved coding the transcripts. Coding was done both deductively and inductively [28]. The deductive codes were derived from existing Ghanaian and global mental health literature [11, 12, 18]. The inductive codes were derived from context-specific issues within the communities studied. The coding process was iterative, with new inductive codes from the transcripts being added to the framework as the coding progressed.

The next stage involved developing the codes into themes. Attride-Stirling (2001) identified basic, organizing, and global themes. The basic themes were derived by drawing basic similarities and linkages between the codes. The next stage involved deriving organizing themes. At this stage, social representations analysis was drawn on to subject the basic themes to further analysis. At this level, the focus was on analysing the content, sources and functions of knowledge. The content of knowledge focused on what the participants knew about mental disorders. Sources of knowledge were also analysed focusing on the domains of knowledge where participants drew their ideas from, using cognitive polyphasia as an analytical tool. An interpretive representational framework was developed by adapting a stock of knowledge framework by de-Graft Aikins et al., (2015) to organize the themes into sources of knowledge [18]. Three stocks of knowledge have been identified in making sense of socio-psychological epidemics [29] and chronic illness [30].

Findings

The findings are presented based on; content of mental health knowledge, sources of mental health knowledge, and functions of mental health knowledge.

Content of mental health representations

Content of mental health knowledge encompassed understanding of mental illness broadly as a concept, understanding of specific mental disorders, and causal theories of mental illness within the communities.

Understanding of mental illness as broad concept

Mental illness is understood within the communities in seven thematic ways; (i) spoilt mind, (ii) bizarre behaviours, (iii) psychological struggles, (iv) emotional disruptions, (v) social struggles, (vi) socio-cultural deviations, and (vii) substance addition.

Spoilt mind

Participants used lay term ‘madness’ to mean a state of ‘spoilt’ mind. The participants used phrases such as ‘something has gone wrong in the mind’, ‘the mind is spoilt’, and ‘mind no longer working’ in their narratives: You see, the people we meet on the streets everyday…they wear dirty clothes, carrying things and talking to themselves. Their minds have spoilt [FGD Participant, Jamestown]. Another participant indicated that; mental illness is when a person’s mind has spoilt. When the mind spoils like that, you get mental illness [Key Informant, Usshertown].

Bizarre behaviours

Participants indicated that mental illness is characterized by behaviours and actions that are strange and unusual. They used phrases such as ‘unexpected behaviours’, ‘strange things’, ‘absurd things’ ‘understandable’ among others when describing behaviours or actions that people with mental illness exhibit: Mental illness makes people do strange things. They don’t know anything they do and so they just act anyhow. All these mad people we see every day on the streets, all the strange things they do, they don’t even know [FGD Participant, Usshertown].

Psychological struggles

This theme encompassed frustration, sleeplessness, excessive thinking, worry, and hopelessness: I think thinking too much is part of the mental health problems. There are people who think too much. They worry a lot. Everything and they are worried and frustrated. They are all some of the problems of the mind [Man, 52, Jamestown].

Emotional disruptions

Sadness, depression, grief, and anger were identified as dominant mood disruptions; You see, there are some people who are always unhappy. Every time you see them, you see they are sad, you don’t see any sign of happiness in them. These are all illness of the mind [Woman, 42, Jamestown]. Emotional disruptions were gendered, being seen as preserve for women and the aged, except excessive anger, which were attributed to men. A 45-year-old man who had attempted suicide said, we all know that the sadness and depression are for women. But for a man to experience it, I was even embarrassed.

Social struggles

Participants described a continuum of social struggles, ranging from from social isolation (loneliness, isolation) to social conflicts (constant fighting and insults) as constituting mental disorders: In this community, one thing you notice is that there are lot of insults. People are always insulting themselves and fighting [Male Community Leader, Jamestown]; I know some people who are constantly fighting. They are always fighting every day and fighting everyone in this community [Man, 31, Usshertown].

Socio-cultural deviations

Participants identified prostitution and homosexuality that are contrary to their socio-cultural values as part of mental disorders: All these young women who are selling their bodies for money, they all have mental problems [Woman, 37, Usshertown]. Another participant indicated; Here, so many young men are gays. All these things are part of the mental disorders [Woman, 43, Jamestown].

Understanding of specific mental disorders

Representations of top 4 mental disorders in the communities—depression, madness, epilepsy, and substance addiction, were explored.

Understanding of depression

Participants referred to depression as ‘dwɛnmɔ’ in Ga, and ‘awerɛhoɔ’ in Twi (two dominant local languages in the communities). The term ‘dwɛnmɔ’ in Ga translates to a state of persistent sadness or mental distress, while ‘awerɛhoɔ’ in Twi similarly denotes deep sorrow or emotional pain. Representation of depression depicted a disorder that ‘catches.’ A man who had attempted suicide said: depression has caught me before. That is what almost made me kill myself. A woman giving care to her sister also said: the husband left her [the sister] when she was pregnant. That is what made the depression catch her. A man living with epilepsy said: When you have this thing [epilepsy], the way you are treated alone makes you sad always, so depression catches you often. Representation of depression was also gendered. A fisherman said, the depression and other things they have mentioned are for women. For men, ours is anger. A man also said; I never knew depression can catch my mind like that as a man..

Understanding of epilepsy

They referred to epilepsy as Gbligbli in the Ga language, and ‘ɛtware’ in the Twi language. The term ‘Gbligbli’ in Ga translates to ‘struggling on ground,’ while the term ‘ɛtware’ in Twi translates to ‘circling mind.’ The dominant theme that emerged in their representation of epilepsy centered around a sense of ‘struggling on the ground’. A 33-year-old man in Jamestown said; It [epilepsy] is very disgraceful. One minute you are fine and talking or walking. The next minute you are struggling on the ground. A 38-year-old caregiver in Usshertown said; My brother experiences that sometimes and it not easy at all. When it comes, he just falls to the ground suddenly and be wobbling…hmm only God knows.

Understanding of madness

Was referred to as ‘sɛkɛ’ in the indigenous Ga language and as ‘ɛdam’ in the Twi language. The term ‘Sɛkɛ’ in Ga translates to ‘madness’ or ‘mental disturbance,’ while the term ‘ɛdam’ in Twi translates to ‘madness’ or ‘insanity.’ Representations included dirty clothes, carrying loads, exhibition of bizarre behaviours and losing touch with external reality: There are many mad people in this community. Every day you see them with dirty clothes passing by, with many loads they are carrying, and you don’t know where they are taking them to [Female Caregiver, Jamestown].

Causal theories of mental illness

Participants’ narratives revealed eight thematic causal theories; (i) supernatural, (ii) structural, (iii) psychological, (iv) sociocultural pressures, (v) relational, (vi) trauma-related, (vii) biomedical and (viii) lifestyle causes.

Supernatural

Witchcraft, juju, curses, sakawa and other evil spirits were attributed to cause severe mental illness. These causes are either bought or orchestrated by close associates, as a form of punishment, jealousy, or sheer wickedness: Oh…as for sickness in the mind, you can get it spiritually. Yes, it is very common…. through supernatural powers, one can be affected [Woman, 55, Usshertown]. Some people can throw all sort of diseases in the air and innocent people can catch it. So, madness can be thrown in the air too [Man, 61, Jamestown].

Structural

Poverty and joblessness were also identified as causes that predispose young people in the communities to mental stressors and drug use: In this community, we the young ones we don’t have jobs to do. Every day you see so many young guys roaming up and down doing nothing. Joblessness everywhere, why won’t they use drugs to reduce frustration? [Fisherman, Jamestown].

Psychological

Frustration, worry, aimlessness, and hopelessness were identified as precursors to mental illness: I will add that frustration too is a factor. When you are frustrated, sometimes you don’t even know what you are doing. So yes, frustration can make someone to be mentally ill [Trader, Usshertown].

Socio-cultural pressures

Single parenting, childlessness, unmarried at certain age, and divorce identified as risks to women’s mental health; If you are a woman here and you are not married, it is difficult living in this community. The pressure they put on you, it is as if you have decided not to get married. Sometimes I just want to leave the community but because of my mother that I am taking care of, I can’t go. Every day is stressful for me because I don’t have a husband [Woman caregiver, 39, Usshertown]. Impotence was main risk to men’s mental health: Last month, one man tried to kill himself. He drank DDT [dichloro-diphenyl-trichloroethane] but someone found out and they rushed him to the hospital. That man everyday people tease him that he is impotent. There are stories like that where people are always tease and insult men who are impotent [Fisherman, Usshertown].

Relational factors

Stress from intimate relationships, mainly husbands shirking responsibilities and social withdrawal: The women here we are always stressed. Our husbands don’t help at all. They leave all the burden of the children on you. If you complain, they will say they don’t have jobs. So, every day, the women are the ones going through all the stress [Woman, 46, Jamestown].

Biomedical

Genetics, pregnancy, childbirth, and chronic health conditions were identified: Childbirth can cause mental health problems. I know someone who after delivery suffered a mental health problem but has now recovered [Woman, 38, Usshertown]; I know that sometimes madness can run in a family. Sometimes it can be passed on to children in a family. Some families are like that [Man, 57, Jamestown].

Trauma-related

Mob justice among young men and (gang) rape against young women were identified as major trauma-related risks: There are instances where they beat somebody who is caught stealing and afterwards you will see that no, the person has started developing sickness in the mind [Man, 43, Usshertown].

Lifestyle

Smoking, alcoholism, drug use (tramadol, cocaine): Its through tramadol and some of these hard drugs. When they use the drugs too much, it can cause mental illness [Woman, 38, Usshertown]; Oh yea…. some of our friends that we used to do everything together at base, they went mad. Even now as am speaking, sometimes I see some of them, totally mad. So, I know drugs can cause madness [Self-help group member, Jamestown].

Sources of knowledge and perceptions of mental illness representations

Five stocks of knowledge emerged from their narratives: embodied, common sense, medical, cultural, and religious.

Embodied knowledge

Personal experiences of frustration, worry, aimlessness, hopelessness and suffering from some form of mental ill-health. Embodied knowledge operated at the individual and interpersonal levels. Participants who drew on lived experience at individual level included a middle-aged man who lives with depression, a young man who is addicted to substance abuse, a young lady going through depression, and a middle-aged pregnant woman experiencing pregnancy-induced psychological distress. Caregivers drew on care experience at interpersonal level; a caregiver in Usshertown who provides care to her 15-year-old brother with epilepsy, a woman providing care for her father living with mild stroke, a woman caring for her younger sister going through depression, and other participants who identified marriage, romantic relationships as sources of stress driving mental ill-health.

Common sense

Participants depended on their social observation of people with history of or living with mental disorders in the communities, or the people in the community they encounter in their daily lives to make sense of mental illness. Through social observation, the participants identified poverty and unemployment as structural drivers of poor mental health in the communities.

Scientific/medical knowledge

Participants who have been diagnosed by biomedical practitioners, as well as those with understanding of how some medical conditions can lead to mental ill-health; the man in Jamestown who attempted suicide indicated getting to know about his depression after being diagnosed in Korle-bu Teaching Hospital. The woman providing care for her father living with mild stroke also drew on knowledge from medical doctors in linking the stroke to her father’s depression. Some other participants also drew on biomedical factors such as hereditary and pregnancy in making sense of mental illness. A man in Usshertown drew on heredity in explaining causes of mental illness: I know that sometimes madness can run in a family.

Cultural knowledge

Knowledge from cultural norms, beliefs, and values about acceptable social life. This stock of knowledge operated at the structural level, drawn on to link delayed marriage and infertility to poor mental health in women.

Religious knowledge

Beliefs about supernatural as possible narratives of causes of mental illness, that are either bought or orchestrated by close associates, as a form of punishment, jealousy, or sheer wickedness. The supernatural factors identified included witchcraft, juju (using objects to charm others), curses (invoking supernatural power to inflict punishment), sakawa (combination of cyber fraud with traditional rituals like sacrifices) and other evil spirits.

Functions of mental health representations

Function of knowledge was explored at three levels – community level, relational level, and individual level. At the community level, mental illness representations shaped categorization of mental illness, mental health dialogue, care and stigma. At the relational level, mental illness representations shaped caregiving. At the level of self, mental illness representations shape self-diagnosis and self-care.

Categorization of mental illness

Mental disorders were classified in the communities based on seriousness and severity of the disorders. Three categories emerged – serious, intermediate, and non-serious disorders. Serious disorders focused on violence, strangeness, incurability, and permanence. Conditions within this category included madness, epilepsy, severe forms of drug addiction which were associated with madness. These conditions suffered othering, were seen to be intolerable and highly stigmatized. Intermediate disorders focused on conditions that do not pose apparent danger to others, are not strange to the people, even though takes longer time but are relatively curable. Conditions within this category included depression, suicidal thoughts, substance use, prostitution, and homosexuality. These conditions seem endurable within the communities and as such elicited a mixed feeling of empathy and stigma. Non-serious disorders focused on conditions that pose no threat and are caused by stressors of life and the conditions of poverty. These conditions were seen to temporary and not needing any form of treatment. Conditions within this category included various forms of psychological distress such as anxiety, excessive anger, and frustrations. The conditions were seen as normal in the communities and therefore elicited empathy.

Representations drive mental illness stigma

Representations shape stigmatization towards individuals and families affected by serious mental disorders (such as psychotic disorders and epilepsy), through a process of othering and hostile treatment. Participants indicated that the ‘mad people’ in the communities were not of them, suggesting a labelling as ‘mad strangers’: The mad people in this community come from other communities. They don’t come from here [Man, 56, Jamestown]. High levels of hostility in the form of teasing and name calling are commonly experienced by adults living with epilepsy. The man living with epilepsy said: Me, mine [epilepsy] is very serious. It comes often and it takes long before I am ok. People keep teasing me and calling me names. Every small thing then they refer to the condition. It makes you feel as if you are less of a human being. Instances of beating and other physical abuse experienced by children with severe mental disorders are common; The way some people treat mentally ill people is sad. Sometimes they beat the person. Sometimes they throw things like stones towards them just to drive them away [Woman, 45, Usshertown].

Representations drive mental health dialogue

Representations shape conversations around mental health in the communities. Mental health issues are rarely discussed in the community. There are no structured community level dialogues on mental health: I have never heard of any program that they organize in this community that is about mental health [Man, 57, Usshertown]. Mental health conversations are shrouded in secrecy, and confined within family space: In this community, if your loved one is showing signs of mental problems, people keep it to themselves at home. They only talk about it among the family members. If other people get to hear it, they spread rumours and gossip all over. So, we keep some of these things a secret, and deal with it as a family [Woman, 42, Jamestown].

Mental illness representations drive care

Representations also drive care at within family and friendship spaces. The participants suggested that individuals within the communities always protect their own: Here, people keep their family matters secret to protect their loved ones [Woman, 39, Jamestown]. Sometimes, close friends with deep interpersonal trust also protect their friends who are experiencing mental ill-health. A man who attempted suicide indicated the instrumental role that his friend played in his wellbeing: A friend of my suspected. He disturbed me till I told him what is bothering me. He informed others and they talked me out of it and helped me with some money to start something. He continued about how the said friend helped him receive the needed medical diagnosis and care: He took me to see his friend at Korle-bu and there I got to know I have depression.

Representations informs self-diagnosis and self-care

Participants look for signs of mental ill-health and act. A woman providing care to her sister indicated how her sister’s divorce experience has made her careful in her own mental health: Me I am careful. I don’t put all my hopes in a man. I do everything I need to do as a wife, but I will not let this happen to me. You can kill yourself for a man, but he will still leave you. So, whenever am getting stressed out about what my husband is doing, I always remind myself of my sister’s situation and I just stop worrying myself. A 32-year-old fisherman who uses drugs also indicated how his friends’ mental disorders is making him take actions to stop using drugs: some of our friends we used to do everything together at base, they went mad. Even now as am speaking, sometimes I see some of them, totally mad. So, I know drugs can cause madness. Now I want to stop. There is a pastor here who is helping me.

Discussion

Our study reveals that community members in Jamestown and Usshertown articulate a diverse range of mental disorders, categorizing them into mild and severe conditions. These categorizations align with biomedical classifications, yet the community members provide their own causal theories of mental disorders that span supernatural, natural, psychosocial, and structural poverty explanations. These findings demonstrate that lay mental health knowledge in these communities is more complex and nuanced than the often-held view of poor mental health understanding in such settings. The causal theories and their application are consistent with previous research conducted in Ghana [25, 31] and other African contexts [32, 33].

However, our study also uncovers nuanced differences from existing literature. First, we identified stronger gendered associations with mental health causal theories than previous studies have reported. Unlike prior research, which has not emphasized gendered dimensions, our findings indicate that depression and its associated causal theories are more commonly attributed to women, while anger and substance abuse are more often associated with men. This suggests that within these communities, gender-specific risk factors for poor mental health are prevalent.

Second, while existing studies suggest that supernatural explanations predominantly overshadow other mental health explanations in lay communities [25, 34], our research found that the communities utilize a more eclectic and fluid approach. Participants integrate a variety of knowledge sources—embodied experiences, medical/scientific, cultural, religious, and social observation—to explain mental illness risk, treatment, and care. This aligns with critical social psychological perspectives that argue for a recognition of the multifaceted and complex nature of local knowledge systems [10, 11, 13, 35].

Furthermore, our study highlights that mental health representations within these communities involve different levels of understanding that must be considered in intervention planning. At the intrapersonal level, self-knowledge is prominent, with participants drawing significantly from their own cognitive and emotional experiences. This underscores the importance of self-derived knowledge as a valid source of lay mental health understanding [21]. At the interpersonal level, cognitive-emotional processes underpin mental health representations. Fear and love drive both care and stigma, leading to secrecy surrounding mental health issues, which aligns with previous research on chronic disease experience and care in Ghanaian communities [16, 29, 36]. This secrecy undermines the creation of safe social spaces for mental health dialogue, which is crucial for fostering community mental health competence [11, 37–41].

Mental health representations also reveal a cognitive-emotional process shaped by fear and supernatural beliefs, which drives the hierarchical differentiation of mental disorders. This differentiation results in a coexistence of stigma and empathy depending on the severity of the condition and the identity of the sufferer. Severe and unfamiliar disorders are often deemed illegitimate, while known disorders are granted varying degrees of legitimacy. These findings offer insights into how mental disorders are perceived in terms of social care and destitution risks. Severe conditions like madness, epilepsy, and severe drug addiction face stigma and illegitimacy, whereas conditions like depression, suicide attempts, and substance use receive conditional legitimacy, and milder issues like psychological distress and excessive worry receive unconditional legitimacy.

Our findings challenge the mainstream research that suggests binary (positive or negative) attitudes towards mental health in communities [42], and the notion that poor communities hold predominantly negative views [36, 42]. Instead, our study reveals a complex interplay of stigma and care, demonstrating that community attitudes are more nuanced and context dependent. Individuals with severe conditions from outside the communities are stigmatized as 'mad strangers,' while those with conditions deemed less severe or familiar are more likely to receive care, albeit with some degree of distancing.

Conclusion

We explored how members of two resource poor urban communities in Ghana make sense of mental illness, identify the sources of their knowledge, and understand how these influence their responses to mental illness. Our findings demonstrate that lay communities possess complex and nuanced knowledge about mental health. We identified that mental illness stigma and empathy co-exist within these poor communities, providing empirical evidence that social representations of mental illness contain both symbolic resources and risks. These findings underscore the necessity for fundamental awareness of the dynamic and multifaceted nature of community social spaces where mental health dialogues are formed, shaped, and contested. Such insights should guide the development of interventions that address both social and institutional care needs, ensuring they are culturally sensitive and effective, to foster caring communities that are better equipped to support mental health and well-being.

Author contributions

Agyei conducted the study as part of his doctoral project. The project was supervised by de-Graft Aikins, with co-supervision from Osei-Tutu and Annor.

Data availability

The data for the study are available from the authors upon reasonable request.

Declarations

Competing interests

The authors declare that there are no actual or potential conflict of interests regarding research, authorship, and publication of this article.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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References

1. Bayetti C Bakhshi P Davar B Khemka GC Kothari P Kumar M Jain S Critical reflections on the concept and impact of “scaling up” in Global Mental Health Transcul Psychiatry 2023 60 3 602 609 10.1177/13634615231183928
Bayetti C, Bakhshi P, Davar B, Khemka GC, Kothari P, Kumar M, Jain S. Critical reflections on the concept and impact of “scaling up” in Global Mental Health. Transcul Psychiatry. 2023;60(3):602–9.10.1177/13634615231183928
2. Patel V Farmer PE The moral case for global mental health delivery Lancet (London, England) 2020 395 10218 108 10.1016/S0140-6736(19)33149-6 31950898
Patel V, Farmer PE. The moral case for global mental health delivery. Lancet (London, England). 2020;395(10218):108.31950898 10.1016/S0140-6736(19)33149-6
3. Omigbodun OO Ryan GK Fasoranti B Chibanda D Esliker R Sefasi A Eaton J Reprioritising global mental health: psychoses in sub-Saharan Africa Int J Mental Health Syst 2023 17 1 1 14 10.1186/s13033-023-00574-x
Omigbodun OO, Ryan GK, Fasoranti B, Chibanda D, Esliker R, Sefasi A, Eaton J. Reprioritising global mental health: psychoses in sub-Saharan Africa. Int J Mental Health Syst. 2023;17(1):1–14.10.1186/s13033-023-00574-x
4. Saxena S Kestel D Sunkel C London E Horton R Patel V Swaminathan S Countdown global mental health 2030 Lancet 2019 393 10174 858 859 10.1016/S0140-6736(19)30424-6 30799060
Saxena S, Kestel D, Sunkel C, London E, Horton R, Patel V, Swaminathan S. Countdown global mental health 2030. Lancet. 2019;393(10174):858–9.30799060 10.1016/S0140-6736(19)30424-6
5. Navario PS Upadhaya N Hall BJ Yang LH Global mental health among marginalized communities in pandemic emergencies Front Public Health 2023 10.3389/fpubh.2023.1249575 37546296
Navario PS, Upadhaya N, Hall BJ, Yang LH. Global mental health among marginalized communities in pandemic emergencies. Front Public Health. 2023. 10.3389/fpubh.2023.1249575.37546296 10.3389/fpubh.2023.1249575
6. Anum A Washington-Nortey M Dzokoto V Strategic planning in LAMIC mental health research: A Ghana case study Int J Mental Health 2020 10.1080/00207411.2020.1719621
Anum A, Washington-Nortey M, Dzokoto V. Strategic planning in LAMIC mental health research: A Ghana case study. Int J Mental Health. 2020. 10.1080/00207411.2020.1719621.10.1080/00207411.2020.1719621
7. Read UM Doku VCK Mental health research in Ghana: a literature review Ghana Med J 2012 46 2 29 38 23661815
Read UM, Doku VCK. Mental health research in Ghana: a literature review. Ghana Med J. 2012;46(2):29–38.23661815
8. Mwangi G Sakyi L Ayuurebobi K Lund C Weobong B Mental health and disability research in Ghana: a rapid review Pan Afr Med J 2023 10.11604/pamj.2023.45.166.38808 37900204
Mwangi G, Sakyi L, Ayuurebobi K, Lund C, Weobong B. Mental health and disability research in Ghana: a rapid review. Pan Afr Med J. 2023. 10.11604/pamj.2023.45.166.38808.37900204 10.11604/pamj.2023.45.166.38808
9. Ofori-Atta A Mirzoev T Mensah-Kufuor A Osei A Dzadey A Armah-Aloo K Atweam K Experience of strengthening the mental health information system in Ghana’s three psychiatric hospitals Changing Trends Mental Health Care and Res Ghana 2015 3 13
Ofori-Atta A, Mirzoev T, Mensah-Kufuor A, Osei A, Dzadey A, Armah-Aloo K, Atweam K. Experience of strengthening the mental health information system in Ghana’s three psychiatric hospitals. Changing Trends Mental Health Care and Res Ghana. 2015;3:13.
10. Burgess RA Jain S Petersen I Lund C Social interventions: a new era for global mental health? Lancet Psychiatry 2020 7 2 118 10.1016/S2215-0366(19)30397-9 31653556
Burgess RA, Jain S, Petersen I, Lund C. Social interventions: a new era for global mental health? Lancet Psychiatry. 2020;7(2):118.31653556 10.1016/S2215-0366(19)30397-9
11. Mathias K Mathias J Goicolea I Kermode M Strengthening community mental health competence—a realist informed case study from Dehradun, North India Health Soc Care Community 2018 26 1 179 190 10.1111/hsc.12498
Mathias K, Mathias J, Goicolea I, Kermode M. Strengthening community mental health competence—a realist informed case study from Dehradun, North India. Health Soc Care Community. 2018;26(1):179–90.10.1111/hsc.12498
12. Campbell C Burgess R The role of communities in advancing the goals of the Movement for Global Mental Health Transcult Psychiatry 2012 49 3–4 379 395 10.1177/1363461512454643 23008350
Campbell C, Burgess R. The role of communities in advancing the goals of the Movement for Global Mental Health. Transcult Psychiatry. 2012;49(3–4):379–95.23008350 10.1177/1363461512454643
13. de-Graft Aikins A, Kushitor M, Boatemaa S, Olutobi S, Asante PY, Sakyi L, Agyei F, Koram K, Ogedegbe G. Building cardiovascular disease (CVD) competence in an urban poor Ghanaian community: a social psychology of participation approach. J Commun Appl Soc Psychol, 2020;30(4): 419-440. 10.1002/casp.2447
14. Patterson KD. Health in urban Ghana: The case of Accra 1900–1940 [1]. Soc SciMed 1979;13(4):251–268.
15. Greif MJ Dodoo FNA How community physical, structural, and social stressors relate to mental health in the urban slums of Accra, Ghana Health Place 2015 33 57 66 10.1016/j.healthplace.2015.02.002 25754264
Greif MJ, Dodoo FNA. How community physical, structural, and social stressors relate to mental health in the urban slums of Accra, Ghana. Health Place. 2015;33:57–66.25754264 10.1016/j.healthplace.2015.02.002
16. Kushitor MK Peterson MB Asante PY Dodoo ND Boatemaa S Awuah RB Aikins ADG Community and individual sense of trust and psychological distress among the urban poor in Accra, Ghana PLoS ONE 2018 13 9 e0202818 10.1371/journal.pone.0202818 30261067
Kushitor MK, Peterson MB, Asante PY, Dodoo ND, Boatemaa S, Awuah RB, Aikins ADG. Community and individual sense of trust and psychological distress among the urban poor in Accra, Ghana. PLoS ONE. 2018;13(9):e0202818.30261067 10.1371/journal.pone.0202818
17. Campbell C Jovchelovitch S Health, community and development: Towards a social psychology of participation J Commun Appl Soc Psychol 2000 10 4 255 270 10.1002/1099-1298(200007/08)10:4<255::AID-CASP582>3.0.CO;2-M
Campbell C, Jovchelovitch S. Health, community and development: Towards a social psychology of participation. J Commun Appl Soc Psychol. 2000;10(4):255–70.10.1002/1099-1298(200007/08)10:4<255::AID-CASP582>3.0.CO;2-M
18. de-Graft Aikins, A. Akyeampong E Hill GA Kleinman A Mental illness and destitution in Ghana: a social psychological perspective The culture of mental illness and psychiatric practice in Africa 2015 Bloomington Indiana University Press 112 143
de-Graft Aikins, A. Mental illness and destitution in Ghana: a social psychological perspective. In: Akyeampong E, Hill GA, Kleinman A, editors. The culture of mental illness and psychiatric practice in Africa. Bloomington: Indiana University Press; 2015. p. 112–43.
19. Jovchelovitch S Knowledge in context: representations, community and culture 2007 London Routledge
Jovchelovitch S. Knowledge in context: representations, community and culture. London: Routledge; 2007.
20. Sammut GE Andreouli EE Gaskell GE Valsiner JE The Cambridge handbook of social representations 2015 Cambridge Cambridge University Press
Sammut GE, Andreouli EE, Gaskell GE, Valsiner JE. The Cambridge handbook of social representations. Cambridge: Cambridge University Press; 2015.
21. de-Graft Aikins, A. Familiarising the unfamiliar: cognitive polyphasia, emotions and the creation of social representations Papers Soc Represent 2012 21 1 7 1
de-Graft Aikins, A. Familiarising the unfamiliar: cognitive polyphasia, emotions and the creation of social representations. Papers Soc Represent. 2012;21(1):7–1.
22. Adombiri-Naba S. Knowledge and Perceptions of Mental Disorders among Adualts in Zuarungu and Sumbrungu Communities, in Northern Ghana (Unpublished Master’s Thesis, University of Ghana). 2013.
23. Adeeku F. Perceptions and attitudes towards mental illness: the case of pantang community (Unpublished Master’s Thesis, University of Ghana). 2015
24. Benedicto M Mndeme E Mwakagile DS Mwansisya T Community knowledge, attitudes and perception towards mental illness in Dodoma Municipality, Tanzania ARC J Public Health Community Med 2016 1 3 10 18
Benedicto M, Mndeme E, Mwakagile DS, Mwansisya T. Community knowledge, attitudes and perception towards mental illness in Dodoma Municipality, Tanzania. ARC J Public Health Community Med. 2016;1(3):10–8.
25. Opare-Henaku A Utsey SO Culturally prescribed beliefs about mental illness among the Akan of Ghana Transcult Psychiatry 2017 54 4 502 522 10.1177/1363461517708120 28612682
Opare-Henaku A, Utsey SO. Culturally prescribed beliefs about mental illness among the Akan of Ghana. Transcult Psychiatry. 2017;54(4):502–22.28612682 10.1177/1363461517708120
26. Foster J Unification and differentiation: a study of the social representations of mental illness Papers Soc Represent 2001 10 3 1
Foster J. Unification and differentiation: a study of the social representations of mental illness. Papers Soc Represent. 2001;10:3–1.
27. Morant N Social representations and professional knowledge: the representation of mental illness among mental health practitioners Br J Soc Psychol 2006 45 4 817 838 10.1348/014466605X81036 17393882
Morant N. Social representations and professional knowledge: the representation of mental illness among mental health practitioners. Br J Soc Psychol. 2006;45(4):817–38.17393882 10.1348/014466605X81036
28. Attride-Stirling J Thematic networks: an analytic tool for qualitative research Qual Res 2001 1 3 385 405 10.1177/146879410100100307
Attride-Stirling J. Thematic networks: an analytic tool for qualitative research. Qual Res. 2001;1(3):385–405.10.1177/146879410100100307
29. de-Graft Aikins A, Dzokoto VA, Yevak E. Mass media constructions of ‘socio-psychological epidemics’ in sub-Saharan Africa: the case of genital shrinking in 11 countries. Public Understand Sci, 2015;24(8):988-1006.
30. de-Graft Aikins A, Dodoo F, Awuah RB, Owusu-Dabo E, Addo J, Nicolaou, M., Agyemang C. Knowledge and perceptions of type 2 diabetes among Ghanaian migrants in three European countries and Ghanaians in rural and urban Ghana: The RODAM qualitative study. PloS One, 2019;14(4):e0214501.
31. Read UM Nyame S “It Is Left to Me and My God”: Precarity, responsibility, and social change in family care for people with mental illness in Ghana Africa Today 2019 65 3 3 28 10.2979/africatoday.65.3.02
Read UM, Nyame S. “It Is Left to Me and My God”: Precarity, responsibility, and social change in family care for people with mental illness in Ghana. Africa Today. 2019;65(3):3–28.10.2979/africatoday.65.3.02
32. Egbe CO Brooke-Sumner C Kathree T Selohilwe O Thornicroft G Petersen I Psychiatric stigma and discrimination in South Africa: perspectives from key stakeholders BMC Psychiatry 2014 14 1 14 10.1186/1471-244X-14-191
Egbe CO, Brooke-Sumner C, Kathree T, Selohilwe O, Thornicroft G, Petersen I. Psychiatric stigma and discrimination in South Africa: perspectives from key stakeholders. BMC Psychiatry. 2014;14:1–14.10.1186/1471-244X-14-191
33. Johnson JG First MB Block S Vanderwerker LC Zivin K Zhang B Prigerson HG Stigmatization and receptivity to mental health services among recently bereaved adults Death Stud 2009 33 8 691 711 10.1080/07481180903070392 19697482
Johnson JG, First MB, Block S, Vanderwerker LC, Zivin K, Zhang B, Prigerson HG. Stigmatization and receptivity to mental health services among recently bereaved adults. Death Stud. 2009;33(8):691–711.19697482 10.1080/07481180903070392
34. Benti M Ebrahim J Awoke T Yohannis Z Bedaso A Community perception towards mental illness among residents of Gimbi town Western Ethiopia Psychiatry J 2016 10.1155/2016/6740346 27840817
Benti M, Ebrahim J, Awoke T, Yohannis Z, Bedaso A. Community perception towards mental illness among residents of Gimbi town Western Ethiopia. Psychiatry J. 2016. 10.1155/2016/6740346.27840817 10.1155/2016/6740346
35. Aveling EL Jovchelovitch S Partnerships as knowledge encounters: a psychosocial theory of partnerships for health and community development J Health Psychol 2014 19 1 34 45 10.1177/1359105313509733 24195915
Aveling EL, Jovchelovitch S. Partnerships as knowledge encounters: a psychosocial theory of partnerships for health and community development. J Health Psychol. 2014;19(1):34–45.24195915 10.1177/1359105313509733
36. Adjei P Akpalu A Laryea R Nkromah K Sottie C Ohene S Osei A Beliefs on epilepsy in Northern Ghana Epilepsy Behav 2013 29 2 316 321 10.1016/j.yebeh.2013.07.034 24025488
Adjei P, Akpalu A, Laryea R, Nkromah K, Sottie C, Ohene S, Osei A. Beliefs on epilepsy in Northern Ghana. Epilepsy Behav. 2013;29(2):316–21.24025488 10.1016/j.yebeh.2013.07.034
37. Burgess RA Jain S Petersen I Lund C Social interventions: a new era for global mental health? Lancet Psychiatry 2019 6 10 793 876 31544754
Burgess RA, Jain S, Petersen I, Lund C. Social interventions: a new era for global mental health? Lancet Psychiatry. 2019;6(10):793–876.31544754
38. Burgess R Campbell C Contextualising women's mental distress and coping strategies in the time of AIDS: a rural South African case study Transcult Psychiatry 2014 51 6 875 903 10.1177/1363461514526925 24670517
Burgess R, Campbell C. Contextualising women’s mental distress and coping strategies in the time of AIDS: a rural South African case study. Transcult Psychiatry. 2014;51(6):875–903.24670517 10.1177/1363461514526925
39. Burgess RA, Mathias K. Community mental health competencies: a new vision for global mental health. In: The Palgrave Handbook of Sociocultural Perspectives on Global Mental Health (pp. 211–235). Palgrave Macmillan, London. 2017.
40. Mahr IL Campbell C Twenty years post-genocide: the creation of mental health competence among rwandan survivors through community-based healing workshops J Commun Appl Soc Psychol 2016 26 4 291 306 10.1002/casp.2263
Mahr IL, Campbell C. Twenty years post-genocide: the creation of mental health competence among rwandan survivors through community-based healing workshops. J Commun Appl Soc Psychol. 2016;26(4):291–306.10.1002/casp.2263
41. Campbell C Nhamo M Scott K Madanhire C Nyamukapa C Skovdal M Gregson S The role of community conversations in facilitating local HIV competence: case study from rural Zimbabwe BMC Public Health 2013 13 1 354 10.1186/1471-2458-13-354 23590640
Campbell C, Nhamo M, Scott K, Madanhire C, Nyamukapa C, Skovdal M, Gregson S. The role of community conversations in facilitating local HIV competence: case study from rural Zimbabwe. BMC Public Health. 2013;13(1):354.23590640 10.1186/1471-2458-13-354
42. Stull LG McConnell H McGrew J Salyers MP Explicit and implicit stigma of mental illness as predictors of recovery attitudes of assertive community treatment practitioners Isr J Psychiatry Relat Sci 2017 54 1 31 28857756
Stull LG, McConnell H, McGrew J, Salyers MP. Explicit and implicit stigma of mental illness as predictors of recovery attitudes of assertive community treatment practitioners. Isr J Psychiatry Relat Sci. 2017;54(1):31.28857756
43. Baatiema L Strachan DL Okoibhole LO Kretchy IA Kushitor M Awuah RB the CARE Diabetes Team Contextual awareness, response and evaluation (CARE) of diabetes in poor urban communities in Ghana: the CARE diabetes project qualitative study protocol Glob Health Action 2024 17 1 2364498 10.1080/16549716.2024.2364498 39011874
Baatiema L, Strachan DL, Okoibhole LO, Kretchy IA, Kushitor M, Awuah RB, the CARE Diabetes Team. Contextual awareness, response and evaluation (CARE) of diabetes in poor urban communities in Ghana: the CARE diabetes project qualitative study protocol. Glob Health Action. 2024;17(1):2364498.39011874 10.1080/16549716.2024.2364498
44. Howarth C A social representation is not a quiet thing: exploring the critical potential of social representations theory Br J Soc Psychol 2006 45 1 65 86 10.1348/014466605X43777 16573873
Howarth C. A social representation is not a quiet thing: exploring the critical potential of social representations theory. Br J Soc Psychol. 2006;45(1):65–86.16573873 10.1348/014466605X43777
45. Moscovici S. Social representations: essays in social psychology. Nyu Press. 2001
