Nursing Research paper Assignment on Coping with personal care and stigma: experiences of persons living with schizophrenia

RESEARCH
Coping with personal care
and stigma: experiences of persons living
with schizophrenia
Isaac Tetteh Commey1*, Jerry Paul K. Ninnoni1 and Evelyn Asamoah Ampofo2
Abstract
Living with a chronic mental condition such as schizophrenia impacts significantly on the individual’s social functioning and activities of daily living. However, there is little data on the experiences of people living with schizophrenia,
especially in Ghana regarding personal care and stigma. This study explored qualitatively the experiences of people
living with schizophrenia in Southern Ghana. Nine people with schizophrenia were purposively recruited for this
study. Data were collected using semi-structured interviews and analysed thematically following a descriptive phenomenological data analysis framework. The study revealed that people with schizophrenia are capable of performing
some activities of daily living, such as maintenance of personal and environmental hygiene and medication management. However, some participants narrated their experiences of stigma and thus, resorted to certain strategies such as
spirituality, medication adherence and mental fortitude to cope with schizophrenia. In conclusion, it was evident that
people with schizophrenia, in their lucid intervals, can undertake various activities of daily living, including personal
care, however, living with schizophrenia impacts on psychological well-being enormously, and thus, education, counselling, and client adherence to the treatment may improve quality of life.
Keywords: Ghana, Personal care, Schizophrenia, Stigma, Coping strategies
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Background
Schizophrenia is a chronic mental illness that afects
the person psychosocial and economic well-being with
signifcant burdens on their families [1]. Schizophrenia is characterised by difculties in social contact in
everyday life and limits the individual’s ability to participate in the activities of daily life [2]. Persons living
with schizophrenia have reported challenges including
stigma and difculty with community integration that
afect their physical and psychological wellbeing. Schizophrenia afects over 21 million people worldwide [3].
Understanding schizophrenia has signifcant implications for health service planning and delivery [4]. Mental illness, mainly schizophrenia, presents a severe health
care problem in many African countries; however, limited information exists that explores how the condition
impacts on the individual’s life due to a lack of data and
poor infrastructure [5]. Schizophrenia is reported as the
most diagnosed mental health condition in Ghana [6].
It is claimed that one of the outstanding manifestations of schizophrenia is a disorder of volition [7], where
the individuals fnd it very challenging to maintain their
daily living activities. Tis contributes to why people
with schizophrenia are often seen in tattered clothes with
unkempt hair in our communities. Personal care refects
the individuals’ activities of daily living [8]. Tis may
include personal tasks to the individual, such as eliminating, communication, maintaining a safe environment,
Open Access
*Correspondence: isaac.commey@ucc.edu.gh
1
Department of Mental Health, School of Nursing and Midwifery, College
of Health and Allied Sciences, University of Cape Coast, PMB, Cape Coast,
Ghana
Full list of author information is available at the end of the article
Commey et al. BMC Nursing (2022) 21:107 Page 2 of 9
and mobilising. However, most people with schizophrenia may require support to perform daily living activities [9]. In addition, self-care theory portrays individuals
as autonomous and suggests that self-care is enacted to
regulate the functioning and maintain the health and
well-being of people [10–13]. Te ability of a person to
perform self-care is afected by essential conditioning
factors that include the health state of the individual,
development state, sociocultural orientation, health care
system, family system, patterns of living, environment,
and resources [11]. Personal care becomes a challenge
to individuals if the condition is not well controlled, and
many of them are cared for by their family members and
signifcant others [12].
Furthermore, studies suggest that people with schizophrenia can engage in daily activities such as washing
clothes and utensils, sweeping their compounds, taking
their baths, general maintenance of personal hygiene,
and cooking for themselves and their families [13]. Other
studies argue that people with schizophrenia are also
capable of engaging in meaningful jobs and contributing to society [14–17]. However, in sub-Sahara Africa
including Ghana, people with schizophrenia face enormous stigma, and as a result, they receive limited support
leading to poor physical and psychological wellbeing [18,
19]. Tere is a widening gap in the caregiving literature
in Ghana. It is argued that the service user is the primary
source of any information regarding their lived experiences and the best person to defne recovery [20–24] however, no published study investigated the experiences
of people with schizophrenia regarding personal care and
stigma in Ghana.
It is argued that one of the most common variables
impacting psychological well-being among people with
schizophrenia is stigma [25, 26]. Stigma has widely been
reported among people living with schizophrenia [26].
Tis phenomenon seriously limits and reduces the person to a lower social rank [26]. People with schizophrenia
are often seen as diferent from others and are therefore
labelled with negative references, which draws them away
from the public and limits community integration [27,
28]. One’s ability to cope with negative evaluations and
labelling whilst living with schizophrenia is a crucial indicator of the quality of care. Stigma is known to present
at several levels: public stigma; self-stigma; stigma by
association; structural stigma as the legitimatization and
perpetuation of a stigmatized status by society’s institutions and ideological systems [29]. Following the work of
Gofman, stigma has been categorised into three dimensions: i) stereotypes are beliefs about a person according
to his/her group membership ii) prejudices are attitudes
and afective components felt against a person according
to his/her group membership and iii) discrimination is
behavioural reactions against a person according to his/
her group membership [30].
Tere is considerable evidence showing that people
with schizophrenia have been deprived of context-specifc needs and lack a comprehensive assessment of their
coping strategies adopted in coping with the condition
and the related stigma [31]. Terefore, it is imperative to
know the subjective experiences of suferers who have
lived with the condition. Tis is because, studies that have
focused primarily on the stories of people living with
schizophrenia on coping with personal care and stigma
are lacking in Ghana. Furthermore, there is no clear policy guidelines for the management of people with schizophrenia in Ghana, and people with schizophrenia are
often seen wonder about in the neighborhood with no
shelter. Terefore, it is unclear what the experiences of
people with schizophrenia are in Ghana to inform policies. Terefore, this study seeks to contribute to knowledge by addressing three specifc issues comprising the
context-specifc experiences of personal care, stigma and
the coping strategies among individuals living with schizophrenia in southern Ghana.
Methods
Study design and population
Tis exploratory-qualitative study adopted the Husserlian descriptive phenomenological design for the study
due to the sensitive nature of the subject matter and the
need to break new grounds regarding the phenomena. In
addition, descriptive phenomenology is mainly employed
in qualitative research when little is known about a phenomenon. It focuses on the lived experiences of people
with schizophrenia regarding personal care and stigma.
Te target population for the study included all persons
residing within the Cape Coast Metropolis with schizophrenia who had once been diagnosed and managed at
the mainstream psychiatric hospital. Te Cape Coast is
one of the two regions in Ghana with a public psychiatric
hospital known as the Ankaful Psychiatric Hospital. It is
the only psychiatric hospital in central Ghana that provides mental health services to persons living with severe
mental illness on an outpatient and inpatient basis.
Te purposive sampling technique was used to access
nine (9) individuals with schizophrenia when it was
observed that no signifcant new information was being
gathered from participants regarding the phenomena
[32]. Participants for the study included people diagnosed
with schizophrenia who were within lucidity (the period
between recovery and relapse). Data were collected
using a semi-structured interview guide. Study participants were interviewed face to face at designated areas
predetermined by the researcher and participants. All
participants were contacted through telephone calls to
Commey et al. BMC Nursing (2022) 21:107 Page 3 of 9
explain the study in detail to them. Each participant who
agreed to be part of the study was given a participant’s
information and consent form to read and sign prior to
the study. Tis form clearly spelt out the rules of engagement for the study, including the benefts which the study
is anticipated to bring to persons living with schizophrenia. Tose who had literacy challenge and therefore could
not read and sign had the content read to them by the
researchers after which they signed or thumb printed.
Participants duly read and signed the consent forms willingly. To maintain confdentiality and anonymity, each
participant chose a pseudonym during the interview and
was used throughout the study. In essence, the names of
participants in the manuscript are not the real names of
persons who took part of the study.
Te date, time and place for the interviews were negotiated with the participants. A period of one month
(25th May – 22nd June, 2020) was used for the data collection exercise observing all appropriate Covid-19 preventive protocols, such as social distancing, wearing
of nose masks, handwashing and hand sanitising. Te
study was granted ethical clearance by the Institutional
Review Board of the University of Cape Coast (UCCIRB/
CHAS/2020/37) after demonstrating how conditions of
informed consent, anonymity, privacy and confdentiality will be maintained. Guidelines governing ethical considerations in research and protection of the identities of
persons spelt out by the Institutional Review Board of the
University of Cape Coast were duly adhered to at each
stage of the study.
Inclusion criteria
Participants who met the following criteria were included
in the study:
• Persons lives Cape Coast Metropolis for at least one
year and with a diagnosis of schizophrenia.
• Te person speaks English fuent or any Akan language.
• Adults aged at least 18 years
• Te person can give informed consent.
Exclusion criteria
Participants who met the following criteria were not
included in the study:
• All persons in the Cape Coast Metropolis living with
schizophrenia who were experiencing active psychotic signs and symptoms of the condition and unable to consent
• Persons less than 18 years were excluded
• Inability to speak the English language or a Ghanaian
language
Data analysis
All interviews were transcribed verbatim. Te researcher
familiarised himself by submerging in the data and carefully reading each transcript thoroughly several times
to understand. Signifcant statements directly relevant
to the phenomenon under investigation were identifed.
Furthermore, meanings pertinent to the phenomenon
were then identifed. Formulated meanings were then
clustered into standard pieces across all participants’
accounts that were signifcant to the phenomenon under
study. A complete and inclusive defnition of the phenomenon was written, incorporating all the themes produced under step four. Te researcher then condensed
the detailed description down to a short, dense statement that captured just those aspects deemed essential
to the design of the phenomenon. Finally, verifcation of
the fundamental structure was done. Tis is where the
entire structure statement (report) was returned to all
study participants to ask whether it captured their experience. Tis was done via telephone calls and was duly
recorded with the consent of the participants. Earlier
steps in the analysis were modifed in light of this feedback. Issues other than the phenomenon of concern were
not factored into the report because the focus was on the
experiences of living with schizophrenia. Figure 1 below
demonstrates the step by step approach employed in the
analysis of data.
Results
Key fndings of the study have been presented in this
section and discussed with existing literature. Table 1
under this section shows the demographic data on study
participants.
It can be noted from the table that, out of nine participants, seven were single while two were married. On
the age range of participants, the data revealed that one
of the participants was in the age range of 20 -30 years.
Tis was followed by three who were in the age range of
31–40 years. Also, the remaining fve of the participants
were in the age range of 41 years and above. Concerning
the gender of the participants, six were females whilst
three were males.
As part of the demographic characteristics of the
respondents, the religious afliation of the respondents
was considered. Again, eight of the participants were
Christians except one who declared that he was a Muslim. For the educational background of the respondents, two completed junior high school, four senior high
school and three had tertiary education. Te study also
Commey et al. BMC Nursing (2022) 21:107 Page 4 of 9
took into consideration the number of years respondents
had lived with the diagnosis of schizophrenia. Five of the
respondents had experienced the condition for 21 years
and above. Two respondents had lived with schizophrenia for 11 to 20 years whilst the remaining two were diagnosed with schizophrenia within a period of 1 to10 years
ago.
Summary of key qualitative fndings
Analysis of the interviews data generated two main
themes which describe participants experiences regarding schizophrenia. Tese themes include; personal care;
Stigma and coping strategies which include mental fortitude, Spirituality and adherence to medication.
Personal care: activities of daily living
Study participants expressed their views on sticking to
daily living activities to live with the condition. Participants disclosed that having lived with schizophrenia for
several years, they have accepted that the condition is
part of them and something to live with. Tey indicated
that they could take care of their daily activities such
as meeting their personal hygiene needs, nutritional
demands, and sleep despite their condition. Te account
shows that participants could go about their normal
activities of daily living without any concerns.
“……I have been living with this condition for several
years without any interference in the discharge of
my daily activities both at home and when I go to
school to teach. I do my things as expected of every
human being. I maintain my home very well before
going to school. I teach the children, as usual, interact with colleague staf in the school, and carry out
my responsibilities as the head of my family. I enjoy
my sleep and always take care of myself very well.
It is only when the condition comes that I see some
changes. (Terry, 58years; 25th May 2020).
Another participant also added that:
…… “daily activities have never been my problem.
When you came you saw me washing; I just fnished
cooking for my parents. Tey are inside eating. I will
take my lunch after washing. I enjoy doing house
chores. Tey keep me active and strong” (Favour, 30
years; 28th May 2020).
Fig. 1 Step by step approach to data analysis
Commey et al. BMC Nursing (2022) 21:107 Page 5 of 9
Stigma
Respondents reported that stigma is one signifcant
negative experience they have had to cope with ever
since they were diagnosed with this condition. Tey
indicated that they have been at the receiving end of
name-calling, labelling and neglect at the hands of people. Study participants believed that people in their
community (public concern) are the ones who stigmatise them. It was clear from participants’ accounts that
all these negative experiences did not come from family members. Tey indicated that the family members
did not mistreat them at all. However, people who lived
outside their homes were the ones who negatively evaluated them most often. Participants pointed out that
stigmatisation is associated with schizophrenia just like
any other chronic mental illness, which suferers cannot avoid once they live with the disease. One of the
powerful stories on this subject matter can be found
below:
“…….. this is my major challenge associated with
this condition…over the years, I have come to recognise that people don’t understand my condition…… they point fngers at me, call me all sorts
of names and say negative things about me. One
day, I stopped a car on my way to church, and just
when I was about to board the car, one woman
around the place quickly ran to inform the driver
and the people in the car that I was a mad person,
so the driver should not pick me. I had to walk to
church that day. Tis sometimes makes me angry,
anxious, and sad.” (Beauty, 44 years; 22nd May
2020).
Coping strategies
Mental fortitude
Te data revealed that respondents adopt bold measures
in coping with schizophrenia despite the challenges associated with the condition. Tese measures enable them
to maintain some level of resilience. Study participants
verbalised that the strategy they adopt most often to
cope with their illness is deliberately trying to take their
minds of it. In other words, participants could prevent
possible schizophrenic relapse by avoiding excessive
thinking or worrying about their situation and its associated impact on their living conditions. A participant, for
example, believes that accepting his condition and refusing to worry about it is a way to cope. “Te negative things
associated with this illness do not worry me. I have come
to accept that schizophrenia has become part of me, so I
don’t bother myself with negative things. Te more I think
about it; the more my condition gets worse….” (Godswill,
49 years: 19th June 2020).
Adherence (medical care)
As part of the maintenance of personal care, respondents
afrmed that they adopted some medical measures to
help them stay healthy. Tese participants asserted that
one of the major coping strategies had been medication
adherence. Participants adhered to the treatment plan
at the mental health facilities as part of their care. Tey
explained that failure to comply with the treatment plan
results in schizophrenic relapse.
“… Te medication has helped me a lot; it is my food.
I do not skip my medication because it has saved my
life. Despite the bad side efects associated with the
medication at times, I still think it is what keeps me
from experiencing a relapse.” (Forgive, 38 years; 9th
June 2020).
Spiritual well‑being
Participants expressed that their belief in God who keep
them going. Tis, according to them, sticking strictly to
spiritual principles helps them gain some sense of hope
and encouragement and thus prevents them from experiencing a relapse. In other words, their religious faith
has been a source of hope in keeping them healthy. Tey
indicated that their faith in God and spiritual activities in
Table 1 Results of demographic data
Demographic Information Frequency
Marital status
Married 2
Single 7
Age (in years)
20–30 1
31–40 3
41and above 5
Gender
Male 3
Female 6
Religion
Christianity 8
Islamic 1
Educational background
Junior High 2
Senior High 4
Tertiary 3
No. of Years with Schizophrenia
1–10 2
11–20 2
21 and above 5
Commey et al. BMC Nursing (2022) 21:107 Page 6 of 9
their places of fellowship give them some sense of relief
and increase their understanding of well-being. Remain
resilient.
“……I am a good Christian. I have faith in God,
which has been my source of hope all these years.
Prayer meetings and church activities take place at
my church to take my mind of this illness and give
me some form of relief. I believe I have not sufered
from relapse all this while because of my constant
church involvement.” (Shallom, 19 years, 20th June
2020)
“…. Although I take my medications daily as
instructed, I believe Allah is the true healer who
can heal me of this condition. Whenever I go to the
mosque and meet my fellow Muslim brothers for
prayers, I experience great joy and relief. I feel like
I don’t have any problem in my life anytime I fnd
myself amid Muslim brothers and sisters.” (Bella,
43years, 22nd June 2020)
Discussion
Tis study explored the experiences of persons living
with schizophrenia in Cape Coast, Ghana. It has brought
to the fore, personal care experiences, stigma and coping
strategies adopted by persons living with schizophrenia.
Before the study, there was no empirical literature regarding the subjective experiences of persons with schizophrenia in Cape Coast (Southern Ghana). Tis study
went further to explore personal and subjective issues of
concern in the lives of individuals with schizophrenia. It
explored critical issues centred on how they have taken
care of themselves and coped with schizophrenia-related
stigma despite living with this illness.
Tere is empirical evidence on the coping strategies
adopted by care givers of individuals with schizophrenia
[33]. However, literature on the coping strategies of individuals who have lived with schizophrenia over a period
of time in Ghana is hard to fnd. Participants in this current study pointed out some personal care experiences
whilst living with the condition.
Regarding the maintenance of activities of daily living, the fndings showed that participants could do
things in their rightful sense just like any ordinary person in society. It also suggests that they can do things
independently without necessarily depending on others
in discharging duties such as bathing, eating, washing
and other household chores. It is not surprising that a
previous study supports this assertion. Similar research
was conducted in Sweden [34] to describe the engagements in daily activities of people with schizophrenia
and revealed that being diagnosed with schizophrenia
does not necessarily lead to an impoverished lifestyle.
Instead, individuals with schizophrenia could have a
normal lifestyle and perform activities such as washing, bathing etc. and even observe personal hygiene.
Contrary to an assertion that persons with schizophrenia have certain defcits in their lives that render them
unable to carry out activities of daily living at will [35,
36], participants in this study proved that, despite living
with schizophrenia, the condition did not interfere with
their daily living activities in any way.
Persons with schizophrenia have been at the receiving
end of name-calling, insults, and discrimination over
the years. Tere have been some negative comments,
assessments, and discrimination attributed to persons
living with the diagnosis of schizophrenia by people
who come into contact with them. Stigmatisation has
been noticed to have characterised the lives of persons with schizophrenia [37–40]. Tese individuals are
highly discriminated against, especially in communities
where they live, partly because society perceives them
as mentally ill and a threat to the community. Tus, the
community does not see the essence of associating with
the “mad” people in the community. Another reason
people stigmatise these individuals may be due to the
symptoms people with schizophrenia exhibit, especially
in the relapse stage. Such manifestations scare people,
especially those in the catchment area where study
participants reside [41]. Hence, most people in the
community may consider them highly violent and can
even kill people who may get closer to them. Society
may permanently stigmatise them [41]. Stigma afects
the well-being of people with schizophrenia because it
leads to isolation and rejection of these victims.
Schizophrenia is the most stigmatised of all mental conditions because of its perceived dangerous and
unpredictable nature [40–42]. As a result of stigma,
these persons become angry, anxious, scared of the
unknown, and sad. People’s perception of schizophrenia and how they label people with the condition make
it very challenging for individuals living with the condition to cope with it, especially when they step out
of their homes [42]. Tey, therefore, respond to these
unfortunate situations by using defence mechanisms
such as avoidance, denial, and resorting to wishful
thinking consistent with previous fndings [41]. Contrary to what was found in Croatia on schizophrenia
and stigma, which indicated that, mental health nurses
and nurses working in other general hospitals do stigmatise persons with schizophrenia [42], study participants in this current study verbalized that, mental
health nurses, often get closer to them and encourage
them to avoid taking into how people negatively evaluate them in society.
Commey et al. BMC Nursing (2022) 21:107 Page 7 of 9
Regarding coping through mental fortitude, study participants with schizophrenia believed that the condition
had become part of their daily lives, therefore they do
not stress themselves about the negative manifestations
associated with the condition. Tey are able to deal with
the challenges associated with the condition by indulging
in wishful thinking. Tis presupposes that, if an individual with schizophrenia does not stress him or herself by
thinking excessively about the condition, the possibility
of experiencing a relapse is minimal because it is believed
that stress as a result of thinking excessively about the
condition can lead to frequent relapse. Tis fnding is not
diferent from a similar qualitative study conducted on
the coping strategies adopted by individuals with schizophrenia in Great Britain [43]. He also opined that persons
with schizophrenia engage in activities that divert their
attention from the negative aspects of the condition to
stay healthy.
Participants verbalized that; they cope with their
condition by strict adherence to regular intake of their
prescribed medication. Hence, medication was a decisive factor in protecting individuals from experiencing
a schizophrenic relapse. With adequate adherence to
medicines, participants with schizophrenia could maintain resilience and feel more comfortable going about
their normal daily activities. Participants asserted that,
those of them who adhered to medications had a quality of life compared to their counterparts who did not follow strictly their treatment plan. It is documented that
patients with schizophrenia cope well with their condition through regular adherence to prescribed medications [44–46]. Tis, according to them, makes them
strong and prevents them from experiencing any relapse
[45]. Steady medication adherence helps persons with
schizophrenia improve their care and cope with the
condition.
Spiritual wellbeing, including participating in religious
activities, creates a sense of belonging, enables them to
deal with difcult situations, and gives them the strength
to move on despite their condition. Tis may imply that;
religion possibly provides positive coping to patients
with schizophrenia and subsequently help in recovery.
Religious coping was the most common strategy used
by people with schizophrenia to cope with daily activities associated with the condition [47–49]. Tis may
be because participants indicated that religious coping
enhances self-esteem and reduces adverse efects associated with schizophrenia. Increased self-esteem can be
shown to contribute to a positive health outcome. Religious faith also serves as a source of strength for persons
with schizophrenia and assures them that they can survive complex events in their life. Participants’ belief in
their maker improves their relationship with family and
other people in their communities [49]. Persons diagnosed with schizophrenia cope well through religious
activities such as exorcism or sacraments, which they
believe could restore their mental and physical well-being
to normalcy [47]. Te implication is that people with
schizophrenia will always depend on religion to manage
the condition due to the relief or solace they derive from
it.
Conclusions
Tis study has shed light on how people with schizophrenia live and cope with their personal care and the stigma
associated with their conditions in Ghana’s resourceconstrained setting. Participants in their lucid state lived
an everyday life and could maintain daily living activities
successfully. Again, study participants verbalised being
labelled and seen as diferent within the communities in
which they reside. It was evident in the study that persons with schizophrenia adopt subjective measures that
help them to live with the condition and cope with the
associated stigma despite the challenges that the situation
presents to them. Tis calls for the need to intensify education to reduce public stigma regarding schizophrenia.
Overall, these fndings are not dramatically diferent
from those reported in the literature; however, the support needs of people with schizophrenia may difer from
a cultural and spiritual point of view. Africa and, therefore, Ghana is highly religious, and people fnd solace in
religious coping strategies. As patient advocates, nurses
also need to appraise their educational programs to
address stigma and avoid the increasing trend of societal beliefs regarding persons living with schizophrenia.
Positive media representation of people diagnosed with
schizophrenia would also go a long way in reducing their
opposing expectations of themselves and replacing them
with personal strength, hope and aspirations.
Limitation of the study
Qualitative research is often criticised for lacking generalizability and being too reliant on the subjective interpretations of researchers. Terefore, the results of this
study cannot be generalised as the true refection of all
persons living with schizophrenia in the country. However, it was not the researcher’s aim to make generalisations but to understand and describe the experiences of
persons living with the diagnosis of schizophrenia in the
Cape Coast Metropolis of Ghana.
Recommendations
Based on the fndings of the study, the following recommendations were made:
Commey et al. BMC Nursing (2022) 21:107 Page 8 of 9
Nursing practice
Community psychiatric nurses should continue to intensify their home visits to individuals living with schizophrenia in their catchment area to support clients who
have challenges with personal care and stigmatisation.
Education
Te mental health authority (MHA) of Ghana should
intensify health education on issues relating to schizophrenia to create awareness on issues afecting the lives
of Persons Living with Schizophrenia.
Policy
Tere are no clear policy guidelines in Ghana that primarily focuses on the management of schizophrenia
in the country. Tis study, however, recommends that
authorities at Cape Coast metro health directorate should
establish a counseling centre within its premises to house
accredited religious ministers and professional psychologists to meet the needs of clients with schizophrenia and
their families.
Suggestions for further study
Research can be conducted on gender diferences in the
experience of Persons Living with Schizophrenia to fnd
out if diferences exist between males and females living
with schizophrenia.
Acknowledgements
We want to express our profound gratitude to study participants for availing
themselves of this study at a crucial time when the COVID 19 pandemic
was at its peak in the country. Again, the authors want to acknowledge the
Directorate of Research Innovation and Consultancy (University of Cape Coast,
Ghana) for the insightful contribution to the production of this manuscript.
Conflict of interest
The authors have declared no confict of interest.
Authors’ contributions
ITC, JPKN, and EAA contributed equally to this paper (development of the
research concept, data collection, data analysis, and manuscript drafting). EAA
contributed to developing the research concept and critical review of the
paper. ITC, JPKN and EAA were involved in data collection, data analysis, and
manuscript drafting. All authors approved the fnal draft of the manuscript
before submission.
Availability of data and materials
The raw and analysed data are available with the corresponding author on
reasonable request.
Declarations
Ethics approval and consent to participate
Ethical Clearance was obtained from the Institutional Review Board (IRB) of the
University of Cape Coast (UCCIRB/CHAS/2020/37). Participation in the study
was voluntary; participants were allowed to opt out of the study without
any punitive measures. Furthermore, clients were taken through participant
information and consent forms before the examination. They all signed the
consent form before being engaged in the data collection.
Consent for publication
Study participants were informed at the beginning of the study that the
fndings from the study would be published to contribute to knowledge
generation in the mental health discipline. However, their identities will not
be part of the publication. Participants subsequently gave their consent for
publication after the study.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Department of Mental Health, School of Nursing and Midwifery, College
of Health and Allied Sciences, University of Cape Coast, PMB, Cape Coast,
Ghana. 2
Department of Maternal and Child Health, School of Nursing
and Midwifery, College of Health and Allied Sciences, University of Cape Coast,
PMB, Cape Coast, Ghana.
Received: 28 January 2022 Accepted: 3 May 2022
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