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Dear Editor
Increasing populations and an increasing incidence of mental health problems challenge many developing countries, including Ghana1,2. Long distances, financial limitations, lack of mental health personnel, and pessimism about the effectiveness of treatment, make it difficult for people to access help1-3. In 2011, only 0.3% of Ghana’s 25 million population received psychiatric services2.
Telepsychiatry has become an important component of rural health care, especially in the developing world, contributing to improvements in various conditions and populations1,3. Cultural factors influence how comfortable patients are with telepsychiatric services4. Considering cultural factors when planning and implementing telepsychiatric services may contribute to the success of these services and thereby increase service utilization in underserved rural and remote populations4,5.
The first author has worked as an assistant psychologist in rural northern Ghana. Drawing on his professional experience as well as on information he has received from other people involved in mental health care in the area, he thinks it is quite common for health personnel to be perceived as persons worthy of honour and with a high degree of authority, not very different from perceptions of local chiefs. In-person consultations are associated with respect, seriousness of problems being presented, and customary ways of seeking attention from a higher authority. Clients may therefore opt to consult with mental health personnel in person, regardless of the distance to the hospital, rather than utilize any potential telepsychiatric service.
To understand the potential impact of this cultural perception on telepsychiatry, one should consider the institution of chieftaincy within Ghana. Chieftaincy still exists in contemporary Ghananian society and constitutes an indigenous pre-colonial traditional political system with lawmaking authority, cultural leadership, political representation of the community and its social identity, social control and land administration responsibilities, among other roles6. The perception of mental health clinicians as chiefs appears to be linked with a broader cultural phenomenon of ascribing chiefly status to the elite within the local communities for the roles they play6.
Some people may perceive technology as a hindrance to the normative forms of cultural self-expression and communication and as a creator of interpersonal distance. People who perceive technology as a threat to their cultural organization may harbor fears of telepsychiatry undermining their ability to connect with clinicians and hamper their ability to express their sociocultural values such as respect for traditional authority, normative ways of seeking help, and accepted ways of expressing suffering. However, some technologies may be more culturally acceptable than others.
Implementers of telepsychiatry in rural and remote areas should factor in cultural perceptions of the use of technology, to avoid wasting scarce resources. The early involvement of local communities and users may help secure support for new services7,8. Moreover, involving communities and users may help in selecting the culturally most appropriate technology and/or other means of needed service provision. Stakeholders in rural health-related policy matters should be aware of the integral role of rural cultures and traditions and create health policies that accept and dignify the varied cultural beliefs, customs and practices that may be encountered when developing and implementing e-service-related health policies. More knowledge is needed to further examine how telepsychiatry can be successfully implemented in a culture-sensitive way, and we invite readers to contribute to the discussion.
Mr Jeremiah W. Acharibasam, Department of Mental Health, Navrongo War Memorial Hospital, Navrongo, Kassena-Nankana District, Ghana
Professor Rolf Wynn, Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway and Division of Mental Health and Addictions, University Hospital of North Norway, Tromsø, Norway