The distribution of psychiatrists significantly differs throughout the world. In most of sub-Saharan Africa, there is less than one fully qualified psychiatrist for every one million people and an ongoing exodus of trained doctors from the developing to the developed world (1). Nevertheless, the burden of mental illness in the developing world is significant; for example, it is estimated that by 2020 major depression will occupy second place in global disease burden (2). There is a need to train psychiatrists from African nations to build a mental health work force capable of meeting the needs of the population and to train future generations of doctors in primary and secondary care who may treat patients with mental illness. Therefore, it is essential to attract medical students to psychiatry. Even if many move to the developed world, some will return to Africa to contribute to mental health care.
The medical school at the University of Science and Technology in Kumasi, Ghana, was established in 1965 and has had an integrated psychiatric program since 1982 (3). It trains approximately 100 medical students per year and is one of two fully established medical schools in Ghana. A well-established mental health service in the teaching hospital meets significant clinical needs (4). Very few medical students, however, go on to specialize in psychiatry, and it is not clear why. Possible reasons include a negative attitude toward a career in psychiatry and a lack of opportunity to specialize in psychiatry compared with other specialties.
We sought to answer the following research questions: What are the attitudes toward psychiatry of final-year medical students in Kumasi, Ghana? How do these attitudes compare with those of medical students in Spain and the United States, where similar surveys of attitudes to psychiatry have been reported?
During a psychiatry course for final-year medical students in 2006, which was in addition to earlier clinical placements, medical students were asked to complete a questionnaire on their attitudes toward psychiatry. Students were asked to be as honest as possible, and their anonymity was emphasized. They could choose not to complete the questionnaire. They were also asked their gender, age, and intention to pursue a career in psychiatry (Table 1).
The questionnaire used was previously designed by Balon et al. (5) in the United States and permission was obtained to use it in this study. This questionnaire was also used among medical students in Barcelona, Spain (6). It consists of 29 questions, although we removed one because it was deemed insensitive in this context. This left 28 questions covering the overall merits of psychiatry; efficacy, role, and the function of the psychiatrist; possible abuse and social criticism; career and personal reward; and medical school factors (Table 2).
The questions were analyzed with chi-squared tests using the SPSS statistical package, with separate comparisons with the previously published results from Spain and the United States (SPSS Version 13.0 for Windows). Consent to participate in the project was assumed by the act of completing the questionnaire. The project was initially approved verbally by the local ethics committee, and the approval was subsequently collected in writing.
Questionnaires were completed by 94 out of 105 students (response rate 89.5%); 51% were men and respondents ranged in age from 24 to 28 years old. Some students did not complete all the questions, but between 84 and 94 students (80.0%–89.5% of the class) answered each question.
The intention of students to pursue a career in psychiatry is summarized in Table 1, along with findings for the same question given to U.S. students (5). These data were not available from the Spanish study. Ghanaian students were less inclined to consider a career in psychiatry; but nearly 15% of Ghanaian students were considering a career in psychiatry, suggesting hope for future recruitment.
The results of the questions on attitudes to psychiatry are given in Table 2. The main findings can be summarized by theme.
Overall Merits of Psychiatry
Ghanaian students felt positively about the merits of psychiatry, with 75% agreeing (i.e., scoring “strongly agree” or “moderately agree”) that research has made good strides in advancing care and 60% agreeing that psychiatry is a rapidly expanding frontier of medicine.
Ghanaian students believe in the efficacy of psychiatry; 82% would agree to recommend a psychiatric consultation to a relative, and 83% agree that psychiatric treatment is helpful to most people who receive it.
Role Definition and Functioning of Psychiatrists
Most Ghanaian students believe in the validity of psychiatry, but a striking finding from this questionnaire is that Ghanaian students believe that psychiatrists adopt a model based too much on theoretical and psychodynamic ideas and are not attentive enough to biological factors in illness. On commenting on the relative merits of psychiatrists compared with psychologists and social workers, it must be remembered that working teams are very different to Spain and the United States. There are very few social workers in Ghana.
A significant minority of students were concerned that psychiatrists misuse their powers to detain patients, although 70% of students did not agree with this. There was a realistic appraisal that psychiatrists make less money than other doctors, because independent practice is less lucrative in psychiatry compared with other medical disciplines.
Career and Personal Reward
There is strong evidence of stigmatization in the attitudes of Ghanaian medical students. They perceive a low prestige of psychiatrists among the public and other medical disciplines. Students feel that fellow students who are interested in psychiatry are seen as odd, strange, or neurotic. Another striking finding is that 69% of students strongly or moderately agreed that they feel uncomfortable with patients who have mental illness. However, students are not discouraged from practicing psychiatry by their families or fellow students.
Specific Medical School Factors
The students were quite positive about the quality of teaching of psychiatry, junior and senior psychiatric role models, and the levels of respect psychiatry receives in the medical school. Over 79% of students felt psychiatrists were clear, logical thinkers. Most students believed that there was adequate encouragement to practice psychiatry.
Differences Between Ghana, Spain, and the United States
Overall, the responses of students from Kumasi, Ghana, were closer to those from Spain than those from the United States. While faith in the merits of psychiatry was strong in Ghana, students were less positive about psychiatry than their U.S. counterparts, and less likely to support a referral of one of their own family (χ2=13.6, df=3, p<0.001). Ghanaian students were very different compared with those in the United States and Spain in viewing psychiatry as less biological and too theoretical/psychodynamic. Ghanaian students were more concerned about psychiatrists abusing their power to detain patients against their will compared with U.S. students (χ2=35.0, df=3, p<0.001), although this finding was similar compared with students in Spain (χ2=2.9, df=3, p=0.40). Whereas the stigma against psychiatry and psychiatrists was stronger in Ghana, students had received less discouragement from families and fellows than their U.S. counterparts. In all three countries, medical school experience was positive, with different strengths shown in each region.
This study involved a survey of the attitudes of final-year medical students toward psychiatry in Kumasi, Ghana. The strengths of the study include the use of a well-designed questionnaire, which was used previously in the United States and Spain, and a response rate of 89.5% of all final-year medical students. The limitation of this study was using a sample from only one medical school in Ghana, which may not be representative of other students in Ghana or the rest of sub-Saharan Africa.
The attitudes of final-year medical students in Kumasi are generally quite positive. They are similar to attitudes of students in Barcelona, Spain, but not as positive as those of U.S. medical students. Among notable positive attitudes, students mostly see psychiatry as a valid branch of medicine, making strides in research and expanding. The vast majority of students would recommend a psychiatric consultation to a relative. They are not discouraged from a career in psychiatry by family or fellow students, and they value their experience of psychiatry in medical school.
However, the majority of the students felt uncomfortable with psychiatric patients and believed that psychiatry has a low prestige among the public and the medical profession. This suggests significant stigmatization of patients and psychiatrists. This stigmatization has also been found in Australian students in a recent qualitative study (7) and a quantitative study (8). A minority of students in Kumasi also believe psychiatrists abuse their powers of detention. This might indicate the importance of efficient mental health legislation to protect patient rights. Ghana’s stretched mental health services struggle to utilize mental health legislation, which may be reflected in these student responses.
This study suggests that the difficulty recruiting psychiatrists in Ghana is not predominantly due to negative attitudes to psychiatry among medical students. With 15% of students indicating some interest in a career in psychiatry, it may be possible to recruit more students into psychiatry. Students were fairly positive about psychiatry, comparable with attitudes among Spanish students. Although improving attitudes is possible (e.g., U.S. students have more positive attitudes overall), this may not necessarily have a big impact on recruitment, which fell in the United States despite improved attitudes in the 1990s (5). However, reducing the stigmatization of patients with mental illness and psychiatrists would be desirable, and reducing the concerns about abuses of powers of detention could also be addressed.
If negative attitudes to psychiatry are unlikely to be the main cause of the low number of psychiatrists, as this study suggests, other factors may need to be examined. Although these issues are beyond the scope of this article, it is possible that increasing opportunities for postgraduate training would have an impact on recruiting psychiatrists. Currently Ghanaian doctors need to go abroad to specialize in psychiatry. If this was facilitated, with encouragement to return to Ghana to practice, recruitment may improve. If doctors in Ghana were able to train locally in psychiatry, mental health care provision within the country may benefit further. Institutions delivering psychiatric training programs in developed countries may be in a position to support local training programs, and this may help to reduce the loss of doctors to wealthier nations.
We thank Colin Pritchard for statistical assistance and Maureen Worthy for secretarial assistance.
At the time of submission, the authors disclosed no competing interests.