Mental Health: Global Challenges Journal

https://www.sciendo.com/journal/MHGCJ

ISSN 2612-2138

Mental Health Advocacy in The Gambia, West

Africa

Safiya Njai, Stephanie Thorson-Olesen

Antioch University, Seattle, WA, USA

Abstract

Introduction:

To promote mental health globally, including low-and middle-income

countries, research and advocacy are essential. The Republic of The Gambia is one of the

smallest countries in the world and is the focus of this research.

Purpose:

This study examines social and cultural aspects of access to mental health

treatment in The Gambia, West Africa.

Methodology:

The population of focus consisted of adults over 18 living in The Gambia. The

methodological approach was a qualitative phenomenological study involving semi-

structured interviews conducted via Zoom, by a researcher from The Gambia.

Results:

Data were collected from 17 participants living in The Gambia at the time of the

study. A team of analysts with diverse backgrounds evaluated transcripts and identified

five themes highlighting social and cultural conceptualizations of mental health and

mental illness, sociocultural determinants of health, interventions, barriers to care, and

legal frameworks to support mental health change.

Conclusions:

The findings from this study are significant for mental health providers who

seek to understand different perceptions of mental health and mental illness and the

associated stigma. Furthermore, this study suggests several opportunities for mental health

advocacy in The Gambia.

Keywords

mental illness, mental health, The Gambia, Africa, stigma

Address for correspondence:

Dr. Safiya Njai, PhD. Antioch University, Seattle, WA, USA,

E-mail: snjai@antioch.edu

This work is licensed under a Creative Commons Attribution-Non-Commercial 4.0

International License (CC BY-NC 4.0).

©Copyright: Njai, 2023

Publisher: Sciendo (De Gruyter)

DOI: https://doi.org/10.56508/mhgcj.v6i1.174

Submitted for publication: 08

June 2023

Revised: 10 September 2023

Accepted for publication:

16 September 2023

Mental Health: Global Challenges Journal

https://www.sciendo.com/journal/MHGCJ

ISSN 2612-2138

Introduction

The Republic of The Gambia, commonly

known as The Gambia, is a former British

colony that gained independence in 1965. It

features a democratic system of government

consisting of three branches: the legislature,

the judiciary, and the executive. The president

of the republic is the head of the executive

branch and is assisted by a vice-president and

a cabinet of ministers. The Gambia is one of

the smallest countries in the world, with an

estimated population of 2.2 million people

(World Health Organization [WHO], 2018).

According to The Gambia Bureau of Statistics

(GBOS, 2013), more than half of the

population is female, and over 63% are youth.

Moreover, approximately 50% of the

population lives in rural regions, which

comprise 60% of the country (GBOS, 2013). The

Gambia is also one of the poorest countries in

the world, with an estimated gross domestic

product per capita of $773 in 2020 (World

Bank Group, 2022). The mental health services

comprise one community mental health team

and an in-patient unit called Tanka Tanka

Psychiatric hospital (Kretzschmar et al., 2012).

The exact prevalence of mental illness in

The Gambia is unknown. A situational analysis

of mental health conducted by the Mental

Health Leadership and Advocacy Program

(MHLAP) in 2012 revealed that, of an

estimated population of 1.478 million people,

approximately 120,000 had a mental disorder

(MHLAP, 2012). Since then, the size of the

population has nearly doubled, but no recent

studies have been conducted on the

prevalence of mental illness in the country.

Global Burden of Disease (GBD) statistics from

2017 indicated that more than 34% of

Gambians have a depressive disorder and

35.9% have an anxiety disorder. Mental health

stigma has been identified as a factor

significantly affecting people with mental

health problems in The Gambia.

Stigma is a pervasive condition that often

discredits individuals and leaves them feeling

lesser than others (Abdullah & Brown, 2011;

Goffman, 1963; Monteiro, 2015). The plethora

of emerging research on mental health stigma

in low- and middle-income countries (LMICs)

highlights the role of culture and cultural

differences in conceptualizations and

understandings of mental health (Amuyunzu-

Nyamongo, 2013; WHO, 2012, 2014). In The

Gambia, explanatory beliefs about the

causes and attributions of mental illness and

associated labels are stereotypical, isolating,

discriminating, and stigmatizing toward those

with mental health issues, which may result in

mental health stigma. Empirical studies have

provided a foundational understanding of the

scale, nature, and lack of access to necessary

mental health services (Barrow, 2016; Barrow &

Faerden, 2022; Coleman et al., 2002). These

studies have mentioned the need for better

information on the role, association, and

impact of stigma on care-seeking attitudes

and as a deterrent to service utilization. An

investigation of lived experiences of mental

health stigma would generate significant

findings and serve as a resource for the

Gambian government, which plans and

implements services, and nongovernmental

organizations and institutions that provide

mental health services. Such an investigation

could address the 90% treatment gap

(MHLAP, 2012).

Given the multitude of needs, it is essential

to prioritize those that are most fundamental

to health, including access to treatment and

addressing stigma. Although MHLAP (2012)

indicated that it did not specifically examine

mental health stigma, this factor likely

influences service underutilization. Mental

health in The Gambia is rooted in culturally

nuanced concepts and understandings that

significantly impact the social identity of

people with mental health disorders.

Furthermore, they define treatment pathways

and modalities for mental health care and

fuel the public stigmatization of mental health

issues.

The globalization and decolonization of

mental health in Africa have led researchers

and scholars to call for action to extend the

bio-psycho-social framework of mental health

assessment, diagnosis, and treatment on the

continent (Monteiro, 2015). The bio-psycho-

social model has long been used in contextual

approaches to mental health interventions in

low to middle-income countries (LMICs) in

response to the need to address factors that

determine or improve mental health (Engel,

1977). Research has examined systemic and

structural factors in mental health, such as

lack of funding, limited healthcare

infrastructure, lack of mental health policy

and laws, and mental health stigma and

discrimination (Akinsulure-Smith & Conteh,

2018; Becker & Kleinman, 2013; Monteiro,

2015). Although such a model has increased

overall mental health status in LMICs, mental

health remains a stigmatized and neglected

area of health and well-being in these

countries. Furthermore, due to the widespread

prevalence of mental illness, it has been

described as an epidemic in LMICs (Hohenshil

et al., 2015; Monteiro, 2015). As an LMIC, The

Mental Health: Global Challenges Journal

https://www.sciendo.com/journal/MHGCJ

ISSN 2612-2138

Gambia shares similar systemic and structural

problems as many other African countries with

regard to the prioritization and delivery of

mental health care (Akinsulure-Smith &

Conteh, 2018).

One way to conceptualize views of mental

health in The Gambia is through the

ecological systems theory of human

development, which can be helpful for

examining mental health care and access

(Bronfenbrenner, 1977). Ecological systems

theory considers the influences of multiple

systems at different levels, which interact to

influence individuals’ lived experiences and

the systems that surround them (Crawford,

2020). According to this theory, human

development results from interactions

between developing human organisms and

environments at five significant levels: the

microsystem, mesosystem, exosystem,

macrosystem, and chronosystem. The

microsystem consists of a person’s immediate

environment and includes their personality,

beliefs, and temperament. The mesosystem

refers to the connection between different

microsystems. For example, elements of the

microsystem affect the individual’s

experiences (e.g., how school and home

interact). Both the microsystem and the

mesosystem must include the individual.

Systems that affect environments at the

meso level but do not include individuals are

the exosystem, which consists of microsystems

interacting with each other. However, at least

one of the microsystems does not include the

individual at the center of the system. For

example, a parent's workplace does not

include the child, but the latter could be

affected by characteristics of the parent’s

workplace (e.g., the parent is required to work

long hours or stressed from work). However,

because the child is not part of the parent’s

work environment, the workplace is not part of

their microsystems or mesosystems. The

macrosystem influences the characteristics of

interactions between different systems; in

other words, it influences the “social design” of

the broader culture or subculture. For

example, family culture develops within a

family in the microsystem, which is influenced

by the mesosystems and exosystems of each

family member. All of these systems are then

affected by broader society and culture.

Bronfenbrenner emphasized the importance

of cultures within groups and the exchange

patterns within and among groups. This theory

emphasizes the reciprocal effects of these

different systems on personality development

and social and psychological outcomes

(Crawford, 2020). Thus, ecological systems

theory provides an essential perspective for

investigating West Africa, access to mental

health care, and associated stigma. This study

begins by examining individual perspectives,

then identifies themes through a

phenomenological interpretive analysis. In the

discussion of the findings, these themes are

viewed through the lens of ecological systems

theory to provide insight on how different

levels of frameworks interact in the context of

one’s life.

The significance of this study cannot be

underscored enough in the context of

opportunities for mental health advocacy in

The Gambia. First, as an LMIC, The Gambia

should make mental health a public health

priority. Mental health is a global pandemic,

and the treatment gap for mental illnesses is

between 76% and 85% in LMICs, compared to

35% to 50% in high-income countries (Barrow,

2016; Evans-Lacko et al., 2012). This wide

treatment gap necessitates an investigation

of factors that impact this disparity.

Second, Patel and Prince (2010)

investigated the intersection of treatment

outcomes and care-seeking behavior to

bridge this treatment gap. They posited that

current interventions utilized in African mental

health care are ineffective without behavioral

change. Furthermore, Summergrad (2016)

underscored the need for early intervention to

avoid secondary effects not only with regard

to general health goals but also socio-

economic development in particular.

Therefore, qualitative and quantitative

research are greatly needed to understand

the nature and scale of the problem (Barrow

& Faerden, 2022). With this in mind, the current

counseling-, advocacy-, and social justice-

focused research can provide a better

understanding of how mental health is

experienced and thus inform interventions.

Third, although the Gambian government

has acknowledged mental health care as a

priority, it has not yet implemented a

framework for developing a viable system.

Although The Gambia has developed a

mental health policy for 2021–2030 and

validated a mental health bill in 2019 to

legislate mental health laws, this has not yet

been implemented or enacted. Extant mental

health legislation consists of the Lunatic Act

(1964). Therefore, the findings from this study

could inform mental health policy

development and bring The Gambia in line

with its obligations under the Convention on

the Rights of Persons with Disabilities (2008),

which it ratified.

Mental Health: Global Challenges Journal

https://www.sciendo.com/journal/MHGCJ

ISSN 2612-2138

Fourth, mental health care interventions

must be decolonized in The Gambia. The

current counseling and social justice research

aim to reflect cultural and social

understandings of the research phenomena

and facilitate closer understanding, empathy,

and more interactions with people with

mental illness. This study is well-situated for this

facilitation through its inquiry into the social

and cultural factors that impact mental well-

being. To approach a study with cultural

humility, a term coined by Tervalon and

Murray-García (1998), health practitioners

must exercise restraint in applying previously

acquired cultural knowledge to avoid

perpetuating power imbalances in the

therapeutic setting (Zhu et al., 2021).

Purpose

This qualitative phenomenological study

aims to explore and understand experiences

of mental health and the role of mental health

stigma among adults in The Gambia. To this

end, two research questions were developed

for the study. The first research question is,

"What are the lived experiences of mental

health among adults in The Gambia?” The

second research question is, "What is the lived

experience of mental health stigma among

adults in The Gambia?” No hypotheses were

developed due to the qualitative nature of

the study.

Methodology

Study design

The philosophical ideals that underpin this

study are grounded in phenomenology and

social constructivism, which assume that

absolute realities do not exist. Instead, realities

are constructed through subjective

experiences shaped by the environment and

social interactions (Moustakas, 1994). A

phenomenological approach recognizes the

subjectivity of participants through their

interpretation of the truth, not what is

attributed to or imposed on them by the

researcher (Moustakas, 1994). Therefore,

several steps were followed to gather

qualitative data after the institutional review

board granted approval for the study. No

intervention was undertaken, as this study is

qualitative in nature and focuses on

participants’ lived experiences. For the

purposes of the study, mental health was

defined as a state of optimal well-being that

incorporates physical and mental health

(WHO, 2014). Mental health stigma is a socially

constructed identification that “a social group

creates of a person or group of people based

on some physical, behavioral, or social trait

perceived as being divergent from group

norms” (Goffman, 1963, p. 54).

Participants

The population of focus consisted of adults

over the age of 18 in The Gambia. A

convenience sampling strategy and snowball

sampling technique were used, and

participants were recruited through various

means (e.g., email and social media).

Additionally, the informed consent,

demographic questions, and interview

process required an eighth grade-level

understanding of English.

Data sources and collection

To collect data, a recruitment message

was shared with potential respondents,

including a link to SurveyMonkey. On

SurveyMonkey, interested individuals were

asked to review the informed consent form

and demographic questions. The latter

included the following:

•Do you live in The Gambia?

•Which age range do you fit into?

•What is your gender?

•What is your marital status?

•What is your level of education?

•How many people live in your

household?

•What best describes your religious or

spiritual beliefs?

•Which dates and times would you be

available for a 30-minute Zoom interview

regarding mental health in The Gambia?

Once a suitable date and time for the

Zoom interview was determined, the primary

researcher contacted the participant via

email to confirm these. During the interviews,

the researcher followed a script with a set of

open-ended questions. At the beginning of

the interview, the participant was reminded

that it would be audio recorded. Next, they

were informed of the purpose of the study,

then asked the open-ended questions. The

interview questions included the following:

•What do you know about mental

health or mental illness in The Gambia?

•How do you think people feel about

mental health/illness in The Gambia?

•What is your understanding of how

people see mental health?

•What is the meaning of mental health

in your language/cultural group?

Mental Health: Global Challenges Journal

https://www.sciendo.com/journal/MHGCJ

ISSN 2612-2138

•How might people get help for their

mental health issues in The Gambia?

•What is your experience with seeking

local and traditional healing for mental

health?

•What is your opinion about why mental

health services might be underutilized in The

Gambia?

Upon completion of the interviews,

participants were thanked for their time. The

audio recordings were transcribed, and any

identifying information was removed. The

recordings were then stored on a password-

protected computer for the duration of the

study.

Data analysis

The demographic data were evaluated

with descriptive statistics using JASP, a

statistical analysis program. Then, the

qualitative data were analyzed after the

transcription of the interviews. In

phenomenological studies, researchers are

expected to bracket their feelings,

assumptions, biases, and judgments about the

phenomenon to arrive at the true essence

and a deeper understanding of participants’

lived experience (Moustakas, 1994).

Bracketing allows researchers to process the

identification of the research questions, data

collection, data analysis, and understanding

of the essence of the lived experiences

(Creswell, 1998). Furthermore, as a practice,

bracketing is used to enhance trustworthiness.

All three researchers identified as female and

were aged 33 to 52. Moreover, two

researchers identified as Black and African,

while the third identified as White and of

European descent. During the bracketing

process, it was determined that two

researchers had related lived experiences,

while one had methodological experience.

Potential biases and positionality included the

fact that all three researchers had an interest

in mental health in the population of interest,

were concerned about stigma, and were

aware of the impact of colonization.

Verbatim transcripts of data collected from

the interviews were analyzed. First, a team of

three analysts, including the principal

researcher, developed an understanding of

the data through reading and note-taking.

The data were then coded, and a matrix was

utilized to chart identified commonalities

across analysts. The primary researcher also

collaborated with available participants to

review the data and its interpretation to

achieve triangulation and saturation and

provide some checks and balances.

Throughout the study, the American

Counseling Association Code of Ethics was

referenced (ACA, 2014), and permission was

obtained from the institutional review board to

conduct this research.

Results

Data were collected from a total of 17

participants living in The Gambia at the time

of the study. This section presents

demographic information about the study

sample and reports results from the research,

including direct quotations from participants.

Demographic information

A control question about residence was

asked to ensure that all participants met the

criteria for participation; 100% of participants

indicated that they lived in The Gambia. In

terms of age ranges, one person was 18–19

years old, three participants were 20–29 years

old, 10 participants were 30–39 years old, one

was 40–49 years old, one was 50–59 years old,

and one was 60–69 years old. Regarding

gender, 70% of participants were male and

30% were female. In addition, 65% of

participants were married and 35% were

single. Regarding level of education, five

participants had a high school degree or

equivalent, seven attended college but did

not obtain a degree, two had an associate

degree, and three had a graduate degree.

When asked how many people lived in their

household, three participants indicated three

to four people, four participants indicated five

to six people, four participants indicated

seven to eight people, four participants

indicated nine to 10 people, and two

participants indicated 11 or more people.

Finally, with regard to religious or spiritual

beliefs, 88% of participants responded that

they were Muslim and 12% responded that

they were Protestant Christian.

Themes

Five themes were identified during the data

analysis: social and cultural

conceptualizations of mental health and

mental illness, sociocultural determinants of

mental health/mental illness, mental health

care interventions and bio-psycho-social

interventions, barriers to mental health care,

and legal frameworks to support mental

health change.

Theme 1: Social and cultural

conceptualizations of mental health/mental

illness

Mental Health: Global Challenges Journal

https://www.sciendo.com/journal/MHGCJ

ISSN 2612-2138

Constructions of mental health and mental

illness differ across cultures and communities.

One participant said, “I want to clarify

something, and I can see that the question

has made a distinction between mental

health and mental illness. Here in The Gambia,

there is not a distinction between the two.”

Regarding etiology, one participant stated,

"Others tend to say that they steal from

people; that is why they are taken to the

marabout and the marabout put a charm on

them.” Another participant said, “Some

people feel like they are possessed by

demon[s] or things like that, you know. The

public will run away from them because it’s

believed that these people are cursed, an evil

spell from the Devil or wicked spirit.” Another

participant shared that mental health was

also seen as something that could be inflicted:

“To some people, it’s just a problem that is

prompted by a jinn. It’s more common here

that people see it as something that is being

inflicted from the spiritual world.” While many

participants believe that the spiritual world

inflicts mental illness, a participant stated, “My

understanding of the whole thing from

people’s perspective is mental illness is not

God’s doing. It’s not God’s doing.” Another

participant said, “Those ones are the ones that

are mentally imbalanced. Like one of their

senses is lacking.” Another participant added,

“They lack self-esteem. That’s what they lack.

Self-esteem and common sense.” One

participant explained that “mental health or

illnesses have some interesting classifications,

ranging from drug abuse related, absent-

mindedness either by drug addiction or

affliction by black magic.” Participants also

believed that disease is a cause of mental

health/mental illness. For instance, one

participant said, “Epilepsy is also believed to

be part of the problem. Yeah, a gradual

process that can send somebody crazy.”

Another participant stated, “Some believe, for

example, that cerebral malaria causes

[mental illness].”

Many participants questioned whether

there is a cure for mental illness. For example,

one participant explained that, “in The

Gambia, mental health is something that is not

easily curable. It’s not easy for people that

have mental health to recover from the

mental illness in [the] Gambia.” Another

participant also discussed suffering related to

mental illness: “Since I was a child to now over

40 years old, people that I know that had

mental illness are still suffering from it.” Another

participant said, “Traditionally, you cannot be

healed when you have mental health [issues].

You cannot be healed by traditional means.

Something is lacking in your brain, or your

system is lacking something, so a marabout

cannot heal you.”

The participants also expressed concerns

about helping those with mental health issues.

One participant explained, “People fear them

thinking that they might attack them.”

Another participant noted, “Some people

even go to the extent of chasing them away

because they think when people are near the

mentally affected, that they themselves might

also contract the mental illness.” One

participant said, “So, because they don’t

understand it, they have a concept, a

prevalent belief system in the society, a belief

that when you touch them the thing that is

affecting him or her will fight you.” The

participant further shared, “I've seen that. It’s

like when you start helping the person, for

example, even by simply escorting the person

to a healer, like, for example, the hospital or

even the traditional healer, you will start

seeing strange things happening to you.”

Theme 2: Sociocultural determinants of

mental health/mental illness

The second theme focuses on sociocultural

determinants of mental health/mental illness.

Regarding this topic, one participant said,

“Personally, from my own point of view, I think

mental illness, if it’s not caused by society,

then society will exacerbate it.” Another

participant stated, “In fact, to be possessed

doesn’t always mean you have to be mad.

However, even with the lack of access to

opportunity here, many would believe the

person is possessed.”

Respondents also suggested that poverty

plays a role in mental illness. One participant

said, “Society now believes that you have to

have money in order to be a human being.

Once you don’t have money, which means

you have mental problem.” Another

participant stated, “The majority of members

of the society feels that once you are poor,

then there’s something happening to you.

Some may call it bewitching, like the guy in

Bewitched; that is why he is poor. The person

cannot have opportunity.” Another

participant said,

In fact, 79 of the patients at Tanka

Tanka, when I asked them, they said

their condition is directly related to

poverty. They traveled to look for money

in Europe or America. And, when

deported, it’s like they have no purpose

living any longer. They said that their

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ISSN 2612-2138

parents sold all compound or cattle;

they had to send them through back

way to Europe. If they don’t reach or

they are deported, they have nothing

left.

A prominent subtheme was migration or

failed migration. Participants discussed various

issues related to this topic. One person stated,

“They see their friends are finally sending

money back home, taking care of their

families. And here they sit, unable to do the

same. Some people actually do go insane just

because of this.” One participant shared, “We

have a saying over here. We say, ‘Nerves.’ We

say, ‘This boy is nerves.’ What that means is

that this person wants to go abroad so bad

that they’re starting to go crazy.” Another

participant associated deportation with

mental health/mental illness: “What

aggravates the problem of these people is

mostly when they are deported back to their

native land. There is this stigma that goes with

it when they come back.” One participant

also stated, “People see them as failures. They

went to search for money and opportunity but

ended up being sent back with nothing.”

Another subtheme related to the labels

and names that are used to describe and

refer to people with mental illness. Participants

shared meanings associated with mental

health/illness in some of their languages and

cultural groups. For example, one participant

said, "Yes, we call them Nymatou in Mandinka.

In Wolof, they call them Duff; in Jola, also, they

call them Ahnymatou. These mean crazy or

mad person.” Another participant said, “If you

call somebody who is not mad, you call them

kangardo, they will not like that. You are

abusing them.”

A third subtheme was stigma,

discrimination, social isolation, and labeling.

One participant explained that “the stigma

around mental health is very high. This is one of

the reasons why even with the awareness

creation that we are doing at the moment,

many people are still reluctant to come out to

local services.” This participant also said,

“There’s this common statement that we say,

a crazy person can never be well again (Duff

due musa wayrl)” and “if you have any

mental problem, you will never recover from

it.” This statement alone is very powerful in

stigmatizing an individual. One participant

also shared, “Whenever there is talk of

somebody being mentally disturbed, the first

thing people do is try to stigmatize the person.

Yeah, that’s stigma, that will start even from

the immediate family members, most of the

time.” Another participant also stated,

“Instead of taking you for services, they might

even lock you in the house because of stigma

that can follow the family.” One participant

stated, “It’s like when people feel that one is

mad, they will not eat with the person. They will

not sit with the person in one place. So, total

isolation and discrimination.”

Theme 3: Mental health care and bio-

psycho-social interventions

A significant theme addressed is mental

health care pathways in The Gambia. A

subtheme of mental health care and bio-

psycho-social interventions was local and

traditional healing. For example, one

participant stated, “In most cases, many

people tend to go to [a] traditional healer or a

marabout rather than medical.” Another

participant stated, “Traditional healers, but

mostly religious, like they normally cure with

the Quran, such as Ruqya. Yeah, I’ve

personally seen that, using methods from the

Quran and some, you know, Arabic textbooks,

Islamic textbooks to cure them.” One

participant clarified, “I’ve experienced the

Muslim way of treating the problem aside from

[the] medical way of treating. There is this

religious formula that they use called Ruqya.

Ruqya, I think is exorcism in English.” Another

participant shared, “People believe when you

successfully cure a mentally ill person, that

disease or that mental problem will transfer to

you. If it cannot do anything to you as the

healer or as the traditional doctor, it will

transfer to the family.”

When discussing additional treatment

options, the participants emphasized a lack of

support. One person said, “Normally, lots of

family people here cannot afford to take their

mental illness people to the medical sector for

them to be treated, so they lack support.”

Another participant shared, “As you can see,

there is only one center in The Gambia where

they normally take these mad people. They

shove them in one place, that is Tanka Tanka.”

One participant said, “The medical side, they

only give them medication to tame them, if

the person is violent, but not actually to treat

the person.” One participant described this

treatment pathway as follows: “Mental health

in The Gambia is more chemotropic. When I

say chemotropic, I mean the use of drugs

(medication). They look at every mental illness

or issue as being treated only with the use of

drugs.”

In terms of counseling services, one

participant shared, “Just recently, people are

becoming aware of counseling and

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ISSN 2612-2138

psychosocial support. And I think that one is

more related to people who are mentally

distressed.” Another person said, “Many of the

deportees may know about Western

treatment because they are coming from

detention camps. I understand that they give

them counseling when they are at those

camps.” Another participant stated, “As for

counseling and psychotherapy, they are new

innovative treatment[s] but are not known.

Some Europeans are starting it here. They

need to sensitize the public.”

Theme 4: Barriers to mental health care

The participants mentioned several

subthemes under the theme of barriers to

accessing mental health care: mental health

literacy, awareness, and affordability. They

discussed increasing access to mental health

services and shared relevant experiences.

One participant recounted, “We have

succeeded in decentralizing the outpatient

services in every region … there is one in Basse,

one in Bansang, Soma, Farafeni, and Esau. But

for the in-service mental health facility, we

have not succeeded in the same capacity

yet.” This participant continued,

For the community mental health

team, previously, they used to go

around the country quarterly, every

three months, they will take around all

their equipment, and then they will

announce their outreach dates. But

recently, also due to gross lack of

finance or lack of a sponsor in [the]

mental health sector, such services

[have] been truncated in such a way

that it is only available within [the]

greater Banjul area. And even the

greater Banjul area, it’s only few

communities that are benefiting from

that community mental health services.

Mobility is a problem … they used to visit

prison, every month. But that also has

not been possible as we are speaking.

Another person stated, “They should build

more health places to have those that are

mentally ill.” In addition, one participant

expressed the need to “sensitize people on

the use of the drugs and order stuff and taking

care of our children in our own place.”

On the issue of counseling awareness, one

participant stated, “And, to me, the idea of

going for counseling is still not widely spread.

There needs to be awareness, and people

need to accept it. It’s new, and people don’t

trust it yet.” Another participant emphasized,

“People may not realize the kind of behavior

that the person is indicating, or the kind of

signs that will warn them that this person is

developing certain things.” Another

participant added, “We need to create more

health awareness, educate people about

health, make them know about mental health

issues, especially people that don’t know

about mental health, the illiterates will be

taught [about] mental health and what to do

with a person with mental health.”

Theme 5: Legal frameworks to support

mental health change

A subtheme concerned human rights. One

participant described human rights violations

against people with mental illness who seek

traditional healing:

When they reach that place, if the

craziness has deeply entered inside the

person’s system, they might chain the

person. They might put a chain on the

legs to avoid misbehaving, and the

marabout there will have a lot of men,

big men, strong men that would help

him when he is reciting and doing the

healing. There are some healers that will

chain some of the patient[s] that then

are quite aggressive to make sure that

they are in one place. And some will

even include beating them. So, yes. In

providing these services, they are also

abusing the people, which is also

against their human rights. Human right

violations. That’s [the] downside of the

traditional healing.

Participants further discussed the need for

comprehensive mental health policies and

legal frameworks for mental health. One

participant noted, “We have a mental health

bill that has been validated in 2019. But

unfortunately, it has not yet been enacted.

We are pushing very hard, but yeah, it has not

been enacted yet.” They clarified, “The law

that we are going by is the Lunatic Act. It’s the

law of the land, which does not provide any

rights to a person with [a] mental disorder. And

it’s very vague.” One participant also

expressed interest in attempting to “train non-

mental health specialists to be able to assess,

diagnose, and make simple interventions for

common mental health problems. … to train

the general health care personnel, to make

sure that mental health services can be

accessed at every facility, irrespective of

where you are.” One participant also

expressed, “So, of recent, what we have

started developing is to incorporate mental

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health services into the primary health service,

that is the existing health services.”

Discussion

The current phenomenological

investigation aims to understand the

phenomena of mental health and mental

health stigma among adults living in The

Gambia. The findings from the study

demonstrate the role of culture in people’s

understanding of mental health. These

perceptions significantly impact the social

identity of people with mental health issues,

the limited access to treatment pathways and

modalities for mental health care, and the

public stigmatization of mental health/illness.

The first theme identified in the data

analysis was social and cultural

conceptualizations of mental health/mental

illness. Given that 90% of Gambians identify as

Muslim, it was surprising that cultural norms

featured more prominently than religious

beliefs in the participants’ conceptualizations

of mental health. The causes of mental

health/illness were seen as spiritual and

beyond the human realm and attributed to

many explanatory forms, such as mysticism,

possession by jinns or demons, and even

revenge on healers or family members from

responsible agents for healing or helping a

person with mental illness. The transgression of

norms by a person or their family member

were also identified as a cause of mental

health/illness. Mental illness was seen as

retaliation, either from spiritually unseen forces

or a wronged individual who took revenge by

inflicting the condition through spiritual means.

These beliefs are so long-standing that they

have contextualized how people experience

mental illness and are labeled, stereotyped,

and discriminated against (Galvin, 2021). To

foster improvements in mental health, the

population must be educated on the etiology

of mental health, treatments, and possibilities

for care that have been identified elsewhere.

Unless this education is provided, the

treatment gap and mental health stigma will

remain.

Firdos et al. (2021) conducted a

community-based study on beliefs about

mental illness in different populations in Al-

Ahsa. The sample consisted of Muslim

participants with similar beliefs about the

causes of mental illness as the participants in

this study. This study is crucial for

understanding how similar Muslim countries

conceptualize and experience the research

phenomenon. Cultural beliefs are key to

addressing mental illness in The Gambia. To

contend with the gap in treatment,

psychoeducation for both the awareness and

treatment of mental health concerns must

consider the context of beliefs that impede

treatment at both the individual and systemic

levels. For mental health providers, developing

cultural humility necessitates continual

learning and openness toward their clients’

diverse cultural experiences and beliefs (Zhu

et al., 2021).

The second theme identified in this study

was sociocultural determinants of mental

health/mental illness. The Gambia is a LMIC; as

in many similar countries, there is inherent

economic inequality. This affects people's self-

concept in terms of lifestyle choices. In

addition, social issues such as poverty impact

the majority of the Gambian population. The

participants in this study discussed substance

abuse and poverty as causes of mental illness

and factors that deter people from accessing

treatment. They also noted family support in

the form of providing financial assistance to

obtain treatment and purchase medication.

The findings from this study align with those of

a recent foundational study on mental health

in The Gambia (Barrow & Faerden, 2022),

which significantly discussed poverty as a

factor that impedes positive mental health

outcomes and cited the high costs of

treatment, prescription injections, and

medications as a frequent barrier to accessing

care. Barrow and Faerden (2022) also found

that the cost of consulting traditional healers

was approximately $187 and that the cost of

biomedical interventions for injections and

medications ranged from $9–12. These high

costs and disparities are significant barriers to

accessing services (Barrow & Faerden, 2022).

Barrow and Faerden (2022) also noted that

reducing the factors that contribute to mental

illness would significantly reduce the

prevalence of mental health issues and help

close the treatment gap, which is consistent

with the findings from this dissertation.

In addition, participants in this study

referenced failed migration as a social issue

that leads to the displacement of Gambian

youth. They noted that globalization has led

many Gambians to seek better lives and

improve their family’s living conditions. Since

opportunities are not available in their own

country, they look to distant shores. One way

of seeking opportunity is through the “back

way” by illegally migrating through the Sahara

Desert and the Atlantic Ocean and entering

Europe. Although this approach has proven

fruitful for some, participants noted that

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widespread illegal migration has led to more

control and repatriation agreements, which

have made it somewhat easier for migrants to

be held in detention centers and eventually

deported. Participants also shared that, when

people plan to leave The Gambia, their

families often incur debt or sell land and

resources to ensure that their children will

succeed and be able to support them and

augment the family's status. Conversely, entire

families may suffer when people do not

successfully migrate, are detained for many

years, and eventually deported or returned,

as stigma is also attached to these

deportations. As described by participants,

returnees are viewed as having lost an

opportunity and mitigated to a life of poverty.

This can result in stress, depression, and

traumatic conditions, which may be

compounded by stigma and limited access to

professional counseling services.

The understandings, descriptions, and

labels attached to mental illness reflect the

highest level of public stigma. Stigma is socially

constructed and permeates all aspects of

Gambian society. Research on mental health

stigma has posited that language shapes

perceptions and can significantly influence

psychological or cognitive processes

(Granello & Gibbs, 2016). The terms that

participants used to describe mental health

did not reflect linguistic relativity (Wolf &

Holmes, 2011) or align with “people-first”

language (Granello & Gibbs, 2016). Instead,

they used stereotyping and portrayed mental

illness as a permanent, incurable condition

that affects the self-esteem and social identity

of affected people. A prevailing sentiment

among participants was that people do not

associate with those who suffer from mental

illness. Globally, there is evidence that public

stigma is a deterrent to seeking treatment for

mental illness, which aligns with the findings

from the present study. Participants shared

that many people would lock up a family

member with a mental illness rather than face

public stigmatization. Women from families

with mental illness are particularly affected,

and their marriage prospects are limited due

to the negative connotations attached to

their family history of mental health

(Amuyunzu-Nyamongo, 2013).

The third theme identified in the data

analysis was mental health care and

biopsychosocial interventions. The prevailing

belief among participants was that local,

traditional, or faith-based healing is the most

popular and accessible type of intervention.

In a seminal study on mental illness in The

Gambia, Coleman et al. (2002) found that

approximately 80% of the population resorts to

local and traditional pathways. These are

more aligned with people’s understandings of

mental health, as they are rooted in local and

cultural beliefs. Biomedical services in The

Gambia are the mainstream conventional

system of treating mental health in terms of

legal services. There is limited access to

outpatient services; currently, there is only one

inpatient facility in the country. The

participants shared that, as a result, people

must find the finances to travel to the region or

not go at all. The findings from this study also

suggest that there was previously a

community mental health team that traveled

around the country every three months to

provide greater access. However, this

program has been challenging to maintain.

Thus, a lack of funds significantly impacts

community services that could enhance

access to medical and mental health care.

From a multicultural standpoint (Ratts et al.,

2016; Bharti et al., 2021; Sue, 1994), it is

essential to recognize that counseling is an

emerging field in The Gambia. Although some

nongovernmental organizations are working

to increase services, a lack of awareness of

mental health issues in communities is a risk

factor for their sustainability. Given the

importance of the globalization and

internationalization of mental health

counseling in African countries, there have

been significant intersectional challenges

related to contextual factors such as stigma,

lack of awareness, and lack of infrastructure

(Amuyunzu-Nyamongo, 2013). Multicultural

counseling may also involve certain ideals,

such as decolonizing concepts. Due to

people’s beliefs about mental health, it is

difficult to demonstrate the potential healing

capacity of Western counseling.

Acknowledging current beliefs while showing

the possibilities of mental health care requires

balance, which a multicultural counseling

approach might be able to help with.

The traditional healing system of treatment

includes local, traditional, spiritual, and faith-

based pathways. Participants shared that

these are the most available and accessible

forms of treatment; they are grounded in local

belief systems and accepted by many people

as their first choice of treatment. Other

regional studies have also highlighted this

alignment with local cultural beliefs and the

accessibility of treatment. Furthermore, the

Work Health Organization Alma-Ata

Declaration (1978) recognized the role of

traditional medicine in the primary healthcare

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sector. The participants in this study

empathized with this treatment modality.

Findings from the subregion also showed that

80% of people who seek mental health

treatment in Ghana rely on the

abovementioned system of care (Krah et al.,

2018). Findings show that, although The

Gambian health sector is relatively small-

scale, it is moving toward full integration of

mental health care. This provides an

opportunity to foster the integration of

traditional healing into delivery and

multicultural counseling into mainstream

biomedical services or collaboration with local

and traditional healers. The Gambian

government could also help with the

integration of multicultural counseling and

psychoeducation.

The fourth theme identified in this study was

barriers to mental health care. All participants

suggested poverty was a social factor that

immensely impacts mental well-being. They

described poverty as a barrier to mental

health treatment and a cause of mental

illness. Therefore, reducing the circumstances

that cause economic inequality could be a

prime policy matter for the government. Since

around 60% of the population consists of

youth, the government could support training

and skills development of projects to alleviate

poverty among young people. Furthermore, a

lack of funds to pay for medication or daily

meals can impact mental health and well-

being. The current research did not examine

mental health among youth and women,

which are two groups significantly affected by

poverty; however, this area needs attention.

In addition, there is a need for mental

health literacy in The Gambia while also

respecting long-held traditions and values.

Local people could be trained to know about

mental health practices that promote

wellness. Some efforts are already underway

in this area, which could promote access to

services. As participants shared, community

mental health services could also improve

access. Although such programs have been

implemented in the past, they were cut due to

a need for more funding. This sentiment was

highlighted in a study by Kutcher et al. (2016),

which aligns with the findings from the present

study. For communities to benefit from

counseling, adequate training from qualified

professionals is required. These professionals

could work within the guidelines of

multicultural counseling practice and ethical

standards. So far, no known counselor training

programs or institutions exist in The Gambia.

The training of paraprofessionals could be

helpful, but they would only partially replace

professionals. Professional associations could

also provide counseling in underdeveloped

nations. Furthermore, the field of mental

health counseling must be regulated to

ensure that professionals who treat people

have an appropriate clinical background.

The fifth theme identified in the study was

legal frameworks to support mental health

change. The Gambia has stated its stance on

mental health: to promote it. To this end,

greater attention should be paid to mental

health policy, laws, facilities, and access to

services. In addition, there has been a call to

meet United Nations conventions. For

instance, it addresses the rights of people with

disabilities. The Gambia has an opportunity to

identify well-trained, experienced mental

health professionals and collaborate with

them to improve services and policies. It is

important to have a mental health policy in

place to guide mental health regulations and

access. Other studies have mentioned the

need for protection for people with mental

illness. For example, Lund et al. (2011) argued

that legislation and policies are required to

optimize mental health services in LMICs. The

Gambia alludes to this in its mental health

policy for 2021–2030.

With regard to policies, the ministry could

begin by revising practices in the existing

facility and increasing standards of care. For

instance, only one facility offers substance

abuse treatment and conventional mental

health care. A lack of halfway houses was also

noted in this study. Furthermore, it is essential

to address the financial burden of family

caregivers, if possible. Currently, a risk factor is

that the government does not regulate

traditional healing practices, which sometimes

entail physical beatings and other human

rights violations that can further exacerbate

mental illness. There has also been a call to

ensure access to food, housing, employment,

safe living and working conditions, gender

equity, and mental health (Cosgrove et al.,

2021). Collaboration between traditional

healers and counseling professionals could

result in the identification of common ground

to uphold human rights.

Limitations of the Study

While a qualitative data analysis yields

descriptive data, it needs to be more

generalizable and show the exact prevalence

of issues and needs in The Gambia.

Additionally, this study was conducted in

English, which only sometimes

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accommodates local dialects. It also

excluded many people who needed to speak

English. Furthermore, the data were collected

via Zoom, which required an internet

connection. Another limitation was that this

study did not focus on women and children,

who are the most widely affected.

Future Directions

Many opportunities exist for further research

on implementing mental health services in The

Gambia while considering the challenges of

an LMIC. Future research could utilize a

quantitative approach to identify the

prevalence of mental illness and the need for

mental health services more accurately.

Additionally, a quantitative approach might

identify the specific needs of people with

statistical data. Future research could also

investigate opportunities for multicultural

counseling professionals to collaborate with

traditional healers and biomedical services.

Furthermore, researchers could collaborate

with the government to identify legislation and

policies that promote mental health and well-

being in the country. This also sets a framework

for other LMICs to promote mental health

globally.

Conclusions

There are many opportunities for mental

health care and advocacy in The Gambia

and beyond. Yet, it is also essential to

recognize traditional healing practices and

beliefs about mental health, as these can

impact mental health stigma. While working

with populations that are only beginning to

explore mental health services, it is vital to

recognize community-based resilience in The

Gambia. For instance, people must become

accustomed to independently seeking care.

Instead, family members are typically tasked

with caring for them. Furthermore, recognizing

people’s inherent worth, and acknowledging

and accentuating their personal strengths

can help provide a buffer against the impact

of mental illness. This also challenges the idea

that people are solely defined by their deficits,

illnesses, or life circumstances; they are

capable and resilient when connected to

caring communities and systems (Ward &

Reuter, 2011). This reiterates the importance of

ecological systems theory and how different

systems interact and have great importance.

Utilizing Bronfenbrenner's ecological

systems theory, many people with mental

health issues rely on the family system for care

and access to mental health care.

Participants noted that families utilize

pathways that align with their worldviews and

cultural nuances since they are the decision

makers for individuals who need mental

health care. This reflects the family’s vital role

in a collectivist system. The mesosystem

concerns the connections between peers

and family. Sometimes, families fear sharing

that a family member is struggling with mental

illness because of prevailing beliefs about

being possessed or cursed. This can cause

isolation and stress for the family system. In

addition, it is essential to recognize that, with

some psychoeducation, communities might

be able to unite for early intervention. The

exosystem involves links between social

systems that do not directly involve an

individual (e.g., a family member’s job requires

travel). The macrosystem describes the

overarching culture, such as the challenges of

socioeconomic status and poverty in The

Gambia. Finally, the chronosystem involves

beliefs embedded in the Gambian culture

that can be passed down from generation to

generation, such as the assumption that all

people with mental illness are dangerous,

cursed, and often incurable. As evidenced by

the results from this study, there is also a widely

held belief that little can be done to support

the health of people with mental illness

beyond attempts to use traditional methods

of healing or institutionalization. However,

some participants with a higher level of

education recognized that there are

opportunities to revise policies, systems, and

care. In LMICs, mental health care cannot be

one-dimensional, and financial needs must be

addressed. In addition, cultural humility is vital

to advocate for people in The Gambia. It is

essential to help clients identify issues as they

see them and focus on the specific needs of

populations worldwide to promote mental

health and well-being.

Conflict of interest

The authors declare that they have no

conflicts of interest.

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