This novel study demonstrated the positive impact of the WHO QualityRights e-training programme in Ghana for addressing stigmatising and discriminatory attitudes towards people with mental health conditions and psychosocial, intellectual, or cognitive disabilities and for aligning attitudes with a human rights-based approach. In particular, participants (who comprised mental health/healthcare professionals, academics, administrative staff, and people with lived experience) completing the e-training programme showed highly significant attitude changes aligned with human rights across all items, with scores changing by approximately 40% between baseline and follow-up. This change was unaffected by sex, age, or background experience.
This result is especially impactful given the nature of the e-training provided: uptake of the e-training highlights that online training is accessible to a large number of people even in lower income countries, and this accessibility suggests that the e-training could easily be introduced into the curricular training of health professions’ degree programmes, or staff training programmes.
Generally, the impact of training programmes can be measured in terms of effect on knowledge, attitudes, and practice: they do not always co-occur. In this case, we know that knowledge has improved, as demonstrated by progression through the e-training course and successful completion of the continuous assessment elements of each module, and the current study provides strong support for an impact on attitudes. It is often assumed that attitudes are largely predictive of behaviour (per the Theory of Reasoned Action), but evidence on the attitude-behaviour relationship tends to show low correlations at best.38 Therefore, the question remains in this case as to whether attitude changes are predictive of practice change.
The idea that people who are familiar with (i.e., knowledgeable about) human rights will believe in and commit to upholding others’ rights39 (i.e., change their attitudes and practice in line with this knowledge) has face validity, and there is evidence that knowledge of human rights makes support for people using services more effective, as well as that specific human rights training is beneficial for people with lived experience, staff, and organisations.40 A meta-analysis of attitudes’ prediction of behaviour concluded that attitudes were more predictive if they were strong beliefs, stable over time, easy to recall (accessible), and relevant to their behaviour (i.e., they had direct experience of related situations).41
A qualitative synthesis of ten human-rights based approaches (HRBAs) in mental healthcare settings (through various training interventions/clinical decision-making guides) suggested that HRBAs can lead to behaviour (practice) change, as they showed clinical improvements at relatively low costs, contributing to positive therapeutic outcomes such as treatment satisfaction for people using services, their increased involvement, reduced use of seclusion, improved hygiene, improved health check access, reduced falls incidence, reduced need for anti-psychotic medications, and reduction in severity of challenging behaviour.25
As such, we could expect human rights training to alter attitudes, and for this to be predictive of behaviour, especially for people with personal experience of human rights violations and for those working in settings where human rights violations occur. In a qualitative investigation of particular relevance to the current study, Human Rights Watch conducted seven interviews with Ghanaian mental health professionals, most of whom had completed the QualityRights e-training, and found a marked shift towards human rights-based approaches in both attitudes and practice in Ghana.42 Consequently, there is substantial evidence that human rights-based training can impact both attitudes and behaviour, causing changes in practice and therapeutic outcomes.
The results of the current study in terms of capacity building are particularly important in the context of changing the paradigm of mental health care: the same Human Rights Watch article reported that coercive practices are in the process of reducing, with more awareness that mental health is not simply about taking medications or keeping patients secluded to reduce risk of harm – interview responses showed a shift to a person-centred, human rights-based approach to care.42 The WHO QualityRights training therefore has the potential to change coercive practices and promote a new, human rights-focused paradigm of care.
Ghana represents an excellent example when considering the wider implications of this work, as the problems their mental healthcare system faces are comparable (albeit with their own specificities) to other countries across the world, e.g., underfunding, societal stigma, discrimination, and human rights violations, including the use of coercive practices and denial of legal capacity amongst others. The WHO QualityRights Initiative e-training was be made available worldwide without need for an access code in April 2022, and as such many other countries may follow in Ghana’s footsteps, with many hundreds of thousands of healthcare professionals (and anyone with an interest) able to benefit from the e-training.
Nevertheless, there are some limitations, including the relative lack of follow-up questionnaire responses, as well as the lack of identifying information/assigned codes allowing us to match up baseline and follow-up responses. This limited the potential sample size and resulted in separate analyses being conducted for both the matched and unmatched responses, in order to make best use of the data available. However, on the whole, we were still able to access a huge sample size, with over 5000 completed questionnaires from Ghana alone, and the sample size was more than sufficient given the size of the effect of the training. Furthermore, as the questionnaires were not mandatory at either baseline or follow-up, there are many potential participants for whom outcomes from the e-training have not been measured.
Furthermore, the follow-up responses are likely to be biased as only those who have completed the e-training are given the link to the follow-up questionnaire, and so participants who found the training too difficult (or found it conflicted with their beliefs) are less likely to have completed the follow-up questionnaire, meaning the percentage change in attitudes may be somewhat inflated. There is also, as always, the impact of courtesy and social desirability biases, where participants are likely (especially after training) to give answers which reflect what they think the researchers would like to hear or what they feel they ought to say, rather than their true attitude or beliefs.
Additionally, our analyses were limited mostly to healthcare professionals, who made up around 80% of our sample. There was a general paucity of participants who identified as having lived experience (even more so in the matched sample): this unfortunately limits the breadth of our analysis in applicability to attitudes in people with mental health conditions and psychosocial, intellectual, or cognitive disabilities themselves. This may represent either stigma in sharing identifying information (hence reduced numbers in the matched groups, if they were less willing to share identifiable details) or may indicate that people with lived experience are less likely to complete the e-training; future research exploring the accessibility of the e-training for people with lived experience would be useful. Conversely, the increased proportion of mental health practitioners in the matched sample may suggest that they were more likely to complete the training (and give identifiable personal details) because of its relevance to their work or because it was required by their employer/paid.
In future, it would be ideal if further research could take an integrated approach to assessing attitude change, including the pre- and post-training questionnaires as essential elements of the programme, linked directly to the user’s account to ensure both responses can be linked. It would also be extremely beneficial to have a direct comparison between outcomes on units where staff have and have not yet undergone the training, perhaps through an observational study on compliance with human rights-based approaches (e.g., frequency of coercive practices) or through service user satisfaction surveys.