Mental health-related conditions cause a high burden of disease globally, Reference Fan, Fan, Yang and Fan1–Reference Vigo, Jones, Atun and Thornicroft3 and are estimated to affect over 400 million people directly each year. Reference Fan, Fan, Yang and Fan1 Depression and anxiety are the most frequent diagnoses. Reference Fan, Fan, Yang and Fan1 Mental health conditions disproportionately affect those who are socioeconomically disadvantaged, Reference Bernard, Wildman, Tanner, Stoniute, Still and Green4,5 and are a leading cause of disability and loss of economic productivity in low- and middle-income countries (LMICs). Reference Groce, Kembhavi, Wirz, Lang, Trani and Kett6,Reference Patel, Araya, Chatterjee, Chisholm, Cohen and Silva7 In 2021, the highest age-standardised incidence rate was found in Central Sub-Saharan Africa, with estimates of 8706 new cases of mental health disorders per 100 000 people. Reference Fan, Fan, Yang and Fan1 However, mental health services are usually underfunded and undeveloped. 8 The World Health Organization (WHO) recognises that to improve mental health services and systems, and to achieve health equity, high-quality research is needed. 9
To produce evidence-based research there needs to be frameworks of research priorities. Organisations such as the Grand Challenges in Global Mental Health initiative have produced mental health research priorities with worldwide relevance. Reference Collins, Patel, Joestl, March, Insel and Daar10 In Cameroon, there is limited research that could be used to shape mental health policy despite a growing need. Reference Ngwa, Mpofu, Patricia, Libwea, Obiora and Keinamma11 For example, there are no recent general population prevalence studies on mental disorders currently available. 12,13 This gap is important to address, especially in the North-West Region of Cameroon (NWR), where an ongoing sociopolitical crisis has added to a cycle of poverty, disease and mental health disorders. Reference Crawford, Kiven Kewir, Annan, Gaby, Kah and Kiwoh14,Reference Kibuh and Fokum15 Ensuring that mental health research is part of the research ecosystem is crucial. Reference Mviena, Fanne, Gondo, Mwamelo, Esso and Epée16,Reference Niba17
Mental health research in Cameroon
Mental health research in Cameroon is scant but emerging; here we briefly describe recent systematic reviews addressing mental health research. Fakembe and colleagues Reference Fakembe, Cockburn and Wallace18 emphasised the need for mental health intervention studies, locally relevant research and support to mental health researchers. They noted that the mental health strategy of the Cameroon Ministry of Public Health may address some gaps. Reference Fakembe, Cockburn and Wallace18 Another review of prevalence, risk factors or interventions for common mental health disorders in Cameroon identified only 32 studies for inclusion, with none addressing prevalence in the general population. Reference Ngwa, Mpofu, Patricia, Libwea, Obiora and Keinamma11 Samuel and colleagues Reference Samuel, Ntone-Enyime and Kamga Olem19 identified 96 studies in a retrospective, cross-sectional study of psychiatric research from ‘the private libraries of the teachers of Psychiatry at the Faculty of Medicine and Biomedical Sciences’, University of Yaoundé, for the period 2010–2020, identifying only one study taking place in the NWR. Few of these studies addressed Cameroon’s mental health systems. Mviena and colleagues Reference Mviena, Fanne, Gondo, Mwamelo, Esso and Epée16 described government efforts to reduce the burden of mental illness during the COVID-19 pandemic. Toguem and colleagues Reference Toguem, Kumar, Ndetei, Njiengwe and Owiti20 conducted a situational analysis of the mental health system in the West Region, finding it to have many challenges, including a dearth of psychiatrists and specialised programmes.
These reviews indicate that mental health practice in the NWR is not well studied. To address this gap, Ngwen and colleagues (details available from the author on request) used the Assessing Mental Health and Psychosocial Needs and Resources Toolkit for Humanitarian Settings 21 to conduct a review of mental health research literature concerning the NWR. In this unpublished desk review, 40 articles were identified and summarised. The authors did not identify any broad situational analysis or epidemiological studies about mental health generally in the NWR, nor about specific conditions such as depression, schizophrenia or anxiety. They stated that ‘there are high levels of stigmatization and discrimination towards people with mental health issues and illnesses’, with little research about attitudes, and cited Tanyuy et al’s Reference Tanyuy, Aguocha, Nwefoh and Wankam22 study of stigma, discrimination and other attitudes toward mental illness in Jakiri, a town in the NWR, which found that negative attitudes, discrimination and social exclusion were common.
Mental health services in the NWR
There is growing awareness of the need for mental health services in the NWR. The ongoing sociopolitical crisis in Cameroon has traumatised the majority of people in the region and has increased awareness regarding the need to improve mental healthcare. Reference Niba17,Reference Burris, Pacholek, Prostean, Cockburn, Nganji and Nadege23 Humanitarian organisations have been intervening by providing mental health services, including basic counselling, psychological first aid (PFA) and case management. 24 This awareness has led to several non-governmental organisations (NGOs) developing mechanisms to provide mental health and psychosocial support (MHPSS) by specialised staff, trained primary healthcare providers and others who have no formal mental health training Reference Niba17,Reference Handerson25,26 but who play important roles in integrating mental health into a range of primary healthcare and community-based services. Although not well researched, anecdotal reports found that the majority of mental healthcare being provided in the NWR is by people who are not trained in mental health.
Niba studied the effectiveness of telephones for the provision of community-based mental health services, and reported that this could positively affect their provision. Reference Niba17 They identified several limitations, including inadequate financial resources to pay for airtime, lack of training for mental health professionals and reduced motivation by mental health practitioners to use telephones for service delivery. Reference Niba17
The Cameroon Baptist Convention Health Services (CBCHS) has trained a cadre of mental health technicians, who are supervised by higher-level practitioners; they selected experienced trained nurses and gave them 1 year of mental health training, which differs from the country’s regular 2-year professional training provided to certify registered nurses as mental health specialists. Reference Handerson25 Some primary healthcare providers are trained on the Mental Health Gap Action Programme (mhGAP) for 1 week; however, CBCHS training includes two mhGAP training sessions over 2 years to better equip these people to act as facilitators in the integration of mental health into primary healthcare (mhGAP IG). 27 We found no evidence of research on the effectiveness of these interventions.
In addition to the above reviews of the literature, these anecdotal reports show that in the NWR there are increasing numbers of front-line practitioners and students who have an interest in mental health but an extremely small number of academic researchers. There is a need for a clear research agenda to guide mental health research in the NWR.
To build on the systematic literature reviews and descriptions of local issues above, this paper presents a proposed research agenda for mental health, mental disorders and related issues in the NWR. The paper aims to enhance awareness about mental health issues and the related need for research studies, including evidence about what is needed and effective.
Method
This study was conducted by a group of people who had experience in mental health and psychosocial support services in the NWR and shared a concern about the lack of research. The group decided to use a modified Delphi approach, Reference Nasa, Jain and Juneja28 which is shown in Fig. 1.
Process of developing the research agenda (adapted from Nasa et al Reference Nasa, Jain and Juneja28 ).
Identification of panel members
Although Delphi studies rely on expert panels, the definition of who is an ‘expert’ is varied and can be contentious. Reference Nasa, Jain and Juneja28 Contextually, expert refers to someone with knowledge and experience on a subject matter – in this case, expertise on experiences and services related to mental health and illness in the NWR. Notification about the intention to carry out this project was sent to the general WhatsApp group of all mental health and psychosocial providers in the NW and SW Regions (Thematic Working Group for MHPSS), with the invitation to indicate interest in participation. When members opted in, the project leaders screened them based on their interest, commitment and experience in mental health in the NWR. Panel members were also recommended by members of the research group and by key people in the region. No formal testing of members was carried out, but we did strive to have as many people with expert experiences as possible, as well as variations in levels of experience, professional background and areas of practice, in order to have a breadth of perspective when considering the recommendations and reaching consensus. There were a very small number of people working in the NWR at the time of this project, and some were not interested in research or evidence. Due to space limitations, we will not describe the educational and regulatory systems in Cameroon related to psychiatry and counselling, but we note there are few options for people who want to work in the mental health sector. Selection bias was not addressed, but rather we highlight the importance of recognising that all knowledge is produced within social and cultural contexts, that there are no ‘neutral observers’ and that affirming experience, cultural identities, reflexivity, relationships and connection to the community is a strength rather than a source of bias in this kind of project.
In total, 13 members joined and participated in the panel; their characteristics are summarised in Table 1. All members of the panel were invited to participate in both Delphi rounds, and in the analysis and writing-up of the final results for the current paper.
Participants included in the panel
MHPSS, mental health and psychosocial support; NWR, North-West region of Cameroon.
Identification of problem areas
To begin the process, we conducted literature reviews and held team discussions, workshops and WhatsApp group chats to identify an initial broad list of topics and areas of research needed. Key concepts included in the list were the need for localised and culturally appropriate research; inclusion of people with lived experience; prioritising action-oriented research; and research that would use decolonising approaches and understandings.
Ethical consideration and consents
Ethics approval was not required for this paper because the activity involved expert consultation without collection of sensitive personal data. All participation was voluntary, and participants were aware that they could stop participating in the process at any point, without explanation. Formal consent was not required for this study; all participants provided their consent by accepting the invitations, participating in the work and collaboratively writing the paper.
Delphi rounds
Once the broad list was identified, we adapted a Delphi process to refine it. Because many of the key people involved in mental health in the NWR were part of the project group, rather than having an anonymous panel, the group decided to have an engaged, collaborative learning process that would involve discussion and learning after each round. Google Forms allowed the provision of systematic voting and feedback, and to identify and suggest topics of most relevance. Votes were tabulated (each having equal weight), and both written and oral comments were provided to support choices.
Round 1
All members of the group were invited to participate in the first round. The first list of 44 topics were grouped into 6 categories, with several options for open-ended responses, and then the questions were sent out using a Google Form. The first round was open for one week, 15–22 January 2024. The results were then summarised and discussed by the team to develop the second round.
Round 2
For the second round, again all members of the group were invited to participate by completing a Google Form that had a refined list of research priorities based on Round 1 results. Each person was asked to identify their top three priorities in each of the six categories and could vote once for these; all three were weighted equally. The second round was open for 10 days. Responses were returned and discussed by the team. It was decided that an additional round was not needed because the results were clear.
During discussions of the results, members provided general contributions, questions and critique; significant comments were added to the list of written comments explaining why choices had risen to the top of the list. Draft results were shared in writing with the team for 1 week before specific changes regarding interpretations were incorporated into the final list. Suggestions and key points that received no objection from team members were added to the list. If there were objections or suggestions for modification, it was expected that at least 50% of those who debated a point would agree in favour before it was added to the results.
The final phase
The final phase was to discuss the results, reach consensus on recommendations and write this report. Again, all members of the group were invited to become involved. The group strategised to address challenges experienced by some members, due to frequent electricity and internet outages and lack of previous academic writing experience.
Results
The priority topics from the second round were placed into four categories (groups), presented in Table 2.
Priority categories and topics for mental health research in the North-West Region of Cameroon (NWR)
Group 1: broad and large research studies
The need for research on a broad range of topics about mental health, mental illnesses, local understandings and mental health services was deemed vital, with emphasis on three areas. First, a full situational analysis of mental health conditions and services in the whole NWR was considered crucial by 7 of the 13 members (54%). Comments addressed the need for the situational analysis to include the roles of health and non-governmental and humanitarian organisations, including a comprehensive examination of cultural and religious organisations. A strong recommendation was that the Ministry of Public Health should become a partner, to ensure successful completion.
Second, 8 of 13 people (62%) highly ranked studies about how the religious, cultural and ethnic groups in the region (and subgroups within them) use practices, language and concepts for mental health conditions and treatments. Four people placed this localised research as the most important area for focus, because mental health diagnosis is largely influenced by local traditional, cultural and religious beliefs, and understandings differ among cultural and religious groups. Several comments highlighted that limited resources and research have impeded understanding of the range of impacts of culture and religion on mental health, and that research is needed to inform practitioners, funders, researchers and policy- and decision-makers about how the diverse cultural groups view and handle mental health issues.
Third, conducting large studies regarding the lived experiences of people with mental health conditions, and their families and friends, including interviews and focus groups, were deemed important. Comments addressed the need for knowledge about diagnosis of mental illness, and that many general practitioners (e.g. doctors, nurses) do not know how to identify mental health conditions and may not know how to talk with people or understand their experiences. There was a recognised lack of mapping and testing of appropriate tools to diagnose mental health conditions. Mapping of current diagnostic practices was deemed crucial as part of the situational analysis.
Group 2: mental health interventions
The second group of topics focused on intervention research. The three most important topics were: (a) the development and evaluation of optimal interventions and treatments for trauma and post-traumatic stress disorder; (b) interventions that are grounded in local realities and ways, focusing on effectiveness; and (c) the optimal combinations of mental health treatments, including cost evaluations. Research is needed that identifies combination interventions that are both context specific and cost-effective. Ensuring that economic components are included in the development of interventions is crucial, because of the extremely high levels of poverty. There was recognition that research is needed on interventions for specific mental health conditions such as depression, anxiety and other responses related to both communicable (e.g. HIV) and non-communicable diseases (e.g. stroke, diabetes).
Emphasis was placed on research that addresses local realities, including the impacts of long-term trauma, colonisation and loss of population due to high death rates and migration. Comments called for mental health research to be integrated into the public health system. One person wrote: ‘I think burnout, post-traumatic stress disorder and depression are the most common mental health conditions in the region, but we don’t really know.’
Group 3: examining in depth the experiences, strengths and needs of subgroups
The third group of topics addressed in-depth aspects of mental health issues and contexts, because the panel recognised that there is almost no research about sub-populations and specific issues. In the survey responses, 2 options were deemed the highest priority, each receiving 4 votes of 13 (31%) as being most important in this grouping: (a) poverty and unstable small businesses were identified as significant factors impacting mental health, affecting groups such as single-parent families and individuals with chronic health conditions; and (b) gendered, systemic analysis to highlight how gender roles and expectations contribute to mental health issues within individuals (men and women) and families. With 3 of 13 votes each (23%), the next topics were: (c) the complexities of sexual abuse during conflict, emphasising its impact across different ages and genders; and (d) adolescents’ and young adults’ mental health.
Comments reflected the understanding that high levels of alcohol and drug consumption fuel mental health issues among youth and adults, and that developing a detailed research programme on alcohol and drug use should be a high priority; and included the crucial need for focusing on support for children’s, adolescents’ and young adults’ mental health in the next decade, given the ongoing sociopolitical conflict.
Group 4: performing mental health research
The fourth group of topics focused on researching locally appropriate methods and methodologies of performing mental health research. In this category, 10 of 13 votes each (77%) were given for how to carry out mental health research and for studies on how students are, and could be, involved in mental health research in local universities. The third priority was to review mental health-related research conducted at the University of Bamenda and other local universities. Comments focused on mental health research being conducted by graduate students, because currently there is no online repository.
Discussion
This paper presents a clear list of priorities for mental health-related research in the NWR, developed by a diverse group of mental health researchers and professionals. This research agenda can bolster mental health promotion and improve outcomes for individuals living with mental illnesses, encourage collaboration among researchers and community members and enhance the quality and relevance of mental health and psychiatric research. It encourages researchers in related areas such as public health, environmental studies and education to prioritise and include mental health research, and to advocate with government, NGOs and universities to make resources available to carry out the priority research that has been identified. For example, there is an urgent need for conducting baseline situational analyses and for research on locally grounded trauma interventions.
Broad studies, such as situational analyses and epidemiological studies, could provide baseline information about conditions, mental health services and the human resources that are available and needed. Large studies about mental health and mental illnesses can assist health and social service providers and provide guidance for decision-making and policy development within organisations and government offices, and in research settings. For example, the results of a broad situational analysis focused on mental health and illness across the NWR could be used by NGOs and governments to set programme priorities, and to identify gaps in mental health policy.
Our work indicates a clear need for intervention research, because there are very few studies published about mental health interventions in the NWR. Reference Fakembe, Cockburn and Wallace18 For example, we are not aware of any publications about evidence-based trauma interventions, although there are mental health resources, listening and orientation units for gender-based violence and other psychosocial support programmes available in the region. 24,Reference Lemal, Jamar and Nhake29
In the context of the current crisis, there is significant need for mental health support because the population is currently traumatised. Reference Chandini, Van den Bergh, Agbor Junior, Willliam, Obi and Ngeha30 This current priority-setting process recognises that the crisis influences all aspects of mental health service provision, and that research is needed to understand the depth and breadth of the impacts. Anecdotal reports are that religion leads to a lot of misunderstanding about mental distress, and people request formal assistance late in the experience of having mental difficulties; also, they do know the kinds of support available and are encouraged to believe that religious practices will solve problems. Although there are significant challenges to conducting mental health research in times of political crisis, our group has demonstrated interest and commitment. Partnerships among a range of organisations, including governments, NGOs and local and international universities, could effectively address these challenges.
This study contributes suggestions about how a panel of experts in a region can collaborate to create a research agenda, using a process that can be used by others in low-resource settings. Our process was low-cost, using primarily WhatsApp for communication and was based on volunteer contributions.
This list of research priorities is an important contribution to mental health practitioners, primary healthcare providers and researchers, and to students in the NWR, because it encourages the use of research in their work. We hope that this process can inspire similar consensus-building processes to develop mental health practice priorities. Collaboratively working with NGOs and governments could lead to projects and policies that truly reflect and address the needs of citizens and service providers. Policies and projects could gain high levels of community acceptance and participation because they have been based on evidence using participatory processes.
Our list can be used by front-line mental health specialists to think broadly and to consider becoming involved in the planning of mental health research, promotion, prevention, treatment, rehabilitation and other programmes, and to feel connected to, and better understand, international perspectives on recovery processes. The proposed agenda contributes to better understanding of the role of research in informing best practices and evidence-based treatments for mental health conditions, emphasising the importance of staying up to date with current research findings.
We hope that this list will expose other health professionals to research topics related to mental health, encouraging them to consider how mental health can be included in areas such as HIV, malaria, stroke and diabetes, which are among the leading causes of death in Cameroon. 31 Collaborative, interdisciplinary work can increase access to resources and training opportunities. Highlighting the inclusion of mental health research might reduce stigma among healthcare professionals and researchers.
This agenda can support capacity-building initiatives for NWR NGOs, and emphasise the role of research in informing effective interventions and advocacy efforts. Using the research agenda can enhance their evaluation and research efforts and contribute to the realisation of evidence-based practices. Collaboration between researchers, students and NGOs with communities and stakeholders could raise awareness about mental health issues, and promote reduction in discrimination and stigmatisation.
The proposed research agenda strongly supports the incorporation of mental health research into academic curricula to educate the next generation about evidence-based practices, and emphasises the need to organise seminars, workshops and conferences that showcase the impact of research on advancing mental health knowledge and improving outcomes. This list can provide students with research topics for academic studies, including thesis work.
For regional governmental and NGOs, the availability of the research agenda can be used for advocacy and organisational budgets and initiatives. Governments and researchers could collaborate to demonstrate the societal and economic benefits of investing in mental health research, such as reducing healthcare costs, improving productivity and enhancing overall well-being. These priorities can be linked to strategies for the achievement of the Sustainable Development Goals (SDGs), particularly those related to health, mental health and psychosocial support, such as SDGs 3 and 4. 32
Limitations
This study has some limitations. Although we included a diverse group of experts, others from different fields or organisations might have differing perspectives. We used a modified Delphi process to allow study team members to learn from the process; having a more opaque process, in which participants responded only to questions about research priorities without team discussion, might have led to different results. Although all participants had interest and experience in mental health services in the NWR, some were less familiar with the global discussions and scholarly discourse about psychiatry, mental health and mental illness, which might have limited their contributions; having the team discussions assisted these members to develop their understandings of global mental health research.
Conclusions
We have presented a research agenda for mental health in the NWR, emphasising interdisciplinary collaboration, participatory approaches and addressing community needs. Inter-regional and international partnerships are encouraged to foster locally relevant interventions, emphasising participatory research approaches. The changing dynamics of community needs and the absence of a culture of evidence-based health decision-making need to be considered. There is a need to build on previous studies both within and external to the NWR, to develop interventions that are locally relevant, scalable and sustainable.
In addition to research that focuses on interventions and psychosocial support, we call for research on capacity building and monitoring in mental health research, including in universities, to ensure effective use of limited resources. Local organisations play crucial roles in shaping the research ecosystem, promoting evidence-based practices that incorporate both indigenous and external knowledge to truly meet the needs of individuals, families and communities. This collaborative agenda-setting process has emphasised the importance of consensus-based research and will contribute to better understanding, reduce stigma and build stronger connections among researchers, practitioners, community members and policy makers who continue to support the people of the NWR.
Statement of relevance
This paper presents several advantages regarding the development of the mental health sector, including recommendations about improvement in research and advocacy leading to better service delivery in the NWR, and in LMICs. It has identified research gaps, indicating the need for more effort to improve mental health research. The results indicate specific areas that need more research effort, facilitating the potential for researchers and students to select relevant research themes that will have a better, reliable and sustainable impact. In addition, they provide specific areas for which advocacy and funding should be directed to create better impact.
Data availability
The data obtained as part of this research have been securely retained in records, and access can be made available with a reasonable request for the purpose of reproducing results or replicating procedures by contacting the first author.
Acknowledgements
We thank the assistance and contribution provided by Professor Fomban Emmanuel, Dr Khamelou Ibrahim and Ms Nangah Geraldine in the early parts of this project. The anonymous reviewers provided very helpful feedback that strengthened the paper, and we are grateful for the time and thought they took to make this important contribution.
Author contributions
F.S.N., L.C. and T.N. were responsible for project administration. F.S.N., L.C. and T.N. were equally responsible for writing the original draft of the manuscript. All authors participated in the conceptualisation of the project, development of the methodology, data curation, formal analysis, validation of the results and writing (including reviewing and editing) of the final manuscript.
Funding
The research received no specific grant from any funding agency, commercial or not-for-profit sector.
Declaration of interest
None.
Transparency declaration
This is to affirm that this manuscript is an honest, accurate and transparent comprehensive report of the study establishing mental health research priorities and gaps in the NWR of Cameroon. and that no relevant component has been omitted.
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