Shelby Cobb Reflection – OTD Level II Fieldwork in Accra, Ghana

Shelby Cobb was awarded a Center for Global Health Student & Trainee Travel Grant in the fall of 2022 to pursue a project with Child Family Health International in Accra, Ghana. View more photos of her project in this Flickr photo gallery.

Introduction

As an occupational therapy (OT) student, we spend our final year completing two 12-week “Level II Fieldworks” which consist of structured clinical experiences where we are exposed to specific settings including hands-on learning, meant to show us to what life is like in these settings and allow us to develop the clinical skills needed practice after graduation. For my first Level II Fieldwork, I went to Accra, Ghana. I wanted to experience occupational therapy delivery in another country, including different cultural considerations, treatment delivery, and any barriers to practice. During my 12 weeks there, I worked at a teaching hospital in an inpatient psychiatric setting with adults, in a rural community clinic which saw the entire lifespan, and an outpatient pediatric clinic. Throughout this write-up, I will describe my time in each of these settings including things I learned and impactful experiences.

In-patient Psychiatric Ward (adults)

The inpatient psychiatric ward at Korle Bu Teaching Hospital in Accra, Ghana consists of 12 beds (six male, six female) in a “ward” style. There is one OT who sees the entire inpatient caseload in addition to doing home visits. She is part of a mental health team which consists of mental health nurses, psychologists, and interns where collaboration is prioritized for patient care. Most diagnoses included schizophrenia, bipolar disorder, major depressive disorder, and substance abuse disorders. The mental health team worked together to provide interventions and create plans for these clients to allow them to become stable enough for discharge and maintain that stability as they go on to their normal lives after discharge.

Many of the treatment interventions that were used in the ward were group style, which made the most sense for the set-up of the facility, but also allowed the clients to create relationships and bonding experiences. We conducted exercise classes, dancing classes, played games, engaged in community art, and beading activities, all geared toward the skill set that each individual needed to develop. Some of my favorite interventions included beading and drawing because they really exposed me to unique cultural aspects. Beading is huge in Ghana; it has cultural significance and is frequently used as a way to make an income and provide purpose through work. This activity allowed them to get into a “flow state” which comes from repetitive motions (such as stringing beads) to open the door for deeper conversations. This allowed the participants to open up about how they were feeling about being discharged soon, their motivating factors and plans for change, and things they were concerned about. This was cool for me to experience, especially because they had just met me and were already comfortable sharing intimate details about their lives with me. The drawing interventions created a similar atmosphere for the participants and again exposed me to cultural aspects on a deeper level. Clients would often draw scenes of significance and some of these included depictions of the villages they were from, their work and livelihoods, and motivating factors. Some drawing sessions were based off the Kawa Model, which utilizes the metaphor of a river to allow participants to identify cultural and environmental factors that impact their life as well as barriers and facilitating factors that are present in their life.

Taking part in home visits after clients had been discharged was by far my favorite part about being in this setting. Through these visits I was immersed in various cultural aspects related to the country of Ghana including “compound” living environments, first-hand experience of the stigmatization associated with mental health in Ghana and experiencing Ghanaian hospitality. It also gave me the opportunity to engage in follow-up care and adapt care plans as the clients progressed and experienced new challenges and obstacles.

Outpatient Community Clinic (pediatrics and adults)

My time spent in this rural setting allowed me to reflect on community-based care, including its relevance and importance to the field of OT, despite the fact that OTs are rarely present in these settings. As a previous community psychiatric nurse, my clinical educator, Daniela went back to school to study OT where she continued to fuel her passion for community-based care. This clinic was developed out of a need and the passion that Daniela possessed and despite the poor job security and subpar pay, she knew this was where she was meant to be. What started as a space given out by the Shai Osudoku District Director of Health Service to hold support groups, quickly turned into a fully operating therapy clinic which saw the entire lifespan and various diagnoses. The startup of this clinic was also supported by GoTherapy, an OT-led NGO that supports the elderly and stroke survivors. Activities at the clinic include facilitating of wheelchair fittings, advocacy for inclusive education, educating facilitators and caregivers, and organization of community outreach and screening programs. All of which are important roles that are only addressed by the OTs in this clinic. The clinic’s place in the community is significant and is evidenced by how quickly their caseload grew, based solely on word of mouth which transitioned into referrals from other healthcare professionals as well.

There are many cultural considerations that are relevant in this setting that further emphasize the importance of community-based OT. For example, many individuals with disabilities in Ghana are stigmatized, to the extent that children are not allowed to attend school and some parents choose to keep their children at home to be out of sight of the public. Inclusive classrooms are not common, and this remains a concept that Daniela is still working to change. As an OT, she understands the value that participating in school has for the child’s communication skills, relationship building, and overall cognitive development that is necessary to function in everyday life. Therefore, she is responsible for educating and engaging with teachers, administrators, directors, and parents to create inclusive classroom experiences for the children in the district.

Another unique aspect of community-based OT is the diverse caseload in this setting. This requires the practitioners to be knowledgeable about a variety of diagnoses and in this case, they must be willing to travel to treat many of the more rural clients. During my three weeks in this setting, there were three outreach days organized by the clinic. These were set up via collaboration between the OTs at the clinic and the community members of the outreach areas. Prior to the outreach day, the clinicians sent out a memo to be delivered to the community area they were going to visit. The memo specified prospective clients, including any signs and symptoms that may qualify them to attend the screening, and was announced on the community’s information center multiple times for everyone to hear. The clinicians rely on memo announcements like this one, as it is the most effective way to deliver a message to the greatest number of people. Aside from the organized community outreaches to screen for those that may need OT services, the community-based clinic also conducts monthly therapy sessions in the communities. This has become a necessary additional role since most clients live a considerable distance from the community OT clinic in Dodowa and are unable to attend weekly therapy due to difficulties with transportation, mobility, and finances. These efforts (screenings, outreach, home visits, school visits) make a huge impact on the community but also drain money from the clinic, as the clinicians must financially support the entire process. This makes it challenging for the community clinic to sustain these outreach and screening days which are so greatly needed by the community.

The many roles filled by the OTs at this community clinic deserve applause, but that praise isn’t enough to support the extensive efforts they are making in the community. Lack of resources is a factor that is often mentioned with African countries, and this was my exact experience as compared to many US clinics. However, the OTs here were still able to address client needs and engage clients in age-appropriate occupation-based activities throughout their sessions, which is the ultimate purpose of OT. It is recommendable to note that despite the “lack of resources” they are still achieving their goals with what they have available, an indication that life for the therapists and the clients would be much better if they had the needed support. Evidence of the limited resources are, however, much felt, when it comes to interventions outside of the clinic. For example, the community outreach and screenings suffer most due to lack of funding thus, hindering therapists and other team members’ ability to deliver appropriate care. Unfortunately, these community activities are some of the most valued aspects of “Community OT” and the efforts that allow for equal access to care.

Outpatient Pediatric Clinic

The OT department located in the child health department at Korle-Bu Teaching Hospital serves the pediatric population, including various diagnoses, with the majority of cases being autism and developmental delays. Many of the referrals for the OT department here come from within the hospital at the outpatient neuro clinic that occurs weekly or from the local children’s hospital Princess Marie Louise, which does not have its own OT department (although they do have PT). The space consists of two rooms about the size of a large closet where multiple clinicians are seeing clients simultaneously in the same space. Often, the caregivers (parents, grandparents, siblings) take part or sit in on the session as well, making things a bit crowded. Because this clinic is located inside the teaching hospital, there are many other health care professionals around however, the interprofessional collaboration at this site is limited. The OT department will often receive referrals from speech and language pathology (SLP) and they collaborate with doctors and nurses on the wards when they get referrals to see clients there (but this is rare). Additionally, there is a social worker who spends some time in the OT department which allows for collaboration on any mutual clients. There is an obvious potential for more collaboration with physical therapy (PT) here. Many of the clients in the OT clinic also see PT, but the PT clinic is located in another area of the hospital, and these OT and PT clinicians do not discuss their mutual clients. Collaboration between all therapy services could be very beneficial, especially in cases where client behaviors or sensory needs are interfering with PT delivery.

As mentioned above, in more rural areas of Ghana, it can be uncommon for children with any kind of disability to attend school due to the stigmatization. This greatly impacts many developmental skills and therefore impacts therapy services and their progress over time. However, almost all of the clients I saw in my time at this clinic were enrolled in and attending school, which could be due to being in a more developed area with greater resources. Another cultural aspect that impacted clinical care was that parents here were quite interested and invested in their child’s therapy, progress, and diagnosis. Most were present for their child’s therapy sessions, and they often asked questions to further understand the diagnosis, why we engaged the child in certain activities during therapy, and what they could be doing at home to support them. This allowed us to create home programs that were actually used and therefore benefitted the client’s progress. Having the caregivers present for the sessions also allowed them to better understand OTs role and see the benefits firsthand. Additionally, it allowed them to learn how to engage their child in activities at home in a hands-on way. This parental involvement was quite different from what I experienced in Dodowa, where most caregivers did not engage in these behaviors to this extent. There are a number of reasons this could be the case; perhaps parents in Dodowa were not as comfortable asking questions or maybe being in a more rural area meant less education therefore making it less likely that parents would know what questions to ask, additionally, the stigmatization of disabilities in the more rural areas could be impacting parental involvement.

Conclusion

Spending time in such a wide variety of settings allowed me to better understand OT delivery, cultural aspects of care, resource management, barriers and facilitators, and client understanding of OT across many populations in Ghana. I was surprised about the similarities of OT in the United States compared to Ghana and equally surprised at the differences between countries and within the country of Ghana as well. The kindness and welcoming demeanor of the people here made this experience what it was. It’s a special kind of feeling to be welcomed into someone’s home and treated with the utmost respect and kindness despite being a foreigner and making the occasional naïve mistakes that come with learning a new culture and way of life. The relationships I formed and learning experiences I had during the three months I spent in Ghana will continue to impact me as an individual and as a practicing OT.