Community Mental Health Service User-Led Crisis Planning and Compulsory Admission Rates in Ghanaian Districts: A Stepped-Wedge Cluster Evaluation

Compulsory admission remains a contested feature of community mental health services in Ghana, and service user-led crisis planning has been proposed as a means of reducing its incidence. The evaluation was designed as a before-after-control-impact (BACI) estimator with a stepped-wedge rollout, and its operating characteristics were characterised under a declared variance structure with an intraclass correlation of 0.64, between-cluster standard deviation of 6.0 and residual standard deviation of 4.5. Power was estimated across 2000 design cells for cluster counts of 8, 16, 24 and 32 and effect sizes of 3, 5 and 8 percentage points. The analysis indicates that 54 clusters would be required to detect a 5 percentage point reduction at 80% power. The stepped-wedge BACI design is feasible for this intervention only at cluster counts substantially above those typically available to Ghanaian district mental health programmes, and that the evidentiary standards for user-led crisis planning must be calibrated to this constraint. The contribution is a design-based account of what can and cannot be learned about compulsory admission reduction from user-led crisis planning in this setting.