Mental Health Awareness in Primary Health Workers using Focus Groups
in a Rural and an Urban setting in Nigeria
Geraldine Idoniboye MD, MBA, FAPA (corresponding author)
There is a global shortage of services to address mental health problems. Since developing countries have fewer resources, it is imperative to seek out preventive measures to reduce the burden of mental illness. Community involvement in developing a service improves the likelihood that the service will succeed.
Focus groups were conducted in Gidan Mangoro (a rural setting) and Apapa (an urban setting) in 2011 in Nigeria. Participants discussed a number of mental health beliefs and strategies to help people living with or affected by mental illness; and were given information to improve their mental health awareness.
Unemployment, limited finances, overcrowded accommodation, substance abuse, problem behavior in children and lack of knowledge of how to deal with mental illness were the main issues described by the Gidan Mangoro group. Lack of employment, food, money, or good health were identified by the Apapa group. In Apapa, problems such as loud noise from radios and loudspeaker announcements, stress at work for those employed, expectations and demands of extended family, problems in relationships of adults to children and to each other within the family also contribute to stress.
The focus groups provided an opportunity for participants to discuss mental health issues. Participants initially said that they do not have any clients with mental health problems. Training to improve the mental health awareness of primary health workers will support them to assess and respond to mental health needs of their clients.
Primary health workers, health beliefs, mental health services, integrated care.
There is a global shortage of mental health services particularly for young people (World Health Organization, 2019b). In the search for ways to address mental health problems, a number of strategies have been developed (Idoniboye, 2008).
These include community based outpatient clinics where clients go for evaluation and care, community outreach services that go to assess and treat young people in their home setting and inpatient services for those who are diagnosed as not being safe to themselves or others (McGorry et al, 2011; de Girolamo et al, 2012).
It is widely recognised that developing countries have less resources to provide mental health care than developed areas; such as the Western world (The United Nations Children's Fund, 2003; World Health Organization, 2019b). As the budgets for health services are diminishing worldwide, there are increasing needs for identification and treatment of mental illness in particular.
It becomes imperative to seek out preventive measures to reduce the burden of mental illness and especially so for communities with the least resources. For example, in Australian schools where mental health promotion is provided to young people this has improved their emotional well-being and learning outcomes (The United Nations Children's Fund, 2003). In contrast, the Sub-Saharan region has high prevalence of mental health problems in children with the children in areas of greatest deprivation at greatest risk (Cortina et al, 2012).
Where is the best place to start devising preventive measures? It has been shown that where the community itself is involved in developing a service there is more community ownership and likelihood that the service will succeed in attaining its objectives (Petersen et al, 2008). The primary health care setting is where many people go for health care. Integrating mental health and primary health care services is an efficient way to reduce costs, and potentially reducing inpatient stays (Ezenduka et al, 2012) .
Many people with mental illness do not attend to their physical health. By integrating mental and physical health care the morbidity and mortality from common physical disorders in people with mental illness will potentially be reduced. Previous studies in primary care have shown that cardiovascular related illness is most prevalent (Li et al, 2009). People with mental health problems experience higher rates of morbidity and mortality from cardiovascular and other physical diseases than the general population, even in developed areas (Meehan & Robertson, 2012).
Globalisation, manifested by increased social, political, economic, cultural and ideological interchange; has created new sources for individual and communal stress (Bhugra & Diazgranados, 2018). The shift of populations due to migration from rural to urban areas and from third world to western countries, in search of greater opportunities, also presents new challenges to mental health in vulnerable groups (Halbreich, 2018).
In this study, primary health workers at both the rural and urban clinics initially stated that they do not have any clients with mental health problems. This is consistent with research findings in other primary health clinics in Africa where the primary health workers deny the existence of mental health issues in clients (Mash et al, 2012). This denial of known problems is probably due to lack of knowledge or stigma associated with mental illness.
However, screening for common mental health problems in the primary health care setting will improve identification of people suffering from or at risk of mental illness (Amoran et al, 2012). This study was done to engage primary health workers in discussion about how they can help clients at risk of mental health problems and when to refer clients with mental illness to specialist centers.
To identify mental health beliefs in a rural and an urban setting in Nigeria and improve mental health awareness in primary health workers.
Focus groups were conducted in Nigeria. The Federal Republic of Nigeria is a federal constitutional republic comprising thirty-six states and one Federal Capital Territory. The country is located in West Africa and shares land borders with the Republic of Benin in the west, Chad and Cameroon in the east, and Niger in the north. Its coast lies on the Gulf of Guinea, a part of the Atlantic Ocean, in the south. The capital city or Federal Capital Area is Abuja.
Gidan Mangoro is a remote community located in the greater Abuja area within Sokoto State (Sokoto State Government Nigeria, 2012). Apapa is a local government area within Lagos State (Lagos State Government Nigeria, 2012). Lagos State is a heavily commercialized area with many industries, institutions of higher learning, foreign investors and cultural venues.
The clinics at Apapa and Gidan Mangoro were selected for this study because primary health clinics located there were viewed as a place to potentially offer mental health services alongside physical health care.
In Gidan Mangoro the focus group was facilitated by a worker at the primary health clinic. The participants included primary health workers and some community representatives. The community representatives included a teacher and women’s group leader. The facilitator wrote down what was said by participants about health beliefs, sources of stress and how to help people with mental health problems in the community. Refreshments were provided and transport costs reimbursed.
In Apapa the focus group was facilitated by the author. The participants were primary health workers at the clinic. The facilitator wrote down what was said by participants about health beliefs, sources of stress and how to help people with mental health problems in the community. Refreshments were provided. Members of both focus groups gave unanimous feedback that they found the session useful and agreed to participate in subsequent discussions.
" Major causes of stress within families/communities:
1. High rate of joblessness.
2. Financial stress in most homes.
3. Parents and their children living in one room.
4. Not knowing how to handle one who is depressed in the family.
5. Lack of understanding of one another - husband and wife, children and parents.
6. Loss of one’s job.
7. Children not behaving well.
8. Having no shelter.
9. Having no food.
10. Drug abuse.
11. Frantically and aggressively looking for ways to survive, sometimes at the cost of stepping on other people’s toes."
" Major causes of stress within families/communities:
1. Lack of employment.
2. Lack of food.
3. Poverty or lack of money.
4. Lack of good health.
5. Loud noise from radios and loudspeaker announcements all day.
6. Stress at work for those who have jobs.
7. Expectations and demands of extended family members for support with education, food and other expenses from those who are working in the city.
8. Problems in relationships between couples.
9. Problems in communication between parents and their children."
Psychosocial and environmental problems such as homelessness and unemployment have been used to prepare evaluation reports on people with mental illness (American Psychiatric Association, 2013). The World Health Organization (WHO) has described mental disorders as ‘a broad range of problems, with different symptoms.
However, they are generally characterized by some combination of abnormal thoughts, emotions, behaviour and relationships with others. Examples are schizophrenia, depression, mental retardation and disorders due to drug abuse. Most of these disorders can be successfully treated’ (World Health Organization, 2019a). The WHO also publishes an international classification of diseases manual to inform the planning and implementation of health care services across the globe (World Health Organization, 2018).
Both the APA and WHO publications also describe mental health problems in terms of how they limit life enjoyment and productivity in those affected. Early age of onset of mental illness is associated with longer duration of illness and poorer clinical outcomes (McGorry et al, 2011). It is important to screen for mental illness in young people and offer support and treatment to those at greatest risk.
Early intervention in the early stages of mental illness will help achieve better control of clinical symptoms and improve outcomes for people with emerging mental illness (de Girolamo, 2012). The costs of treating the highly prevalent disorders will also be reduced if detected and treated at the time they emerge in childhood or adolescence.
Although there are more financial and other resources in the Western world, there are also disturbing rates of morbidity and mortality from mental illness in young people in developed areas (de Voursney et al, 2012). The WHO and other bodies’ statistics about longer life expectancy (LE) in the Western world may mask other dimensions of quality of life.
For example, between 1981–2006, in Great Britain, disability-free life expectancy (DFLE) at birth increased for both males and females and healthy life expectancy (HLE) at birth also increased for each sex (Office for National Statistics, 2012). In fact, the difference between estimates of LE and HLE/DFLE can be regarded as the number of years a person can expect to live in poor general health or with a limiting persistent illness or disability. The increase in LE over these periods largely exceeded increases in both DFLE and HLE, which equates to a rise in the years of life spent with a limiting persistent illness or disability and the years spent in poor general health.
Though developing countries have fewer resources for health, people in the Western world, such as those in Great Britain; are living greater proportions of their lives in poor health or with persistent illness or disability. This may be part of the reason why it is in developed areas that stakeholders have been more likely to influence sustained funding for health studies including mental health research; the results of which have helped the global community to improve the level of knowledge of the course, treatment and prognosis in mental illness.
The factors associated with increased risk of mental illness or disorders include physical health problems, such as HIV infection/ AIDS (Kagee, 2012), though this was not specifically mentioned in the focus groups’ discussion. In addition, it is well known that young people with chronic physical illness such as sickle cell disease or cystic fibrosis have mental disorders precipitated or exacerbated by having to cope with physical problem (Myrvik, 2012; Withers, 2012).
The initial disavowal, of mental illness in the clients they treat, by primary health workers may reflect lack of knowledge or stigma associated with mental illness. Bearing in mind the mental health issues itemised by community members, and what they recognised as the causes and effects, a program could be developed with existing primary health workers to understand how best to present mental health care to the community and to the young people in particular.
Eventually, targeted community mental health services can be developed for this area, including integrating mental and physical health education and treatment; by
1. Building up peer education groups.
2. Screening for mental disorders.
3. Managing physical health problems which are so often under diagnosed and treated in people with mental disorders.
4. Tackling stigma towards those affected with mental illness and those who treat them.
5. Definitive and effective community mental health services such as counselling, treatment and continuing care would require providers to take the time to build up a trusting relationship with the community members so that they utilize the service, as well as offering affordable and appropriate care.
6. Stakeholders should be identified, who would support primary health care providers in their role.
The most prevalent mental disorders emerge at an early age. Providing services to identify young people at risk of mental illness and offering treatment and support at the early stage of illness improves clinical outcomes and reduces costs.
In this study, focus groups were used to elicit the health beliefs and improve mental health awareness of community members and workers at primary health clinics in a rural and an urban setting in Nigeria.
The focus groups’ discussion highlighted crucial mental health issues including those that affect young people. It is important to involve community members in developing health services so that it is owned and used by the people in that area.
In a recent study, mental health service users and their families expressed their need to be listened to, to have practical help, support or assistance with problem solving and skills training to cope with mental illness (Fossey et al, 2012). They also identified service attitudes, staff expertise or cost as limiting access.
Though the research evidence is scarce, there is indication of compromise of several rights - such as health, education, nutrition, non-discrimination, and physical and mental integrity - in developing areas (Franca-Junior et al, 2006). Training to improve awareness about mental health issues will improve the ability of primary health workers to identify people at risk and when to refer to specialist centres. Engaging stakeholders is vital to support the primary health service to provide integrated physical and mental health care.
Sister Cecilia Nya supported the focus group in Gidan-Mngoro by facilitating and allowing use of the clinic space; Sister Maria Ruiz supported the focus group in Apapa by attending and allowing use of the clinic space.
This research received no specific grant from any funding agency, commercial or not-for-profit sectors. The author has no financial, professional and personal relationships with the potential to bias the work.
Conflicts of interest
The author affirms that no human or animal experimentation was conducted during this research. No misconduct or ethical breaches occurred during or after completion of the focus groups.
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