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KNOWLEDGE AND ATTITUDE CONCERNING MENTAL HEALTH OF PRIMARY HEALTH CARE WORKERS IN NIGERIA O.A. ABIODUN
SUMMARY health
in
Primary (PHC) developing countries continues to rely heavily on paramedical personnel. Using a structured questionnaire, 207 PHC workers in Nigeria were assessed on the concept, attitude to, detection and treatment of mental disorders. PHC workers without previous exposure to mental health training were significantly more likely to hold on to traditional views on the aetiology of mental disorders. Most of the health workers (82%) indicated that mental disorders accounted for 5% or less of their patient load. Detection rate for the vignette on neurosis as a case of mental disorder was poorer than that for psychosis (36% vs. 71 % of respondents respectively). Psychopharmacological knowledge of the PHC workers was found to be poorest for antidepressant medication. Only 30% of the health workers could suggest specific types of mental health programme that could be introduced at PHC level. Many of them (72%) expressed a generally negative attitude towards mentally ill patients. Suggestions are made on the short and long term training requirements of the PHC workers in order to ensure the successful integration of mental health care into the primary health care programme in Nigeria. care
INTRODUCTION Mental disorders are commonly encountered in primary health care and community settings in Africa and other third world countries (Abiodun, 1990; German, 1987). Most studies have found morbidity rates similar to those in developed countries despite the high prevalence of preventable physical disorders (eg. malaria, gastroenteritis and malnutrition) in the former (Sriram et czl. 1990; Abiodun, 1989; Harding et al. 1980; Orley & Wing, 1979; Giel & Luijk, 1969). Mental health care personnel and facilities however continue to be grossly inadequate to cope with the magnitude of mental health problems in these developing societies (Abiodun, 1990; Wankuri, 1984; WHO, 1975). In order to rectify the situation and extend mental health care services to the needy population, it has been suggested that the existing health staFf in general health services (where most patients with mental health problems first present) need to be actively involved (Sartorius & Harding, 1983; WHO, 1975). As observed by Wig et al. (1980) this is a positive shift, since hitherto the care for mental disorder had rarely been given any priority and most third world health planners were known to have often limited the scope of mental health services to mental hospitals with mainly custodial functions. In Nigeria, a National Mental Health Policy which places emphasis on the provision of mental health services through primary health care has just been formulated. However, in
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involve fully the primary health care workers in the provision of mental health of the necessary steps is to obtain information on their attitudes, knowledge and skills regarding mental health problems (Ignacio et al. 1983). This would provide the necessary information on the training needs of this category of health workers. The present study therefore reports on the knowledge and attitudes concerning mental health of primary health care workers in Nigeria prior to designing a training programme for them.
order care,
to
one
Study Area study took place in the Irepodun local government area (ILGA) of Kwara state one of the twenty one states in Nigeria, a country in the West African sub-region. The country operates on a three-tier system of government (local, state and federal). Kwara state (located in the middle belt region of the country) with a population of about 3.5 million people is divided into 12 local government areas, one of which is ILGA from where the present study population is drawn. The study area (ILGA) was chosen because it is one of the local government areas used by the University of florin Medical School for its community outreach programmes (the Medical School operates a community based education and service programme). The The
MATERIALS AND METHOD
A structured questionnaire design was used for the study. The questionnaire had sections on sociodemographic data, nature of duties performed (eg. proportion of time spent on curative/preventive services), knowledge of causes of mental disorders, ability to recognise descriptive cases of mental disorders (two of the four Star vignettes (paranoid
schizophrenia
and
anxiety neurosis/depression) previously
used in
community/primary
studies in the country (Ayorinde & Erinosho, 1977; Erinosho & Ayorinde, 1978) were included for this purpose. Other sections included questions on attitude to patients with mental disorders and knowledge of drugs commonly used to treat mental disorders. The last section (to be reported separately) involved questions on the knowledge and attitude of primary health care (PHC) workers about drug abuse.The initial phase involved obtaining the list of all primary health care facilities (both public and private) in the local government area. Primary health care workers in the health facilities who provided some form of preventive or curative health care were included in the survey which took place in February 1989 (labourers, clerks, drivers and others in the primary health care services not directly concerned with health care were thus excluded). The questionnaires were distributed to various health care facilities in the study area by four research assistants who were very familiar with the local government area and the location of the various health facilities. The PHC workers were very enthusiastic and cooperative throughout the period of the survey. The most senior health worker in charge of each primary health care facility took responsibility for distributing the questionnaires to eligible respondents and care
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115 Table I
Categories of Primary Health Care Workers Irepodun Local Government Area
in
for collecting them back. The research assistants then returned a few days later to collect the completed questionnaires. Repeat visits were necessary in some cases in order to ensure that all completed forms were retrieved.
RESULTS Two hundred and seven out of 240 eligible respondents participated in the study (86%). There were 131 (63 %) female and 76 (37%) male respondents. Distribution by age showed that 17 (8%) of the PHC workers were aged between 20-24 yrs.; 58 (28%) were in the age group 25-29 yrs.; 47 (23%) in the age group 30-34 yrs; 41 (20%) were aged between 35-39 yrs.; 27 (13%) were in the age group 40-44 yrs.; 12 (6%) were in the age group 45-49 yrs.; while five (2%) were aged between 50-54 yrs. The mean age for the study population was 33.9 yrs. Table 1 indicates the categories of PHC workers involved in the survey. This shows that primary health care services in developing countries continue to rely heavily on paramedical personnel. Table 2 shows the various PHC facilities where the health personnel worked. One hundred and sixty one (78%) of the PHC workers spent 50% or more of their working time largely on health centre based curative services, leaving relatively less time for community-based preventive health care.
I3~Y~~ata1 health training, attitude and skills The majority of the PHC workers still held on to traditional beliefs about the causation of mental disorders. Forty seven (23%) of them believed that mental disorders always/often result from charms, evil spirits, witchcraft or being cursed by enemies while an additional 113 (55%) believed that these factors may occasionally cause mental disorders. Furthermore, 23 (11 %) respondents claimed that emotional factors such as worries never result in psychological impairments. PHC workers without previous mental health training were significantly more likely to hold on to these traditional views on the aetiology of mental disorders (~2=6.31; p < 0.05). Similarly, significantly more of the PHC workers (44%) who held the view that mental disorders could be transmitted to a
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116 Table 2
Primary health
care facilities where personnel worked
the PHC
Table 3 PHC workers’ estimates of patients with mental disorders in PHC facilities
child if
a mentally ill mother breastfeeds the child, had no exposure to mental health training (:~Z = 42.9; p < 0.05). The majority of the PHC workers (82%) believed that mental disorders accounted for less than 5% of patients that they came across in their PHC facilities (Table 3). These low estimates were given irrespective of previous exposure to mental health training (X2 = 0.031; p > 0.05). Although 166 (80%) of the PHC workers believed that mentally ill people could be helped in existing health facilities, many of them (70%) felt that a new set of health workers (rather than themselves) should deal with mentally ill patients at the health centres. Thus, 198 (96%) of the PHC workers would prefer referral either to general hospital psychiatric units or admission to mental hospitals if more mentally ill people came for help at the health centres. Few of them (30%) were able to suggest specific types of mental health work (such as education on drugs and alcohol, treatment of epilepsy and acute psychosis and support for patients with life crisis) that could be
introduced in local health services. No mention was made of support to families with retarded children, preventive work with mothers and young children or treatment for chronic psychotic patients. It was found that significantly more of the PHC workers with previous exposure to
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mental health training were able to recognise the vignette on paranoid schizophrenia as a case of mental disorder (X~ =10.85; p 0.05). Twenty seven (13%) of the PHC workers believed that mental illness always/often responds better to traditional or native treatment than to orthodox (hospital) therapy. An additional 134 (65%) of the health workers felt that better response to native therapy may occasionally occur. Only 46 (22%) of the PHC workers believed that mental illness never responds to native therapy as well as it does to hospital treatment. Thirty-seven (18%) of the PHC workers would themselves prefer to be treated simultaneously by both native therapy and hospital treatment if they became mentally ill, whilst three others (I %) would prefer only native treatment. The remaining PHC workers (81 %) would want hospital treatment. Most PHC workers were aware of diazepam and chlorpromazine (75% and 70% respectively of the respondents) as being useful drugs in treating mental disorders. Ninety (34%) of them were not familiar with haloperidol. In addition, 53% of the PHC workers did not know that immipramine and amitriptyline (anti-depressant medication) are drugs used in the treatment of mental disorders.
DISCUSSION The findings from the present study show that traditional views on the aetiology of mental disorders remain common among the PHC workers studied. Such traditional views have commonly been reported among communities in third world countries (Odejide & Olatawura, 1979; Erinosho & Ayorinde, 1978). However, since PHC workers (who have the closest link with the communities) are expected to play a frontline role in educating their communities on various aspects of health related issues (including mental health education eg. on the aetiology of mental disorders) there is an urgent need to re-orientate these health workers on the nature and causes of mental disorders. This will in turn ensure the dissemination of accurate information to lay community members. It was also observed that many of the PHC workers did not recognise the vignette on neurotic illness as a form of mental disorder, despite the fact that such disorders occur commonly in PHC settings of both developing and the developed countries (Abiodun, 1990; Harding et al. 1980). This poor recognition may partly explain the generally low estimates of cases of mental disorders which the PHC workers claimed to have come across as part of their clinical duties. It is therefore essential to train the primary health care workers to be able to detect common mental disorders that occur in primary health care settings. In addition, it will also be necessary to encourage the health workers to show positive changes in attitude toward mentally ill patients (it is well recognised that attitudinal factors may play important roles in determining the response of health
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workers to their patients’ treatment (Anderson & Clement, 1987)). This will ensure that a positive therapeutic staff-patient relationship exists between these health workers and their mentally impaired patients. Previous studies have shown that such positive changes in attitude can be achieved (Bairan & Farnworth, 1989; Ayorinde & Erinosho, 1977). It is noteworthy that a significant proportion of the PHC workers were of the opinion that mental illness may respond better to native (traditional) treatment than to hospital therapy and indeed some of them were willing to patronise traditional healers if they became mentally ill. This shows a major area of conflict (inherent in the traditional views of these health workers about the aetiology and therefore the required treatment for mental disorders) that could affect the effectiveness of these PHC workers in their new envisaged role as providers of mental health care. Similar observations were made by Ogunlesi and Adelekan (1988) in another local government area in southern Nigeria. Thus, mental health education to change the therapeutic orientation of these PHC workers would be necessary. In keeping with results from previous studies (de Jong, 1987; Ignacio et al. 1983; Gullick & King, 1979), it was found that the psychopharmacological knowledge of the PHC workers was poorest for antidepressant medication. This may be corroborated with the general observation in previous studies that many cases of depression go unrecognised at PHC level (Abiodun, 1989; Katon, 1982; Goldberg, 1979; Goldberg & Blackwell, 1970). However, in the present study, although many of the PHC workers were aware of chlorpromazine and diazepam as being useful drugs in managing mental disorders, no attempt was made to test their knowledge on dosage, indication and side-effects. These are also areas where PHC workers have been noted to show deficient knowledge (Ignacio et ccl. 1983). Attention would therefore also need to be paid to these areas in any educational package for the PHC workers. Finally, the results from the present study support the observation that successful integration of mental health care into the general health care services in developing countries (including Nigeria) necessitates both short and long-term training programmes for the PHC workers (Abiodun, 1990). On a short term basis, training programmes (eg. using operational manuals such as flow charts) for the present crop of practising PHC workers would need to be embarked upon in order to improve their knowledge on the aetiology, detection and management of mental disorders that present in primary care settings. On a long-term basis an adequate mental health component to training would need to be introduced for those categories of PHC workers where none currently exists (eg. pharmacy technicians who may sometimes be in charge of dispensaries). There is also a need to revise the current mental health component of the training curricula for the other categories of PHC workers (eg. nurses, doctors) in order to increase the scope of their theoretical and clinical exposure, in keeping with the new demands which they now have to cope with in the provision of mental health care at PHC level. All categories of PHC workers will need to be stimulated and motivated by provision of regular supervision and continuing mental health education programmes (Abiodun, 1990; de Jong, 1986). They would also need to be encouraged to spend more of their working time in the community on preventive or promotive health care (including mental health care). All these measures will serve to ensure an enduring success of the programme of
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integrating basic mental health care into the existing health structure. Based on the present findings, a training programme is being designed for the PHC workers in the study area.
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Dr. O.A. Abiodun, MBBS(Ib.), FMCPsy.(Nig.) Lecturer/Hon. Consultant Psychiatrist, Behavioural Sciences, Faculty of Health Sciences, University of Ilorin, Ilorin, Nigeria.
Department
of
Currently: Hon. Clinical Research Fellow, Department of Psychiatry, University of Manchester, UK. Mailing address: Tower Block 1, Flat 410, Withington Hospital, West Didsbury, Manchester M20 8LR, UK.
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