Acceptability of mental health toolbox talk in primary health care service; a case study of Oshodi/ Isolo local government area, Lagos state, Nigeria

International Journal of Community Medicine and Public Health Silas UJ et al. Int J Community Med Public Health. 2024 Jun;11(6):2198-2206 http://www.ijcmph.com pISSN 2394-6032 | eISSN 2394-6040

DOI: https://dx.doi.org/10.18203/2394-6040.ijcmph20241477

Original Research Article

Acceptability of mental health toolbox talk in primary health care

service: a case study of Oshodi/ Isolo local government area,

Lagos state, Nigeria

Usen J. Silas1*, Doris A. Dotim2, Rukayat Oladunni1

1Department of Community Health Science, Wesley University Ondo, Ondo State, Nigeria

2Department of Community Health Science, Bayelsa Medical University, Yenagoa, Bayelsa State, Nigeria Received: 04 April 2024 Revised: 18 May 2024 Accepted: 20 May 2024 *Correspondence: Usen J. Silas, E-mail: usen.silas@wesleyuni.edu.ng Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT Background: Mental health services at the primary healthcare level remain at their lowest ebb in most developing countries. Mental health toolbox talk is a way to solve mental health needs in the community. This study aimed at assessing the acceptability of mental health toolbox talk in primary health care (PHC), in Oshodi/Isolo, local government area (LGA). Methods: This is a descriptive cross-section study conducted among 119 PHC staff. A multistage sampling technique was used to select participants for the study. Data were collected and analyzed using the statistical package for social sciences (SPSS) 26 and the EPI Info application. Result: Findings revealed that the majority 79% of respondents were females and were within the age range of 40-60 years of age. Also, 76% of PHC staff showed poor knowledge of mental management, while 94% of the respondents accepted the integration of mental health toolbox talk into PHC. Findings revealed that professions (χ2=12.998, p<0.05) had a significant association with the respondents’ knowledge about mental health. However, the analysis of variance shows there is a statistically insignificant difference in knowledge between the professional groups of PHC staff on the provision of mental health services in the PHC facilities, (f=0.616; p=0.688) (p>0.05). Conclusions: Lack of knowledge on mental health was observed to mitigate PHC staff in the management of mental health disorders, and the need for training on mental health toolbox talk was determined. Keywords: Mental health, Mental health toolbox talk, PHC, Community health practitioners

INTRODUCTION

The concept of PHC emerged after the embroilment of the United States of America and world political wrangling, that emphasized the marginalization of healthcare services to the developing nations. A call for change in medical elitism was proposed, and at that instance, the world health organization (WHO) was forced to concede to the new proposal called PHC.1 These new proposals for health and development appeared and questioned the transplantation of the hospital-based

healthcare system to developing countries and the lack of emphasis on prevention of diseases were raised.

The Alma-Ata declaration on PHC which was made in 1978 became the new bride and it was meant to address the main health problems in communities by providing promotive, preventive, curative, and rehabilitative services.2 Nigeria was among the 134 signatories to this invaluable idea. Subsequently, several re-organizations of the Nigeria health structure to align with the new vision were made.3

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The WHO defined health as: “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”.4,5 Mental health was an integral part of the definition. The goals and traditions of public health and health promotion can be applied just as useful in the field of mental health as they have been in infectious diseases and tobacco control.6

Mental health services at the primary healthcare level remain critical in most developing countries, especially in resource-poor and crisis-stricken communities.7 Mental health was described by WHO as a state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and can contribute to his or her community.4,5 It has always remained a neglected public health problem in low and middle-income countries (LMICs). This core concept of mental health is consistent with its wide and varied interpretation across cultures.2

For the successful integration of mental health into PHC, primary care health professionals are the key personnel who are responsible for the management of mental, neurological, and substance use disorders.8-10 The use of less specialized general health workers to deliver defined tasks such as identification, treatment, delivery of psychological therapies, or family psycho-education termed ‘task sharing’ or ‘task shifting’ which has been demonstrated to be successful LMIC.11-14 In addition, part of the tools suggested to be offered in the facilities is a mental health toolbox talk.15-17

A mental health toolbox talk is a great way to deliver information on mental health and raise awareness.16,18 The mental health toolbox talk has been designed to help everyone improve their mental wellbeing.19 Toolbox talk is holistically defined as an informal group discussion that focuses on a particular safety issue. These issues bother mostly on mental health and behavioral health problems.20-22

The WHO estimates that close to one billion people live with a mental disorder out of the eight billion inhabitants worldwide, and 25% of the population will suffer from mental illness at some time in their lives.23

Epidemiological work has demonstrated that the burden of disease associated with mental and neurological illness is among the highest for all disorders globally.24 A study conducted in South Africa reported that, among the general public, knowledge of mental illness was low and stigma was high.25 Despite the high level of disability, more than 85% of people with severe mental illness in LMICs do not receive the care they require.26,27

Nigeria, however, experiences critical health workforce shortages, with a current health workforce density of 2.2 per 1000 population-far less than the threshold of 4.45 per 1000 population required to achieve the United Nation’s sustainable development goal.28 The WHO estimates of mental healthcare manpower for a population of 213.4

inhabitants, as 0.10/100,000 for psychiatrists, 0.70/100,000 for psychiatric nurses and 0.02/100,000 for psychologists.29,30 In addition, over 45% of the population which is about 89 million inhabitants, lives below the poverty line and with the barrage of skilled workers leaving the country.31 While payment for health care services is largely out-of-pocket.3,11 However the traditional views on the etiology of mental disorders still suffice, most people with mental disorders never receive effective care while a wide range of stigmatization still exists even when the financial obligations are met by the families.7,25,30,32

It is therefore paramount to integrate mental health toolbox talk into PHC services with a sustainable model to solve the anomaly.

Objectives

Objectives were to evaluate the level of knowledge of the toolbox talk approach among PHC staff in Oshodi/Isolo LGA, to evaluate the competence level on the use of the toolbox talk approach among PHC staff in Oshodi/Isolo LGA and to explore the perception of PHC Staff in Oshodi/Isolo LGA toward the mental health toolbox talk approach in PHC services.

Hypotheses

H0: There is no significant association between respondents’ professions and knowledge about mental health toolbox talk.

H0: There is no significant knowledge difference among cadres of PHC staff toward the provision of mental health services.

METHODS

This is a cross-sectional study with a quantitative approach to evaluate their knowledge, competence level, and perception toward mental health toolbox talk approach. Respondents were chosen from the three local council development areas (LCDA) in the LGA.

Study population

The study population comprises of community health practitioners (junior community health extension workers, community health extension workers, and community health officers) 49, nurses, 47, medical doctors, 15; medical records, 17; pharmacy technicians, 26; and medical laboratory technicians, 18, that amounted to 172 PHC workers serving at 3 LCDA’s in the LGA.

Period of study

The study started from 17/07/2023 and a total of fourteen days were used for data collection, which ended on 31/07/2023, while additional 10 days were also used for

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compilation and analyzing of data and did end on 10/08/2023.

Inclusion

The cadre of health workers that were included in the study were community health practitioners (JCHEW, CHEW, and CHO), nurses, medical doctors, medical records, and pharmacy technicians, who are working in the LGA.

Exclusion

Another cadre of health workers who are not mentioned above and all cadre who are mentioned above but did not give their verbal consent were excluded.

Sample size determination

The EPI Info version 1.4.3, statistical application was used to calculate the sample sizes of a known population sizes.

Setting the confidence level at 95%; setting confidence limits at 5%; population size of respondents=172 and sample size=119

Sampling technique

A multistage sampling technique was deployed to enable every member of the population have a chance of being selected since they are from different PHC facilities in the LCDAs, and every cadre was proportionally represented in the sample.

First Stratified sampling technique was used to divide the LGA into three LCDAs.

Stratified random sampling formula=total sample size/entire population×population of subgroups.33,34

Let N=total population=N (172 PHC workers)

n=Sample population= n (119 respondents)

Sub groups=A, B and C

𝑛

𝑛

𝑛

𝑁 × 𝐴;

𝑁 × B;

𝑁 ×C

=

Calculation for sub group A (PHC workers in Oshodi LGA)

119

172 × 63 = 43.6 (44 respodents)

Calculation for sub-group B (PHC workers in Isolo LCDA)

119

172 × 55 = 38.1 (38 respondents)

Calculation for sub-group C (PHC workers in Ejigbo LCDA)

119

172 × 54 = 37 (37 respondents)

Secondly, the simple random sampling technique was used to recruit the number of participants from each stratum (LCDA) for the study.

Instrument

The instrument for this study was adapted with some modifications. The instrument comprises two sections; section ‘1’ covers the personal data of the respondents, while section ‘2’ is divided into three distinct parts, namely; (knowledge of mental health) which consists of eleven items that seek to examine respondent knowledge of mental health. (Service rendered in PHC) which consisted of 10 variables that appraised the services in the PHC. And respondents' views toward toolbox talk in approach PHC, which consisted of four items that seek respondents' views on the intrusion of mental toolbox talk in PHC services.

Validity and reliability of instrument

The study tool was examined and pretest, and the items were valid at α=0.05, using a bi-variate correlation with a Cronbach's Alpha of 0.77, which made the questionnaire to be adapted.

Data management and analysis

Descriptive statistics were presented in a frequency distribution table and charts; and measures of central tendency and variability. multivariate analysis was carried out which included Chi-square (for categorical variables) and t test (for continuous variables). The level of significance was set at p<0.05, and the data were analyzed using SPSS version 26.0.

Measures of knowledge on mental health

Five questions were used to test for knowledge with a four (4) point Likert scale, with “strongly agree and agree” coded as good knowledge while “strongly disagree and disagree” was coded as poor knowledge. The scores range from four to twenty (4-20). Respondents who scored between 4 to 12 were adjudged to have poor knowledge while those with 13 to 20 were regarded to have good knowledge in mental health. This was coded because knowledge is absolute.

Ethical consideration

Ethical approval was obtained from the health research ethics committee (HREC) at Lagos state university teaching hospital (LASUTH), and a letter of introduction was also obtained from the school of post graduate

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studies, university of medical science, Ondo State. This study adhered to ethical guidelines, ensuring participant confidentiality, anonymity, and right to withdraw at any point.

RESULTS

Background characteristics of respondents

The study revealed the socio-demographic characteristics of the respondents which showed that more than three- quarter of the respondents were females (78.8%). While 57% of participants were between age 40 and 60 years. And majority of respondents were married (92.4%).

However, a higher percentage of the respondents were community health practitioners (28.8%), closely followed by nurses and pharmacists’ technicians at (27.1%) and (15.3%) respectively. The majority of the respondents were between 13 and 16 grade level (61%), this depicts that participant had experience.

Information in the study depict that a handful of respondents had attended mental health training programs (28%). Similarly, about 32% of them had attended to mentally ill patients in their practices, of the mental concerned patients seen, 65% were referred to psychiatric hospitals while 35% were referred to general hospitals. The study also revealed that about 31% of the PHC staff acquired the knowledge and skill on how to manage mentally retarded patients through a structured setting and they were issued certificates for participation or diploma for studying the course, and 30% of them acquired experience on-job. However, the study did show that 64% of the participants had poor knowledge about mental concerns.

The study revealed that a high proportion of the participants (87.3%) agreed that mental health toolbox talk approach is needed in PHC.

Also 94% of the participants agreed that the approach will eliminate the stigmatization and improved the knowledge and skills of the PHC practitioners.

Hypothesis one

Association between respondents’ socio-demographic characteristics and their knowledge about mental health

H0: There is no significant association between socio- demographic characteristics and their knowledge about mental health.

The study depict association between respondents’ socio- demographic characteristics and their knowledge about mental health. It was observed that age (𝜒2=25.223, p<0.05), marital status (𝜒2=10.941, p<0.05), and grade level (𝜒2=34.349, p<0.05) had significant association with the respondents’ knowledge about mental health. While gender (𝜒2=3.725, p>0.05) did not had significant association with respondents’ knowledge about mental health

Hypothesis two

Association between respondents’ profession and knowledge about mental health

H0: There is no significant association between respondents’ professions, knowledge about mental health.

Study showed association between respondents’ professions and knowledge about mental health, profession (χ2=12.998, p<0.05) significant association with respondents’ knowledge about mental health.

Staff knowledge toward mental ill clients

H0: There is no significant knowledge difference among cadres of PHC staff toward the provision of mental health services.

Information in table; it was observed both, between and within groups whether there is significant knowledge difference among cadres of PHC staff toward provision of mental services. Table showed that there is no significant knowledge difference among cadres of PHC staff toward provision of mental services (p>0.05).

Table 1: Socio-demographic characteristics of the respondents.

Continued.

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Table 2: Respondents’ exposure to mental health courses.

Table 3: Respondents’ knowledge about what mental health services.

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Table 4: Steps consider when creating a mental health toolbox talk approach.

Table 5: Association between respondents’ socio-demographic characteristics and their knowledge about mental

health.

*f=Fisher exact.

Table 6: Association between respondents’ profession and knowledge about mental health.

*f=Fisher exact. H0: There is no significant association between respondents’ professions and knowledge about mental health. Table 6: showed association between respondents’ professions and knowledge about mental health. It was observed in the table that profession (𝜒2=12.998, p<0.05) had significant association with the respondents’ knowledge about mental health.

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Table 7: ANOVA table for different in the knowledge of PHC staff on patient with mental condition.

Figure 1: Knowledge PHC staff on the management of

mental cases.

DISCUSSION

This study is novel in its attempt to explore the knowledge and exposure amongst PHC workers in relation to mental health toolbox talk. The study did unravel that majority of the PHC staff were community health practitioners, a presentation that most PHC workers comprises of mainly community health practitioners, nurses with sparse doctors.11,35,36 From this study, it was observed that the worker has sufficient experience, however one of the major obstacles to the integration of mental health care is that most PHC workers have minimal mental education which is insufficient for effective mental health service delivery. The study also unravels respondents’ knowledge about the management of mental cases which indicated that majority of them had poor knowledge in the management of mental disorder clients and patients. Our study did collaborate the findings of other scholars that enunciated that PHC workers had very poor knowledge of mental disorders and virtually this mitigated the offering of mental health services in the primary healthcare facilities.19,34

It is an applaudable gesture that practitioners are willing to seek for a new approach in providing mental health services this affirmed other scholar studies, which meant to contextualized mental health gap in the country, the study also showed the need for innovative approach to improve coverage and access to mental health services and the participants agreed to be trained to acquire the skills to manage mental, neurological and substance abuse conditions in Nigeria setting.11,30 Likewise there is

a significant relationship between profession and knowledge of mental health care services among PHC workers, and it is noted clearly in this study, that mental health promotion depends on a collective responsibility and not just an arm of medicine or a single profession.4,26 Hence, the study proposed statistically significant knowledge difference between the groups of PHC staff on the provision of mental health services was rejected by the respondents. It was also observed that task-shifted interventions for mental health services delivered by lay health workers were effective, equally pragmatic and potentially useful components of primary mental health care in resource-poor settings and can be ascribed as an acceptable model in solving mental health illnesses in LMIC.4,34

Limitations

The limitation observed was the intra professional wrangling among PHC professionals which hindered the full participation of respondents.

CONCLUSION

PHC in developing countries continues to rely heavily on paramedical personnel. Human resources (HR) are the most valuable asset of a mental health service. Such a service relies on the knowledge competence and motivation of its personnel to promote mental health, prevent disorders, and provide care for people with mental disorders. The results from this study indicated that respondents support the approach of the novel therapy, mental health toolbox talk, which is cost- effective and encourages community participation. Though majority of them lack the knowledge in mental health management, there is an urgent need to start developing more effective awareness-raising, training and education programme among health care providers. In solving this enigma, there should be an increased consensus, commitment and political-will within and around government in monitoring and adhering to standard practices of mental health care.

ACKNOWLEDGEMENTS

Authors would like to thank to the Dr. R. J. Akinniyi, member of the team and Dr. Adeyalo.

Funding: No funding sources Conflict of interest: None declared Ethical approval: The study was approved by the Institutional Ethics Committee-LREC/06/10/2201

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