Barriers, enablers and perceived benefits of mental health services among workers in primary healthcare facilities in Rivers State: a qualitative approach

INTRODUCTION

Mental/neurological/substance use disorders has continued to be a huge global health problem, forming a very large part of the world’s disease burden. With poor access to the necessary MHS still prevalent especially in low- and middle-income countries (LMICs), poor mental health can have an adverse effects on general health and economy.^1-3

The World Health Organization (WHO) has called for the incorporation of MHS into the PHC delivery system, as a result of its ability to provide a comprehensive, universal, equitable and affordable healthcare. This may aid in the reduction of the vast mental illness treatment gap, curb stigmatization, impact positively on quality of care, and greatly improve social integration.^1,2,4 These notwithstanding, there are various factors needed to be tackled to ensure MHS accessibility and availability at the primary care level. These include the lack of MH integration within primary care, inadequate manpower for MH, lack of public MH leadership, and exclusion of mental health from the public health agenda along with funding implications.⁵ Others include absence of necessary medications to treat minor to moderate MH issues, poor referral systems, organizational barriers, cultural issues, and PHC employees' reluctance to take on more responsibility.⁵ These factors can potentially result in inequalities in MHS provision in terms of quality-of-service delivery, and timeliness in delivering the service.²

In Africa, the present state of health systems of a number of countries cannot effectively sustain mental healthcare delivery.² Despite the adoption of the MH Act signed into law in 2023 in Nigeria, the necessary mental healthcare services are not readily available in PHC centres because of a shortage of a psychiatric health workforce (psychiatrist to population ratio of 0.09/100,000), among other factors.^2,6 These have inadvertently contributed to high rate of MH illnesses in various African countries.^1,2,4

It is crucial that as the MH needs of a population are increasing, there should be an increase in the number of trained health personnel, as certain populations tend to seek help of faith healers, as well as traditional healers as a first resort, due to their proximity and accessibility.^6,7 To overcome this problem, various solutions have been provided including the use of community health workers (CHW) who are healthcare workers that are closest to the people socially, especially in rural communities, leveraging existing community networks and support groups, and also community psychiatry models for early detection, identification and management individuals with mental illnesses, as opposed to waiting until hospitalization is necessary.³

Despite formulation of Nigerian National MH Policy and Action Plan to integrate mental healthcare into primary health services, MHS have been systematically excluded from the PHC facilities in Nigeria. This is evident in absence of trained psychiatric health professionals at these community-centred healthcare facilities, and resultant effects of increasing prevalence of mental disorders.^3,6 These services have also been reported to be grossly unavailable in PHC facilities in Rivers State, where there is also an experience of mental health disorders including, schizophrenia (58.19%), depression and depressive symptoms of 37% and 54.9% respectively among inmates of Port Harcourt prisons, and out-patients at University of Port Harcourt Teaching Hospital.^8-10

To be able to tackle this problem, the health system disparities affecting the delivery of these services in Rivers State in relation to structure, quality, and financing of care, need to be deeply examined, with the aim of providing better MHS to the populace.^2,3,8 In view of doing this, it was necessary to identify the various barriers and enabling factors affecting the integration and subsequent provision of MHS at the PHC level in Rivers State. In Rivers State, Nigeria, there are scant published studies showing these factors. The evidence generated from this research can be used to improve the provision of mental health services. This study was aimed at using a qualitative approach in exploring enablers and barriers affecting the provision of MHS at PHC facilities in Rivers State, as well as the perceptions of the workers on the importance of primary mental health initiative in the State.

METHODS

This qualitative study was conducted among 12 purposively selected PHC facility heads rendering services at the PHC facilities assessed in this study using topic-guided in-depth and key informant interviews to collect data on the enablers and barriers of the capacity of the PHCs to provide MHS. The interview-guide was used to explore their views of the enabling and limiting factors affecting provision of these services by the PHC facilities, as well as their perceptions of the importance of primary mental health initiative. Sample size for this study was dependent on thematic saturation, and respondents were selected based on their willingness to participate in the study. Analysis was done using NVivo software.

Ethics approval was obtained for this study from health research ethics committee of the Rivers State hospital management board (Approval no.: RSHMB/RSHREC/2024/031). Permission to carry out the evaluation was obtained from the executive secretary and director planning, research and statistics of the Rivers State PHC management board (RSPHCMB). Informed consent was also obtained from each respondent before conducting and recording interviews. Data collection tools were anonymised to ensure protection of the privacy of respondents and confidentiality of their responses.

Interviewer guide

Interviewer guide was-Position at the PHC? What is your opinion on MH disorders (definition, which sex is more affected, types, etc.)? What is your opinion on the readiness of this PHC to provide primary mental health care to Rivers State population? (manpower, equipment, technical know-how, logistics, drugs). Do you think integrating MHS at the primary care level is important? If yes, why? From your experience and years of practice, has mental health problems been treated in this facility before. If yes to question 3 above, can you provide some details on these problems that have been treated in this facility in past? Were any challenges experienced during the course of providing these primary MHS? If yes, what were the challenges that were experienced? Do you believe that the clients utilizing health care services in this facility will be willing to seek primary MH care here?

Interviews recorded on recording application on android phone, transcribed and analysed using thematic content analysis. In order to assure trustworthiness, we performed member checking by discussing early results with 5 participants to evaluate our interpretations in addition to returning transcripts to participants for verification. An audit trail of codebooks, memoranda, and documentation of analytical conclusions was used to show dependability. Rich contextual explanations of study procedure, participants, and setting supported transferability. We saw researcher reflexivity and participation as contributing to reliability and rigor of qualitative investigation rather than seeing subjectivity as prejudice.

RESULTS

Sociodemographic details of study participants

Among the 12 heads of facility that participated in this study, it was identified that their ages ranged between 32 and 53 years with a mean age of 45.3±5.7 years. In addition, 9 (75.0%) were females and 3 (25.0%) were males, and all of them were married 12 (100.0%). Also, 6 (50.0%) were nurses, 3 (25.0%) were medical officers, 2 (16.7%) were community health officers, and there was a community health extension worker 1 (8.3%) (Table 1).

The themes and subthemes of the enablers and barriers confronting the provision of MHS are shown in Table 2.

Enablers and barriers facing MHS provision

The assessment of the enablers and barriers facing the provision of mental health services revealed subthemes of the enablers to include the availability of the staff, as well as the willingness of the staff to provide the services. Additionally, barriers identified to limit the provision of MHS included unavailability of trained staff, manpower and other resource shortages, poor MH awareness as well as the unavailability of mental health-related medications.

Supporting quotes included the following:

Enabling factors

For the enabling factors favouring the provision of MHS, the availability of workers was coded as an enabling factor:

Participant 1: Okay, in the first place, we have some staff on ground. But it's a very new system coming on board. So firstly, I would like my staff to be trained. In the process of the training, we'll know more about what we are expected to do.

Another identified enabling factor was the willingness of the workers to provide the services:

Participant 3: We cannot say we are ready but there is willingness to work.

Participant 5: Ongoing training would be required apart from that we are 100% ready to provide this service.

Barriers limiting provision of services

For unavailability of trained staff to provide these services, some responses shown below:

Participant 2: No training, we have not been trained, to handle such issues.

Participant 4: We need training on this subject matter, the government should help us employ more workers and train us, because the training is important.

Participant 6: Basically, the challenge is, the training is not there at all.

Workers also of opinion that there was a predominance of poor MH awareness among members of the populace:

Participant 3: Hmm, they don’t know they are suffering from mental health problems they see as normal.

Participant 4: In this community, the people lack awareness they don’t know that there are suffering.

The shortage of manpower and other resources was also cited as a potential barrier to the provision of MHS:

Participant 5: We need training and we need more workers. The government should provide this thing so we can be prepared to offer these services.

Participant 11: We need to get training and extra hands also we don’t have equipment to perform this service.

The unavailability of required mental healthcare medication was also a problem facing the effective provision of these services as seen in the following quotes:

Participant 12: No medications for the mental health issues.

Perception of the healthcare workers on primary MH initiative

Also, data on the perception of the healthcare workers regarding the primary MH initiative was obtained. The associated subthemes are shown in Table 3.

Supporting quotes for each of these subthemes are stated below:

The pressing need for the services due to cases of mental illness as well as problems of economic hardship:

Participant 8: Yes, like in this community we usually have cases of different types and when it comes to this mental health, it is a very serious problem.

Participant 10: Yes, everybody is suffering in this country. Stress is one of the cause of this mental health problem so if this service is provided it will help the community by counselling them on various issues concerning mental health.

The second subtheme: The advantage of providing an avenue for counselling and mental therapy has the following supporting quotes:

Participant 7: It's actually important because I have seen some of my patients who were depressed come out of it through counselling and education. I stress the importance of family support when counselling them and their loved ones.

Participant 9: Having these services here in this facility will help us a lot. It can reduce the burden on emergency services if something like this is here in this unit, and it can also serve as a therapy unit of the facility.

The final subtheme: “Will improve mental awareness among health workers and the populace”, is expatiated in the following quote:

Participant 4: It will help this community. If the services are available in the facility it will help them create awareness on this condition.

DISCUSSION

This study assessed the enabling and limiting factors affecting the effective provision of MHS as well as workers’ perception of the primary MH initiative in Rivers State. It was identified that enablers enhancing the provision of these services included the availability of workers to provide the services, and having workers who were willing to provide these services. This finding of available and willing healthcare workers to provide these services implies that these workers probably have a good and different view of mental healthcare services and mental illness, despite the pervading problem of discrimination and stigma around mental illness in Nigeria.^3,8,11,12 The willingness is also a pointer for capacity building sessions, which should be made a regular feature at all levels of healthcare, in order to keep healthcare workers abreast with the current trends and approaches to MHS.^13,14

This provides an excellent opportunity for holistic incorporation of MHS into the PHC delivery system as recommended by the WHO.^1,2,4 It also in-turn improves the accessibility of these services to the populace, enhance prompt detection and management of mental health problems at the community level, and improving the MH indices in Rivers State and Nigeria as a whole due to improved health of the populace.^1,4

Regarding the barriers affecting the provision of MHS, various factors were identified to be limiting the effective provision of these services in the State. They included the unavailability of trained staff to provide these services, the prevailing poor mental health awareness among the populace, the shortage of manpower and other resources, as well as the unavailability of mental healthcare medications. These barriers have also been reported in other studies as being capable of hindering the effective provision of MHS especially at the PHC level.^1,3,8 It is therefore crucial that all concerned MH stakeholders work as a team to find lasting solutions. This is because, when allowed to fester, it would allow the proliferation of unskilled mental healthcare manpower especially at the primary level of care, who are well patronized in certain climes due to their proximity to the populace.^6,8 It can also result in higher risks of wrong diagnoses and mismanagement of MH disorders, resulting in the likely progression of mild mental illness to more severe disorders.^1,4,5 It also implies that these services may not be readily available at the PHC facilities, which affects negatively impacts on service accessibility, and utilization. This in-turn results in traveling long distances to tertiary-level mental healthcare services or patronizing traditional mental healthcare providers, religious houses and other unskilled MH providers.⁶

In addition to these problems, the unavailability of medications can worsen the existing challenge of mental healthcare delivery in the State. This is because the unavailability of essential medications can disrupt treatment efforts, considering that the patients may be unable to adhere to prescribed therapies, leading to poor MH outcomes. These problems show the need for a multifaceted approach in ensuring the optimal incorporation of MHS into PHC.^2,6,7 This can include the adoption of the community MH model where all community-level actors known to handle mental illness are co-opted and trained to adopt the correct management approaches and refer whenever necessary.^3,6 The approach would also involve public orientation activities to improve MH awareness and behaviour; targeted recruitment of skilled mental healthcare manpower; and establishing supply chain mechanisms to ensure the consistent availability of essential MH medications in PHC facilities.^3,8

Regarding the perceptions of the workers of the primary mental health initiative desired to be launched in the State, it was identified that there was indeed a pressing need for the services among the populace, which provides them an avenue for counselling and mental therapy, and help to improve mental awareness among health workers and the populace. This is an important finding that underscores the urgent need for mechanisms to be put in place to enhance the mental healthcare delivery in the State, which would enhance the health of the populace, alongside promote economic development and productivity.^2,4,15

Despite its relevance to public health, this study was limited by its study design. This study employed a qualitative design and hence lacks generalizability because of the small sample size. Future studies can incorporate a mixed method approach to gain more insight and understanding from the study.

CONCLUSION

Mental healthcare services provision in Rivers State is still faced with various challenges that can severely limit its effectiveness. In light of the findings made in this study, the following recommendations have been made:

The Rivers State government needs to make a stronger commitment to driving the availability of quality MHS to the Rivers State populace, formulation of policies and orientation programmes to promote the provision of these services.

The PHC management board should also ensure capacity building for PHC personnel and establish effective referral/feedback systems to ensure unfettered access to quality care at all levels when needed.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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