Integrating mental health screening into routine community maternal and child health activity: experience from Prevention of Mother-to-child HIV transmission (PMTCT) trial in Nigeria

In all, 93 % (n = 4,747) of the pregnant women and their male partners who consented to participate in this study completed the GHQ-12 questionnaire. Most of those who did not complete the questionnaire were the male partners who anecdotally reported to field staff that they felt that this survey was more “for the women”. To assess whether completers differed significantly from non-completers, we followed up a sample of 20 non-completers. Our review of their socio-demographic characteristics did not suggest that non-completers were markedly different from completers. A majority of the participants were married (96.4 %), had post-primary education (66.8 %) and some form of employment (52.7 %). A larger proportion were female n = 2,796 (55.2 %) with the mean age of 28.68 (SD = 6.5). Women participants were younger (28.68 vs. 37.07 years old), less likely to be married (93.5.9 vs. 99.9 %), more likely to be unemployed (58.3 vs. 33.7 %), more likely to have secondary education (56.7 vs. 44.3 %) and more likely to be living in rural areas (71.3 vs. 67.9 %). There were no significant gender differences in the number of people in the household, distance to closest health facility, awareness of sickle cell trait status or HIV status. The mean GHQ-12 score for the sample was 8.71 (SD = 5.0) (Table 1).

Overall, 21.7 % of the respondents scored above the threshold of 11 indicating significant psychological distress (Table 2). About 3 % scored 20 or over, indicating severe psychological distress. The level of psychological distress in the pregnant women was higher than in their male partners as shown by a significantly higher mean score (9.10 vs. 8.23 p < 0.0001) (Table 1). These findings seemed to indicate that the women were slightly more vulnerable to develop and experience psychiatric disorders perhaps related to pregnancy. In general, higher scores on the GHQ-12 were significantly correlated with being single (χ ² (2) = 23.67, p < 0.001), having only primary education (χ ² (3) = 16.29, p < 0.01), being unemployed (χ ² (2) = 15.04, p < 0.01) and not knowing their sickle cell trait status (χ ² (1) = 8.42, p < 0.01). There were no significant associations between high scores on the GHQ-12 and HIV status, sickle cell trait status, age or number of children in the household (Table 3).

A proportion of respondents either did not answer all the 12 items or provided more than one choice for each question. These were grouped under missing data (9.4 %, Table 2).

This pilot study focused primarily on testing the feasibility and acceptability of conducting mental health screening during routine church-based programs for pregnant women in Enugu, southeastern Nigeria. Having a mental health problem in Nigeria remains a taboo and its acknowledgment is fraught with stigmatization. This limits health seeking from psychiatric professionals [31‐34]. The result is that most Nigerians with emotional distress and common mental health disorders seek help and support from their churches, spiritual healers and traditional medicine men [19, 35]. Introducing mental health screening as part of a holistic approach to wellness through this faith-based approach goes a long way to both raising awareness and de-stigmatizing mental illness and can make mental health interventions more accessible and acceptable. There were very few women who declined to complete the screening questionnaire. We interviewed a random sample of participants and although a detailed qualitative analysis of respondents is being done at this time, initial analysis and anecdotal reports show a reasonably high uptake of the program and surveys. One important aspect of this program was the buy-in by the church leaders who viewed it as a significant support for their parishioners at a happy but vulnerable time. They also believed that it was a capacity building process for their church-based lay workers. In addition, integrating the screening with other laboratory tests done in the church was normalizing and reduced the stigma otherwise attached to seeing a psychiatric specialist or going to a psychiatric clinic. The rate of psychological distress reflected in these findings is in keeping with the rate in previous surveys and studies which were primarily conducted in medical settings [36‐38].

Some limitations of this pilot study are worth pointing out. The initial protocol did not include a second screener or assessment after this initial GHQ-12 test for those who scored above the 25th percentile to determine the true prevalence of psychological distress or psychiatric disorder. At the beginning of the study, we concluded with the church leadership that participants will be referred to the nearest medical facility for pregnancy care. Participants who were identified with high GHQ-12 scores were referred for evaluation with their regular provider or to the closest psychiatric facility at the University of Nigeria Teaching Hospital. However, during the study, we noted an acute shortage of psychiatric clinicians and have initiated a process with the psychiatric department at the University of Nigeria to train priests as first-line counselors with a referral mechanism with the University teaching hospital.

Another limitation is the absence of a formal evaluation of the CHA’s competence in administering the survey and respondents’ rating of their experiences in this innovative program. However, as shown by the very high level of response from participants and anecdotal field reports, participants and staff alike had a generally positive view of the process. Moreover, the most important question for this pilot study was whether these mental health screenings can be done during routine church-based activities and whether this cohort of women and their partners would be willing to complete a mental health screening questionnaire during these routine church activities. The authors are currently completing qualitative analysis of respondents’ satisfaction surveys and exit interviews and plan to add evaluation tools including pre and post tests, for CHAs and clergy training in subsequent proposals.

Findings from this pilot study indicate that mental health screening can be integrated into a community-based program designed to improve health outcomes for pregnant women. It also showed that lay church-based health advisors with no previous psychiatric training can be trained to deliver mental health screening survey instruments in church settings. Community-based approaches such as the HBI can become platforms for developing interventions to integrate mental health assessment into community program and linkage to care at primary-care centers.