Introduction
The prevalence of mental, neurological, and substance use (MNS) disorders is on the rise globally [
1]. These rates are comparable between high-income countries and low-and-middle-income countries (LMIC’s). However, LMIC’s often have healthcare systems with far less capacity to address such conditions [
2]. Nigeria, Africa’s most populous nation and an LMIC [
3], has over 7 million people with depression and over 4 million people with anxiety disorders (the highest number of cases compared to other countries in the African region) [
4]. The published national lifetime prevalence of any mental disorder in Nigeria is approximately 12% (although experts have estimated this to be 20–30% in actuality) [
5], with some regional studies indicating even higher numbers [
6‐
8]. The prevalence of neurological disorders vary by condition, but epilepsy, for instance, has been estimated at 8 per 1000 people [
9]. Substance-use disorders have been estimated between 20 and 40% among youths and 14% in the general population [
10].
Despite these dire numbers, only about 10% of Nigerians with mental disorders receive any formal specialist mental health care irrespective of severity [
5]. Poor and underserved populations are particularly vulnerable to the adverse effects of mental disorders, experiencing a more severe impact on functioning, having drastically limited access to early intervention, and discontinuing treatment due to cost [
11]. Significant factors limiting access to formal mental health care in Nigeria include the scarcity of mental health specialists, with only 0.15 psychiatrists per 100 000 of the population (compared to the US’s 10.54 per 100 000) [
12], a lack of community-level care for mental disorders [
13], the limited integration of mental health integration in primary care [
14], and the pervasive stigma towards mental disorders, even among health care providers [
15,
16]. In Nigeria, stigma has been widely documented as a deterrent to help-seeking [
17‐
20]. Self-stigma (internalized mental illness stigma leading to diminished self-esteem and self-efficacy) and public stigma (the prejudice and discrimination endorsed by the general population that affects a person) about mental illness are pervasive [
21,
22]. Studies using validated and widely used measures of stigma, attitudes, and beliefs across different parts and populations in Nigeria show that the most common understanding of the causation of mental illness was supernatural causes (magic, witchcraft, sorcery, and divine punishment). Social distance and isolation are the most common attitudes, and traditional (unorthodox) medicine is a major treatment preference [
23]. There are also stigmatizing beliefs and myths that perpetuate the idea that mental disorders are untreatable [
24]. Stigmatizing and negative attitudes toward mental disorders and people with mental illness are also common among health care professionals in Nigeria, which can adversely impact the therapeutic alliance and clinical outcomes [
16,
25,
26]. However, to date, only three Nigerian States (Lagos, Osun, and Ogun) have implemented state-wide mental health training for primary health care workers, which are the first contact for people with signs of mental illnesses [
27‐
30].
In accordance with emerging evidence and WHO recommendations, Nigeria’s Mental Health Policy (adopted in 1991 and reviewed since) established that mental health care was to be integrated into primary healthcare, with responsibility for implementation delegated to local governments [
31]. This policy, however, was poorly implemented due to insufficient training and supervision of primary care workers, funding, and political will [
32]. A revision of this policy in 2013 gave rise to the Policy on Mental Health Service Delivery. It recognized the nuances of integrating mental health care within the primary healthcare system and outlined specific recommendations for primary, secondary, and tertiary care. For instance, for primary care, the policy recommended that primary care centers (PHCs) have a reliable stock of psychiatric medications and strengthen community outreach, health promotion, social rehabilitation, and referral processes. For secondary care, recommendations included that there be inpatient and outpatient mental health services at all hospitals and strengthened inter-sectoral governance structures to manage MNS services. For tertiary care, recommendations included bolstering services for pediatric and elderly populations, developing initiatives to tackle substance use disorders, and supporting secondary care services with expertise. Further, it encouraged the use of public-private partnerships to innovate the mental health system. Finally, it recommends adequate training, retraining and continuing professional education on screening, identification, and treatment of MNS conditions at all levels of care for key medical personnel [
34,
35].
Finding innovative approaches to increase access to effective treatments for MNS disorders in LMICs like Nigeria is in line with WHO Sustainable Development Goals [
35]; however, the challenge is to find feasible, acceptable, effective, and sustainable strategies. An effective approach is training non-specialist mental health workers to deliver packages of mental health care under the supervision of mental health specialists in a collaborative, stepped-care, task sharing approach [
36]. A common effective strategy for scaling-up mental health care is implementing the Mental Health Gap Action Programme (mhGAP) [
37]. This programme is an initiative of the WHO to help national and subnational leaders scale-up mental health care in their communities. Included in this program is the mhGAP-Intervention Guide (mhGAP-IG) that contains a package of interventions for assessing and managing MNS disorders [
38]. The main goal is to build and strengthen non-specialists’ capacity in the detection, treatment, and management of MNS conditions through stepped-care, collaborative task sharing. The full modules of mhGAP-IG include: Introduction, Essential Care and Practice, Depression, Psychoses/Mania, Epilepsy, Child and Adolescent Mental and Behavioral Disorders, Dementia, Disorders due to Substance Use, Self-Harm/Suicide, and Other Significant Mental Health Complaints. Although there are no specific anti-stigma modules in the mhGAP, it contains discussions on avoiding stigmatizing language, showing empathy, and increasing awareness about mental illness in the community [
38]. There is also evidence to show that stigma improves among trainees pre-and post-mhGAP training [
39].
The mhGAP-IG has been implemented and evaluated in many countries. In a review of 162 studies, Keynejad et al. concluded that more research is needed to look at mhGAP implementation especially focused on contextual adaptations [
39]. In other state-wide mhGAP projects in Nigeria, only clinical outcomes and trainee skill retention have been evaluated so far [
27,
29,
30]. There is need for more studies tailoring training programs and content to local and general care contexts. This can potentially lead to more acceptance and increase the chance for sustainability. By applying a convergent, mixed-methods approach [
40], this proof-of-concept study aimed to evaluate the pilot of the mhGAP-IG-based and stigma-focused
Health Action for Psychiatric Problems In Nigeria including Epilepsy and SubstanceS (HAPPINESS) project. In particular, this study identifies implementation barriers, facilitators, and opportunities, with a focus on the impact of its training component on mental illness stigma among trainees.
Methods
The HAPPINESS Project Intervention
In 2018, the Yale Global Mental Health Program and CBM International, in collaboration with Imo State University Teaching Hospital (IMSUTH) and Imo State Primary Healthcare Development Agency, initiated the HAPPINESS pilot project [
41]. During the planning phase of the project, needs assessment meetings with stakeholders took place to prepare for the pilot project’s launch. Stakeholders (e.g., mhGAP-IG experts and PHC staff) convened to discuss the needs of staff and common MNS disorders seen in the community. Together, a team of researchers, psychiatrists, and public health officials adapted and used the mhGAP-IG [
38] to train primary healthcare workers (i.e., community health extension workers, nurses, and non-specialist physicians) to assess and treat MNS disorders in their communities while consulting or making referrals to specialists as clinically indicated. There were six main components to the HAPPINESS pilot project:
Training, Refresher Training, Clinical Practice, Support Supervision, Community Engagement, and the Drug Revolving Fund (DRF).
Training
The training aimed to improve knowledge of MNS disorders, attitudes towards persons with mental illness, and skills in assessing and managing MNS disorders. Of the nine modules in the mhGAP-IG, we chose Essential Care and Practice, Depression, Psychoses/Mania, Epilepsy, and Substance Use Disorders and made relevant adaptations based on local needs. We also created a module that focused on stigma reduction. Adaptations, module selection, and the idea to embed a stigma module into the mhGAP were decided during the needs assessment meetings.
The module on depression teaches symptoms/signs, differential diagnoses, assessment, including risk assessment, and biopsychosocial treatment planning over time. The module on psychoses/mania teaches both psychosis versus mania in bipolar disorder symptoms and signs, diseases’ natural history and course over time, assessment, and treatment planning including managing adverse reactions and side effects of medications. The module on epilepsy teaches convulsive versus nonconvulsive seizures, contextual symptoms and signs, causes, and assessment (especially reactive seizing). The module on substance use disorder (SUDs) introduces the misuse of substances (alcohol, opioids, benzodiazepines (BZDs), khat, tobacco, stimulants), their signs and symptoms, biopsychosocial impact, assessment of SUDs, and the biopsychosocial treatment and management over time. It also includes motivational interviewing and management of medical and psychiatric emergencies related to SUDs such as intoxication, overdose, and withdrawal. The module on stigma reduction discussed common, local stigmatizing language, myths, beliefs, and ways to decrease associated stigma, discrimination, and human rights violations.
The training was delivered in person, facilitated by five trainers experienced in mhGAP-IG training. It was a 9-hour per day, 5-day training (with scheduled breaks) that contained sessions composed of didactics, group workshops, and role-plays. Didactics were based on mhGAP-IG modules with adaptations made, following initial needs assessment meetings with community stake holders and clinicians, to include local content, examples, and narratives (see Table
1). Group workshops were interactive sessions of 5 to 7 people each who read, reviewed and discussed identified topics. Role-plays were enacted by 3 trainees (that took turns as a client, clinician, and observer) and observed by a facilitator. They simulated scenarios such as initial evaluation, psychoeducation, and first aid for seizures. Trainees completed the mhGAP-IG pre-and post-training test before and after each day of training on the specific modules. Lastly, we also included
observed practice sessions to evaluate trainees on MNS screening, assessment, treatment, and follow-up planning. Post-training certification was based on the following: 100% attendance to all training activities, a score of at least 90% on the post knowledge test, and a “pass” grade on the observed practice session as scored by trainers according to pre-set competency rubrics (patient assessment, patient education, diagnosis, and treatment). A one-day in-person refresher training was scheduled for every six months for all trainees and topic-based discussions using a group WhatsApp forum was planned for every two weeks. Refresher training topics included depression and substance use as these were deemed high priority by clinicians. WhatsApp forums were led by primary care nurse trainees on a rotating basis (nurses from different participating PHCs took turns every two weeks) and topics varied depending on need (e.g., medication management and side-effects, psychosis).
A few adaptations to the training were made in consideration of the local setting as suggested by the primary health care teams. First was the inclusion of specific potential community resources for patients, including local churches, women’s groups, youth clubs and local hospitals, in the relevant modules. Second was the choice of mhGAP-IG modules to train on. This was made based on feedback from the stakeholders and experts during needs assessment about the common disorders they see in the area.
Table 1
Examples of adaptations to the mhGAP modules on psychosis, epilepsy, and substance-use disorders
Psychosis | Introduction to psychosis | - Identified and listed local names for psychosis/mania: e.g., “Isi ngbaka”, “ara”, Isi nmebi” - Identified and listed local myths and beliefs about psychosis/mania: e.g., “untreatable”, “once the affected persons go to the market, it becomes incurable” |
Assessment of psychosis | - Incorporated local concepts of bizarre behavior; e.g., “ogbanje”, “mami-water” |
Management of psychosis | - Identified and listed local brand names/generic equivalents for antipsychotics/mood stabilizers on the essential drug list: e.g., Lanzep/Prexal = Olanzapine |
Role-Play | - Developed script for role play vignette in local Igbo language |
Epilepsy | Introduction to epilepsy | - Identified local myths and beliefs about seizures: e.g. It is infectious, it is a spiritual attack, it is untreatable |
Assessment of epilepsy | - Identified and listed local names for seizures: e.g., “akwukwu”, “ihe odido” |
Management of epilepsy | - Identified and listed local brand names for anti-seizure medications on the essential drug list: e.g., Cartol, Epicar = carbamazepine and Epilim Chrono = valproate - Identified and listed available local specialist/tertiary care centers for referral |
Role Play | - Developed script for role play vignette in local Igbo language |
Substance-use disorders | Introduction to disorders due to substance use | - Identified, listed local names for commonly used drugs and alcoholic beverages. Example: Liquor like rum, bourbon called “ogogoro”, Cannabis: called “Igbo”, “ahihia” “anwuru ike” and Cigarette and tobacco products called “anwuru” |
Assessment of disorders due to substance use | - Identified and quantified local measures of alcoholic beverages using NIDA guidelines/standards |
Management of disorders due to substance use | - Identified, characterized, and listed available community resources for people with SUD |
Role Play | - Developed script for role play vignette in local Igbo language |
Clinical practice
Informed by the input from community stakeholders, we developed a clinical practice Standard Operating Procedure (SOP) for all the trainees depending on their roles in the primary health center (see Additional file
1). This document streamlines patient healthcare delivery, continuity of care, as well as clinical support and regular program evaluation. For example, the design and development of a personalized pocket-sized appointment reminder was an accessible and affordable way to facilitate treatment adherence and support paper chart medical record organization. The SOP also included a clear flowchart for
Screening, Assessment, Treatment, Follow up, Documentation, and
Periodic evaluation.
The project team leaders participated in a local radio morning show to raise awareness of the project and provide public health education about mental illness and emotional health. Trained primary health workers also engaged their local communities via local churches, town hall meetings, and visits to traditional rulers. The HAPPINESS project’s social media platforms (Facebook, Instagram, and Twitter) also engaged with local groups, individuals, and organizations to create mental health awareness and disseminate information about the project.
Drug Revolving Fund (DRF)
The project utilizes a DRF to ensure consistent availability, affordability, and accessibility of high-quality psychotropic and anticonvulsant medications for those who need it [
42]. Medications are dispensed with a marginal mark-up but below market retail price. Any generated net profit is used to offset logistic issues and ensure the sustainability of the scheme (see Additional file
2 for further details).
Setting
Imo state has a population of about 4 million people, with 527 PHCs staffed by 453 nurses, 76 community health officers, and 864 community health extension workers spread across the State’s urban and rural areas (as of 2017). Each center has a part-time or full-time covering physician. During initial planning meetings, 10 PHCs from five local government areas of the State were selected for the pilot study based on the availability of staff (to take over while some attended training), proximity to the state capital (for physical accessibility), and geopolitical representation.
Study design and measures
This is a convergent mixed-methods [
40] proof-of-concept study that aims to understand the implementation of the HAPPINESS pilot project quantitatively and qualitatively, with a particular focus on stigma. The quantitative questionnaire captures the effect of the HAPPINESS project training’s stigma components on mental illness stigma among trainees. The qualitative interviews explore trainees’ experiences of the project (e.g., project training and support) as well as barriers (e.g., resources availability), facilitators (e.g., aspects of training materials), and opportunities (e.g., future directions) related to the project. These discussions offer insight into project implementation as well as trainees’ perceptions and knowledge regarding mental health, which can be converged with quantitative results on stigma.
Questionnaires
As a part of the HAPPINESS project’s SOP, all trainees completed a paper-based pre-and post-initial training stigma questionnaire that captured the local stigmatizing beliefs and negative attitudes about mental disorders. The questionnaire took 15–20 min to complete. Trainees were not additionally compensated for responding to the questionnaire but were given meals during the training and reimbursed for transportation costs. Trainees’ perceptions of mental disorders and attitudes towards people with mental illness were assessed using a 43-item questionnaire (see Table
2) that was created using (1) social distance questions from the Fear and Behavioral Intentions (FABI) Toward the Mentally Ill questionnaire, (2) social stigma, social acceptance and possible treatment options questions from the Community Attitudes to Mental Illness (CAMI) scale, and (3) items about conceptions of mental illness causes from a questionnaire developed for the World Psychiatric Association (WPA) Program to Reduce Stigma and Discrimination [
43‐
45]. These three stigma measures are well-validated and widely used in stigma studies in Nigeria [
23]. We have pilot-tested and used this 43-item questionnaire in previous studies in Nigeria. It includes four subscales (acceptance of socializing with people with mental illness, favorable attitudes towards normalized activities and relationships with people with mental illness, beliefs in witchcraft as a cause of mental illness, and endorsement of a biopsychosocial perspective of mental illness) [
46‐
48].
Table 2
Stigma Questionnaire Questions (paraphrase) and Subscales
A. Socializing |
I would have a former psychiatric patient as a friend. |
I would live with a next-door neighbor who is a former psychiatric patient. |
I am not afraid of people with mental illnesses. |
I am not afraid of making conversation with people with mental illness. |
I would have conversation with neighbors who previously had mental illness. |
I would invite a previously mentally ill person in my house. |
I would marry a person who was previously mentally ill. |
I am not ashamed if someone in my family was diagnosed with mental illness. |
I am not upset working on the same job with a mentally ill person. |
I would not avoid conversation with a neighbor who is mentally ill. |
B. Normalizing Relationship |
Mental illness is an illness like any other illness. |
The best therapy for mentally ill people is to be a part of society. |
People with mental illness do not tend to be retarded. |
I would be willing to work with somebody with a mental illness. |
People with mental illness are far less of a danger than people think. |
I would maintain a friendship with a person with mental illness. |
Residents should not be afraid of people coming to their neighborhood to receive mental health |
Mentally ill people can work in regular jobs. |
Persons who show signs of mental illness should not be immediately hospitalized. |
Mental illnesses are caused by poverty. |
C. Witchcraft |
Mental illness is not caused by someone putting a curse on you. |
Mental illness is not caused by witchcraft. |
Mental illness is not caused by possession by an evil spirit. |
Mental illness is not caused by God’s punishment. |
Mentally ill people can be treated outside of a hospital. |
D. Biopsychosocial |
Virtually anyone can become mentally ill. |
Mental illness is caused by a brain disease. |
Mental illness is caused by physical abuse. |
Mental illness is caused by biological factors. |
Mentally ill people are not dangerous because of violent behavior. |
A separate paper-based questionnaire was also administered to document self-reported sociodemographic characteristics (age, gender, and years of education), profession (i.e., community health extension worker, community health officers, doctor, or nurse), where they were born, and where they currently live.
Qualitative interviews
A purposive sample was recruited by reaching out to stakeholders from the pre-project needs assessment meetings (including primary care doctors, nurses, mental health specialists, state health officials, etc.). Semi-structured interviews were conducted after the initial training and one refresher training between 2019 and 2020. These interviews explored participants’ experience of the project training and pilot implementation, including their perspectives of the project’s impact as well as implementation barriers, facilitators, and opportunities that may exist in the context (e.g., organizational or structural). The interview guide was developed with the Consolidated Framework for Implementation Research (CFIR) with a focus on
“innovation characteristics”(HAPPINESS project training, materials, and implementation),
“outer setting” (healthcare system and community perceptions of mental health),
“inner setting” (primary care clinics structure, hours, and functioning), and “
characteristics of individuals” (changes in participants’ skills and personal beliefs) [
49]. Development of the interview guide was an iterative process including independent review and revision by three researchers and pilot-testing with 3 participants (a nurse, a doctor, and a community health extension worker) to ensure the relevance of the items and areas explored. Participation was voluntary and uncompensated. Each interview ranged from 20–60 minutes using a structured interview guide and additional prompts as needed during the interview for clarifications and relevant details. An overview of the interview guide can be found in Table
3.
Table 3
Interview Guide Overview
1. Please give me a brief description of your job and what your average workday looks like? (When do you come in? Where do you spend most of your day? Who do you interact with the most? What takes up most of your time?) |
2. Did you participate in the HAPPINESS project training and refresher training? If so, what are your initial thoughts about the training/refresher training? |
3. Are there any aspects of the training that you think need to be changed (i.e. timing, schedule, duration, content, trainers, etc.)? |
4. How has the training affected your work with patients? |
5. How was your experience with the Drug Revolving Fund? Was it helpful? |
6. What is your perception of the quality of supporting materials (i.e. training modules and other documents)? |
7. In your opinion, how well was the HAPPINESS project integrated into primary care? |
8. What kinds of incentives are there to help ensure that the implementation of the HAPPINESS project is successful? |
Data analysis
In our convergent mixed-method approach, results from this study’s quantitative and qualitative components were integrated using a narrative, contiguous approach [
40]. This involved separately analyzing and reporting findings from each component, followed by merging complementary findings. Specifically, we merged the quantitative component’s measure of changes in stigma among trainees pre-and post-training with qualitative themes and sub-themes that demonstrated attitudes and beliefs among trainees regarding mental illness. It was necessary to merge these results since quantitative measures alone fail to capture nuanced perspectives about stigma. Similarly, asking about informants’ internalized stigma towards people with mental illnesses may be challenging in an interview format alone due to personal biases.
For the questionnaires, thirty questions were included in the analysis and categorized into four subscales as per previous studies that utilized the same questionnaire (
socializing, normalizing, supernatural causation, and biopsychosocial approach) [
46‐
48]. Responses were analyzed using a paired sample t-test conducted on each of the four subscales using the R statistical software. Variances for each of the subscales were considered unequal except for the biopsychosocial subscale; however, deeming the variance equal or unequal did not affect the results of the t-test.
The qualitative interviews were conducted by NR in person and audio recorded with participants’ consent. Interviews were transcribed by CC with the assistance of NR’s interviewer field notes in cases where audio was difficult to decipher. Thematic analysis was chosen as a way to inductively derive themes from our transcripts [
50]. This was chosen as opposed to deductive coding using the CFIR framework because although our semi-structured interview guide directly asked about project-specific aspects, we wanted an analytical process that would allow us to flexibly find patterns within the data about any contextual barriers and facilitators related to the project, for example, the project training, clinical practice guidelines, community engagement or the DRF. Coding was done by CC using the Dedoose software (Version 8.3.17), where transcripts were uploaded. The initial round of coding was descriptive and hierarchical, where initial parent and child codes were coded. Throughout this process, initial codes were collapsed or re-labeled on Dedoose where necessary. These codes were defined to form an initial codebook and the codebook was re-applied to transcripts until saturation was achieved (no emergent codes). This codebook was downloaded from Dedoose as a Microsoft Word document (where codes and corresponding transcripts were automatically listed) and collaboratively reviewed by CC, TI, and KW to ensure clarity and to extract themes and sub-themes. After the final codebook and themes were formed, transcriptions that corresponded to each theme and sub-theme were analyzed to generate findings and conclusions regarding the HAPPINESS pilot project and training.
Discussion
This study evaluates the impact of the HAPPINESS pilot project mhGAP-IG training on trainees’ mental illness stigma perceptions and knowledge as well as barriers, facilitators, and opportunities related to project implementation. Findings from the stigma questionnaire were congruent with the qualitative data that showed a favorable change in attitudes regarding mental illness following the HAPPINESS project training. As indicated by the questionnaire, trainees reported significantly more acceptance of socializing with people with mental illness and more favorable attitudes towards normalized activities and relationships with people with mental illness; further, they were less likely to endorse supernatural causes of mental illness. These preliminary quantitative results were supported by emergent themes from the interviews, which showed that trainees gained a better understanding of mental illness, learned new skills in providing diagnosis and treatment, and developed (and acted with) more empathy and respect towards patients. A demonstrated increase in empathy and respect from the interviews also demonstrated biopsychosocial perceptions of mental illness (which was insignificant in the analysis of the stigma questionnaire). Moreover, participants emphasized the importance of integrating patients back into society and regular life (e.g., their workplace) after treatment. This is a key component of the “recovery approach”, which has long been used to guide the creation and delivery of mental health services [
52]. The improved knowledge and perspectives regarding stigma among trainees, which were a main focus of our study, are in line with qualitative and quantitative evidence from other LMICs on the impact of mhGAP-IG training [
53‐
55].
A notable concept that emerged from the qualitative component of this study is the negative downstream impact of the lack of public awareness regarding mental illness on people receiving timely and suitable care (particularly seen in our
lack of awareness and
promoting early detection and raising awareness sub-themes). These discussions provide interesting insight into and demonstrate trainees’ understanding of the mental health context of the HAPPINESS project, especially regarding public stigma. Informants often described how lack of awareness among people, their families, and the community-led to delayed care-seeking and detection of a mental illness, which leads to poor management of mental illness. Specifically, they reported that misinformation and stigmatization often alienated people with a mental illness (which may exacerbate their illness) and led them to be brought to churches for treatment (i.e., from the belief that mental illness is caused by spirits). This supports the need for the HAPPINESS project and other mental health programs to organize awareness programs in the community to improve treatment receptiveness. Eaton and Agomoh show that such a program can help increase help seeking for mental disorders in Nigeria, especially if it ties in the availability of mental health services [
56].
Regarding the HAPPINESS project training, many respondents recommended increasing the length of time (to have more time to learn) and tailoring training for different health professions (since some clinical workers have had less exposure to the workshop content previously). Additionally, respondents still desired extra training on how to differentiate between illnesses and additional topics they wanted to be covered. Thus, a challenge will be to slow down the training’s pace while adding additional topics. The HAPPINESS project’s refresher trainings can address this need for continuous training; however, longer trainings with new topics may not be financially feasible long-term or accessible to all trainees. Thus, it is crucial to bolster and continue offering alternative learning avenues, such as the HAPPINESS project’s WhatsApp forum and specialist supervision. Ongoing specialist supervision and collaborative and multi-disciplinary peer-to-peer learning (the “Community of Practice” approach) was noted by Fargeh et al. as a solution to similar learning gaps found in initial mhGAP training in Chad, Ethiopia, Nigeria, Guinea, and Haiti [
57].
Beyond the training, respondents suggested working closely with community leaders and creating promotional material to improve awareness of mental illness to promote primary care center visits for people who may have a mental illness. The HAPPINESS project had already taken steps to address these avenues via raising awareness on social media and on local radio shows (whose effects may not have been captured at the time of this study). Additionally, some project sites have made outreach visits to traditional rulers, village committees, and councils (with anecdotally positive results so far). This also aligns with recommended best practices for community engagement in global health implementation research and projects [
58]. Another issue that the HAPPINESS project has been addressing includes implementing trainee retention strategies. The project team is currently working with the local university to develop this training into a university-based certificate program. This way, trainees will get recognition for the time and effort they spent on building new skills in mental health.
This study adds to the limited literature on the impact of mhGAP-based training on stigma, specifically, how embedding anti-stigma components into mhGAP training can improve mental illness stigma among primary care trainees. The barriers that were identified in the implementation of this project are also consistent with other cultural and contextual challenges to the mhGAP-IG implementation identified by Fargeh et al., including the local perception of mental disorders, the healthcare system, available support for trainees, prior knowledge of trainees, trainee recruitment, and the larger socio-political context [
57].
The present study complements previous Nigerian mhGAP-IG projects’ studies that focus mainly on trainee skill retention and clinical outcomes by detailing challenges that arise in initiating a mhGAP-IG implementation project, as well as how external factors (e.g., awareness) contribute to the success of the project [
27,
29,
30,
59]. The quantitative component revealed a reduction of stigma among trainees, complemented by qualitative findings regarding trainees’ new perceptions and knowledge about stigma after training. The qualitative component also identified implementation barriers, facilitators, and opportunities for this pilot project which are helpful not only for the growth of the HAPPINESS project but also for other project teams who are initiating or expanding their mhGAP-IG interventions.
Although one of the main strengths of the HAPPINESS project is its use of the widely available primary healthcare system in Imo State, it should be acknowledged that there are challenges to access that go beyond an easily accessible PHC. Most of these factors are connected to the community and system-level stigma and negative attitudes toward mental health, leading to low interest and minimal investment in mental health services. Firstly, this study revealed that a lack of human resources limits aspects of project implementation and day-to-day primary healthcare center functions. Respondents expressed that the lack of psychiatry training programs within Imo State means that local people will unlikely become psychiatrists. With brain drain being very common, Imo State natives that are trained elsewhere may also choose not to return home to practice [
60]. Having a small supply of healthcare workers limits the pool of potential trainees and supervisors and the availability of current trainees and supervisors. This may not be a current concern, but as the project expands, more supervisors will be needed to offer online and in-person support. Secondly, there is poor access to adequate healthcare resources, including difficult physical access to primary care centers (mentioned by a respondent as a barrier for supervision) and a lack of basic health assessment tools (e.g., stethoscopes and blood pressure cuffs). Beyond this study, it has been found that primary healthcare facilities in Imo State are often dilapidated, poorly staffed, lack essential drugs, have long wait times, and have high costs for treatments [
61,
62]. To combat some of these issues, the HAPPINESS project has given basic medical tools to the partnering clinics. However, there are still limitations to what the project can ameliorate. For instance, although the DRF was highly regarded by the respondents of this study, it only provides oral medications on the national essential drugs list (thus, restricting the types of therapies available) [
51].
Beyond challenges within PHCs, there are also severe disparities with regard to individuals’ abilities to pay for care in Nigeria. Even with the establishment of the federal National Health Insurance Scheme (NHIS) in 2005, more than 90% of the national population (and 5 million people in Imo State) remain uninsured [
63,
64]. NHIS is also more challenging to obtain for those who are unemployed (which is common for those with a mental illness). In southeast Nigeria (where Imo State is located), 27% of households incur catastrophic health expenditures, and this rate was higher for rural regions and for people with a mental illness (factoring in both direct and indirect costs of the illness) [
65‐
67]. Even if people obtained NHIS, these plans only cover care at certain federal hospitals and do not cover drugs that are not on the essential drug list of Nigeria, which excludes many common psychotropic medicines (e.g., SSRIs) [
51]. NHIS plans also do not cover care provided by clinical psychologists, social workers, and occupational therapists, and they also do not cover mental health services such as psychotherapy and addiction clinics [
24].
Instead of being fully reliant on federal health insurance programs, the Imo State Health Insurance Agency, in 2019, started to collaborate with the WHO and different unions and health organizations in the community to improve health insurance for people in Imo State [
64]. Looking ahead, these improvements to health coverage in Imo State will be highly essential to the success of the HAPPINESS project, as it will increase the number of people who can access PHC services without paying out-of-pocket. Additionally, any upcoming improvements to bolstering primary healthcare’s infrastructure and human resources will be conducive to the HAPPINESS project’s expansion.
There were methodological limitations to this study worth noting. Firstly, due to financial constraints, this was a small pilot, proof-of-concept study that focused on integrating mental health into primary healthcare using the mhGAP-IG in select LGAs in one state in Nigeria. Because of these constraints, it was not possible to train a large cohort of staff (which would have increased survey participants) nor was it feasible to incentivize interview participation, leading to a low sample number. Thus, the findings may not be generalizable to larger portions of the state or the country. Optimistically, the project team has received funding to use the data and lessons learned from this pilot study to conduct a larger, prospective study to evaluate the feasibility, acceptability, and effectiveness of the HAPPINESS intervention across the entire state (Imo State).
Secondly, this study was not designed to evaluate the community engagement components of the HAPPINESS project as these effects are more challenging to capture within our time frame and with a small sample size of informants that were already actively involved with the project. Future evaluations of the HAPPINESS intervention will aim to capture community perspectives to evaluate this component.
Thirdly, less than half of the questionnaires were complete and included in the analysis, limiting the robustness of the findings. However, the results align with existing literature and provide useful insight into approaches for integrating anti-stigma components into mental health capacity-building interventions in primary care settings. Additionally, the use of convergent data was helpful. For example, our qualitative data found positive ideological changes in trainees’ perceptions of mental illness, which bolstered findings from the quantitative questionnaire. We will incorporate lessons learned in this pilot project to ensure a higher survey completion rate in future studies.
Lastly, this study only examined the perspectives of healthcare workers (doctors and nurses) and health systems leaders. It did not include any community health workers (CHWs), community health extension workers (CHEWs), or the patients’ perspectives. In the next, planned larger implementation study of the HAPPINESS intervention, the study team intends to include perspectives from CHWs, CHEWs, patients, families, and other relevant community stakeholders.
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