Perceived challenges and opportunities arising from integration of mental health into primary care: a cross-sectional survey of primary health care workers in south-west Ethiopia

Mental, neurological and substance use (MNS) disorders are prevalent in all regions of the world and are major contributors to morbidity and premature mortality [1]. MNS disorders alone contribute 10.4% of the total global burden of disease, mostly accounted for by depression and other common mental disorders, alcohol and substance-use disorders, psychoses and epilepsy [2]. Mental disorders are at least as disabling as cancer or heart disease in terms of lost productivity and premature death [3]. In Ethiopia, schizophrenia and depression are ranked in the top ten contributors to disease burden [4]. Despite this, the amount of money spent on mental health care in low- and middle-income countries (LMICs) is disproportionately low when compared to physical health problems [5]. Evidence-based treatments for MNS disorders are available and have been shown to be appropriate for LMIC settings [6]. However, the availability of effective mental health care does not match the burden of MNS disorders, leading to a large treatment gap: in LMICs up to 90% of persons with severe mental disorders go untreated [7], compared to less than 50% in high-income countries [8]. The consequences of untreated mental disorders in LMICs are substantial, associated with personal suffering, premature mortality [9], poorer physical health and health care [3], poverty [10], caregiver burden [11], stigma, discrimination and abuse [12].

Specialist mental health workers are scarce in LMIC settings and cannot, in isolation, provide the solution to the MNS disorder treatment gap [13]. In Ethiopia, there is about one psychiatrist per two million people [14] and only an estimated 0.68 mental health professionals per 100,000 people [15], largely concentrated in urban areas and hospital settings which are not accessible to the majority of the population. Integration of mental health care into primary health care (PHC), through a model of task sharing with mental health specialists, is therefore advocated as the best approach to narrow the treatment gap for MNS disorders [1]. Providing mental health care in the PHC setting has other potential benefits, including more holistic care and better physical health outcomes, reduced stigma and more locally available care with a resultant decrease in the economic burden of care and a greater chance of maintaining contact with community and family support systems [16]. Furthermore, co-morbidity between physical and mental health conditions is high [3] and the expression of mental health problems as physical symptoms (somatisation) is widespread (and often undetected) in general health care settings [17]. However, despite the desirability of task sharing from a public mental health and health service planning perspective, little is known about the perspectives of frontline PHC workers on taking on these new mental health care roles. A recent systematic review of the acceptability and feasibility of task sharing mental health care with PHC workers in LMICs found that studies were scarce and were often concerned with clearly circumscribed interventions for specific disorders rather than providing a general mental health service [18].

This paper contributes to our understanding of the perspectives of PHC workers towards mental health care in a sub-Saharan African setting characterized by a high burden of infectious diseases and under-nutrition and over-stretched PHC services. Such information is essential in order to meet the training and support needs of PHC workers and contribute to the successful scale up of mental health care. The aim of the study was, therefore, to assess the perceived challenges and opportunities for integrating mental health care into a primary health care from the perspective of PHC workers in a regional zone in Ethiopia.

In this cross-sectional survey of frontline PHC workers from a low-income sub-Saharan African country setting, comprehensive information was obtained about knowledge gaps and the acceptability and feasibility of task sharing mental health care with PHC workers.

Whereas almost all of the PHC workers considered MNS disorders to be a problem in Ethiopia, accepted the need for mental health care and supported the integration of mental health care into the health centres where they worked, a somewhat lower percentage (66.9%) expressed interest in actually being involved in the delivery of mental health care themselves. Furthermore, it is noteworthy that the envisaged role of PHC was largely in mental illness prevention, referral to specialists and follow-up of patients seen by specialist mental health workers: the acceptability of a more active role in delivering mental health treatment, for example, as outlined in the WHO’s mhGAP Implementation Guide [24], was less clear. This disconnect between recognising the need to deliver mental health care in PHC and willingness to be personally involved in the delivery of mental health care has been seen in several previous studies [23, 25‐27]. In a qualitative study in South Africa, primary care-based HIV workers recognised the need for mental health care in the PHC setting but reported that, after screening and referral, this care should be delivered by another professional, preferably a mental health worker [25]. In the seminal WHO studies carried out over 30 years ago to evaluate integration of mental health into PHC in seven LMICs, the findings were much the same: although not overtly opposed to the idea of expanding PHC to include mental health care, the PHC workers expected this to be carried out by mental health workers rather than becoming part of their work [22].

Several factors could be influencing PHC worker willingness to provide mental health care in our study, including their perceived competence, the perceived effectiveness of modern medicine and stigmatizing beliefs about MNS disorders. It is important to note that over a quarter of respondents thought that persons with MNS disorders would pose a risk to other patients. Similar concerns were expressed in a study of PHC workers in Zambia, with the majority of respondents recommending that services for persons with mental illness should be delivered in a separate facility and expressing discomfort about the idea of direct involvement in delivering care to people with mental illness [26]. Concerns about the dangerousness of persons with mental illness have also been found in studies of PHC workers in Nigeria [28]. This indicates that many PHC workers equate MNS disorder with the overt manifestations of mental illness seen in acute psychosis or mania, similar to the findings from a community study in Ethiopia [29]. Training of PHC workers needs to target this misperception, as well as properly addressing the concerns of PHC workers with regard to safe management of the small proportion of persons with MNS disorders who do pose a potential risk to others.

More highly trained health workers were more favourably disposed towards the idea of delivering mental health care and less likely to consider supernatural factors to be important in aetiology of mental disorders, in keeping with findings from a study of PHC workers in Nigeria [27]. PHC workers with pre-service clinical attachments in mental health care were much more likely to express a favourable attitude towards the idea of delivering mental health care. Practical exposure to mental health care has the potential to be more effective in overcoming reluctance to provide care. First-hand contact with persons with mental illness has been shown to be a potent factor in reducing stigmatising attitudes [30]. At present only a small proportion of PHC workers (31.4%) reported that they had been exposed to practical attachments during their training and none had received any in-service or on-the-job training in mental health care. The current lack of mental health specialists in Ethiopia means that there are a limited number of facilities available for training PHC workers. These training facilities are often overloaded with students from a range of disciplines (medical students, health officers, medical interns, psychologists, psychiatric nurse trainees and psychiatric residents) which may limit opportunities for hands-on clinical training. Furthermore, most mental health facilities are hospital-based and concerned with the care of persons with severe mental disorders, usually psychosis, whereas PHC workers also need to develop skills in detecting and managing the common mental disorders (for example, depression, anxiety and alcohol use disorders). This serves to underline the importance of expanding the specialist mental health workforce and developing their role as trainers in order to be able to support scale up of mental health care integrated into PHC settings [1, 31].

The general level of knowledge about MNS disorders and pharmacological treatments was low in this sample of PHC workers. Depression and anxiety were the most frequently reported MNS disorders (reported by 60.0% and 41.1%, respectively). However, when asked to list symptoms that are characteristic of the disorders, no PHC workers identified the common presenting symptoms of depression in the Ethiopian PHC setting, i.e. headache, non-specific aches and pains and fatigue [32, 33]. This may indicate a more theoretical rather than practical knowledge of depression and anxiety arising from a lack of clinical exposure during training. The context of PHC in Ethiopia also needs to be considered in this regard. The number of patients seen by PHC workers per day is very high which might mitigate against acquisition of detailed knowledge about symptoms of depression and anxiety, akin to findings from training of general doctors in India [34]. Training will need to emphasise more common and easily identifiable presentations of depression and anxiety for the setting. When asked about the possible causes of MNS disorders, more than half of the PHC workers reported genetic predisposition and neurochemical imbalance as risk factors for MNS disorders, which is similar to a study of PHC workers in Nepal [23]. However, the pluralistic nature of attributions for MNS disorders was evident, with 45% of PHC workers also endorsing supernatural causes of MNS disorders (51.9% of diploma nurses).

The marked difference between degree and diploma level PHC workers with regard to knowledge about MNS disorders and psychotropic medications, and attitudes towards mental health care in PHC, has important implications for the scale-up of mental health care in Ethiopia. Diploma level nurses make up the majority of the PHC workforce (around three-quarters in this study) and are the cadre of health professional who are expected to deliver the mhGAP interventions in Ethiopia, including identification of MNS disorders and initiation of psychotropic medication where indicated. Brief, stand-alone training is unlikely to be sufficient to equip these health workers with sufficient clinical competence and confidence to deliver mental health care independently. As recommended by previous studies [35], ongoing training and supportive supervision by mental health professionals is likely to be essential. A previous study of the impact of brief mental health training of community health workers in India found that recognition of MNS disorders increased and faith in non-helpful pharmacological interventions (e.g. non-indicated vitamin injections or benzodiazepines) decreased, but that stigmatising beliefs were more resistant to intervention [36]. This further underscores the need for training courses to target known misconceptions and include personal testimonies with MNS disorders who have experienced mental health care [30].

Substantial logistical challenges to task sharing mental health care were evident from this study. If mental health care is going to be integrated successfully into PHC, structural problems such as lack of examination rooms, non-availability of medications for MNS disorders and the shortage of time for PHC workers to diagnosis and treat MNS disorders will need to be addressed. Provision of clinical guidelines and periodic supportive supervision by a mental health professional would be possible ways to support integration of mental health care into PHC, supported by evidence from previous studies [35]. However, in this study, the health centres were up to five hours travel from the Zonal town, where the psychiatric unit is located, limiting the feasibility of this approach without additional availability of specialist mental health workers [37]. Evaluation of an implemented model of task sharing mental health care in PHC in Ethiopia is underway and will yield important insights regarding acceptability and feasibility of this approach [38]. Other innovative approaches may also need to be considered in addition, or even as an alternative to, the task sharing approach with PHC workers. The biggest burden of mental health care in Ethiopia currently falls upon the family [11], with traditional and religious healers contributing to the care of people with severe mental illnesses such as psychosis. Capitalising on existing community expertise and interest in the problem of mental illness may be a more sustainable approach in the longer-term, for example, training up local mental health champions who would be linked to PHC and provide a focus for mental health care.

The high level of acceptance of the need to decentralise mental health care to PHC by the health centre workers is a positive starting point, although the lower level of willingness to be actually involved in delivery of mental health care will be a challenge to implementation. The feasibility of integrating mental health into PHC in this sub-Saharan African setting is limited by important gaps in PHC worker knowledge and expectations regarding mental health care, coupled with health system constraints. In addition to clinically-based refresher mental health training, expansion of the specialist mental health workforce will be needed to support integration in practice.