Mental health literacy among pediatric hospital staff in the United Arab Emirates

The United Arab Emirates (UAE) is an Arabian Peninsula nation formed in 1971 from seven sheikdoms. It is currently ranked as one of the top 25 countries worldwide in population growth [1]. Despite rapid population growth and the relative wealth of the nation, there are concerns that mental health services are not growing at a rate that matches the country’s needs [2]. In 2010, the UAE government prioritized mental health as one of the top five health priority areas requiring attention [3]. Another pressing concern directly linked to the UAE’s rapid population growth is the need to optimize care for young people aged 0–24 years, who comprise approximately 35% of the total population [1]. Improvements in the quality of healthcare and a marked decrease in infant mortality have resulted in a growing number of children with chronic conditions (e.g., asthma, type 1 diabetes, cardiac conditions, and genetically-transmitted conditions such as thalassemia and cystic fibrosis) who are able to actively participate in the community. However, children living with chronic conditions face multiple challenges that may impede or delay their achievement of developmental and social milestones [4]. Challenges include repeated hospitalizations, ongoing periods of poor health, decreased physical strength and skills, or changes in appearance due to illness [4, 5]. Improved health outcomes and the multiple challenges experienced by children living with chronic illness mean that community service providers (e.g., mainstream schools, primary healthcare centers, and hospital-based pediatric services) need to provide enhanced support to enable these children to achieve their full potential.

Children and adolescents living with chronic physical health conditions have increased vulnerability to mental health problems such as anxiety and depression [6‐12] [6‐12] [6‐12] [6‐12] Undetected mental illness in children or adolescents further disrupts the achievement of developmental tasks required for optimal health and vitality in adulthood [6‐12]. Early detection of mental illness and referral to appropriate treatment is essential to avoid more serious mental illness in future. Therefore, health professionals caring for this age group need adequate knowledge and understanding of the nature and treatment of mental health problems; that is, they must demonstrate sufficient mental health literacy (MHL) to identify emerging mental illness, provide information to the child/young person and their carers, and make referrals to appropriate services. Although mental health services have been identified as requiring further development, Sayed [13] reported that well-established, comprehensive in- and outpatient mental health services are co-located with hospitals in major UAE cities, and other mental health services are accessible via educational and community settings. However, community-based mental health services staffed with specialist mental health clinicians are limited.

MHL is defined as “knowledge and beliefs about mental disorders which aid their recognition, management or prevention” [14]. MHL encompasses: a) the ability to recognize specific disorders; b) knowledge of how to seek mental health information; c) knowledge of risk factors and causes, self-help treatments, and professional help; and d) attitudes that promote recognition and appropriate help-seeking. Research has demonstrated that improved levels of MHL can achieve two key outcomes. First, MHL empowers the recipient community with an understanding of mental disorders that facilitate prevention, early intervention, and treatment. Second, individuals with a sound level of MHL have the means by which they are able to make informed decisions about accessing mental healthcare [15].

To our knowledge, no study has examined MHL among pediatric health professionals working in hospitals in the UAE. Measuring MHL in this cohort may inform development of focused mental health training programs for health professionals in the UAE, and more broadly inform mental health promotion programs. This study aligns with the priority on the ongoing development of evidence-based mental health services in the UAE, based on research evidence conducted within the country. Given the paucity of literature, no “a priori” hypotheses were determined. However, this study aimed to determine knowledge of, and beliefs about, helpfulness of treatment interventions and providers of care for three common mental health conditions (posttraumatic stress disorder [PTSD], depression with suicidal thoughts, and psychosis) among healthcare professionals working in pediatric hospital settings in the UAE. A large proportion of the healthcare workforce in the UAE is expatriate; many are separated from their families or have come from countries affected by sociopolitical upheaval. Therefore, a secondary objective of this study was to explore potential associations between healthcare professionals’ level of distress and their ability to identify these three mental health conditions. A cross-sectional measure of non-specific psychological distress in the target population was administered to allow this exploration.

The importance of optimal recognition and promotion of early and appropriate mental health treatment has consistently been demonstrated as associated with improved mental health outcomes [15]. The promotion of good mental health should encompass all healthcare professionals, rather than relying on mental healthcare providers alone. This study, which is the first of its kind in the UAE, sought to assess the MHL of healthcare professionals working with children and adolescents with chronic conditions. We found variation in the recognition of mental health disorders and beliefs regarding treatment that differed from the recommended practices taught in most health professional degrees based on a Western biomedical approach, and from those reported in research assessing levels of MHL in healthcare professional groups [21‐23]. Although participants in this study represented a range of different cultures and may bring belief systems congruent with their cultural background to their clinical work, the UAE has largely adopted a Western biomedical approach to mental healthcare. In clinical settings, the DSM-V is used as the basis for diagnosis and treatment planning, and it is expected that participants would be familiar with this framework.

Specifically, our results demonstrated limited recognition of mental health disorders, ranging from 47% for PTSD to 54.3% for psychosis. Approximately half of the participants were unable to correctly identify the disorders described in the vignettes. This finding is concerning, particularly as it may result in potentially lethal consequences if the need for intervention is not identified (i.e., depression with suicidal thoughts). Research has demonstrated that identification or recognition of mental illness is associated with early and appropriate treatment seeking [15]. Therefore, our findings highlight the need for focused investment in mental health education and promotion programs for healthcare professionals in the UAE.

The low level of mental health knowledge shown in this study is congruent with other studies. A Nigerian study [24] that assessed healthcare professionals’ level of familiarity with mental health problems revealed that although a slight majority held positive attitudes toward persons with mental illness, many did not. The levels of education and knowledge about mental illness among participants in that study were significantly related to other factors such as prior exposure to reports in the media about mental health problems. Recommendations from that study included developing programs to improve health workers’ MHL and attitudes toward those with mental illness [24].

Other studies indicated that knowledge deficits also exist among specialized mental healthcare professionals, such as psychiatrists and nurses working in psychiatric healthcare settings [25, 26]. An assessment of MHL relating to eating disorders among 126 psychiatrists in the United Kingdom reported variable knowledge of eating disorders, with specific gaps in both diagnosis and management of eating disorders [25]. That study identified the need for focused education for psychiatrists regarding diagnosis and management of such disorders. Other recommendations to address identified knowledge deficits included implementing training programs and making information readily available [25].

Differences in MHL between healthcare professions may also impact the level of care provided. A Chinese study comparing psychiatrists’ and registered nurses’ levels of MHL in a Chinese general hospital identified psychiatrists as highly accurate in correctly diagnosing mental health problems, whereas registered nurses were less accurate [26]. Although the role of nurses in the UAE does not include the diagnosis of mental disorders, the ability to correctly identify and recognize signs and symptoms of major mental health problems is important in enabling nurses to appropriately refer patients to more specialized services. In the present study, the small number of participating medical doctors precluded comparisons of MHL between nurses and medical doctors in the UAE. However, differences in undergraduate education and training programs and opportunities for ongoing professional development for nurses and medical doctors may contribute to lower levels of MHL among nursing professionals.

The findings of this study have important implications for education and mental health promotion. The low levels of MHL in our sample suggest potential for healthcare service delivery to be compromised, especially in regard to identification and early treatment for children and young people with chronic physical health problems. This gap in knowledge requires attention from service planners and decision makers. A growing body of research demonstrates that focused training programs positively affect MHL [22, 27]. A US project evaluated a two-tiered training program to improve family physicians’ skills and confidence in diagnosing and treating patients with mental health problems. The program provided family physicians with training in adult mental health, and included mental health first aid training for medical office assistants. Those authors reported the training had a positive impact on participants’ clinical practice, and the behavior-change tools (provided as a training component) were effective [22]. Australian researchers reported on a longitudinal evaluation of changes in healthcare providers’ knowledge and beliefs regarding mental illness; following implementation of multiple national mental health promotion activities, there was improvement in MHL compared with the results of earlier studies (conducted between 1996 and 1997) [27].

The marked cultural diversity of the UAE population may require health professionals to be even more mindful of the potential influence of cultural factors on mental health issues. Expatriates comprise a large proportion of the UAE workforce. For many of the expatriate workforce, work or economic factors resulted in separation from families who remain in their homeland; many have families living in unstable regions of the world, or have themselves been displaced from their homelands for sociopolitical reasons. These factors contributed to the interest in exploring the participant’s levels of psychological distress as measured by their K10 scores and whether this influenced their MHL. Our findings indicated that 40% of participants scored moderate to severe levels of psychological distress. When exploring associations with MHL, it was noted that those with higher K10 scores were more likely to select the correct diagnosis when presented with the ‘depression with suicidal thoughts’ vignette. Further, an association between those with lower K10 scores and next most correct diagnosis of ‘depression’ was also noted for the same vignette. Previous studies of MHL in clinical populations such as traumatized refugees noted that levels of PTSD symptomology were not associated with improved recognition when participants were presented with a PTSD clinical vignette [17]. Further, given that no other associations were noted between psychological distress levels and the other vignettes in this study, this finding should be interpreted with caution and warrants the need for future replication.

In the UAE context, the patient population and the healthcare workforce are culturally heterogeneous. Only 3% of the UAE nursing workforce is Emirati nationals. Most non-Emirati clinicians completed their education in a range of different countries and educational systems. Consistent with the heterogeneity of the nursing workforce, it is expected that culturally-specific beliefs about mental health may impact on clinical practice. The potential impact of personal cultural and religious belief systems was explored in a qualitative study investigating the impact of South African Muslim general practitioners’ beliefs about mental health on their clinical practice [28]. Participants in that study held different religious beliefs from the majority of the South African population. That study analyzed the impact of clinicians’ belief systems on clinical practice in relation to mental illnesses, perceptions of the mental illness, the effect of religion and culture, and treatment of mental illness (including aspects of spiritual illness); the findings highlighted the need for greater awareness among these healthcare professionals regarding mental illness and an understanding of the differing religious and cultural taxonomies of illness held by the people to whom they provided care [29].

The present study demonstrated that MHL is low among the UAE healthcare workforce. Future research using a mixed methods approach should be undertaken to further elucidate the relationships between cultural beliefs and stigma and MHL levels in this population.