Ability and Preparedness of Family Physicians to Recognise and Treat Adolescent Mental Health Disorders in Nigeria and Ghana

Abstract

Background:

Management of mental health disorders has not been fully integrated into primary care despite been advocated by the World Health Organisation (WHO) and the World Organisation of Family Doctors (WONCA). This study therefore seeks to assess the ability and preparedness of Family Physicians to recognise and treat mental health disorders in adolescents.

Methodology:

A descriptive cross-sectional study of 233 randomly selected Physicians Practicing in Family Medicine Clinics in Nigeria and Ghana was conducted using a semi structured self-administered questionnaire that was developed by the researchers and validated with a Cronbach’s alpha coefficient of .85. Data analysis was done with the Statistical Package for Social Sciences™ (IBM Corp, Armonk, NY, USA) version 22.0.

Results:

Respondents had a mean age of 43 ± 8 years, were mostly males 130 (55.79%), practised in Nigeria 168 (72.10%) and have been in practice for over 10 years 149 (63.95%). Majority of respondents 153 (65.67%) received at least one Medical Education sessions in mental health in the preceding 12 months of the study. Out of these, 146 (95.42%) said the sessions enhanced their knowledge of mental health, and 121 (79.08%) said the sessions enhanced their abilities and preparedness to attend to patients with mental disorders. Barriers included stigmatisation 156 (66.95%), poor facilities 136 (58.37%), non-conducive environment 135 (57.94%) and non-cooperation from patients 133 (57.08%).

Conclusion:

This study showed that a lot of family physicians in Ghana and Nigeria are able and prepared to manage adolescent mental health disorders. They however cited stigmatisation, poor facilities and non-conducive environment as barriers to management of adolescent mental health disorders in primary care. Considering the severity of the disorder, there is a need to increase the training of Family Physicians in the management of adolescent mental health.

Introduction

Background

The period of adolescence is between 10 and 19 years of age, which is sometimes described as, persons in the second decade of their lives.^1-4 It is a critical, formative and key period in the development of every individual as there are a lot of physical, mental and social changes that render individuals in this category more prone to mental health issues. ⁵ Before the mid 1990s the general understanding in psychiatry was that depression, as one of the major mental health conditions, was only seen in adults. It has however been proven that adolescence is a pivotal period for mental health. ⁴

It is estimated that the global prevalence of adolescent mental health disorder is 10% to 20% ⁶ and about 50% of the mental health problems in adolescents if left untreated can progress into adulthood. This will eventually have an untoward effect on cognitive, physical, social, work productivity and disability. ¹

Mental health should be seen as a valued source of human capital or well-being in society as it contributes to individual and population health, happiness and welfare. It enables social interaction, cohesion and security and feeds national output and labour force productivity. ² Mental health also has huge financial implications for individuals, families, nations and the world as a whole. Two of the most common mental health conditions, depression and anxiety, cost the global economy US$ 1 trillion each year. ⁷ Investments in adolescent health and wellbeing bring benefits today, for decades to come and for the next generation. ⁸ We need good mental health to succeed in all areas of life, hence the need to critically and aggressively identify and manage appropriately mental health diseases especially in the adolescent period.

Mental health disorders are common among adolescents in sub Saharan Africa with a treatment gap of 98% of the about 30% adolescents with mental health disorder in Ghana^9-11 and west and central Africa are projected to have the highest increase in the burden of mental health (upto 129%) by 2050. ¹⁰ Patients hardly present to mental health physicians in the region for fear of stigmatisation. ¹² This is coupled with the dearth of mental health physicians in the region with about 200 psychiatrists attending to 170 million Nigerians. ¹² Integrating mental health into primary care has been advocated by the World Health Organisation (WHO) and the World Organisation of Family Doctors (WONCA) ¹³ . Management of mental health disorders however, has not been fully integrated into primary care in West Africa despite the need. ¹² This study therefore seeks to assess the ability and preparedness of Family Physicians to recognise and treat mental health disorders in adolescents as well as identify the barriers to its integration into primary care in Nigeria and Ghana with a view to addressing them. It is expected that findings from this study will help improve the management of mental disorders in primary care thus reducing the morbidity and mortality associated with the disorders in the subregion.

Methodology

The study was a descriptive cross-sectional study conducted in Family Medicine Clinics in Nigeria and Ghana. The 2 countries were chosen as representatives of the West African sub region as they share sociocultural characteristics and have similar health dynamics which are not significantly different from those of most countries in the sub region. The clinics included General Outpatient Clinics of Teaching Hospitals, Polyclinics, General and District Hospitals and other primary care clinics where Family Physicians practice in both countries. A total of 233 Physicians Practicing in Family Medicine Clinics in Nigeria and Ghana who consented to the study were randomly selected for the study using a multistage sampling technique. Two countries, Nigeria and Ghana were selected using purposive sampling. Simple random sampling was then used to select Family Medicine clinics across both countries and all the Family Physicians in the selected clinics that met the selection criteria were recruited for the study. Those included were Consultants/Senior Specialists, Specialists/Senior Registrars/Registrars and Medical Officers in Family Medicine Clinics in both countries. Those who were not currently practising were excluded from the study. The sample size was determined using fisher’s formula, with 50.0% used in the absence of proportion. The Association of General and Private Medical Practitioners in Nigeria (AGPMPN) and the Society of Family Physicians of Ghana estimates that there are currently 1200 and 125 Family Physicians in Nigeria and Ghana respectively. Thus, the sample size for finite population was determined to be 302. Proportionate sampling was then used to determine the sample size for Nigeria and Ghana to be 254 and 48 respectively. However, 233 respondents made up of 168 and 65 from Nigeria and Ghana respectively. This gave a response rate of 77.2% with a country response rate of 66.1% for Nigeria and 135% for Ghana. Physicians from Ghana cooperated more hence more were recruited to increase the power and compensate to some extent for the poor response from Nigeria.

A semi-structured self-administered questionnaire containing information on sociodemographic variables, information on mental health disorders seen among adolescents as well as information on the ability and preparedness of respondents to recognise and treat mental health disorders among adolescents was used to obtain information from respondents electronically. The questionnaire was developed by the researchers in line with the objectives and evaluated by a team of experts in Family Medicine and Mental Health for face and content validity and reliability. A Cronbach’s alpha coefficient of .85 was obtained. This is indicative of high dependability of the instrument. It was pretested among medical practitioners of the staff clinic of Irrua Specialist Teaching Hospital, Irrua before commencement of the study. The database of the Association of General and Private Medical Practitioners in Nigeria (AGPMPN), Society of Family Physicians of Nigeria (SOFPON) and that of Ghana as well as training centres accredited for the training of Family Physicians in Nigeria and Ghana was used in identifying and selecting respondents. Questionnaires were sent to study participants through Email and WhatsApp. Responses were received through same channels.

Data analysis was done with the Statistical Package for Social Sciences™ (IBM Corp, Armonk, NY, USA) version 22.0. Tables and charts were used to present data. Continuous variables were expressed as mean ± standard deviation while categorical variables were described as frequencies and percentages.

Ethical approval was obtained from the Health Research Ethics Committee of Irrua Specialist Teaching Hospital, Irrua, Nigeria (ISTH/HREC/20221403/275).

Results

The study looked at the ability and preparedness of Family Physicians to recognise and treat adolescent mental health disorders in Ghana and Nigeria. The ages of the 233 respondents that participated ranged from 30 to 64 years with a mean age of 43 ± 8 years.

Majority of respondents were males 130 (55.79%), practised in Nigeria 168 (72.10%) and have been in practice for over 10 years 149 (63.95%) as illustrated in Table 1.

Table 1.

Sociodemographic characteristics of respondents (N = 233).

Variable	Frequency (n = 233)	Percentage
Age (years)
30-39	83	35.62
40-49	88	37.77
50-59	36	15.45
60-69	26	11.16
Sex
Female	103	44.21
Male	130	55.79
Country of practice
Ghana	65	27.90
Nigeria	168	72.10
Cadre
Consultant/Senior Specialist	81	34.76
Senior Resident/Specialist	76	32.62
Resident	61	26.18
Medical Officer	15	6.44
No. of years in practice
⩽10	84	36.05
>10	149	63.95

A total of 116 (49.79%) respondents received specialised training in the management of Adolescent Mental Health Disorders. These trainings were mainly during mental health posting 96 (82.76%) which is a requirement of the residency training programme in Family Medicine for both the National Postgraduate Medical Colleges of both countries and the West African College of Physicians.

Majority of respondents 153 (65.67%) received at least one Medical Education Sessions in mental health in the preceding 12 months of the study. Out of these, 146 (95.42%) said the sessions enhanced their knowledge of mental health, 121 (79.08%) said the sessions enhanced their abilities to attend to patients with mental disorders, and 130 (84.97%) said the sessions improved their collaboration with mental health professionals Table 2.

Table 2.

Ability of family physicians to treat adolescent mental health disorders.

Variables	Frequency	Percentage
Receive specialised training in Adolescent Mental Health (N = 233)
Yes	116	49.79
No	117	50.21
Type of Training Received (n = 116)*
Online	20	17.24
Seminar	34	29.31
Short Courses	23	19.83
Workshops	23	19.83
Psychiatry Posting During Residency Training	96	82.76
Medical Education Sessions in Mental Health Received in the preceding 12 months (N = 233)
0	80	34.33
1-2	102	43.78
⩾3	51	21.89
Received sessions enhanced knowledge of Mental Health (n = 153)
Yes	146	95.42
No	7	4.58
Received sessions enhanced the ability to attend to patients with mental disorders (n = 153)
Yes	121	79.08
No	32	20.92
Received sessions improved your collaboration with other mental health professionals (n = 153)
Yes	130	84.97
No	23	15.03

^*Some respondents had more than one type of training.

Most respondents were confident in their ability to diagnose depression 150 (64.38%) and generalised anxiety disorder 145 (62.23%). They were however, less confident in their ability to diagnose bipolar affective disorders 111 (47.64%).

Majority of respondents were also confident that they could correctly treat depression 123 (52.79%), generalised anxiety disorder 126 (54.08%), and have a productive conversation with a mental health physician to care for an adolescent with mental health disorder 124 (53.22%). They were however less confident in their ability to treat Bipolar Affective Disorders 89 (38.20%), manage an acutely suicidal patient 92 (39.48%), as well as treat a patient with both medical and mental health disorders 110 (47.21%). Table 3.

Table 3.

Respondents’ confidence in correctly diagnosing and treating adolescent mental health disorders (N = 233).

Variable	Frequency (N = 233)	Percentage
Ability to diagnose depression
Yes	150	64.38
No	83	35.62
Ability to diagnose generalised anxiety disorder
Yes	145	62.23
No	88	37.77
Ability to diagnose bipolar affective disorder
Yes	111	47.64
No	122	52.36
Ability to treat depression
Yes	123	52.79
No	110	47.21
Ability to treat generalised anxiety disorder
Yes	126	54.08
No	107	45.92
Ability to treat bipolar affective disorder
Yes	89	38.20
No	144	61.80
Ability to manage an acutely suicidal patient
Yes	92	39.48
No	141	60.52
Ability to treat patients who have both medical and mental health disorders
Yes	110	47.21
No	123	52.79
Had a productive conversation with a psychologist to care for a patient with mental health disorder
Yes	124	53.22
No	109	46.78

Figure 1 shows the type of treatment given by physicians in Family Medicine clinics to adolescents with mental health disorders. Majority of respondents (27.90%) usually combined counselling/psychotherapy with pharmacotherapy.

Figure 1.

Type of treatment given by physicians in family medicine clinics to adolescents with mental health disorders (N = 233).

Figure 2 demonstrates the preparedness of respondents to manage adolescents with mental health disorders. Over 60% of respondents were prepared to manage adolescents with mental health disorders with 23% of them being very prepared. However, 16% of respondents said they were not prepared while 21% said they were fairly prepared.

Figure 2.

Preparedness to manage adolescents with mental health disorders (N = 233).

Most respondents reported barriers they encounter in the management of Adolescents with mental health disorders to include stigmatisation 156 (66.95%), lack of basic facilities to aid practice 136 (58.37%), lack of conducive environment 135 (57.94%), and lack of cooperation from patients 133 (57.08%) as illustrated in Table 4.

Table 4.

Barriers encountered in the diagnosis and treatment of adolescents with mental health disorders? (N = 233).

Variable	Frequency (N = 233)	Percentage
Lack of cooperation from patients
Yes	133	57.08
No	100	42.92
Lack of cooperation from caregivers
Yes	96	41.20
No	137	58.80
Stigmatisation
Yes	156	66.95
No	77	33.05
Lack of conducive environment
Yes	135	57.94
No	98	42.06
Lack of basic facilities to aid practice
Yes	136	58.37
No	97	41.63
Lack of an effective referral system
Yes	81	34.76
No	152	65.24
Poor training
Yes	112	48.07
No	121	51.93

Discussion

Health is now widely acknowledged as having both a physical and mental health dimension. Indeed, as far back as 1948, WHO’s constitution recognised health as ‘a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity’. ¹⁴ Despite this, many primary healthcare systems in countries around the world focus on physical care, failing to provide mental healthcare to their populations. The principal goal of this study was therefore to determine the ability and preparedness of primary care physicians to recognise and treat adolescent mental health disorders in Ghana and Nigeria.

The majority of the respondents were male physicians (55.79%) practising in Nigeria (72.10%). Nigeria, with a population of greater than 200 million people, accounts for the highest population in Africa. ¹⁵ According to Statista, in 2019, there were 24.6 thousand doctors in Nigeria for a population of about 206 million people. ¹⁶ The majority of them were male doctors, which accounted for 16 thousand, while female doctors were 8.6 thousand. ¹⁶ This pattern of the respondents is therefore consistent with the statistics reported.

Most of the physicians were of senior specialist cadre (34.76%) who had practiced for more than 10 years (63.95%). This is an impressive discovery and a testament to the postgraduate training in both countries. Over the past 30 years, the West African college of Physicians (WACP) and National Postgraduate Medical College of Nigeria (NMPCN) have successfully trained doctors in Family Medicine, some of whom have now become Professors. Rotation in the Department of Psychiatry is part of the requirement of the postgraduate Fellowship in Family Medicine.

Unfortunately, more than half of the respondents (50.21%) did not receive any form of specialised training in adolescent health. This is similar to findings in South East Nigeria were training in mental health was low among primary care providers as less than 20% of them had additional training in mental health. ¹³ Findings were also similar to those of a study in Ghana were the primary care providers in 2 district hospitals studied only had minimal education in child and adolescent development and psychology but did not have specialised training in mental health. ⁹ This is disheartening as the importance of adolescent mental health in primary care cannot be overemphasised. When mental healthcare is available in primary healthcare, it means that people can access the treatment and care that they need near to their homes, and thus keep their families together, maintain their support systems, remain integrated and active in the community and continue to contribute to household productivity.

Among physicians who received training in adolescent mental health (49.79%), the 2-month rotation during residency was responsible for most (82.76%) of the training received by the respondents. Emphasis is made during these postings on screening, diagnosing and treating the common mental health disorders in our environment which are depression and anxiety disorders. As such, most respondents were confident in their ability to diagnose depression (64.38%) and generalised anxiety disorder (62.23%). They were however, less confident in their ability to diagnose bipolar affective disorders (47.64%), suicidal conditions and other complicated mental health illnesses.

In recent times, mental health in primary care has received much attention and so has been inculcated in many Continuing Medical Education (CME) series. However, despite this awareness, only a few physicians in both countries have participated in CMEs where adolescent health was discussed in the past year (34.33%). Thus, advocacy for adolescent mental health needs to be increased.

Though a good number of respondents were able (49,79%) and prepared (63%) to manage adolescents with mental health issues, there were however, several barriers that Family Physicians face which affect their ability to correctly diagnose and treat adolescent mental health disorders in the primary care environment. Majority of the reasons were centred around stigmatisation (66.95%), lack of co-operation from the patients themselves as well as lack of co-operation from the caregivers. This is similar to findings by Gureje et al where stigmatisation was identified as a major barrier to the implementation of mental health service in Nigeria. ¹² Most of the physicians agreed that lack of training was not the major reason for the physician’s inability to manage mental health issues in adolescents.

Limitations

The study was conducted in 2 countries in West Africa. Though most Family Medicine Clinics in the region are in these 2 countries, the results still may not be a true representation of the entire region.

Also, the study was conducted among doctors. However, most primary health care centres in the region are run by primary care nurses, community health officers and community health extension workers. These category of primary care providers were not included in the study even though they attend to most of the patients presenting to primary care facilities in the region.

The researchers also encountered challenges in the recruitment of the research subject, which led to coverage of 70% of the calculated sample size.

The generalisation of the result to the 2 countries was another limitation of this study.

Conclusion

This study showed that almost half of the Family Physicians in Ghana and Nigeria have not received training in the management of adolescent mental health. This lack of training has significantly translated to a majority of them not being able to recognise and treat complicated mental health issues beyond depression and anxiety. Barriers identified as limiting diagnoses and treatment of adolescent mental health disorders in primary care include stigmatisation, dearth of facilities, non-conducive environment and lack of cooperation from patients and caregivers. Consequently, this significant gap in healthcare needed to be addressed. By attending to both the mental and physical health needs of people, a primary care worker can provide treatment and care in a holistic manner that greatly increases the likelihood of better health outcomes in the general population.