Attitudes of Primary Healthcare Workers towards Mental Health – An Interventional study in rural Belagavi, Karnataka

Mental illness is a debilitating condition that affects individuals emotional, psychological and social well-being.[1] It is estimated that about 15% of Indian population experience some form of mental disorders like schizophrenia, depression, substance use disorders, anxiety disorders, bipolar disorder and neurodevelopmental disorders.[2] Individuals with mental illnesses often experience discrimination, stigma, and prejudice from general public and healthcare professionals.[3]

Despite the availability of various community-based rehabilitation centers, cost-effective pharmaceuticals, and psychological treatments, nearly 90% of individuals in low- and middle-income nations are not receiving adequate mental healthcare.[4] The scarcity of mental health professionals, particularly in rural areas, further limits psychiatric care access to most people.[4] In low-income countries like India, integrating mental health services into primary healthcare enables primary healthcare workers to identify, refer, and support individuals with mental health disorders.[5]

Several studies have examined the influence of psychiatry training on medical students’ attitude towards mental illness from different regions and cultures, yielding varied findings.[6-8] However, studies on community health workers have shown inadequate understanding and awareness of mental disorders.[9, 10] Community health workers with a better mental health knowledge would provide appropriate treatment and care for affected individuals. Hence, the present study was intended to assess the primary healthcare workers’ attitude towards people with mental illness and determine the effectiveness of health education intervention in improving their perceptions.

Categorical variables were presented as frequency tables and continuous variables as mean ± SD. Normality of variable was checked using Shapiro Wilk test and QQ plot. If the data followed normal distribution, we used parametric tests. Friedman test was used to compare the change in attitude over time. Pairwise Wilcoxon test with Bonferroni adjustment was used for post hoc analysis. P-value less than or equal to 0.05 indicates statistical significance.

Table 1 shows positive change in attitudes toward mental illness over time. Initially, most participants strongly agreed with negative statements, such as linking mental illness to lower IQ, strange behavior, or inability to marry or have children, recover, or work. However, after the intervention, there was a noticeable increase in the number of participants who disagreed with these views.

Supportive attitudes also increased, believing that family and community support can help with recovery and that individuals with mental illness can work or return to normal life after treatment. However, still few misconceptions persisted, such as difficulties in forming friendships or achieving workplace success.

Table 1. Attitude Scale for Mental Illness (ASMI) Responses at Pretest, Post-test, and Follow-up.

Table 2 shows an individual’s overall attitude towards mental health before and after psychiatry training. Psychiatric training significantly improved primary healthcare workers overall attitude towards mental illness (p<0.001). We found a significant increase in benevolence (p<0.001), suggesting more positive attitudes. However, separatism (p<0.001), stereotyping (p<0.001), and restrictiveness (p<0.001) also increased, indicating an increase in negative attitudes. While the intervention did not significantly impact pessimistic prediction. These changes were largely maintained until the follow-up assessment.

Table 2. Comparison of attitudes of primary healthcare workers towards Mental Health

*indicates statistical significance.

Figure 1: Mean plot of Benevolence over time

Attitude toward mental health greatly affects the practice of primary healthcare workers. A positive attitude can enable healthcare workers to provide proper health education, active treatment and rehabilitation guidance. Negative attitudes can result in poor patient functioning and overall outcomes.[10, 12] The present study examined how psychiatry training affected primary healthcare workers attitude towards mental health. The findings revealed psychiatric training improved benevolence but stigma, stereotyping, restrictiveness and separatism increased after the training. Despite the rise in certain stigmatizing attitudes, the overall attitude of primary healthcare workers towards mental illness improved. The changes are largely maintained till the follow-up assessment.

A study conducted in India involving Accredited Socail Health Activitists (ASHA) workers who underwent 18 months of psychiatric training showed a significant improvement in benevolence, social restrictiveness, and community mental health ideology towards those with mental illness (p<0.001).[4] Results from a South African study on community health workers who received training improved confidence, and overall attitudes. Specifically, they became more benevolent, less socially restrictive, and increase in tolerance to psychiatric rehabilitation with no change in authoritarian attitudes.[9] Primary healthcare providers in rural China were pessimistic and had negative attitudes toward individuals with mental illness. Most providers believed that these individuals were prone to impulsive property destruction (71.3%) and viewed them as burdens to their families and society (72.9%).[10] Another study in India showed that the training course improved community health workers ability to recognize a mental disorder, reduced their belief in harmful pharmacological interventions, and slightly decreased stigmatizing attitudes.[13]

Overall, our findings confirm that psychiatric training increased the benevolence or kindness of primary healthcare workers toward those with mental illness, however other are not significantly changed by the existing psychiatric training program. The study has a few potential limitations that needs to be acknowledged. Firstly, as the participants were primary healthcare workers and convenient sample from a single institution, findings may not be generalized. Secondly, as this is a cross-sectional interventional study, it may be difficult to establish causality between variables. Hence, to achieve generalization, it is necessary to include diverse populations and increase the sample size. Despite these limitations, the study presents noteworthy findings that are of interest to both academic and mental health professionals. The present study also informs revisions to current curriculum and teaching methodologies in specific domains.

Overall, the study states mental health education training program alone is insufficient in completely shifting healthcare workers attitudes towards the right direction in a few domains. Multiple factors such as personal beliefs, family environment, education, social circle, and media exposure might have influenced their attitude. Hence, to improve mental health services, raise awareness and build an integrated health system, healthcare institutions should take an active and effective role.

Our study demonstrates that psychiatric training is effective in improving the attitude of primary healthcare workers toward mental illness to some extent, particularly in the domain of benevolence. Furthermore, the sustained impact of the training until follow-up emphasizes its effectiveness in developing positive attitudes towards mental health. However, the increase in negative attitude in few domains suggests the need to provide more holistic care to the individuals with mental illness.

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