Attitudes and beliefs about mental illness among church-based lay health workers: experience from a prevention of mother-to-child HIV transmission trial in Nigeria.

Common mental disorders are prevalent in Nigeria. Due to stigma and a limited number of trained specialists, only 10% of adults with mental illness in Nigeria receive any care. The Healthy Beginning Initiative is a community-based maternal/child health program that includes screening for perinatal depression and was implemented by lay, volunteer, church-based health advisors (CHAs). The aim of the study was to assess the beliefs and attitudes about mental illness among the CHAs. The study used a cross-sectional survey of 57 CHAs, who completed a 43-item, self-administered questionnaire that assessed their beliefs and attitudes about mental illness. The response rate was 71%. Respondents were mostly female (79%), married (83%) and aged 40-49 years (M = 41.16 SD = 10.48). Most endorsed possession by evil spirits (84%), traumatic events (81%) and witchcraft (60%) as causes of mental illness. A majority (69%) believed that people with mental illness were a nuisance, and less than half (46%) believed that mental disorders were illnesses like any other illness. It is concluded that stigmatizing attitudes and beliefs about mental illness are common among the CHAs. Training for lay health workers in Nigeria should include education on the known bio-psycho-social basis of mental disorders and the role of social inclusion in recovery.

Introduction

Common mental health disorders like depression and anxiety are as prevalent in low- and middle-income countries as they are in high-income, developed countries (Kessler et al., 2006; Bromet et al., 2011; Gureje, Lasebikan, Kola, & Makanjuola, 2006). Depression disproportionately affects women (Bebbington, 1998; Singleton, Bumpstead, O'Brien, Lee, & Meltzer, 2003) and is a significant contributor to maternal morbidity, poor infant health and lost economic opportunities (Adewuya, Ola, Aloba, Mapayi, & Okeniyi, 2008; Patel, Rahman, Jacob, & Hughes, 2004; Rahman, Iqbal, Bunn, Lovel, & Harrington, 2004; Schulz et al., 2000; Tripathy et al., 2010).

In Nigeria, an estimated 10–20% of women experience depression during pregnancy and the postnatal period (Abiodun, 2006; Adewuya, Eegunranti, & Lawal, 2005; Uwakwe, 2003). However, only 10% of adults with any mental health disorder in Nigeria receive any care, irrespective of severity (Gureje & Lasebikan, 2006; Gureje et al., 2006). With only about 150 psychiatrists for a population of more than 160 million people (Kakuma et al., 2011), Nigeria exemplifies the severe lack of capacity for mental healthcare provision seen in low and middle-income countries. Furthermore, among the general population, including healthcare professionals, in Nigeria, stigma and negative attitudes toward people with mental illness are common, and explanatory models of mental illness include strongly held beliefs in the role of witchcraft and evil (Gureje, Lasebikan, Ephraim-Oluwanuga, Olley, & Kola, 2005; Gureje, Olley, Ephraim-Oluwanuga, & Kola, 2006; Iheanacho, Marienfeld, Stefanovics, & Rosenheck, 2014; Iheanacho, Stefanovics, Makanjuola, Marienfeld, & Rosenheck, 2014). These beliefs, stigma and negative attitudes affect help seeking for behavioral and emotional problems and can have effects on health outcomes (Corrigan & Watson, 2002; Schulze, 2007).

Recently, increasing attention has focused on training non-psychiatric health workers and lay people to deliver mental health interventions (van Ginneken et al., 2013). These innovative approaches, which utilize task-sharing, stepped-care approaches, depend on individuals whose knowledge and beliefs about mental illness may conflict with current understanding of treatment options and interventions for mental disorders. The Healthy Beginnings Initiative (HBI) is one such innovative program. The HBI is a congregation-based initiative that utilizes volunteer church-based health advisors (CHAs) and clergy for screening women and their partners for mental health disorders, HIV, hepatitis B, sickle cell and malaria, and linking them to care (Ezeanolue et al., 2013). The CHAs were trained to screen for psychological distress using the 12-item General Health Questionnaire, provide brief psycho-education and refer participants who scored above the cut-off point of 11 to their community health clinics for care and those who had acute psychiatric symptoms to the University of Nigeria Teaching Hospital Psychiatric Unit. Details of this have been published elsewhere (Iheanacho, Obiefune et al., 2014). To our knowledge, no published study has explored attitudes and beliefs about mental illness among church-based health workers in Nigeria. One may assume that the CHA's attitudes and beliefs about mental illness could be influenced by the traditional Igbo ideas of mental illness (Achebe, 1986) or the catholic church's teaching on mental illness (Koenig, 1998) or both. This study aimed to assess the beliefs and attitudes about mental disorders among the CHAs who had no prior psychiatric training and who led the HBI mental health screening and linkage to care (Iheanacho, Obiefune et al., 2014), and to determine differences, if any, in these beliefs and attitudes by factors that shape attitudes and beliefs about mental illness, such as gender, education and rural or urban residence (Wirth & Bodenhausen, 2009; Wrigley, Jackson, Judd, & Komiti, 2005).

Methods

Setting and design

This study is a cross-sectional survey of volunteer CHAs aged 18 years and over who attended a two-day, in-service training as part of the HBI, a large cluster-randomized trial funded by the United States National Institute of Health. The HBI was designed to evaluate the effectiveness of a church-based intervention that uses prayer sessions to recruit pregnant women and their partners early in their pregnancy, utilizes baby shower activities to deliver multiple health interventions (including health education, mental health screening and integrated laboratory testing for HIV, sickle cell genotype and hepatitis B) and baby receptions to follow up with the women and link them to continuing care after delivery (Ezeanolue et al., 2013). Volunteer CHAs were trained to conduct mental health screening and refer women and their partners who were positive for psychological distress to treatment. Details of the CHA's training has been published elsewhere (Iheanacho, Obiefune et al., 2014). Briefly, we recruited and trained over 140 CHAs in churches participating in HBI to administer the 12-item General Health Questionnaire to pregnant women and their partners. The CHAs first received specific training on completing the 12-item General Health Questionnaire (GHQ-12) and translating the questions to the local Ibo language so that they could provide assistance and respond appropriately to participants’ inquiries while completing the questionnaire. In addition to providing assistance to the participants in completing the GHQ-12, the CHAs provided education to the families on medical screening, breastfeeding, mother-child bonding, mental health and nutrition.

Participants

For this study, conducted mid-way through HBI implementation, we invited a convenience sample of all 80 CHAs, two from each of the initial 40 churches participating in the HBI, to complete a 43-item, self-administered questionnaire to assess perceptions and attitudes towards mental health disorders and individuals with mental illness. The CHAs were all members of community churches, they spoke English and the local Igbo language fluently. None of the CHAs was a healthcare professional or mental health specialist. We did not ask about personal or family history of mental illness (Table 1 describes the demographics of the study participants).

Table 1.

Sociodemographic characteristics of the volunteer church based health advisors (n = 57).

Demographics	Mean	SD
Age (years)	41.16 (22–72)	10.48
	N	%
Gender (male)	12	21
Marital status
Single	8	14
Married	47	83
Widowed	2	3
Residence at birth
Rural	37	65
Semi-rural	9	16
Urban	11	19
Current residence
Rural	33	58
Semi-rural	6	11
Urban	16	28
No response	2	3
Religion
Catholic	40	70
Anglican	16	28
Other	1	2
Employment
Full-time	34	60
Part-time	10	18
Unemployed	8	14
Education
Primary	5	9
Secondary	15	26
Tertiary	37	65

Measures

The 43-item questionnaire was constructed from modified items taken from the Fear and Behavioral Intentions toward the mentally ill (FABI) questionnaire (Wolff, Pathare, Craig, & Leff, 1996), selected items from the Community Attitudes to Mental Illness (CAMI) scale (Taylor & Dear, 1981) and from a modified version of a questionnaire developed for the World Psychiatric Association Program to Reduce Stigma and Discrimination (World Psychiatric Association, 2000). The questionnaire also documented self-reported sociodemographic characteristics and educational attainment, place of living, place of birth and religious affiliation (Table 1) .

The measures addressed: (1) conceptions of the cause of mental illness based on questions developed for the World Psychiatric Association Program to Reduce Stigma and Discrimination because of Schizophrenia, (2) possible treatment options based on the CAMI scale, (3) social distance, with questions derived from the FABI questionnaire and, finally, (4) social acceptance and social stigma as assessed by a series of questions based on the CAMI questionnaire. This instrument has been used in previous studies that explored attitudes to mental illness among trainees and healthcare professionals in Nigeria (Ighodaro, Stefanovics, Makanjuola, & Rosenheck, 2015; Iheanacho, Marienfeld et al., 2014; Iheanacho, Stefanovics et al., 2014).

Data collection

Each subject completed the semi-structured self-report questionnaire, which had been distributed by hand to the individuals and collected in person on the day of its distribution. The instrument was used in the original English version as English is the official national language of Nigeria and although participants could speak the local language, majority were unable to read the local Igbo language but can read English. Participation in the survey was completely voluntary and anonymous. The research assistants who handed out the questionnaires were available to answer specific questions from the participants who otherwise completed the questionnaires on their own.

Data analysis

First, chi-square tests for categorical variables and analysis of variance for continuous variables were used to examine differences in sociodemographic characteristics. Then, a chi square test and Fisher's exact test, where appropriate, were used to identify any significant differences in responses among men and women, among two educational levels (primary/secondary versus tertiary) and two different areas of living (rural and urban). All analyses were performed using SAS 9.3 statistical software (SAS Institute Inc., Cary, North Carolina, USA). Statistical significance was evaluated at the 0.05 level. The study was approved by the Institutional Review Board of the University of Nevada, Reno and the Nigerian National Health Research Ethics Committee.

Results

Of the 80 invited CHAs, 57 completed the questionnaire (a response rate of 71%). The majority of the respondents were female (79%), married (83%), aged between 40 and 49 years (mean age 41.16, SD = 10.48) and had attained at least a high school education (91%). Most were born in rural areas (65%) and reported living in rural areas (58%) at the time of the survey. The majority reported being in full-time or part-time employment (78%) and 70% were members of the Catholic Church, with 28% reporting membership of the Anglican Church (Table 1).

The survey results show that most of the respondents believed that mental illness is caused by alcohol or drug misuse (97%), brain disease (90%), genetic inheritance (90%), possession by evil spirits (84%), traumatic events (81%) and witchcraft (60%). Most agreed that virtually anyone can become mentally ill (79%) although less than half (46%) believed that mental disorder is an illness like any other. Less than half of the respondents (44%) agreed with the idea that mental hospitals are an outdated means of managing mental illness. Although 69% of the CHAs felt that people with mental illness are a nuisance, more than 95% agreed that the best possible care should be provided for people suffering from mental disorders and less than 5% agreed that increased spending on mental health services is a waste of money (Table 2).

Table 2.

Differences in beliefs and attitudes by gender, education and area of living.

	Gender			Education			Area of living
	Male	Female		Primary/Secondary	Tertiary		Rural	Urban
Cause of mental illness	N (%) (n = 12)	N (%) (n = 47)	p	N (%) (n = 21)	N (%) (n = 38)	p	N (%) (n = 22)	N (%) (n = 35)	p
Drug /alcohol use	11 (91.7)	44 (93.6)	0.8	18 (85.7)	37 (97.4)	0.08	22 (100)	32 (91.4)	0.16
Evil spirit	11 (91.7)	37 (78.7)	0.3	16 (76.2)	32 (84.2)	0.44	19 (86.4)	27 (77.1)	0.39
Traumatic event	11 (91.7)	35 (74.5)	0.2	16 (76.2)	30 (78.9)	0.8	20 (90.9)	25 (71.45)	0.08
Stress	8 (66.7)	15 (31.9)	0.03	7 (33.3)	16 (42.1)	0.5	13 (59.1)	10 (28.6)	0.02
Genetic inheritance	10 (83.3)	41 (87.2)	0.7	15 (71.4)	36 (94.7)	0.01	21 (95.4)	29 (82.95)	0.15
Physical abuse	4 (33.3)	18 (38.3)	0.7	6 (28.6)	16 (42.1)	0.3	11 (50)	10 (28.6)	0.1
Biological factors	7 (58.3)	33 (70.2)	0.43	12 (57.1)	28 (73.7)	0.19	15 (68.2)	24 (68.6)	0.97
God's punishment	5 (41.7)	25 (53.2)	0.47	10 (47.6)	20 (52.6)	0.71	9 (40.9)	20 (57.1)	0.23
Witchcraft	9 (75)	25 (53.2)	0.17	13 (61.9)	21 (55.7)	0.62	11 (50)	23 (65.7)	0.23
Brain disease	11 (91.7)	40 (85.1)	0.55	16 (76.2)	35 (92.1)	0.08	21 (95.4)	29 (82.8)	0.16
Poverty	5 (41.7)	14 (29.8)	0.43	4 (19.1)	15 (39.5)	0.12	11 (50)	8 (22.9)	0.03
Curse	8 (66.7)	24 (51.1)	0.33	13 (61.9)	19 (50)	0.38	12 (54.5)	19 (54.3)	0.98
People with mental illness
Can be treated outside the hospital	8 (66.7)	30 (63.8)	0.85	13 (61.9)	25 (65.8)	0.76	16 (72.7)	22 (62.8)	0.44
Tend to be mentally retarded	8 (66.7)	25 (53.2)	0.4	6 (28.6)	27 (71.1)	0.002	14 (63.6)	18 (51.4)	0.36
Are a public nuisance	10 (83.3)	26 (55.3)	0.07	11 (52.4)	25 (65.8)	0.31	17 (77.3)	18 (51.4)	0.05
Can work in regular jobs	3 (250	7 (14.9)	0.4	4 (19.1)	6 (15.8)	0.75	4 (18.2)	6 (17.1)	0.92
Are dangerous because of violent behavior	10 (83.3)	39 (82.9)	0.97	17 (80.9)	32 (84.2)	0.74	19 (86.4)	29 (82.9)	0.72
In interacting with someone with mental illness, I would be
Unwilling to share a room	8 (66.7)	32 (68.15)	0.92	10 (47.6)	30 (78.9)	0.01	18 (81.8)	21 (60)	0.08
Would you invite somebody in to your home if you knew they suffered from mental illness	4 (33.3)	21 (44.7)	0.48	5 (23.8)	20 (52.6)	0.03	11 (50)	13 (37.1)	0.34
On social acceptance of someone with mental illness
A woman would be foolish to marry a man with mental illness even though he seems fully recovered	3 (25.5)	13 (33.3)	0.58	10 (55.6)	6 (18.25)	0.006*	3 (14.3)	11 (39.3)	0.04*
Anyone with mental illness should not be given any responsibility	8 (66.7)	11 (26.8)	0.01	7 (36.8)	12 (35.3)	0.91	10 (47.6)	8 (26.7)	0.12
Virtually anyone can become mentally ill	11 (91.7)	34 (85)	0.34*	17 (94.4)	28 (82.3)	0.18*	21 (100)	23 (79.3)	0.02*
People with mental illness are far less of a danger than most people suppose	11 (91.7)	27 (61.4)	0.03*	10 (52.6)	28 (75.7)	0.05*	15 (71.4)	22 (66.7)	0.22*
The best therapy for mentally ill people is to be a part of a normal community	10 (83.3)	22 (48.9)	0.03*	13 (65)	19 (51.5)	0.14*	14 (63.6)	18 (54.5)	0.18*
Residents have nothing to fear from people coming into their neighborhood to obtain mental health services	7 (58.3)	36 (80)	0.09*	13 (65)	30 (81.1)	0.10*	13 (59)	28 (84.8)	0.02*
Mental hospitals are an outdated means of treating people with mental illness	5 (45.5)	20 (44.5)	0.26*	11 (57.9)	14 (37.8)	0.08*	6 (27.3)	19 (59.4)	0.01*

Note: Results shaded in grey were considered statistically significant when p < .05. *Fisher's exact; DF = 1.

There were some statistically significant differences among respondents on the four domains represented by these questions, as previously described by the authors (Iheanacho, Marienfeld et al., 2014). These domains are: (1) belief in witchcraft, curses and other external supernatural causes of mental illness, (2) personal desire or acceptance of socializing with people with mental illness, (3) favorable attitudes toward normalized activities and relationships for people with mental illness and (4) bio-psychosocial perspectives toward mental illness. On beliefs about causes of mental illness, more men than women endorsed stress as a cause of mental illness (67 versus 32%, p = 0.03). Church-based health advisors with tertiary education were significantly more likely to endorse genetic inheritance as a cause of mental illness than those with primary or secondary education (95 versus 71%, p = 0.01). Those who lived in rural areas compared to those living in urban areas were more likely to report stress (59 versus 29%, p = 0.02) and poverty (50 versus 23%, p = 0.03) as causes of mental illness (Table 2). Overall, the vast majority of the respondents interestingly endorsed both the biological and perceived supernatural causes of mental illness.

On measures of acceptance and socialization, CHAs with tertiary education compared to those with primary/secondary education were more unwilling to share a room with someone with mental illness (79 versus 48%, p = 0.01) but more likely to invite them to their homes (53 versus 24%, p = 0.03). On measures of normalization of mental disorders, males were more likely than females to endorse withholding responsibility from people with mental illness (67 versus 27%, p = 0.01). On domains that normalize mental illness, CHAs with only a primary or secondary education compared to those with tertiary education were more likely to endorse not marrying people with history of mental illness even if they have recovered (56 versus 18%, p = 0.006). Respondents who lived in rural areas were more likely than those in urban areas to believe that virtually anyone can become mentally ill (100 versus 79%, p = 0.02). Men were more likely than women to believe that people with mental disorders are not as dangerous as perceived (92 versus 61%, p = 0.03) and should be allowed to be part of a normal community (83 versus 49%, p = 0.03) (Table 2).

Discussion

Our study findings demonstrated significant stigmatizing beliefs and attitudes among the volunteer health advisors participating in the HBI. It found that a large proportion of the CHAs endorsed culturally accepted models of the causation of mental disorders that lean heavily towards the role of supernatural forces and ‘evil' in causation of mental illness. Many scored low on measures of socialization and acceptance of people with mental illness. However, the results also show that most respondents believe that genetic factors, stress and psychoactive drugs and alcohol can contribute to the onset of mental illness. In our view, this result reflects the dual and seemingly contradictory community perception of mental disorders that, on one hand, attributes mental illness to external supernatural forces and, on the other hand, accepts the role familial inheritance and stress play in causation of mental disorders. These dual beliefs are strongly held even among healthcare professionals in Nigeria (Adewuya & Oguntade, 2007). Our findings are also in keeping with results from survey of other population groups in Nigeria (Adewuya & Makanjuola, 2005; Gureje et al., 2005).

This presents a challenge for Western trained psychiatric specialists and researchers who develop intervention tools based on the commonly accepted biological and psychological constructs of mental illness. Successful implementation of training programs for non-psychiatric specialists in resource-limited, low- and middle-income countries like Nigeria would require understanding and addressing these widely held beliefs about the etiology of mental disorders. It does seem that those with higher education had more bio-psychosocial perspectives about the causes of mental illness, indicating that education plays a role in enhancing understanding about mental disorders. However, there is no clear evidence that belief in witchcraft as a cause of mental illness and belief in bio-psycho-social model of mental illness are incompatible (Legare, Evans, Rosengren, & Harris, 2012). Thus there may be no need to criticize cultural beliefs in order to provide training in bio-psycho-social approaches to care.

It is important, however, to address negative, stigmatizing beliefs and attitudes. This was a quantitative analysis based on a survey instrument that has not been validated in the Nigerian context. A qualitative approach to evaluating the attitudes of the CHAs could possibly be more informative. The authors are currently supplementing the data presented here with a qualitative study of beliefs and attitudes of lay health workers leading the HBI, the church-based prevention program in Enugu, Nigeria. They are also currently designing pilot studies to test the effects of targeted anti-stigma interventions that can be included in formal training programs for lay health workers in Nigeria.

One limitation of this study is related to the unsystematic sampling procedure. The study population targeted convenience samples of CHAs and thus cannot be assumed to be representative. Another limitation is the small sample size. However, the sample size is adequate for the descriptive objectives of this study as it is not a hypothesis testing study.

In addition, the reliability and validity of the survey instrument used has not been extensively evaluated. However, the instrument has been previously used in pilot studies in Nigeria (Ighodaro et al., 2015; Iheanacho, Marienfeld et al., 2014; Iheanacho, Stefanovics et al., 2014 ) and found to be relevant, simple and easy to understand, allowing its use in natural settings in which only a brief instrument can be employed. Finally, the questions referred to ‘mental illness' as a general category, without delineating specific types of mental health diagnoses. This may reduce the precision with which the survey questions can be interpreted, and attitudes towards people with depression or anxiety disorder would most likely be more positive than those toward schizophrenia or other severe mental illnesses (Kingdon, Vincent, Vincent, Kinoshita, & Turkington, 2008). However, this approach had been established in previous studies of stigma and attitudes to mental illness (Kingdon, Sharma, & Hart, 2004).

Conclusion

Beliefs about supernatural causes of mental illness and stigmatizing, negative attitudes towards people with mental illness were common among the church-based lay health advisors who participated in this study. Training programs for lay health workers in Nigeria should include education on the known bio-psycho-social basis of mental disorders and the role that community and social inclusion play in recovery from mental illness.