The integration of mental health in primary care was considered one of the best strategies to address the increasing incidence of mental health disorders. This study determined the level of mental health integration in primary care in the province of Capiz and the level of challenges of primary health workers in the process of integration in terms of knowledge, skills, and health system constraints encountered. The 381 primary health workers were surveyed using a validated and reliability-tested researcher-made questionnaire. The results revealed that the level of mental health integration in the province of Capiz based on primary health practice was only slightly integrated. Primary health workers were highly challenged in the process of integration in terms of their knowledge and skills, which therefore needs enhancement. They were also highly challenged by the health system constraints encountered in the different areas of the current health system, which necessitates support from the Local Government Unit (LGU). The mental health integration level and the challenges of primary health worker respondents when grouped according to profile disclosed a significant difference. Moreover, their level of challenges as to their knowledge, skills, and health system constraints encountered did not significantly affect the level of mental health integration.
Everyone has a probability of acquiring a mental disorder, according to mental health experts. The World Health Organization (WHO) defined mental health as "a condition of well-being in which one understands his or her own abilities, can cope with everyday stressors, can work creatively and fruitfully, and is able to contribute to society" (Galderisi et al., 2015). WHO stresses that mental wellness is a vital and significant component of being healthy and that there can be no health without mental health because it affects a persons ability to make sound decisions for themselves.
The National Alliance on Mental Illness (NAMI) (2022) reported that in the United States, 1 in 6 adole-scents ages 6 to 17 experiences a mental health condi-tion annually, 1 in 5 adults have mental illness every year, 1 in 20 adults have serious mental illness, 50% of lifelong mental illness begins by age 14, and 75% by age 24. Suicide is the second most common cause of death for adults between the ages of 10 and 34.
In the Philippines, the Department of Health (DOH) in partnership with the World Health Organization (WHO) is jointly raising awareness on the importance of mental health, which started several decades ago and especially amidst the COVID-19 pandemic. The National Center for Mental Health (NCMH) reported a considerable increase in the number of hotline calls for depression, with figures climbing from 80 calls before to the lockdown to nearly 400, despite the fact that the nation came in fifth place on the worldwide optimism index (WHO, 2021; Ahmed et al., 2023).
The presidents signature of the Philippine Mental Health Act, also known as Republic Act (R.A.) 11036, advocates for increased public awareness of and support for mental health issues in all spheres of society. The establishment of community-based mental health programs and delivery systems within each Local Government Unit (LGU) is encouraged. The primary medical professionals take up tasks that were previously handled by mental health professionals as part of the integration process. The ability of these healthcare professionals in addressing mental health concerns at the community level is lacking as a result of this paradigm change. Further-more, the process of integration causes imbalance in the equilibrium of the current health system causing pressures and chal-lenges, which need to be addressed for the program to succeed. The importance of primary health care professionals as essential figures and the initiative behind the program must be emphasized. This posed queries on challenges encountered and their essential needs for the program to succeed, thus, the researcher was motivated to study and assess their integrations challenges.
Design/Participants
This is a descriptive - correlational study. The resear-cher used the quantitative data collected and analyzed them to find out if there is a cause-effect relationship in the level of mental health integration and the challenges and constraints encountered by the primary health workers of Capiz. The respondents were the primary health workers in different municipalities of Capiz. Out of the total 4,556 primary health workers, the sample size calculated using the Cochran formula was 381. The respondents consisted of different categories of primary health workers: rural health physicians, nurses, midwives, and Barangay Health Workers (BHWs).
Research Instrument
The study used one set of questionnaire divided into three parts. Part I collected the data on the respon-dents profile. Part II dealt with the statements on the level of mental health integration based on primary health practice. Part III was composed of statements on the challenges of primary health workers in the process of integration. The challenges were classified as to their knowledge, skills, & constraints on health system, which include areas on financial resources, human resources, facilities, patients process flow, clinical supervision, and external communication. The instru-ment was translated to the local dialect for improved comprehension because the majority of respondents were not particularly proficient in the English language.
The researcher-made questionnaire was subjected to content validation by the panel of experts from the graduate program of the College of Management of Capiz State University, Main Campus. It was validated based on its content to ensure that the information gathered served their purposes. The suggestions and recommendations of the panel were incorporated in the final copies before it was reproduced for a reliability test. To determine the reliability of the questionnaire, it was subjected to pre-testing to thirty (30) health worker respondents in barangay health centers in Roxas City, Capiz. Health worker respondents were chosen randomly. The Cronbach alpha determined the reliability coefficient since no right or wrong answers. The scores were computer-processed through Statis-tical Package for Social Sciences (SPSS). The com-puted reliability coefficient was 0.862, thus, the instrument is considered reliable.
Procedure
After the validation and the reliability, the instrument was ascertained; permission was requested through a formal letter to the head of the provincial health office to administer the questionnaire to the different muni-cipal and barangay health workers in the province. The researcher personally administered the questionnaires for doctors, while those for the nurses and midwives were channeled through the help of their rural health physicians. For the Barangay Health Workers (BHWs), the questionnaires were handed to them through the municipal midwives during their field work. Some questionnaires for BHWs were channeled through the barangay captains in different barangays in the province. The researcher made sure that those who assisted in the gathering of data were briefed and made to understand the content of the questionnaire for them to be able to assist and answer queries from the respondents. In cases, which the assistants were unable to answer the respondents question, they sent mess-ages to the researcher for her to shed light on the matter. The respondents consent was obtained prior to the survey. The researcher personally gathered the answered questionnaires in the different municipalities and selected provincial barangays to ensure hundred percent retrieval rate. Upon receiving the question-naires, they were examined for completeness and if ever statements or data were missing, the researcher immediately requested the respondents to completely provide entries to the questionnaire. After the retrieval of the questionnaires, they were collated, scored, and entered in the master data. Then, they were ready for computer processing using a licensed IBM SPSS Statistics 28 program. In addition to assigning the appropriate verbal interpretation for each indicator, the researcher ensured that the responses were properly scored.
The frequency, percentage, mean, t-test, F-test (ANOVA), and Pearson product moment correlation coefficient were utilized as statistical tools in the analysis and interpretation of the gathered data. The respondents personal profile as to age, sex, civil status, occupation, length of service, and educational attainment were determined through frequency and percentage. Frequency aids in analyzing the nominal and ordinal data. The mean determined the level of mental health integration and challenges encountered by health workers in the integration process. The data were presented in tables.
The t-test and One-Way ANOVA were used to evaluate the variances between the mean scores of the variables and to determine whether there are overall differences between the groups. The t-test compared the two means, while the One-Way ANOVA compared the three or more means. For the significant relation-ship between the mental health integration level and the challenges encountered by the primary health workers, Pearson-r measured the significant relation-ship between these variables.
Ethical Considerations
A courtesy visit was made to the Provincial Health Officer to formally introduce this endeavor and personally ask permission to conduct it in the muni-cipal health centers of the province through a formal letter. After this, the researcher informed the municipal health officers of the selected municipalities and asked their approval, respectively. Permission from the barangay officials of the randomly selected barangays, where the study was performed, was also obtained. Generally, the communication was done with honesty and transparency and the data gathered were treated with confidentiality.
Table 1 discloses the mental health integration level based on primary health practices. When all the three hundred eighty-one (381) respondents were taken as a whole group, Statistics showed a grand mean of 2.45, verbally interpreted as “Slightly Integrated”.
Table 1: Level of mental health integration based on primary health practices.
Legend: 4.21-5.00 = Fully Integrated; 3.41-4.20 = Highly Integrated; 2.61-3.40 = Partially Integrated; 1.81-2.60 = Slightly Integrated; 1.00-1.80 = Least Integrated.
Table 2 reveals the level of challenges encountered by the primary health workers in mental health inte-gration. The result showed a grand mean score of 2.39, which implied that the respondents were “Highly Challenged” by the challenges they encountered in mental health integration.
Table 2: Level of challenges encountered by primary health workers in mental health integration.
Legend: 4.21-5.00 = Least Challenged; 3.41-4.20 = Poorly Challenged; 2.61-3.40 = Moderately Challenged; 1.81-2.60 = Highly Challenged; 1.00-1.80 = Very Highly Challenged.
Table 3 discloses the differences in the respondents mental health integration level as to their profile. Statistics showed that there were significant differ-ences in the level of mental health integration when the respondents were grouped according to their profile because the p-values were less than 0.05 alpha. The result implied that the respondents perception on the level of mental health integration based of primary health practices differs as to their profile.
Table 3: Differences in the respondents level of mental health integration as to profile.
p-value < 0.05 = significant
Table 4: Differences in the level of challenges encountered by the respondents in mental health integration as to their profile.
p-value < 0.05 = significant; p-value > 0.05 = not significant
Table 4 shows the differences in the level of challen-ges encountered by the respondents in mental health integration when grouped as to their profile. Statistics revealed significant differences in the level of challen-ges encountered by the respondents in mental health integration as to age, sex, occupation, and educational attainment because the p-values were less than 0.05 alpha. The result implied that the level of challenges encountered by the respondents in mental health integration was the same regardless of their age, sex, occupation, and educational attainment.
On the other hand, there were no significant differ-ences in the level of challenges encountered by the respondents in mental health integration when grouped as to civil status and length of service because the p-values were greater than 0.05 alpha.
Table 5 reveals the relationship between the level of mental health integration and the level of challenges encountered by the primary health workers. The result revealed that there was an indifferent or negligible relationship between the level of mental health integra-tion and the level of challenges encountered by the primary health workers because the Pearson-r value was -0.015. This relationship was not significant be-cause the p-value of 0.770 was greater than 0.05 alpha.
Table 5: Relationship between the level of mental health integration and the level of challenges encountered by the primary health workers.
The findings show that the mental health integration level in the province of Capiz based on primary health practices was slightly integrated. On the other hand, there was a highest mean score of 3.26, interpreted as “Partially Integrated,” on statement that “Primary health workers choose to refer patients with mental health disorders whom I encounter to rural health physician.” The result implied that majority of the respondents chose to refer patients with mental health disorder to rural health physicians because they are believed to be the most visible and accessible mental health expert in the community. The result further inferred that the training of primary health workers in this category is very crucial to enable them to answer the needs of patients with mental health disorder referred to them. However, the lowest mean score of 1.75 with verbal interpretation of “Least Integrated,” was on statement “I am well trusted by mental health experts such that they refer back patients with mental health disorder to me.” This result implied that primary health workers assess themselves to being less trusted by mental health experts to possess the capability to handle mental health care cases in rural areas. This situation indicates a minimal or poor coordination between primary health workers with regards to mental health care. Other evidence of poor collaboration between primary healths workers were supported by other data like the method of referral of patients to experts, which is by instruction only, absence of discussion with experts regarding patients case, and not able to follow-up patients with mental health disorder. The result was supported by the study of Hakulinen et al. (2020). They found that patients with serious mental illnesses were much less productive both before and after receiving a diagnosis. The pres-sure and expectations from family and society are the main reasons why Filipinos are typically unhappy, not just because of economic hardship (such as unemploy-ment, low income, etc.). They asserted that the Philippine Mental Health Act is merely a "deceptive regulation" in reality. They did, however, think there is still a chance that the Philippines mental health problems will be acknowledged as a serious and crucial requirement to enhance the quality of life and the countrys economic structure. The three compo-nents of challenges encountered by primary health workers had grand means, which ranged from 2.16 to 2.68 with verbal interpretations of “Highly Chal-lenged” to “Moderately Challenged.” Thus, the res-pondents assessed their knowledge on mental health to be needing further education to enhance it. Likewise, primary health workers lacked skills, thus, additional trainings are necessary. They also assessed that health system needs additional support and improvement in areas of budget, manpower, facilities, referral system, clinical supervision, and external communication. The mental health training of primary health workers started after the signing of the Mental Health Act in 2018. However, not all health workers were able to avail of the said program because of the surge of COVID-19, which started in 2019.
The result conformed with the study of Kigozi, (2009) which revealed that there is an obvious need to educate health care managers and workers on what integration entails as means of effective implementation of health care strategies. A significant difference was found in the level of mental health integration when the primary health worker respondents are grouped according to their profile such as age, sex, civil status, educational attainment, length of service, and occupation. Like-wise, a significant difference was found in the level of challenges encountered by the primary health workers when they are grouped according to age, sex, educational attainment, and occupation but not for civil status and length of service. The finding conforms with the result of the study of Celmece and Menekay, (2020) that burnout and stress from increased in work during the pandemic is significantly higher in female health care specialists than in men; in married health care workers, especially those with children, they were more stressed than their unmarried or single counter-parts. Additionally, nurses reported much higher levels of stress than physicians and other medical assistants. Health professionals unfavorable attitudes and discri-minatory actions are a significant barrier to providing psychiatric care and have been identified as a major problem when dealing with mental illness. The age, sex, educational attainment, and occupation of primary health workers were factors of variations in their perception of challenges in integration. The result was supported by a survey of Dube and Uys, (2016) in South Africa on the primary health care knowledge, attitudes, and beliefs of nurses with regards to “Integrating mental health care in the primary care clinics”. Their findings demonstrated a relationship between participants general positive views toward people with mental illness and age, professional qualification, and prior experience working with psychiatric patients. There was no significant relation-ship in the level of mental health integration and the challenges of primary health workers in terms of knowledge, skills, and health system constraints. The result implied that the level of mental health inte-gration was not affected nor influenced by the level of challenges encountered by the primary health workers. The benefit of integrating mental health in the primary care are enormous in terms of reducing disease burden, treatment gap and cost burden for individuals and families, promoting respect for human rights and had overall good health outcomes (Arafat et al., 2018).
Conferring to Tanaka et al. (2018), the mental health stigma is thought to be the result of cultural attitudes toward mental disorders, which can be categorized into three groups: familial problems, which family rejects members who have mental health disorders because they think they can be passed down genetically. Unrealistic pessimism and optimism imply that a per-son with a mental illness may either have a long-term cognitive impairment or be capable of handling any mental distress on their own. On the Over-simplified Chronic Course, in which individuals with-out mental diseases assume that those who are ill have a serious illness and anticipate a speedy recovery. In the Philippines, the government and other public sectors place less emphasis on mental health as a result. Additionally, groups that work to eliminate the stigma associated with mental illness and support individuals who are impacted by it do not receive financial support from the Philippine government.
Martinez et al. (2020) found that due of the expen-ditures involved and the assumption that they have more essential things to take care of Filipinos are less inclined to go for mental health treatment. The social stigma that each mental health issue carries, and fear of looking foolish, sense of embarrassment, and adher-ence to Asian ideals of conformity to social con-ventions in which mental illness is considered as unacceptable, are additional reasons why people do not seek treatment. Only when a family member or close friend is unable to manage the condition do Filipinos seek experts help. Filipinos place a high value on their health and are aware of the advantages of getting mental health therapy for their overall quality of life. Seeking mental health care does not signify weakness but rather strength because it takes courage to admit that something is wrong and that you need help to get better.
Insights towards Enhanced Mental Health Program Implementation
The signing of the Universal Health Care Law in 2019 that guaranteed equitable access to quality, affordable and readily available heath care to all Filipinos entails innovations in the primary health care practices, which includes the mental health integration. Health profess-sionals like medical specialists, general practitioners, nurses, midwives, and Barangay Health Workers (BHWs) are crucial to the success of this government initiative. Those who were professionally trained in this job are expected to deliver quality mental health services but BHWs are in different consideration. Among the primary health workers, the BHWs are the most challenged in their role as mental health provider as highlighted in the result of the study since they comprised the majority of the respondents. Their messages indicate several concerns, which the Local Government Unit in different municipalities in the province of Capiz needs to address. Their lack of knowledge, being a primary concern, can be enhanced through orientations, lectures, and seminars conducted by Department of Health (DOH) or any concerned agencies upon the request of the Local Government Unit. Having poor skill is another concern, which necessitates series of trainings under the supervision of experts, which unfortunately is lacking or even absent in the rural health setting; therefore, the Local Govern-ment Unit must find means to address this second issue by requesting the DOH of more detailed mental health trainings among BHWs. Hiring of a psychiatrist or mental health expert would be another option. Baran-gay Health Workers have several concerns with the current health system such as no enough budget to carry out referral and follow-up of patients and some are overwhelmingly tired because of added workload, thus, the Local Government Unit (LGU) should find means to motivate them by providing enough budget, as well as giving of incentives and rewards. Likewise, the LGU should also improve the community-based mental health facilities and ensure that the medical supplies, especially medicines, which are crucial in maintaining the patients well-being, particularly those having mental conditions, are locally and continuously available. The municipal health office must have a reli-able mental health cases baseline data in their geographical area so that provision of resources and other needs accurately provided by the authorities in-charge.
For the province of Capiz to achieve its goals of delivering high-quality healthcare for people with mental disorders, the integration of mental health in primary care was well behind in its integrated level. All of the personnel in basic healthcare faced compar-able difficulties. Different responses are given to the practice of mental health integration by primary health providers depending on the respondent profile. Choosing the appropriate team of healthcare profess-sionals is therefore essential to assisting in the treat-ment of patients with mental illnesses. Primary health care workers perceptions of integration issues vary depending on their age, sex, educational attainment, and occupation. The integration of mental health services and the difficulties faced by primary health-care workers were unrelated. The integration process will finally be successful, though, if attention is paid to finding solutions to the problems that these kinds of health workers face on a daily basis.
Capiz State University, Capiz Provincial Health Officer, Municipal Health Officers, Barangay Offi-cials, Nurses, Midwives, & Barangay Health Workers of different municipalities in the province of Capiz
The author declares no conflict of interest.
Academic Editor
Md. Ekhlas Uddin Dipu, Department of Biochemistry and Molecular Biology Gono Bishwabidalay, Dhaka, Bangladesh.
MD, DPPS, Pediatric Consultant, St. Anthony College Hospital, Capiz Emmanuel Hospital, and Capiz Doctors Hospital, Roxas City, Capiz, Philippines.
Feliciano ATU. (2023). Integration of mental health in primary care: insights for enhanced program delivery, Eur. J. Med. Health Sci., 5(5), 145-152. https://doi.org/10.34104/ejmhs.023.01450152