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Primary Health Care Nurses Attitude Towards People With Severe Mental Disorders in Addis Ababa, Ethiopia: A Cross Sectional Study
Primary Health Care Nurses Attitude Towards People With Severe Mental Disorders in Addis Ababa, Ethiopia: A Cross Sectional Study
Abstract
Background: Negative attitude and discriminatory behavior of health professionals constitute a major obstacle in
psychiatric care and have been pointed out as a key issue in working with mental illness. Understanding about the
attitude of nurses is crucial for quality and holistic care of psychiatric services and essential for the successful integra-
tion of mental health into primary health care. However, there is a paucity of study to examine the attitude of primary
health care nurses towards severe mental disorder in Ethiopia. Therefore, this study aimed to assess the attitude of
primary health care nurses and its associated factors towards people with severe mental illness in Addis Ababa.
Methods: Institutional based cross-sectional study was conducted among nurses working at primary health care in
Addis Ababa from May to June, 2018. Multistage sampling technique was used to select 634 participants. A structured
self-administered questionnaire was used. Data were coded and entered into EPIDATA 3.1 and exported to SPSS ver-
sion 20 for analysis. Bivariate and multivariate binary logistic regression analysis was used to identify factors associ-
ated with attitudes of nurses in primary health care. The level of significance was declared at P-value < 0.05 with 95%
confidence interval.
Results: A total of 610 respondents were included in the study with a response rate of 96.2%. The mean age of
participants was 28.6 ± 5.9 (SD) years and the prevalence of negative attitude was 48.2%. Multiple logistic regres-
sion models revealed that respondents who have diploma [AOR = 3.09, CI (1.20–7.95)], work experience of < 5 years
[AOR = 4.49, CI (2.37–8.49)], respondents who didn’t took mh-Gap training [AOR = 4.92, CI (3.05–7.95)] and poor
knowledge about mental illness [AOR = 2.84, CI (1.82–4.44) were associated with negative attitude towards people
with severe mental illness.
Conclusion: Nearly half of the participants have negative attitude towards people with severe mental disorders.
Therefore, evidence based and contextualized models are warranted to mitigate negative attitudes of primary health
care nurses.
Keywords: Attitude of nurses, Severe mental illness, Nurses, Health center, Primary health care, Addis Ababa, Ethiopia
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Sahile et al. Int J Ment Health Syst (2019) 13:26 Page 2 of 8
Knowledge about
mental illness
Sociodemographic
and work related
factors Attitude
Age, Sex
Marital status
Religion
Qualification
Work experience
Clinical factors
Personal history of mental illness
Fig. 1 Conceptual frame work for factors affecting attitude of nurses in primary health care in Addis Ababa Ethiopia; 2018
Negative attitude greater than (> 57) from MICA-4 was checked daily by the principal investigator for com-
scores. pleteness and neatness. Data collectors and supervisors
Mh-GAP training WHO designed training for scaling were trained before data collection. The data collectors
up services for priority mental, neurological and sub- were psychiatry nurses and supervisors were MSc psy-
stance use disorders. chiatry professionals.
Knowledge awareness about mental illness as meas-
ured by knowledge about mental illness questionnaire, Data processing and analysis
National Institute of Mental Health and Neurosciences Data was coded and entered in-to EPIDATA 3.1 for
(NIMHANS), Bangalore, department of psychiatry a cleaning, storing, and recording. The data were exported
modified version for health workers [19]. to SPSS version 20 for analysis. Descriptive statistics (fre-
quencies, percentages, cross tabulations) were used to
Inclusion and exclusion criteria summarize the sociodemographic and other preliminary
All nurses who were working in the selected health cent- data. Bivariate and multivariate binary logistic regression
ers during data collection period were included in the analysis was used to identify factors associated with atti-
study. Psychiatric nurses were excluded from the study. tude of nurses in primary health care. The level of signifi-
cance was declared at P-value < 0.05 with 95% confidence
interval.
Data collection tools and procedures
An adapted structured questionnaire was used to collect
data about socio-demographic characteristics. Knowl- Ethical considerations
edge about mental illness was assessed by 13 item tool Ethical clearance was obtained from University of
developed by National Institute of Mental Health and Gondar institutional review board, Amanuel Mental Spe-
Neurosciences (NIMHANS), Bangalore, department of cialized Hospital ethical review committee and Addis
psychiatry a modified version for health workers [19]. Ababa health bureau Ethical review committee (ERC).
Clinicians’ Attitude Scale (MICA-4), 16 item tool, was Written Informed consent was obtained from each par-
used to assess PHC nurses attitude towards people with ticipant during data collection. All participants were
severe mental illness. The tool was developed to assess informed about the aim and purpose of the study. Study
attitudes towards severe mental illness of students or participants were given the right to refuse or withdraw
staffs in any health discipline. It is a 6-point Likert scale from participation at any time during data collection. All
(‘‘strongly agree, agree, somewhat agree, somewhat disa- personal information was kept entirely confidential.
gree, disagree and strongly disagree’’). A single over-
all score is calculated by summing each individual item Results
where a high overall score indicates more negative stig- Socio‑demographic characteristics of respondents
matizing attitude with a possible range of 16–96 [20]. For The response rate was 610 (96.2%), out of 634 study par-
the purpose of this study, categorization was done using ticipants. Four hundred thirty (70.5%) of the study par-
the mean score. Subjects were categorized as having neg- ticipants were female. The mean age of participants
ative attitude who scores greater than or equal to mean was 28.6 ± 5.9 (SD) years with range of 20 and 55 years.
(≥ 58). We did pretest of the instruments and experts Majority of the respondents, 440 (72.0%) were in the age
were consulted about the content, face and technical category of 20–29 years. Among the total participants
validities. Internal consistency of MICA-4 was 0.74 using 408 (66.9%) were orthodox Christian religion follow-
Cronbach’s alpha. ers, 342 (56.1%) were single, 344 (56.1%) have diploma
The principal investigator or the research assistant will by qualification and 440 (72.1%) of the respondents
invite participants for the study. After reading the infor- have < 5 years work experience (Table 1).
mation sheet and the consent form, data were collected
from those participants who gave consent. Mental health training
Among 610 respondents, 196 (32.1%) of them were
Data quality assurance trained mh-GAP training (Fig. 2).
The translated Amharic version of self-administered
questionnaire was disseminated to participants. Pre- Clinical related factors with nurses’ attitude
test with 5% of the total sample size was done before the towards people with severe mental disorders
start of actual data collection at health centers out of the Related with clinical factors, 60 (9.8%) of the respond-
selected area. Minor language revision was made based ents have family history of mental illness. Twenty-four
on the findings of the pre-test. The filled questionnaire
Sahile et al. Int J Ment Health Syst (2019) 13:26 Page 5 of 8
Age
Female
20–29
430
440
70.5
72.0
32.10%
30–39 134 22.0 yes
40–49 18 3.0
≥ 50 18 3.0
no
Religion Orthodox 408 66.9 67.90%
Muslim 100 16.4
Protestant 96 15.7
Othersa 6 1.0
Marital status Single 342 56.1
Married 246 40.3
Fig. 2 Proportion of Mh-Gap trained primary health care nurses in
Othersb 22 3.6
Addis Ababa, Ethiopia, 2018
Educational status Diploma 344 56.4
BSc 231 37.9
MSc 35 5.7
Work experience ≤ 5 440 72.1 Table 2 Clinical factors for attitude and associated factors
6–10 66 10.8 of primary health care nurses towards people with severe
≥ 11 104 17.1 mental illness in Addis Ababa, 2018
Working department Medical 316 51.8 Variables Category
MCH 146 23.9
Yes % No %
Emergency 62 10.2
Surgical 46 7.5 Presence of mental illness in the family 60 9.8 550 90.2
ART 40 6.6 Personal experience of mental illness 74 12.1 536 87.9
N.B. aCatholic, Jehovah, Wakifeta, bwidowed, divorced Knowing someone with mental illness 359 58.9 251 41.1
other than a patient
Work experience at psychiatric unit 65 10.7 545 89.3
Table 3 Bi-variate and multivariate factors associated with primary health care nurses attitude towards people
with severe mental illness in Addis Ababa 2018 (N = 610)
Variables Attitude status COR (95% CI) AOR (95% CI) P value
Positive Negative
Educational status
Diploma 109 235 4.132 (1.98–8.60) 2.96 (1.17–7.48) 0.021
BSc 184 47 0.490 (0.22–1.05) 0.405 (0.16–1.08) 0.07
MSc 23 12 1 1
Work experience
≤ 5 172 268 7.44 (4.32–12.8) 4.84 (2.57–9.14) 0.001
6–10 58 8 0.659 (0.269–1.616) 0.24 (0.20–1.50)
≥ 11 86 18 1 1
Mental health training (mh-GAP)
Yes 147 49 1 1 0.001
No 169 245 4.349 (2.980–6.347) 4.95 (3.07–7.96)
Family history of mental illness
Yes 48 12 1 1
No 268 282 1.56 (1.09–2.67) 1.52 (0.74–3.12) 0.25
Personal experience of mental illness
Yes 55 19 1 1
No 261 275 3.050 (1.763–5.278) 1.325 (0.617–2.843) 0.47
Previous experience of working in psychiatry unit
Yes 53 12 1 1 0.07
No 263 282 4.736 (2.475–9.060) 2.319 (0.930–5.782)
Knowledge about severe mental illness
Good 240 128 1 1 0.001
Poor 76 166 4.095 (2.898–5.788) 2.83 (1.82–4.39)
Regarding to mental health training nurses who a direct bearing on attitude development among the
didn’t take mental health training was more likely nurses [30].
to show negative attitude than those who had train-
ing by 4.95 times. This is in line with studies done in
Taiwan, Republic of Ireland and Finland where nurses Conclusion
with less mental health training endorsed negative and About half of the participants have negative attitude
stigmatizing attitude for people with severe mental towards people with severe mental disorders. Edu-
disorders [15, 17]. This is known that health training, cational status, mental health training, professional
clinical experience and increased interpersonal contact experience and knowledge about mental illness were sig-
with people with mental disorders would reduce nega- nificantly associated with negative attitude. Therefore,
tive and stigmatizing attitude [6]. The odds of having it is important to re-initiate training programs for the
negative attitude among nurses with poor knowledge primary health care nurses to reduce negative attitudes
about mental illness were 2.83 times higher as com- towards people with severe mental disorders.
pared to nurses with good knowledge. This aligns with
the findings in the WHO report and a study conducted Abbreviations
AOR: adjusted odds ratio; CAMI: community attitude towards mental illness; CI:
in Sweden [8, 29] which could be explained by lack of confidence interval; COR: crude odds ratio; EPI INFO: epidemiological data; HC:
adequate training and less supervision by mental health health center; KAP: knowledge, attitude and practice; LMICs: low and middle
teams as a cause of lack of knowledge. Accordingly, it income countries; PHC: primary health care; SMI: severe mental illness; SPSS:
statistical package for social sciences; WHO: World Health Organization.
might be argued that increased level of training have
the effect of bringing about a decrease in negative atti- Authors’ contributions
tude among nurses concerning people with mental YS designed the study. SY, BY, AM, DA conducted the study, analyzed
data, developed the manuscript. All authors read and approved the final
disorders and this would reinforce the impression that manuscript.
increased level of knowledge about mental illness has
Sahile et al. Int J Ment Health Syst (2019) 13:26 Page 8 of 8
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