Knowledge and Attitude of Family Doctors Regarding the Provision of Psychological Health Care in Primary Health Care Centers in Baghdad Al-Karkh

Background: Mental health is integrated into PHC as a strategy of WHO to fill the gap in mental health treatment. Part of this strategy needs a level of task shifting so that mental health care is provided by different level of PHC workers and not only specialists such as psychiatrists and psychologists. 
Objectives: To assess the knowledge and attitudes of family doctors regarding the provision of psychological health in PHCC and if there is an association between the certificates of these family doctors and their Knowledge and attitudes to psychological health. 
Subjects and Methods:  A cross-sectional descriptive study with analytic elements was conducted in 8 family health care centers in Baghdad city/Al-Karkh. Data was collected via questionnaire form which consists of three domains: Domain one includes sociodemographic data, domain two was about knowledge and consists of (7) questions and domain three consisted of (12) questions about the attitude of physicians regarding mental health. A convenient sample of (83) family health care physicians were included in the current study. 
Results: The mean age of participants was 42 years (range: 27 – 53). The results revealed that 22.9% of participants were male, 77.1% were female. The percentage of mental illness seen by the physicians daily in the health care center was (15.7%). Physicians with higher degree certificates obtained higher knowledge scores in comparison to residents or practitioners as well as the females reported a significantly higher score of knowledge in comparison to males. Moreover, higher scores of positive attitudes were found. 
Conclusion: Family Physicians with higher certificates have more knowledge and attitude than other certificates.


Introduction
Mental health is defined by WHO as a state of wellbeing in which the individual understands his or her abilities, can adapt to the usual stresses of life, be a productive person, and can participate in his or her community. This definition illustrates the importance of mental health and how integral it is to health and well-being as clarified in the WHO's definition of health; "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (1). The notion of mental health includes subjective well-being, perceived self-efficacy, autonomy, competence, and selfactualization, and emotional potential (2). Mental illnesses are considered clinically significant conditions that affect thinking, emotions, and or behavior (3). They are also associated with poor performance and present as either mild or severe, may last for few weeks or a lifetime (2). Some mental illnesses are considered severe illnesses like schizophrenia, bipolar disorder, and severe depression that are associated with significant poor performance leading to disability. These types of mental illnesses may require hospitalized treatment (4). Mental illnesses are considered one of the primary causes of disability and are estimated that 37% of all healthy life years lost through disease are not taken into the consideration. This results in a wide treatment gap (5). As a result, mental illnesses cause increased costs of health and social care, decreased quality of life, increased risk of disability, decreased work hours, loss of jobs, and increased risk of mortality (6). Also, people with severe mental illnesses have higher chances of premature death as compared to the normal population. For example, patients with major depression and schizophrenia have about a 40% to 60% higher chance of dying prematurely than the general population (1). In high-income countries, men with severe mental health illness die 20 years and women 15 years earlier than those without mental health problems (7). Mental illnesses are also related to other physical health problems that are frequently not taken care of such as; cancers, diabetes, cardiovascular diseases, HIV infection, and suicide (1). Mental health is integrated into PHC as a strategy of WHO to close the gap in mental health treatment (8). Part of this strategy needs a level of task shifting so that mental health care is provided by different levels of PHC workers and not only specialists such as psychiatrists and psychologists (9). Rationale: Mental health care is integrated into the package of services provided in the primary health care centers and the majority of this care is provided by family physicians. Not all family doctors in the PHC received the same level of training on mental health because of differences in their qualifications. Objectives: To assess the knowledge and attitudes of family doctors regarding the provision of psychological health in PHCC and if there is an association between the certificates of these family doctors and their Knowledge and attitudes to psychological health.

Subjects and Methods
Study design and duration: A cross-sectional descriptive study with analytic elements was carried out during the period from the first of Nov, 2017 to the end of July 2018, two days per week. Study setting: The data was collected in 8 family health care centers (1. Al-Mansour PHC, 2. Al-Yarmouk PHC, 3. Al-Khadraa PHC, 4. Al-Adel PHC, 5. Al-Zahraa PHC, 6. Al-Shahid Sadar PHC, 7. Al-Noor PHC, 8. Al-Aaml PHC) in Baghdad city/Al-Karkh, which were chosen conveniently from 4 primary health care sectors (Kharkh, Adel and Kadimiah, and Al-Aaml health care sectors) which were chosen randomly out of 10 primary health care sectors in Baghdad/ alkarkh health directorate. Study subjects: Convenient sample of (83) family health care physicians, who accept to participate in this study and available at the time of data collection, including all physicians and both sex. Tool for data collections: Data was collected via a modifiable questionnaire from previous studies (10) and modified by supervisor senior. Questionnaire forms consist of three domains: Domain one include sociodemographic data, domain two was about knowledge of physicians regarding mental health and consist of (7) questions, domain three consisted of (12) questions about the attitude of physicians regarding mental health service provision and the answers were (Agree, disagree and uncertain) Scoring: The knowledge means the score was calculated as (1) for the correct answer and (0) for the wrong answer. While the attitude was done according to the Likert scale (3) for the correct answer, (2) for uncertain, and (1) for the wrong answer. Inclusion criteria: All family physicians (residents, practitioners, diploma, and board of both sexes in the selected family health care centers in Baghdad/Al-karkh. Exclusion criteria: Physicians who refuse to participate in the current study. Pilot study: Ten Physicians participated in the pilot study, but they were not included in the studied sample, a pilot Ethical approval: The official agreement was obtained from the Research Ethical Committee, Human Resources Training, and Development Center, Ministry of health/Iraq. Agreement of family health centers was obtained before data collection, Verbal consent of all participants was obtained, each questionnaire was given serial code, with no name of the participants and all data confidentially and was not disclosed to non-authorized person. Statistical Analysis: SPSS version 23 was used for data entry and analysis. Frequency and percentage were used to represent the categorical data while mean and standard deviation used to represent the numerical data. Appropriate tests Chi-square (Fischer exact test if not applicable), independent student t-test, ANOVA, and Pearson correlation were used to confirm significance. p <0.05 was considered significant.

Results
The mean age of participants was 42±6.1 years (range: 27 -53). The results revealed that 22.9% of participants were male, 77.1% female,86.7% were married and 13.3% were single. Regarding the medical qualification; the results showed that 43.4% were boardcertified, 33.7% were family practitioners, 14.5% had diploma degrees and 8.4% were resident doctors. The results also revealed that 44.6% of participants had training courses on mental health illness as seen in table1. https://jkmc.uobaghdad.edu.iq/ 21 The PHC statistics showed that the percentage of psychological illness seen by the physicians daily in the health care center was (15.7%) and the rest was other disease complains as seen in fig 2.

Fig:1 Percentage of psychological illnesses seen by doctors in PHCC
Our data indicated that participants with board degrees need less time to examine and diagnose the illness in comparison to other participants and the difference in time of examination among participants was statistically significant (p=0.02) and the meantime for examinations were (8.6±1.92 minutes) as displaced in table.2. The findings of the current study showed that 57.8% of participants can diagnose schizophrenia and 42.2% can correctly recognize three sign and symptoms of schizophrenia, 71.1% were able to diagnose depression status confidently and 63.9% were able to correctly name three sign and symptoms of depression, 54.2% could recognize the psychosis disorders correctly and 67.5% showed the ability to identify three sign and symptoms of psychosis disorders, and only 44.6% said they could prescribe the medication to the patients with mental health illnesses as showed in table 3.

Other disease complains
The results demonstrated that the frequency of participants who had a higher degree of qualification that responded correctly to all statements of knowledge was significantly higher than the frequency of practitioner or resident participants (p≤0.05 for all) as seen in table 5.
The results revealed that the mean score for knowledge statements was significantly differed when compared according to medical qualification of participants and those holding higher degree obtained higher knowledge score in comparison to resident or practitioners as well as the females reported significantly higher score of knowledge in comparison to males(p=0.04) as seen in table 6. The results demonstrated that about two thirds of participants 50 (60.2%) disagreed that mental illness are dangerous, (63.9%) agreed that if the people become mentally ill once they easily become ill again, about half (49.4%) of participants agreed that medications produce a satisfactory result in patients with mental health problems, majority(89.2%) believed that mental health problems are common in the community, about two thirds (69.9%) believed that mental health problems is increasing in the community, (61.4%) agreed that the majority of mental health problems was seen originate from patients' recent misfortunes, (63.9%) agreed that the biochemical abnormality is at the basis of severe mental health problems, (53%) believed that medication is more beneficial than counseling for patients with mental health problems, just( 7.2%) agreed that the mental health problems can improve if nothing is done to treat them, (14.5%) agreed that the mental Health problems are a sign of personal weakness, (59%) agreed to statement that working with patients with mental health problems is difficult and only (19.3%) of participants' agree with statement that the PHC doctors have little to offer patients with mental health problems as displaced in table 7.
The results showed that the frequency of participants with higher qualification and responded correctly toward several attitude statements (such as rate of recurrence of mental disease, increasing the number of patients with mental illness, misfortunate to mental illness, improvement of mental disease without medical interference, the association of mental health problems with personality) was significantly higher than participants with the lower qualification that includes resident and practitioner doctors but no significant difference was reported for other statements as seen in table 8.   P. value less than 0.05 is statistically significant.

Discussion:
As knowledge refers to the understanding of mental illnesses including causes, treatment, symptoms…. etc., attitude encompasses feelings and misconceptions the participants may have towards mental illness and persons with mental illnesses (10). Mental health problems are a public health issue affecting about (20%) of people in modern western societies. There is a wide gap between the mental health needs of the community and the available mental health services in low and middle-income countries (11). Integration of mental health into PHC is one solution to the treatment gap and requires task shifting from mental health specialists to a range of non-specialist health workers including doctors providing PHC (9). The present study found that females were more prominent than the male which is same that mentioned by Armstrong G (12) The current study revealed that less than half of the physicians participated in training courses in mental health. This is in agreement with Nadeer Alkhadhrawi et al study when (57.8%) had no training for such service (13). While Cowan J et al mentioned that about one-third of the participants had not received any training courses in caring for patients with mental health problems (10), Moreover in agreement with Chaudhary RK, study when only (27.1%) had received no training at all in dealing with patients suffering from mental health problems, and just (30.1%) had received training during their graduate study (14). WHO mentioned that one in four people in the world will be affected by mental or neurological disorders at some point in their lives. Around 450 million people currently suffer from such conditions, placing mental disorders among the leading causes of ill-health and disability worldwide (15). In the current study, the percentage of mental illness patients seen by doctors from the total patient's visit the health care centers as collected from PHCC statistics was (15.7%) which is more than that found by Raghid Charara et al (16) study, which found that mental disorders contributed to (5.6%) of the total disease burden in the EMR. This may be explained to the many conflicts and war happened in our country and its complications. The mean time for a patient's examination in the present study was (8.6±1.92 minutes). Which is less than that found by Nadeer H. Alkhadhrawi et al, (13) when the usual time allocated for patients seen in general practice is 10 to 15 minutes. There is insufficient time to provide mental health services to children, adolescents, and their families in PHCC this could be due to the crowding of patients in the PHCC and the shortage of family physicians at the same time. This result is similar to Cloutier et al., (17) who found that 72.8% of respondents that have reported the same views toward this issue, and to Goldfracht et al., (18) study where 85% of participants stated that lack of time was a factor that interferes with the care of mental health problems in primary care practice. Furthermore, Stephen et al., (19) reported that where the majority of GPs give patients with psychological problems a longer consultation time, and also in Falloon et al (20), where 79% of general practitioners considered that they have insufficient time to manage patient.
Regarding the knowledge of the physicians to diagnosis the major three diseases of the mental illness, it was found that about twothirds of them were able to diagnose the depression and more than half were able to diagnose schizophrenia and psychosis, while in a study by Armstrong G et al, (12) the majority of participants were able to correctly recognize depression (76.1%) and psychosis (76.1%) in vignettes. These figures are substantially higher than pretest results from a training evaluation study using the same vignettes among community health workers in the same locality (depression -22.9%; psychosis -8.6%). However, only half of the participants in the Cowan J (10) study were able to correctly name three signs and symptoms of depression and this dropped to less than one-third for psychosis. This may be attributed to the difference in sample size collection. In the present study (52.8%) of the respondents were able to prescribe the medications to the patients with mental health illnesses. The same result was found by Nadeer H. Alkhadhrawi et al, (13) in which about sixty physicians (44.4%) reported low confidence toward providing pharmacological treatment to children or adolescents with mental health disorders. There is a significant association found between the high certificate degree and knowledge on mental illness in the current study, moreover, a significant association is seen between the high certificate degree and their beliefs about mental health problems. Negative and stigmatizing attitudes were commonly endorsed by the participants. For instance, it was commonly thought that mental health problems were a sign of personal weakness (14.3% agree, 57.1% uncertain). Negative attitudes and the related concept of stigma have a substantial impact on the care of people with mental health problems. Stigma in the context of mental disorders is well documented and is linked to discrimination, under-use of mental health services, delay in receipt of treatment, and an impeded recovery process (21). This is in agreement with that found by Cowan J's study when mentioned that negative attitudes were more commonly endorsed by Practitioner doctors than doctors who had not received any mental health training (10). Limitations of the study: As the study was cross-sectional and such designs are weak in predictive explanation. short time for data collection. And small sample size

Conclusion:
Physicians with higher certificates had more knowledge and attitude than other certificates; therefore, raising the awareness among family physicians about mental health services through making workshops, symposiums, more training courses is recommended.