|Ahead of print
|Awareness and utilization of mental health services through primary care centers during COVID-19: A cross-sectional study among adult individuals in rural Mangaluru, India
Jencil D Souza1, Jeby Jose Olickal2
1 MPH Student, Department of Public Health, K. S. Hegde Medical Academy, Nitte Deemed to be University, Mangaluru, Karnataka, India
2 Assistant Professor, Department of Public Health, K. S. Hegde Medical Academy, Nitte Deemed to be University, Mangaluru, Karnataka, India
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|Date of Submission||28-Sep-2022|
|Date of Acceptance||29-Dec-2022|
|Date of Web Publication||28-Feb-2023|
Introduction: Mental health issues were neglected in India. However, coronavirus disease 2019 (COVID-19) had raised the importance of mental health. Hence, this study aimed to determine the prevalence of awareness and utilization of the mental health services provided by primary care centers during the COVID-19 pandemic.
Methods: This community-based cross-sectional study was conducted among individuals aged 18 years and above in selected primary health center (PHC) service areas, Karnataka, South India. The sample size was 388. A semi-structured questionnaire was used to collect the information.
Results: The mean (standard deviation [SD]) age of the participants was 42.7 (±15.37) years and 76% were female. The prevalence of awareness was 47% (95% confidence interval [CI] 41.8%–52.0%), and only 1% (95% CI 0.8%–2.6%) had utilized the mental health services through PHCs during COVID-19. About 82% (95% CI 78.0%–85.8%) were willing to avail the mental health services through PHCs. No formal education (adjusted prevalence ratios [APR] = 7.33, 95% CI 1.81–29.60, P = 0.005) and current psychological distress (APR = 2.99, 95% CI 2.08–4.30, P = 0.00) were significantly associated with unwillingness to avail care from PHCs.
Conclusion: The awareness and utilization of mental health services through primary care centers were poor in the community. Strategic measures must be implemented through the mental health program to improve the utilization of the services.
Keywords: Mental health, rural health, service utilization
|How to cite this URL:|
Souza JD, Olickal JJ. Awareness and utilization of mental health services through primary care centers during COVID-19: A cross-sectional study among adult individuals in rural Mangaluru, India. Arch Ment Health [Epub ahead of print] [cited 2023 Mar 24]. Available from: https://www.amhonline.org/preprintarticle.asp?id=370758
| Introduction|| |
Mental health is the most important health as it may influence people's behavior in extreme conditions of illness. The World Health Organization has serious concern over the increasing burden on mental health care, treatment gaps, and lack of services in developing countries which caused high morbidity and mortality. The current prevalence of mental health morbidity conditions among adults was 7.5% which indicates nearly 1, 12, 500 people need mental health treatment. The early preventive and diagnostic approach related to mental health problems will improve the health of the individual and the community as a whole which further minimizes the financial burden. Despite the fear, stigma is considered one of the evolving problems for mental trauma faced in the community.
Due to the unexpected occurrence of coronavirus disease 2019 (COVID-19), several national health systems collapsed as there was a rapid increase in patients acquiring specialty care. The lockdown during the pandemic bought people at risk of many psychological distresses which increased the burden on health workers. During the pandemic, the cases of mental health illnesses such as depression and anxiety were elevated among the general population due to various norms implemented by the governments. The change in behavior was also seen among community people toward patients who were contacted with COVID-19. Therefore, the focus must be given to raising awareness and sustainability of the mental health services whenever such pandemic occurs.
India introduced the District Mental Health Program in 1996 to deliver adequate mental health services to people. At the primary level, primary health centers (PHCs) are providing mental health care to the community through screening, counseling, and medication. Apart from this, the Government of India has implemented guidelines for the provision of mental health-care services during the COVID-19 pandemic at all levels of the health-care system. However, to the best of our knowledge, there are no studies from India that assessed mental health services utilization during the pandemic among adults in a rural population. Understanding how primary health care is used for mental health can help provide services efficiently to the population they serve. Therefore, we aimed to determine the prevalence of awareness and utilization of the mental health services provided by PHCs during the pandemic among adult individuals in rural Mangaluru, India.
| Methods|| |
Study design, population, and setting
This community-based cross-sectional analytical study was considered in the service area of one PHC of Mangaluru taluk, India. Individuals aged 18 years and above residing in the service area of the selected PHC were eligible to participate in the study. Individuals who were already on treatment for mental health disorders before COVID-19 were excluded from the study.
Sample size calculation
Assuming the prevalence of nonutilization as 60%, (13) with 5% absolute precision and 5% nonresponse rate, the calculated sample size for the study was 388. This sample size was calculated using OpenEpi version 3.01.
The sampling method for the study is depicted in [Figure 1]. Under the District Health and Family Welfare Department of Dakshina Kannada, Mangaluru taluk, was selected conveniently. Of 19 PHCs of Mangaluru taluk, Kotekar PHC was selected by simple random sampling technique. The selected PHC had a total population of 66,746. There were seven subcenters in this PHC, and one subcenter (Kotekar B) was selected by simple random sampling. There were 1712 households in the selected subcenter, and by systematic random sampling (sampling interval of 4), 369 households were selected. One individual from each household was enrolled. We have selected the available person in the house at the time of data collection. If there was more than one eligible participant at a house, one eligible and willing participant was selected randomly.
Study tools and data collection
Data collection was done in April–May 2022. The student researcher and an Accredited Social Health Activist (ASHA) worker visited the household and interviewed the participants at their house. A validated semi-structured questionnaire was used. The questionnaire included sociodemographic and behavioral characteristics and questions related to mental health service utilization from PHCs. The content validity of the tool was done by three subject experts. Based on their suggestions and guidelines, the final version of the questionnaire was prepared. The validated Kannada version of the Kessler Psychological Distress-K10 Scale was used to assess the psychological distress of the participants.
The following questions were asked to assess the awareness and utilization of mental health services provided through PHCs during the COVID-19:
- “Are you aware of health services related to mental health (screening/counseling/treatment) provided by PHCs during COVID-19? ”Yes/No
- ”Have you utilized any mental health services such as screening/counseling/treatment related to mental health from PHCs in the last year?” Yes/No.
The study protocol was reviewed and approved by the Institutional Ethics Committee of K.S. Hegde Medical Academy, Nitte (Deemed to be University), Mangaluru. The approval number is INST. EC/EC/152/2021–22. Appropriate approval was taken from the district health authority. Written informed consent was taken from the participants before enrolment. Confidentiality and privacy were maintained throughout the study.
The data were collected in the paper-based form and were entered into EpiCollect 5 mobile application. Data analysis was done usingv STATA version 14 (StataCorp LLC, 4905 Lakeway Drive College Station, Texas, USA). Categorical variables such as gender, occupation, educational status, marital status, economic status/type of ration card, number of family members, type of family, area of residence, social class, current psychological distress assessed using the Kessler Psychological Distress-K10 Scale, positive for COVID-19 in the past, and quarantined for COVID-19 in the past were summarized as frequency and percentage. Continuous variable like age was summarized as mean (standard deviation[SD]). The prevalence of awareness and utilization of mental health services from PHCs was summarized as percentages with 95% confidence intervals (CIs). The association of categorical variables with unawareness was analyzed using the Chi-Squared test, and the unadjusted prevalence ratios with 95% CI were calculated. The current psychological distress is assessed as a proxy to study the association between psychological distress and awareness. Log binomial regression was performed using variables that had a P < 0.2 in the unadjusted analysis, and adjusted prevalence ratios (APR) with 95% CI were calculated. P < 0.05 was considered statistically significant.
| Results|| |
The mean (SD) age of the participants was 42.7 (15.4) years and 76.0% were female. About 55% were unemployed, 64% belonged to below poverty line, and 71% belonged to nuclear family. About 10% had psychological distress based on the Kessler Psychological Distress Scale, and 71% did not avail mental health services from any provider during the COVID-19 pandemic [Table 1].
About 47% (n = 182, 95% CI 41.8%–52.0%) were aware of the mental health services provided by PHCs. Among them, 62% got awareness from ASHAs, 24% got awareness from health-care workers (HCW), similarly 5% through social media and 4% through newspaper/TV channels. The utilization of mental health services from PHC in the past 1 year was 1% (n = 4, 95% CI 0.8–2.6). Of total, 82% (n = 319, 95% CI 78.0%–85.8%) were willing to avail of mental health services from PHCs. The preferred mode of availing services was direct counseling/screening (69%), teleconsultation/counseling/screening (28%), and video-counseling/screening (3%) [Table 2].
|Table 2: The prevalence of awareness and utilization and willingness to use mental health services from primary health centers (n=388)|
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The factors associated with unawareness of mental health services provided by PHCs during the COVID-19 pandemic are depicted in [Table 3]. None of the studied factors was significantly associated with unawareness. Factors associated with the unwillingness to avail of mental health services from PHCs are shown in [Table 4]. Compared to those who had a higher education, individuals having no formal education had 7.3 (95% CI 1.81–29.60) times higher chances of unwillingness to avail care from PHCs. Similarly, the presence of psychological distress (APR = 2.99, 95% CI 2.08–4.30, P = 0.001) was significantly associated with unwillingness.
|Table 3: Factors associated with the unawareness of mental health services provided by primary health centers during COVID-19 pandemic (n=388)|
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|Table 4: Factors associated with unwillingness to avail of mental health services through primary health centers during COVID-19 pandemic (n=388)|
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| Discussion|| |
The proportion of individuals' awareness about mental health services was 47%. Among them, 62% got awareness from ASHA workers. The proportion of individuals who utilized mental health services from PHCs in the study during COVID-19 was 1%. About 82% were willing to avail of mental health services from PHCs. The preferred mode of availing services was direct counseling/screening (69%). Education and the presence of psychological distress were significantly associated with unwillingness.
A study conducted by Devkota et al. in Nepal reported that the individual's level of utilization of mental health services was 63.64%, and also found that predisposing factors including gender, socioeconomic state, educational qualification, and occupational status were barriers to utilize mental health services. Another study conducted by Luitel et al. reported that the lack of financial condition and poor literacy had an association with the misconception of mental health services at PHCs.
A rise in most of the mental health illnesses during COVID-19 was reflected in the study done in Bangladesh by Banna et al. as the prevalence of stress and anxiety was 33.7% and 59.7%. According to a study conducted by Mwape et al., 71% had a positive perception of the integration of mental health care into PHC and 91% felt training must be provided to HCWs to get services. In a study conducted by Gautham et al., the treatment gap was high for substance use disorders (91%) and common mental disorders (85%). The patients' access to mental health care is restricted by factors such as stigmatization fear, ignorance of the services, sociocultural isolation, a lack of financial support, and geographic isolation.
To the best of our knowledge, this is the first study from India to assess the awareness, utilization, and willingness of availing of mental health services from PHCs in the general population. The awareness and utilization of mental health services from PHCs were very low. However, the majority of the participants were willing to avail mental health services at the primary care level. A study conducted by Lakshmana et al. reported that poor program interventions to reach people were the reason for unawareness. Especially during an emergency situation like a pandemic, primary care plays a major role at the grassroots level. Hence, it is important to strengthen the health system at the primary level. As this study was conducted in Mangaluru, India, specifically from the service area of one PHC, the generalizability of the findings is limited. We have asked about the utilization of the last year, and the possibility of recall bias cannot be ruled out. Furthermore, the current psychological distress and its association with awareness may not be appropriate to study the association of psychological distress during the pandemic and awareness about services at PHCs.
| Conclusion|| |
The awareness and utilization of mental health services through primary care centers were poor in the community. Strategic measures must be implemented through the mental health program to improve the utilization of the services.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Jeby Jose Olickal,
Department of Public Health, K. S. Hegde Medical Academy, Nitte University, Mangaluru, Karnataka
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]
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