Aim and background: The objective of this study was to Identifying Readiness of GPs to provide mental health care within primary health care facilities and its relate to study variables (District, Sex, work experience, place of study, experience in mental health and training). Limited information’s and lack of researches in Arab countries about integration mental health services within primary health care services.

Materials and methods: One hundred seventy eight consenting participants from GPs who are working within primary health care facilities related to MoH in west-bank of Palestine, and they were selected systematically and based on district. The researcher used questionnaire and interview to collect the data during a period of time (two months) and through personal Interview.

Results: The results of study showed that the participants have medium level (61.8%) in total components of readiness to provision mental health services within primary healthcare facilities. (62%) medium level in Attitudes towards mental health (66.6%) medium level in Skills and information about mental health; also (56%) low level in Possibilities to provide mental health services;(56%) low level in Support and supervision and (69%) medium level in training. Also the results showed that the results showed that there is significant statistical differences in level of GPs readiness to provide mental health services within primary health care facilities at the level at (α =0.05)to total score relate to ; district, , experience in mental health and training, but also showed that there is no significant statistical differences in level of GPs readiness to provide mental health services within primary health care facilities at the level at (α=0.05) to total score relate to Sex, work experience and place of study.

Conclusion: These data support that the participants have medium level (61.8%) in total components of readiness to provision mental health services within primary healthcare facilities. And there association between readiness of GPs to providing mental health services within primary health care and District, experience in mental health and training.

Keywords: readiness, intervention, mental disorder, attitude, general practitioner, distress, depression, chronic condition, disease, illness, primary health care

PHC, primary health care; GPs, general practitioner; WHO, world health organization; PCPs, primary care physicians

Primary health care is about providing ‘essential health care' which is universally accessible to individuals and families in the community and provided as close as possible to where people live and work. It refers to care which is based on the needs of the population. It is decentralized and requires the active participation of the community and family.¹ This ideal model of health care was adopted in the declaration of the International Conference on Primary Health Care held in Alma Ata, Kazakhstan in 1978 (known as the "Alma Ata Declaration"), and became a core concept of the World Health.²

International studies show that the strength of a country's primary care system is associated with improved population health outcomes for all-cause mortality, all-cause premature mortality, and cause-specific premature mortality from major respiratory and cardiovascular diseases.³

General practice is the provision of primary continuing comprehensive whole-patient medical care to individuals, families and their communities.⁴ GP is the only clinician who operates in the nine levels of care: prevention, pre-symptomatic detection of disease, early diagnosis, and diagnosis of established disease, management of disease, management of disease complications, rehabilitation, terminal care and counseling.⁵ GPs play a crucial role as 'gateways' to the rest of the medical system.⁶

Psychological problems in general health care settings are frequent, research shows that 24% of the patients who present themselves to primary care physicians suffer from a well defined ICD-1O mental disorder. The majority of these patients 69% across the world) usually present to physicians with physical symptoms and there is ample scientific evidence that many of those cases remain undetected. By 2030, depression alone is likely to be the second highest cause of disease burden.⁷ The principal mental disorders presenting in primary care settings are; depression (ranging from 5% to 20%), generalized anxiety disorder (4% to 15%), harmful alcohol use and dependence (5% to 15%),and somatization disorders (0.5% to 11%).⁸

The global burden of mental illness has been documented in statistics on overwhelmed health systems; unemployment, limited productivity, and deaths due to mental disorders.^9,10 The capacity of health systems to address these problems is restricted in resource-poor settings. Overall, three-fourths of the burden of mental illness (including depression, anxiety, schizophrenia, substance abuse, and dementia).¹¹ Several international health bodies, including the World Health Organization, recommended integrating mental health into primary care settings to facilitate early, comprehensive, and local treatment for mental disorders .Key strategies to improve mental health care in countries include providing treatment for psychiatric disorders in primary health care settings.¹²

There are many advantages for integrating mental health services into primary health care: To reduced Stigma and making this level of care far more acceptable and therefore accessible.¹³ WHO highlighted many barriers facing provide mental health care in primary health; lack of trained health care providers, uncomfortable feeling in dealing with mental disorders, overburdened to deliver multiple health care programs, inadequate supervision of primary care staff and lack of human resources.¹⁴

Integration mental health into primary health care, requires; Investment in the training of staff to detect and treat mental disorders; Primary health care workers may be uncomfortable in dealing with mental disorders and may also question their role in managing disorders; The issue of availability of time also needs to be addressed; In many countries primary health care staff are overburdened with work as they are expected to deliver multiple health care programs; Governments cannot ignore the need to increase the numbers of primary health care staff if they are to take on additional mental health work; Adequate supervision of primary care staff is another key issue which needs to be addressed if integration is to succeed; Mental health professionals should be available regularly to primary care staff to give advice as well as guidance on management and treatment of people with mental disorders; Furthermore the absence of a good referral system between primary and secondary care can severely undermines the effectiveness of mental health care delivered at primary health care level. Finally, governments must pay attention to key human resource management issues in primary health care-adequate working conditions, payment, resources and support to carry out demanding work.¹⁵

One fundamental question that must be addressed is; do primary care workers have the readiness to deal people with severe mental disorders such as schizophrenia and bipolar disorder? And alternatively, whether they will manage common mental disorders such as depression and anxiety

This study was gotten approve by Palestinian ministry of health, and then was sending a formal letter to all primary health care departments in west bank pf Palestine. The study population consisted on (364) GPs and sample consisted on (178) GPs, which selected systemically, the letter was sent to these departments to explain the study methodology, purpose, study population and sample, and field visit agenda. During field visit the researcher asked informed consent from participants, and was clarified for them the study goals and expected benefits of participation and expected risks, privacy and choices. The data was collected by personal interview and by using questionnaire. Each participant filled out self-reporting, reliable, and validated questionnaires for evaluate readiness of GPs to provide mental health service which is consisted on five dimensions; Attitudes towards mental health, Skills and information about mental health, Possibilities to provide mental health services; Availability of Support and supervision and training on mental health. Participants were interviewed individually.

Statistical analysis

Analytic approach was used to identify readiness of GPs to provide mental health services within primary health care facilities and its relate to study variables District, gender, work experience, study place, experience in mental health and training received. The first step was finding the average, standard deviation, frequency and percentage to examine distribution of data, and next step involved using t- tests for two independent groups, One Way ANOVA to compare means of three or more samples, LSD (Least Square Differences) test to compare the mean of one group with the mean of another, the researcher was used a questionnaire, consisted on five dimensions, to measure GPs readiness. Questionnaire was built after reviewing literature and asking consulting ten experts from different background (psychiatric, psychologists, general practitioner, public health specialist and statistical).

The mean score of the questionnaire showed that the participants have medium level (61.8%) in total components of readiness to provision mental health services within primary healthcare facilities. (62%) medium level in Attitudes towards mental health (66.6%) medium level in Skills and information about mental health; also (56%) low level in Possibilities to provide mental health services; (56%) low level in Support and supervision and (69%) medium level in training received (Table 1).

After testing the hypothesis the results showed that there is significant statistical differences of odds ratio (α = 0.05) was observed in the relationship between level of GPs readiness to provide mental health services within primary health care facilities and; District, experience in mental health and training variables. But showed that there is no significant statistical differences of odds ratio (α = 0.05) was observed in the relationship between level of GPs readiness to provide mental health services within primary health care facilities and Sex, work experience and place of study variables.

Also open questions answers were: The first question is: from yours point of view; what are the main obstacles facing you during intervention with people suffering from mental disorder?

The total respondents were 115 with percentage 65% from the total sample. Also the participants highlighted many obstacles facing them during their intervention with people who suffering from mental disorders: 31.3%lack of experience, information, training and skills related to mental health; and 30.2 %work place are not suitable to provide mental health services, the large numbers of patients and not available time; 15.6 %stigma and social concepts about mental health is main obstacles to provide mental health services; 6.4 % lack of psychotropic medications; and 17.5% reported different obstacles such as; lack of team; lack of security; lack of interesting from stakeholders about mental health; lack of supervision form the psychiatrist on GPs; difficulties related to referral system for mental health services; lack of clear protocol for intervention with people who suffering from mental disorder in primary health care.

The second question was: do you think it is interesting to provide mental health services within primary health care system? (Yes or no) if yes mention why?

161 of the participants was respond question, which is equal 90% of total sample; 81% of respondents reported yes, and 19% of respondents reported no. The participants who answer yes, they mentioned many reasons, the most frequent was; 27% there's a lot of people needs mental health services, 20% reported that; mental health and public health are linked and integrated each other, 12% for prevention through early detection, 12% to make mental health services available and more accessible, 10%because of bad conditions for Palestinian population, 7% because primary health care is the first level of contact with the community, 7 % to fight stigma towards mental health and raising awareness, 4% because physical illness affect on mental health, 1% to gain new skills for intervention with mental illness

The mean score of the questionnaire showed that the participants have medium level (61.8%) in total components of readiness to provision mental health services within primary healthcare facilities. (62%) medium level in Attitudes towards mental health (66.6%) medium level in Skills and information about mental health; also (56%) low level in Possibilities to provide mental health services; (56%) low level in Support and supervision and (69%) medium level in training.

Integration into primary health care, requires investment in the training of staff to detect and treat mental disorders. Within the context of training, primary health care workers may be uncomfortable in dealing with mental disorders.¹⁵

Recent research in Salfit district in West-Bank of Palestine showed that two third of them have never received any training while 28% had been exposed to training sometimes, also that many health workers do view their training as not adequate neither organized enough ¹⁶. Some research showed that Primary care providers' have a negative attitudes toward individuals suffering from mental disorder ¹⁷ and others research’s findings showed that the doctors have positive attitudes towards mental health services general.¹⁸ The negative attitudes towards mental health likely to be due to the lack of information in the field of mental health, or due to misinformation and distortion.¹⁹

The results showed that; there is significant statistical differences of odds ratio (α = 0.05) was observed in the relationship between level of GPs readiness to provide mental health services within primary health care facilities and; District, experience in mental health and training received variables. But showed that there is no significant statistical differences of odds ratio (α = 0.05) was observed in the relationship between level of GPs readiness to provide mental health services within primary health care facilities and Sex, work experience and place of study variables.

Also some researchers showed that; there was no statistical relationship between the attitude towards mental illness among relatives of a mentally ill individuals and their age, sex, place of residence and education²⁰ and others research showed the opposite. But in-service training, is also important because all health care, changes as new research and practice produces new knowledge and ways of treating disorders. The effects of training are nearly always short-lived if health workers do not practice newly learnt skills and receive specialist supervision over time. Ongoing support and supervision from mental health specialists are essential.¹ Training and supervision for primary care practitioners help them to gain skills that enable greater competence and autonomy in managing mental disorders.⁸

Also the participants highlighted many obstacles facing them during their intervention with people who suffering from mental disorders: 31.3% lack of experience, information, training and skills related to mental health:^21‒24 and 30.2 %work place are not suitable to provide mental health services, the large numbers of patients and not available time; 15.6% stigma and social concepts about mental health is main obstacles to provide mental health services:^25‒30 6.4% lack of psychotropic medications; and 17.5% reported different obstacles such as; lack of team; lack of security; lack of interesting from stakeholders about mental health; lack of supervision form the psychiatrist on GPs; difficulties related to referral system for mental health services; lack of clear protocol for intervention with people who suffering from mental disorder in primary health care.^31‒36

Also 81% of respondents reported (yes) about; the needs to provide mental health services within primary health care facilities, and 19% of respondents reported no. The participants who answer yes, they mentioned many reasons, the most frequent was;^37‒41 27% there's a lot of people needs mental health services, 20% reported that; mental health and public health are linked and integrated each other, 12% for prevention through early detection, 12% to make mental health services available and more accessible, 10%because of bad conditions for Palestinian population, 7 %because primary health care is the first level of contact individuals, 7 % to fight stigma towards mental health and raising awareness, 4% because physical illness causes mental disorder, 1% to gain new skills for intervention with mental illness.^42‒48

Integration mental health into primary health care requires skills, training to address the overall reluctance of primary health care workers to work with people with mental disorders.^49‒54 The issue of availability of time also needs to be addressed. In many countries primary health care staffs are overburdened with work as they are expected to deliver multiple health care programs.^55‒58 Adequate supervision of primary care staff is another key issue which needs to be addressed if integration is to succeed. Furthermore the absence of a good referral system between primary and secondary care can severely undermines the effectiveness of mental health care delivered at primary health care level.^59‒61 Finally, adequate working conditions, payment, resources and support to carry out demanding work.¹⁵ A World Health Organization recommended to integrate mental health into general health care to tackle mental disorders and associated disability, but there are many barriers facing provide mental health care in primary health:^62,63 lack of trained health care providers, uncomfortable feeling in dealing with mental disorders, overburdened to deliver multiple health care programs, inadequate supervision of primary care staff and lack of human resources.¹⁴

This study showed that; the participants have medium level (61.8%) in total components of readiness to provision mental health services within primary healthcare facilities, also showed that; there is significant statistical differences of odds ratio (α = 0.05) was observed in the relationship between level of GPs readiness to provide mental health services within primary health care facilities and; District, experience in mental health and training received variables.

The authors wish to thank the study participants and for who had provided me support during research implementation process, also I wish to thank Mr. Marwan Zuhd for customizing software programs used in data processing and analysis.

Author declares there are no conflicts of interest.

None.

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