Stan Kutcher1*, Yifeng Wei2, Heather Gilberds3, Adena Brown4, Omary Ubuguyu5, Tasiana Njau6, Norman Sabuni7, Ayoub Magimba8 and Kevin Perkins9
1S Kutcher, ONS; MD, FRCPC, FCAHS, Dalhousie University and the IWK Health Centre, 5850 University Avenue, PO Box 9700, Halifax, Nova Scotia B3K 6R8, Canada
2Sun Life Financial Chair in Adolescent Mental Health team, Dalhousie University and IWK Health Centre, Halifax, Canada
3H Gilberds, Program Manager, Farm Radio International, Ottawa, Canada
4Sun Life Financial Chair in Adolescent Mental Health team, IWK Health Centre, Halifax, Canada
5O Ubuguyu, MD, Muhimbili National Hospital, Kalenga Street, PO Box 65000, Dar es Salaam, Tanzania
6T Njau, Ass. Lecturer/Clinical Psychologist; Muhimbili University of Health and Allied Sciences, PO Box 65001, Dar es Salaam, Tanzania
7N Sabuni, National Coordinator; Mental Health and Substance Abuse, Ministry of Health, PO Box 9083, Dar es Salaam, Tanzania
8A Magimba, Assistant Director; Non Communicable Disease, Ministry of Health, PO Box 9083, Dar es Salaam, Tanzania
9Farm Radio International, Ottawa, Canada
Received: 28 May, 2016; Accepted: 15 June, 2016; Published: 16 June, 2016
Stan Kutcher, Dalhousie University and the Izaak Walton Killam (IWK) Health Centre, 5850 University Avenue, PO Box 9700, Halifax, Nova Scotia B3K 6R8, Canada, E-mail:
Kutcher S, Wei Y, Gilberds H, Brown A, Ubuguyu O, et al. (2016) Evaluating Community Health Care Providers Knowledge and Self-Confidence in the Identification, Diagnosis and Treatment of Adolescent Depression in Tanzania. Arch Depress Anxiety 2(1): 026-00. DOI: 10.17352/2455-5460.000011
© 2016 Kutcher S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Health care providers; Knowledge; Self-confidence; Tanzania; Adolescents; Mental health; Depression; Africa
Background: Depression, which frequently onsets in young people, is projected to become the largest single burden of disease globally in the next decade. Its impact may be disproportionally felt in low-income countries, such as Tanzania, where availability of appropriate care in the community is poor. As part of the development of a health provider work force that can properly address this issue, assessment of current mental health literacy, focusing on knowledge about and self-confidence in the identification, diagnosis and treatment of Depression in young people by community health care providers is needed. This study addresses that need.
Methods: As part of the Integrated Approach to Addressing Depression amongst Youth in Malawi and Tanzania project funded by Grand Challenges Canada and supported by the Ministry of Health and Social Welfare, we evaluated the knowledge and self-confidence of 109 community based health care providers (HCP) in the Arusha and Meru Districts of Tanzania.
Results: Results demonstrate that baseline knowledge about adolescent Depression among HCP’s was poor with a group average score of 55%. However, HCP’s demonstrated high rates of self-confidence regarding their ability to identify, diagnose and treat adolescent Depression.
Conclusions: To our knowledge this is the first study investigating these parameters in a cohort of community HCP’s in Tanzania (and perhaps all of Sub-Saharan Africa) these findings provide valuable information regarding HCP’s knowledge about adolescent Depression. The disconnect between high self-confidence and low level of knowledge suggests that quantitative assessment of baseline competencies in mental health care is necessary when determining future mental health care training needs in this population. This study further indicates the importance of providing training of HCP on adolescent Depression to address the gap between knowledge and self-confidence.
Mental health literacy (MHL) in populations is foundational for mental health promotion, prevention, stigma reduction, and care and is comprised of four components: 1) understanding how to obtain and maintain positive mental health; 2) understanding mental disorders and their treatments; 3) decreasing stigma related to mental disorders; and 4) enhancing help-seeking efficacy [1,2]. While mental health literacy is necessary at the population level, where it can enhance access to mental health care and promote appropriate self-care [1-3], it is also needed amongst health care providers, where MHL must be included as part of the necessary competencies needed to enhance the provision of mental health care. This is particularly prescient in the area of Depression, which, is currently the third leading cause of disability worldwide and, according to the World Health Organization, will become the single largest contributor to the global burden of disease in the next decade . Furthermore, since about half of all cases of Depression can be diagnosed prior to age 25 years it is essential that health care workers be able to appropriately identify, diagnose and treat young people who have Depression.
However, despite the high need for mental health care in general and for Depression in particular, these needs are not a priority in many low and middle income countries (LMICs) [5-12]. In addition to the well-described lack of specialist mental health care providers, such as psychiatrists, psychiatric nurses and psychologists in these settings [13-18], the lack of necessary mental health care competencies among community based health care providers (HCP’s) continues to be a barrier to the identification, diagnosis and provision of effective primary care for young people with common mental disorders such as Depression [11,19-21]. As a result, in many countries throughout sub-Saharan Africa, community-based mental health care for young people with Depression is not available . Improving access to quality mental health care at the community level is well recognized as a necessary strategy to address the mental health care needs of the population in low income countries such as Tanzania [11,13,22-24]. Investment in improving access to and quality of care for Depression in adolescents is particularly important in these settings because of the population age distribution, which has a heavy proportional weighting before age 25 years (Central Intelligence Agency, 2015) The potential positive impacts of improving mental health and health outcomes now and as this cohort ages through access to effective treatment of Depression in young people can be expected to pay an economic population dividend that could be of substantial benefit to low income countries .
Tanzania is located in sub-Saharan Africa and is one of the world’s poorest countries with 67.9% of the population living below the poverty line . The country of approximately 945 thousand square kilometers has a population of over 45 million people , over half (63.93%) of Tanzania’s population consists of those aged between 0 and 24 years (Central Intelligence Agency, 2015) In relation to mental HCPs, there are only 0.04, 0.01 and 0.007 psychiatrists, medical doctors (not specialized in psychiatry), and psychologists respectively per one hundred thousand people. Mental health legislation was most recently revised in 2008 and components of the mental health plan include reallocating services and resources from mental hospitals to community mental health facilities and integrating mental health services into primary care. Expenditure on mental health services sits at roughly 2.4% of the overall health budget .
While research about adolescent mental health is scant in Tanzania, available studies in a neighboring country, Malawi, indicate that Depression is a common disorder. Udedi , found a prevalence rate of roughly 30% in attendees of the Matawade Health Center in Zomba, and Kauye et al. , reported a rate of 19% in attendees of other clinics. In Tanzania, in a study of pregnant women and young mothers (many of whom are teenagers), Stewart et al. , reported rates of Depression ranging between 10.7% and 21.1%. Furthermore, Kim et al. , reported a Depression rate of 20% in adolescents attending HIV/AIDS clinics.
Currently, there is little, if any, data available to describe the level of knowledge about adolescent Depression in community based HCP’s in Tanzania. Mbatia and colleagues , obtained baseline information regarding opinions and attitudes related to adult Depression among HCP’s in urban Tanzania using the Depression Attitude Questionnaire (DAQ) and reported that 2/3 of HCPs were confident in their ability to distinguish between unhappiness and clinical depressive disorder . However, this was a small scale study (n=14) conducted in an urban area primarily addressing HCP’s self-confidence in their competencies, and did not sufficiently assess knowledge about Depression nor compare knowledge with self-competency assessment.
This report thus addresses a gap in empirical evidence related to knowledge and attitudes about adolescent Depression and mental health more broadly in community based health care providers in Tanzania. The baseline study was conducted as part of a larger Grand Challenges Canada funded project – “An Integrated Approach to Addressing the Challenge of Depression among the youth in Malawi and Tanzania” (IACD) – in collaboration with implementing partner Farm Radio International and supported by the Tanzania Ministry of Health and Social Welfare. Ethics permission for this work was obtained through the National Institute for Medical Research (NIMR)
This is a cross-sectional survey measuring community HCP’s knowledge and self-reported confidence in the diagnosis and treatment of adolescent Depression.
With the assistance and support of the Tanzania Ministry of Health and Social Welfare, health providers were recruited to participate in a mental health care for adolescent Depression training program funded by Grand Challenges Canada. Participants were community based HCPs identified by health system administrators in the Arusha and Meru Districts of Tanzania. A representative cross-section of 109 HCPs were recruited for the training program and completed the baseline assessment.
The survey contains two sections: the first assesses mental health knowledge and the second assesses the health provider’s self-reported confidence regarding identification, diagnosis and treatment of Depression in young people.
Participants were asked to respond to 30 questions to assess their knowledge about the identification, diagnosis and treatment of Depression in young people. For each question, participants were instructed to respond “True”, “False”, or “Do Not Know” by marking an X in the appropriate box. If participants selected “Do Not Know”, selected more than one option (without a clear indication of one option being crossed off) or did not select any option the corresponding question was marked as incorrect. Correct answers received a score of 1 and incorrect answers or “Do Not Know” answers received a score of 0. Confidence self-reports were assessed using a 4-point Likert scale that asked participants to rate their confidence from not confident (1 point), somewhat confident (2 points), very confident (3 points), to extremely confident (4 points)
The data was entered and analyzed using SPSS Statistics software for Windows, version 22.0. Descriptive statistics were used to describe the responses to both the knowledge and confidence assessments. An independent samples t-test was used to compare clinician results to other professional groups. A reliability test was conducted to investigate the internal consistency of both the knowledge and self-confidence sub measures.
Of the 46 community HP respondents who identified their sex, 55 percent were female. The sample age ranged from 25 to 59 years of age. Most were clinicians (clinical officers and senior clinical officers; n=73, 67%), followed by nurses (including registered nurses, enrolled nurses, psychiatric nurses and midwives; n=20, 18.3%), and other (including medical attendants, nurse assistants and other health care professionals; n=15, 13.8%)
Knowledge assessment results
The internal consistency of the knowledge measure was α=0.75. The scores on the knowledge assessment ranged from 4 to 27 correct out of a possible 30. The average knowledge score in the sample was 16.5 out of 30 (55%) with the median 17.0 (57%) The questions in which the HCP’s had the largest proportion of correct responses (over 80%) were numbers 3, 9, 11, 18, 19, and 24.
An independent samples t-test comparing clinician results (M=16.62, SD=4.64) to other healthcare professionals (M=16.26, SD=4.06); t(106)=0.392) was not significant (p>0.05) (Table 1)
Confidence self-report results
The internal consistency of the confidence measure was α=0.89. The scores on the confidence assessment ranged from 4 – 16 out of a possible 16. The average score was 11.2 of 16 with the median being 12. This aggregate finding corresponds to HCP’s feeling “very confident” in their ability to identify, diagnose and treat adolescent Depression. No significant differences (p<0.05) were found between clinicians (M=11.39, SD=2.84) and other healthcarev professionals (M=10.85, SD=3.21); t(102)=0.876) (Figures 1,2).
- Kutcher S, Bagnell A, Wei Y (2015) Mental health literacy in secondary schools: a Canadian approach. Child and Adolescent Psychiatric Clinics of North America 24: 233-244.
- Kutcher S, Wei Y, Coniglio C (2016) Mental health literacy: past, present, and future. Can J Psychiatry 61: 154-158.
- Kutcher S, Wei Y, Hashish M (in press) Mental Health Literacy for Students and Teachers: A “School Friendly” Approach. In M. Hodes (Ed.), Positive Mental Health for Children and Adolescents.
- World Health Organization (2008) Mental Health Gap Action Programme (mhGAP): Scaling up Care for Mental, Neurological, and Substance Use Disorders. Geneva: World Health Organization.
- Armstrong G, Kermode M, Raja S, Suja S, Chandra P, et al. (2011) A mental health training program for community health workers in India: impact knowledge and attitudes. Int J Ment Health Syst 5: 17.
- Bruckner TA, Scheffler RM, Shen G, Yoon J, Chisholm D, et al. (2011) The mental health workforce gap in low-and middle-income countries: a needs-based approach. Bulletin of the World Health Organization 89: 184-194.
- Wang PS, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Borges G, et al. (2007) Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet 370: 841-850.
- Patel V1, Maj M, Flisher AJ, De Silva MJ, Koschorke M, et al. (2010) Reducing the treatment gap for mental disorders: a WPA survey. World Psychiatry 9: 169-176.
- Braathen SH, Vergunst R, Mji G, Mannan H, Swartz L (2013) Understanding the local context for the application of global mental health: A rural South African experience. International Health 5: 38-52.
- Kodali S (2015) Depression in Developing Countries. Retrieved from Yale Global Health Review:
- Patel V, Araya R, Chatterjee S, Chisholm D, Cohen A, et al. (2007) Treatment and prevention of mental disorders in low-income and middle-income countries. Lancet 370: 991-1005.
- Patel V, Abas M, Broadhead J, Todd C, Reeler A (2001) Depression in developing countries: lessons from Zimbabwe. BMJ 322: 482-484.
- Saxena S, Thornicroft G, Knapp M, Whiteford H (2007) Resources for mental health: scarcity, inequity, and inefficiency. Lancet 370: 878-889.
- Lund C, Kleintjes S, Kakuma R, Flisher AJ, MHaPP Research Programme Consortium (2010) Public sector mental health systems in South Africa: inter-provincial comparisons and policy implications. Soc Psychiatry Psychiatr Epidemiol 45: 393-404.
- Kilonzo GP, Simmons N (1998) Development of mental health services in Tanzania: a reappraisal for the future. Soc Sci Med 47: 419-428.
- Laugharne R, Burns T (1999) Mental Health Services in Kumasi, Ghana. Psychiatric Bulletin 23: 361-363.
- Feinstein A (2002) Psychiatry in post-apartheid Namibia: a troubled legacy. The Psychiatrist 26: 310-312.
- Njenga F (2002) Focus on psychiatry in East Africa. Br J Psychiatry 181: 354-359.
- World Health Organization (2014) Mental health atlas. Geneva, Switzerland: World Health Organization.
- Kutcher S, Chehil S, Cash C, Millar J (2005) A competencies-based mental health training model for health professionals in low and middle income countries. World Psychiatry 4: 177.
- World Health Organization (2008) The Global Burden of Disease: 2004 Update. Geneva: World Health Organization.
- Desjarlais R, Eisenberg L, Good B, Kleinman A (1995) World mental health. Problems and priorities in low income countries. N Engl J Med 33: 1227-1228.
- Thornicroft G, Tansella M (2004) Components of a modern mental health service: a pragmatic balance of community and hospital care: overview of systematic evidence. Br J Psychiatry 185: 283-290.
- Graham AL, Julian J, Meadows G (2010) Improving responses to depression and related disorders: evaluation of a innovative, general, mental health care workers training program. Int J Ment Health Syst 4: 25.
- Chisholm D, Sweeny K, Sheehan P, Rasmussen B, Smit F, et al. (2016) Scaling-up treatment of depression and anxiety: a global return on investment analysis. Lancet Psychiatry 3: 415-424.
- Central Intelligence Agency (2013) The World Factbook 2013-14.
- World Health Organization (2011) Mental Health Atlas.
- Udedi M (2014) The prevalence of Depression among patients and its detection by primary health care workers at Matawale Health Centre (Zomba) Malawi Med J 26: 34-37.
- Kauye F, Jenkins R, Rahman A (2014) Training primary health care workers in mental health and its impact on diagnoses of common mental disorders in primary care of a developing country, Malawi: a cluster-randomized controlled trial. Psychol Med 44: 657-666.
- Stewart RC, Umar E, Tomenson B, Creed F (2014) A cross-sectional study of antenatal depression and associated factors in Malawi. Arch Womens Ment Health 17: 145-154.
- Kim MH, Mazenga AC, Devandra A, Ahmed S, Kazembe PN, et al. (2014) Prevalence of depression and validation of the Beck Depression Inventory-II and the Children's Depression Inventory-Short amongst HIV-positive adolescents in Malawi. J Int AIDS Soc 17: 18965.
- Mbatia J, Shah A, Jenkins R (2009) Knowledge, attitudes and practice pertaining to depression among primary health care workers in Tanzania. Int J Ment Health Syst 3: 5.
Follow us on Academia.edu
Access denied for user 'root'@'localhost' (using password: YES)