Family Physicians' Experience of the WHO Mental Health Gap Action Programme in Nigeria: A qualitative enquiry

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It is aimed to bridge the mental health gap but this gap still persists, with significant disparities in care access and quality. Family physicians play a crucial role in addressing this gap, but their awareness and involvement levels in the implementation of mhGAP remain unclear. This study explored family physicians’ awareness and involvement levels in the implementation of mental health service in Nigeria and also explored the perceived facilitators and barriers influencing their level of engagement in contributing to the “Mental Health Gap Action Programme”. Methods A descriptive cross-sectional qualitative study using key-informant interview semi-structured questionnaire to obtain information from 23 Family Physicians across the country (cutting across the six geopolitical zones). Responses were transcribed verbatim, typeset and coded inductively and analysed using content analysis process. The findings were presented using thematic representation (by identifying the key themes and patterns). Results Family physicians demonstrated varying awareness of mental health guidelines and interventions. Involvement levels ranged from minimal to proactive as there were no national unified guide. Facilitators to mhGAP involvement and implementation included training of physicians, patient relationships, and multidisciplinary collaboration while barriers included time constraints, stigma, and systemic gaps. Conclusions This study reveals the varying levels of mhGAP awareness and involvement among Nigerian family physicians. While some are proactive, many show limited engagement. Training, patient relationships, and collaboration facilitate involvement, while time constraints, stigma, and systemic gaps hinder it. Targeted interventions are needed to bridge the mental health action gap. Mental health gap action programme (mhGAP) Primary care mental health mental health integration Family physicians Nigeria Figures Figure 1 Figure 2 BACKGROUND Mental health service provision is one of the significant global health issues gaining attention with nearly 90% of untreated cases of mental health conditions residing in low- and middle-income countries (LMICs) where 80% of people have been reported to battle with one case of mental health or the other [ 1 ]. Evidence from the World Mental Health Surveys suggested that in Nigeria, less than 1% of persons with anxiety disorders and 6% of those with mood disorders made any treatment contact in the year of the illness [ 2 ]. The majority of Nigerians who sought treatment did so at primary or general healthcare settings where the service provision is nearly unavailable [ 3 , 4 ]. Recognizing this critical gap, the World Health Organization (WHO) launched the Mental Health Gap Action Programme (mhGAP) in 2008 [ 5 ]. This initiative strives to expand and improve mental health services in LMICs. A key component of mhGAP is the mhGAP Intervention Guide (IG), released in 2010 [ 6 ]. The IG aims to integrate mental health care into primary care and community settings by equipping non-specialist healthcare providers with the necessary tools, training, and support to deliver evidence-based interventions. The focus is on priority mental, neurological, and substance use (MNS) disorders as defined by the WHO for LMICs. The mhGAP-IG has been adopted in over 100 countries, including Nigeria, and has demonstrated effectiveness in delivering evidence-based mental health services within primary healthcare systems in resource-constrained settings [ 7 ]. The core objective is to enhance the capacity of non-specialists in the identification, treatment, and management of MNS conditions through a model of stepped care and collaborative task-sharing. The mhGAP-IG covers a range of modules, including introductory material, essential care practices, and specific guidance on conditions such as depression, psychosis/mania, epilepsy, child and adolescent mental health, dementia, substance use disorders, self-harm/suicide, and other significant mental health complaints. While mhGAP doesn't have dedicated anti-stigma modules, it emphasizes the importance of using non-stigmatizing language, demonstrating empathy, and promoting community awareness about mental illness. Evidence suggests that mhGAP training itself can contribute to reducing stigma among trainees. Family physicians, as primary care physicians are crucial in providing effective healthcare at first contact. Beyond offering comprehensive and continuous care for various health issues, they must also be equipped to facilitate timely referrals to specialized care when necessary. While mhGAP-IG implementation has been evaluated in numerous contexts, a comprehensive review of 162 studies by Keynejad and colleagues highlighted the need for further research on its implementation [ 8 ]. Therefore, this study aimed to investigate the awareness and engagement of family physicians in implementing mental health interventions within the framework of the mhGAP. The study also sought to identify factors that either facilitate or impede their involvement, contributing to a better understanding of how to bridge the mental health action gap. Awareness levels of mhGAP in Nigeria Mental health awareness in Nigeria is a growing concern, with a significant gap between the demand for mental health services and the available resources. Research has shown that primary care workers in Nigeria lack the necessary training and support to provide adequate mental health care [ 3 ]. The Mental Health Gap Action Programme (mhGAP) has been implemented in Nigeria to address this gap. The programme provides training for primary care workers on mental health care, with a focus on community-based care. Physicians in Nigeria are involved in mhGAP, primarily through training and capacity building, clinical supervision and mentorship, program evaluation and monitoring, policy development and advocacy, and community engagement and awareness [ 9 ]. Family physicians’ awareness levels of the mhGAP in Nigeria are crucial for effective mental health care delivery. Physicians' awareness levels of the Mental Health Gap Action Programme (mhGAP) in Nigeria varies. A study done in Nigeria to assess knowledge and attitude towards mental health among primary health care workers reported that knowledge of PHC workers about psychopharmacology was low. Most of them reported negative attitude towards mental illness [ 10 ]. Factors Influencing Awareness Training and education: Research has shown that primary care workers in Nigeria lack the necessary training and support to provide adequate mental health care [ 3 , 11 ]. Physicians who received training on the mhGAP were more likely to be aware of the programme [ 3 ]. A study found that primary care workers need further training to manage the mental health needs of their patients. This study also identified a need for peer support and supervision from experienced clinicians [ 12 ]. An overall 25% improvement in knowledge about MNS disorders following mhGAP-IG training in Iraq shows the effectiveness of training and education [ 13 ]. Hughes et al also reported that in-person training of 52 participants, 25 of whom were primary care physicians, with country-specific and needs-led mhGAP-IG training, showed an 8.5% improvement in post-training test scores [ 14 ]. Professional experience: More experienced physicians were more likely to be aware of the mhGAP [ 8 ]. Access to resources: The key strategy for increasing awareness is providing training programmes for primary care physicians on mhGAP-IG, with a focus on community-based care. This will help inform PCP on mhGAP and thus increase their involvement and implementation of its use. Physicians with access to the internet and other resources were more likely to be aware of the mhGAP [ 6 ]. Reiss et al found that participants improved their knowledge and skills from training on the mhGAP online course [ 15 ]. Physicians’ involvement levels in the implementation of the mental health gap action plan Physicians' involvement in the Mental Health Gap Action Programme (mhGAP) in Nigeria is crucial for effective mental health care delivery. The involvement levels of physician on mental health action gap in Nigeria are a pressing concern. This gap is further exacerbated by the limited availability of mental health professionals, particularly in rural areas. Inadequate training of primary care providers, which results in poor mental health condition recognition and treatment, lack of support and supervision for their work, an uncoordinated referral pathway through the various health service tiers, and policy neglect—which frequently takes the form of inadequate funding, irregular medication supply for MNS conditions, and weak health systems—are the reasons for this gap [ 14 , 15 ]. Additionally, Wakida et al. identified the following barriers: (a) a lack of mental health care in-service training, combined with no formal discussions about mental health disorders with higher level supervisors; (b) a lack of coordination between mental health specialists and general health workers; and (c) a lack of support from the district medical team [ 16 ]. Majority of healthcare providers 236 (58.7%) in Ethiopia had stated that there was poor implementation level of mental health integration [ 17 ]. The experience from other SSA countries have also raised concerns about challenges of integration such as poor policy implementation, insufficient numbers of mental health professionals to drive and support the process, poor community engagement and mobilization, and the non-availability of medications [ 18 ]. Innovative ways of Integration of MHS into PHC care (Key Physicians’ Involvement Levels) To bridge this gap, it is essential to increase awareness and education about mental health issues in Nigeria. This can be achieved through community-based initiatives, public awareness campaigns, and training programs for primary care workers. Mental Health Gap Action Programme (mhGAP) training and supervision : This program provides competency-based training for primary care workers, focusing on mental health care. The mhGAP-IG and a carefully monitored cascade-training methodology make it possible to expand mental health services in Nigerian primary care settings. This teaching approach is practical, economical, and promising, particularly in environments with a shortage of experts [ 3 ]. Primary care workers require more comprehensive training and ongoing support to effectively address mental health issues with the use of WHO guide in MHS treatment support. Physicians should act as Master Trainers, providing training and supervision to non-physician primary care workers. A pilot project in Osun State, Nigeria demonstrated the feasibility of scaling up mental health services through a cascade training model, where Master Trainers trained Facilitators, who then trained primary care workers [ 3 ]. The following obstacles were noted: (a) insufficient mental health care in-service training, in addition to the absence of formal conversations regarding mental health disorders with higher-level supervisors; (b) insufficient coordination between mental health specialists and general health workers; and (c) insufficient assistance from the district medical team [ 16 ]. Clinical Support Mental illness is often stigmatized, leading to delayed or inadequate treatment [ 2 ]. Physicians should offer clinical support to patients and guidance to primary care workers, ensuring conformity to the mhGAP-IG and ease of referral to mental health specialist. Mental health facilities and resources are scarce, particularly in rural areas. Limited resources for mental health treatment provision (eg medicines and staff) in remote areas like Edawu, Nigeria can create challenges in implementing mhGAP treatment plans in the long run [ 19 ]. Hence, the need for physicians to be more involved in the implementation of mhGAP-IG and to maximize the use of the available scarce resources. Encouraging peer learning and support among primary care workers can help bridge the mental health action gap. Monitoring and Evaluation : The purpose of the monitoring exercise was to encourage integrity in the application of the mhGAP standards and to reinforce skills learnt during training. In order to determine the training program's efficacy and pinpoint areas for development, doctors should take part in monitoring and evaluation activities. The monitoring activities may include: 1) going over clinical notes to make sure that all clinical encounters are properly documented; 2) having a supervisor observe the health providers' clinical assessment of patients using the mhGAP-IG in a non-intrusive manner; and 3) holding debriefing meetings with the clinical staff to go over the observations or notes made in (1) and (2) [ 3 ]. Evaluations can be carried out in an organised manner and include comprehensive details regarding patient flow, clinical documentation, fidelity, and the referral process. Digital solutions Leveraging digital platforms and telemedicine can increase access to mental health services, particularly in rural areas [ 20 ]. METHODS Study Design A descriptive cross-sectional qualitative study using key-informant interview semi-structured questionnaire to obtain information from 23 Family Physicians across the country (cutting across the six geopolitical zones). Study Population The study was conducted among specialist primary care physicians (Family Physician) distributed across all the six geopolitical zones in Nigeria. Family Physicians (FPs) treat all patients irrespective of the age, sex or disease entity. Also, FPs co-ordinate care of patients by interacting with other specialist including mental health physicians. Thus, knowledge of their awareness and involvement levels in mhGAP implementation will help mental health service delivery. FPs are in strategic position to give their perception on the situation of mental health services in the country. The cadres of the PCPs used were those who are specialist Family Physicians either as consultants or specialist registrars who were in active service. Exclusion criteria were sick physicians and retired PCPs. Study Site Primary care physicians are first contact doctors encountered at different levels of health care delivery centers. A virtual/on-phone location was utilized for data collection during the interview. Sampling Size An a priori estimation was made, with a purposive sampling size of 24 was used. Although one interviewee could not complete the interviewee due to an emergency midway, indicating a response rate of 95.8%. Study Procedure A stratified sampling technique was used to select PCPs from the six (6) geo-political zones of the country. From each zone, two (2) health facilities were selected from a list of the health facilities in each zone using a simple random method. From each health facility, two (2) interviewees were selected by balloting / picking at random from a list of PCPs obtained from the heads of the Family Medicine units. Data Collection A semi-structured questionnaire to guide the interview was used. The questionnaire consisted of the participant’s socio-demographic data and their knowledge and involvement in mhGAP implementation in Nigeria was obtained. Probes were used for clarification and to obtain in-depth information as needed. The interview guide was piloted among three (3) facilities outside the selected training centres. The interview guide was administered to three participants who met the inclusion criteria and their responses were used to further improve the guide before utilizing it for the main study. English language was the medium of communication throughout the study period. Participants were informed of the study via message or phone call and their consent obtained, then the interview date, time and mode was fixed. A virtual in-depth interview was conducted for each consenting participant after information was given and consent sought. The interviews were audio-recorded and data were stored in a password protected device. To ensure methodological rigour, the following steps was taken: The credibility of this study was ensured through sampling, piloting and member checking. Transferability was ensured through the provision of a clear description of the participants’ characteristics, settings of the study and methodology. The transcriptions were also stored to serve as references. Dependability was ensured through detailed descriptions of the methodologies to enable others to repeat the study if needed. Data collection was guided by the principle of data saturation which ensured that data collection continued until there was no new themes or insights emerging from the analysis. The a priori was adopted from the study by Chu et al on “Integrating Mental Health into primary care: evaluation of the Health Action for psychiatric problems in Nigeria” [ 21 ]. Data Analysis Data were transcribed using a thematic analysis. This study adopted a participatory action research (PAR) design where family physicians and the interviewer actively collaborated at all the stages of the interview. Recorded interviews were transcribed verbatim and typeset for ease of analysis as transcripts were reviewed against audio files seeking clarifications from participants when necessary. Adequate data storage plan was adopted by ensuring that the transcribed data was backed up on an external drive for future use of at least five (5) years. Content analysis was used for analyzing the data and presented using thematic representation of the findings, with themes developed and merged into categories. Responses were coded and entered into a spreadsheet, and relationships within the data were examined. New themes and categories were added gradually as obtained from the recordings until all transcripts were analyzed. Conclusions were drawn to depict the participants' perspectives, with all the researchers meeting to ensure agreement on the representation of views. RESULTS This qualitative study's findings are based on twenty-four (24) in-depth interviews with ten female and fourteen male family physicians from the six (6) geo-political zones of the country Experience in Dealing with Mental Health Issues Physicians encounter various challenges when dealing with mental health issues, which are often seen as unique and complex cases. Respondents reported that managing these cases is both challenging and time-consuming. One major issue highlighted was the unavailability of mental health medications, which are often not stocked in pharmacies, forcing patients to seek alternatives at nearby psychiatric hospitals. Additionally, self-medication and poor follow-up were identified as significant concerns, with patients frequently unwilling to continue treatment or accept diagnoses. ”Some of the barriers we have are actually the availability of drugs, because they are not cases we often see most times; the pharmacists stocked those drugs as in mental health medications. Because the new psychiatry hospital is also close to us, sometimes they will have to go over there and purchase some of the drugs, so that we can stabilize patients. access to medications is one of the major issues that we have; accepting diagnosis is also another issue, as some of the patients or the relatives may not want to accept that those diagnoses are true and then, embark on self-medication; follow up is also a challenge, but most times when we are able to counsel properly, since we have a liaising center in our facilities, they sometimes agree to come for follow up in our facilities.’’ (Female, Consultant, Ogun State). Respondents also pointed out that managing mental health conditions is highly time-consuming and requires substantial energy, as family involvement is often necessary for effective treatment. Results are gradual, and progress can be slow. “…it's really time-consuming and it needs a lot of energy in terms of you having to involve the family or supporter. It's something that you can't just do on your own so it's really challenging. Sometimes I get results, but the results are very slow and gradual.’’ (Female, Consultant, Edo State). Use of the WHO Guide in MHS Treatment Support Responses from interviewees reveal that they have limited familiarity and usage of the World Health Organization's Mental Health Gap Action Program Intervention Guide, which aims to integrate mental health into primary care. Many respondents expressed a lack of awareness or experience with the tool, with some stating that they have never used it or are only familiar with it in theory. The key points from the interviewees’ responses as depicted in Fig. 1 include: Lack of Familiarity and Usage : Multiple interviewees explicitly mentioned that they are not familiar with the WHO Intervention Guide or have never used it before. Some respondents remarked that they only have theoretical knowledge of it and have not put it into practice. “I’ve not used it before I know there's something by WHO but I've not really explored it.” (Male, Senior Registrar, Oyo State). Limited Awareness Several participants acknowledge hearing about the tools but are not well-versed in their application or specific policies related to mental health. A few interviewees mentioned that they are hearing about the tools for the first time during the interview. “Well, I think it's just an awareness theme. I’m not sure, um … well how do I put it now; well, maybe, also part of the curriculum. If it was part of the curriculum training I think I'll probably have seen it in some way so the integration will definitely be helpful at a given curriculum level. .. um of course on personal use and personal study there are a few others that wouldn't know when exactly the gap to by the WHO was initiated but because a few of us people are already so conversant so most people just tend to um get to use that so I think it's an awareness thing” (Male, Senior Registrar, Oyo State) Challenges in Implementation One respondent suggests that the tools should be institutionalized and made more accessible at the primary care level, similar to other basic medical tools. Another participant highlights that while they may be aware of the tools, they rarely use them in practice. “…well probably because they are not really, as I said earlier, it depends on, if these things, if they are not institutionalized, for example, you have a primary care clinic. So, these materials should actually be part of the tools that are available to you. For example, just like you have your thermometer, I think that these tools should actually be handy. Maybe you print them, they are pasted on the wall, I mean, they are there, I leave them on the table. I mean, this is what I think, because these are really lacking.” (Male, Consultant, Ogun State). Potential Benefits Despite the limited use, some respondents acknowledge that these tools could improve diagnosis, treatment, and referral processes if they were more widely implemented and used correctly. The overall sentiment indicates a gap between the availability of the WHO guide tools and their practical application in community-based and primary care settings. This highlights the need for more widespread training, awareness, and integration of these tools to enhance mental health care at the primary level. “Well, the impact, if it's used well, it's going to help in making diagnosis. And it will help in classifying patients to a degree of severity.” (Male, Consultant, Ogun State) Innovative ways of Integration of MHS into PHC care The interviewees discussed various innovative strategies for integrating mental health services into primary healthcare. Their suggestions are illustrated in Fig. 2 . A common suggestion was enhancing the training of family physicians in mental health. They proposed that, just as family physicians receive postings in other specialties, they should also spend more time in mental health rotations. This would allow them to gain a deeper understanding of psychiatric issues, ultimately enabling them to manage common mental health conditions effectively at the primary care level. “…the issue is to use the modular training at the primary care level, and to allow more people to be involved in mental health training. And both colleges now that train family physicians should inculcate mental health posting. So, this posting should be looked at regularly, and there may be need to review curriculum from time to time” (Male, Consultant, Kano State). Another approach highlighted was the integration of telemedicine and virtual platforms for mental health consultations. This method would facilitate communication between patients and healthcare providers, allowing for case discussions and experience-sharing among colleagues. However, interviewees noted challenges such as inadequate technical infrastructure, insufficient manpower, and poor telecommunications systems in Nigeria, which could hinder the effectiveness of telemedicine. “…well maybe just as you're having this zoom now; okay that is the telemedicine and communication with the patients and not just update but gatherings where we can share and communicate with the patients and with colleagues, and we can share cases and experiences together; it may help us to be able to take care of the patients more or the clients more you know.” (Female, Consultant, Edo State) Interviewees also emphasized the need for increased public awareness of mental health issues. They pointed out that many people lack knowledge about mental health conditions and their risk factors. Additionally, they criticized the government's lack of proactive measures in addressing mental health and drug addiction, highlighting the insufficient number of psychiatric specialists and the poor funding of mental health services “The knowledge and awareness of our people in mental health as regards public awareness is still very much lacking. We need awareness in that regard because a lot of people do not really know what are the issues that can predispose someone to mental health. (Male, Specialist Registrar, Oyo State) Furthermore, interviewees discussed the importance of collaboration between primary healthcare centers and tertiary facilities with mental health specialists. They shared experiences of referring patients to specialists when their conditions exceeded the capacity of primary care providers. Such collaborations, they suggested, could reduce stigmatization and cultural barriers to mental healthcare. “So, we refer to the psychiatrist. So, we actually refer our patient to the psychiatrist. We don't have a non-psychiatrist like a clinical psychologist. We don't have that facility in my centre. So, we do our referral to the psychiatrist. And so far, we've been able to have a good rapport with the psychiatrist”. (Male, Consultant, Ogun State) Lastly, the interviewees advocated for a holistic approach in primary care, integrating mental health into the scope of family physicians' work. This approach would involve expanding the family physician's role to include managing common mental health issues, particularly those frequently encountered in primary care, such as depression and other mood disorders. The integration of a psychosocial model into family medicine was also seen as a foundational step toward this goal. “So, all we need to do is to kind of widen the scope of family physician and ensure that basic mental health issues are introduced into a family physician's scheme of work more especially in cases that are commonly encountered for example depression or mood disorders and maternal psychiatric conditions”. (Male, Specialist trainer, Oyo State). DISCUSSION This study explored Family Physicians’ awareness and involvement levels in the implementation of mental health interventions and identified facilitators and barriers to this engagement in order to contribute to the Mental Health Gap Action Programme. This study was conducted among family physicians in the six geopolitical zones of Nigeria. Experience in Dealing with Mental Health Issues This study found that Family Physicians encounter different challenges when dealing with mental health issues, which are both challenging and time-consuming and is similar to the findings of a qualitative study of primary care physicians in California that reported physicians often feel challenged due to insufficient time, difficulty in accessing and communicating with specialists, low reimbursement, poor connections with community social service agencies, and lack of interdisciplinary teams [ 22 ]. Likewise, limited availability of psychotropic medication and specialist mental health personnel, were reported in Uganda as challenges that resulted in a referral bottleneck which is similar to our findings [ 23 ]. Furthermore, in the situational analysis report of three African countries by WHO, poor or uneven implementation of policy, inadequate access to essential drugs and lack of mental health specialists are some of the reasons that significant challenges remain in integrating mental health care into primary health care [ 24 ]. Use of the WHO Guide in MHS Treatment Support Many respondents express a lack of awareness or experience with the tool, with some stating that they have never used it or are only familiar with it in theory. Similar to our findings is the report that inadequate training in the use of mental health screening tools and current evidence-based treatment were identified as reasons for non-usage of skills with regard to integration of mental health services into PHC [ 16 ]. This is corroborated by the findings that PCPs were unsatisfied with the level of knowledge they had in mental health [ 16 ]. Multiple interviewees explicitly mentioned that they are not familiar with the WHO Intervention Guide or have never used it before which is similar to some of our respondents’ remarks that they only have theoretical knowledge of it and have not put it into practice. Limited Awareness: S everal participants acknowledge hearing about the tools but are not well-versed in their application or specific policies related to mental health. A few interviewees mentioned that they are hearing about the tools for the first time during the interview Challenges in Implementation One respondent suggested that the tools should be institutionalized and made more accessible at the primary care level, similar to other basic medical tools. A participant highlights that while they may be aware of the tools, they rarely use them in practice due to lack of time. This is similar to the finding of a study on the evaluation of implementing mhGAP guidelines in Uganda which cited the lack of time for the addition of mental health evaluation to existing clinical work and a high level of ethno cultural diversity in patient populations as underlying barriers to adaptation and adoption [ 25 ]. In LMIC, where specialists are few and often engrossed in the daily routine of providing care for the teeming persons in need, such specialists are hardly available to provide training for the large number of end users (primary care workers) who need to be so trained in order for effective impact to be made on service delivery. Potential Benefits Despite the limited use, some respondents acknowledge that these tools could improve diagnosis, treatment, and referral processes if they were more widely implemented and used correctly. The overall sentiment indicates a gap between the availability of the WHO guide tools and their practical application in community-based and primary care settings. This highlights the need for more widespread training, awareness, and integration of these tools to enhance mental health care at the primary level. Innovative ways of Integration of MHS into PHC care Interviewees discussed various innovative strategies for integrating mental health services into primary healthcare and a common suggestion was enhancing the training of family physicians in mental health. This corroborate the findings of Oseni et al that almost all the physicians studied said the medical education sessions they had on mental health enhanced their knowledge of mental health, and many said the sessions enhanced their abilities and preparedness to attend to patients with mental disorders [ 26 ]. Similarly, The Health Action for Psychiatric Problems In Nigeria including Epilepsy and SubstanceS (HAPPINESS) project in Imo State enhanced trainees’ diagnostic and treatment abilities, mental health awareness, and empathy towards patients [ 21 ]. Telemedicine for mental healthcare as an emerging platform for general healthcare delivery allows physicians to deliver counselling services to patients in any part of the world in real time [ 27 ]. Healthcare professionals can use telehealth and virtual services to provide mental healthcare as highlighted in this study. There are substantially supporting evidences from various studies to support the use of telemedicine interventions in patients with mental disorders although with its attendant pros and cons as noted by participants in this study [ 25 – 27 ]. Although, there are challenges to its use as highlighted in most studies, there are consistent evidence of the feasibility of this modality of care and its acceptance by its intended users, as well as uniform indication of improvement case and quality of life among patients across a broad range of demographic and diagnostic groups [ 27 , 28 ]. Technology with its continuous advancement has great potential to transform Nigeria's overwhelmed mental healthcare landscape [ 20 ]. In a nation like Nigeria, where mental health services are scarce and health gaps and disparities abound, the value of mental health awareness and realistic health policies cannot be overstated [ 29 ]. There is still a significant lack of awareness about mental health issues in Nigeria. Stigma and misconceptions about mental illness are prevalent, and many people are reluctant to seek help due to fear of being labeled as "mad" [ 30 , 31 ]. Hence, the need for increased public awareness of mental health issues as noted in this study. Poor knowledge of causation, negative views of mental illness and beliefs that people with mental illness are dangerous because of their violent behaviour are causality factors. Additionally, the government's lack of proactive measures in addressing mental health issues as identified by the participants can be addressed by a strong and functional mental health system governance (HSG) structure which should translate into a more efficient, integrated, accessible and affordable mental health care services for the generality of Nigerians and result in a decrease in the treatment gap for mental disorders [ 32 ]. Integrating mental health services into primary health care (PHC) is the most viable way of closing the treatment gap and ensuring that people get the mental health care they need [ 3 , 16 ]. The importance of collaboration between primary healthcare centers and tertiary facilities with mental health specialists was stated by interviewees. They shared experiences of referring patients to specialists when their conditions exceeded the capacity of primary care providers. Such collaborations, they suggested, could reduce stigmatization and cultural barriers to mental healthcare. The interviewees also advocated for a holistic approach in primary care, integrating mental health into the scope of family physicians' work. This is similar to the factors identified by Wakila et al which included (a) team collaboration with an adequate record system that is connected with primary care and mental health services (b) improved training and recruitment of specialized and other allied health workers (c) the use of stepped-care model (screening, therapeutic interventions, referrals to higher levels of care) (d) the presence of communication between the various services and (e) patient and provider education opportunities to increase patient awareness and screening [ 16 ]. The integration of a psychosocial model into family medicine was also seen as a foundational step toward this goal. CONCLUSION Overall, family physicians have a vital role to play in the successful implementation of the mhGAP in Nigeria, demonstrating their understanding of the significance of this vital tool for effective mental health care delivery in the country. Areas highlighted to enhance this outcome were; 1) Need for training: There is a need for increased training and education on the mhGAP for physicians in Nigeria, 2) Improved access to resources: Efforts should be made to improve access to resources, such as the internet, to increase knowledge hence the awareness and implementation of the mhGAP and 3) Increased awareness: Raising awareness of the mhGAP among physicians in Nigeria is crucial for improving mental health care delivery and integrating mental health services into primary care. Recommendations Based on the findings of this study, we recommend comprehensive mhGAP training sessions for family physicians, focusing on practical application. There should be launching of stigma reduction campaigns targeting both the public and healthcare professionals. Adequate integration of mental health services into primary care through collaborative models and clear referral pathways are also highly recommended. We also advocate for policy changes and resource allocation to address systemic barriers like time constraints and inadequate infrastructure. Further research is also needed to evaluate the effectiveness of the above recommendations. Abbreviations PCP: Primary care physicians PHC: Primary health care FP: Family physician mhGAP-IG: Mental health gap action plan – intervention guide Declarations Acknowledgements The authors wish to thank all the participants for partaking in the study. Authors’ Contributions ATO conceived and designed the study, approved the design and implementation, coordinated and supervised data collection, and drafted the initial Article. AWA contributed to the study design and was responsible for data collection. OOA contributed to study design and data collection. AOA coordinated and supervised data collection. OAN supervised data collection. AO contributed to the study design and participated in the data collection. OEJ contributed to the study design and data collection. AAJ approved the design and implementation of the study and coordinated and supervised data collection. OAT was the study statistician and created and managed the database. ATO drafted the initial Article with input from AWA. All authors critically reviewed and revised the draft. Funding The authors received no funding for the study. Availability of data and materials All data generated or analyzed during this study are included in this published article. Ethics approval and consent to participate : Ethical approval was obtained from the National Health Research Committee, Nigeria. Approval was also sought from the management of the selected training centres. Confidentiality was ensured throughout the study period as all the interview records were passworded and only the researchers had access. Also, anonymity was maintained with the use of codes and pseudonyms. A written consent was read and explained to each participant and it was made clear to them that consent could be withdrawn at any time even if previously given. The participants provided informed consent to participate. The authors confirm that all study procedures were performed in accordance with relevant guidelines and regulations including the Declaration of Helsinki. Consent for publication: Not applicable. Conflict of interest: Authors declare no conflict of interest. Clinical Trial Number: Not applicable. References James SL, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392(10159):1789-1858. Kessler RC, Aguilar-Gaxiola S, Alonso J, Chatterji S, Lee S, Ormel J, et al. The global burden of mental disorders: an update from the WHO World Mental Health (WMH) surveys. Epidemiol Psychiatr Soc. 2009;18(1):23-33. Gureje O, Abdulmalik J, Kola L, Musa E, Yasamy MT, Adebayo KJBhsr. Integrating mental health into primary care in Nigeria: report of a demonstration project using the mental health gap action programme intervention guide. BMC Health Serv Res. 2015;15:242. Ojagbemi A, Daley S, Kola L, Taylor-Salisbury T, Feeney Y, Makhmud A, et al. Perception of providers on use of the WHO mental health Gap Action Programme-Intervention Guide (mhGAP-IG) electronic version and smartphone-based clinical guidance in Nigerian primary care settings. BMC Prim Care 2022;23(1):264. Funk M, Ivbirajo G. World Health Organization, World Organization of Family Doctors (WONCA). Integrating mental health into primary care: a global perspective: World Health Organization; 2008. Keynejad RC, Dua T, Barbui C, Thornicroft G. WHO Mental Health Gap Action Programme (mhGAP) Intervention Guide: a systematic review of evidence from low and middle-income countries. Evid Based Ment Health 2017;21(1):30-34. Iheanacho T. Integrating mental health into primary care: Evaluating the Health Action for Psychiatric Problems In Nigeria including Epilepsy and SubstanceS (HAPPINESS) pilot project. Research Square 2021;1-31 Keynejad RC, Spagnolo J, Thornicroft GJBMH. WHO mental health gap action programme (mhGAP) intervention guide: updated systematic review on evidence and impact. Evid Based Ment Health 2021;24(3):124-130. Wakida EK, Akena D, Okello ES, Kinengyere A, Kamoga R, Mindra A, et al. Barriers and facilitators to the integration of mental health services into primary health care: a systematic review protocol. Syst Rev. 2017;6(1):171. Abiodun OJIJoSP. Knowledge and attitude concerning mental health of primary health care workers in Nigeria. Int J Soc Psyhiatry 1991;37(2):113-20. Adebowale T, Umukoro OL, Gater R, Akinhanmi A, Ogunlesi A, Helme C, et al. Evaluation of a mental health training course for primary health care workers in Ogun State, South West, Nigeria. J Psychiatry 2014;17(5):14-25. Ali A, Chakraborty N. Mental Health Gap Action Programme training in Nigeria: reflections for progressive learning among primary care workers. BJPsych Int 2022;19(2):41-44. Al-Uzri M, Al-Taiar H, Abdulghani EA, Abbas YA, Suleman MJBI. Impact of mhGAP-IG training on primary care physicians’ knowledge of mental, neurological and substance use disorders in Iraq. BJPsych Int 2024;21(1):14-16. Hughes P, Hijazi Z, Saeed KJBI. Improving access to mental healthcare for displaced Syrians: case studies from Syria, Iraq and Turkey. BJPsych Int 2016;13(4):84-86. Reiss M. Primary Care Physician (PCP) Treatment of Mental Illness: Bridging the Knowledge Gap: University of Hartford; 2017. Wakida EK, Talib ZM, Akena D, Okello ES, Kinengyere A, Mindra A, et al. Barriers and facilitators to the integration of mental health services into primary health care: a systematic review. Syst Rev. 2018;7:211. Abera M, Tesfaye M, Belachew T, Hanlon C. Perceived challenges and opportunities arising from the integration of mental health into primary care: a cross-sectional survey of primary health care workers in south-west Ethiopia. BMC Health Serv Res. 2014;14:113. Petersen I, Ssebunnya J, Bhana A, Baillie K, systems MRPCnvcJIjomh. Lessons from case studies of integrating mental health into primary health care in South Africa and Uganda. Int J Ment Health Syst. 2011;5:8. How M. mhGAP Implementation in Edawu, Nigeria. Mental Health Innovation Network. Ugwu NF, Onayinka TS, Sanni KT. Exploring Innovative Digital Resources and Models for Bridging Mental Healthcare Gap in Nigeria. UNIZIK Journal of Educationla Research and Policy Studies. 2024;17(1):112-131. Chu C, Roxas N, Aguocha CM, Nwefoh E, Wang K, Dike C, et al. Integrating mental health into primary care: evaluation of the Health Action for Psychiatric Problems In Nigeria including Epilepsy and SubstanceS (HAPPINESS) pilot project. BMC Health Serv Res. 2022;22(1):333. Hinton L, Franz CE, Reddy G, Flores Y, Kravitz RL, Barker JCJJogim. Practice constraints, behavioral problems, and dementia care: primary care physicians’ perspectives. J Gen Intern Med. 2007;22(11):1487-92. Petersen I, Ssebunnya J, Bhana A, Baillie K, Mha PPRPC. Lessons from case studies of integrating mental health into primary health care in South Africa and Uganda. International Journal of Mental Health Systems. 2011;5(1):8. Bhana A, Petersen I, Baillie KL, Flisher AJ. Implementing the World Health Report 2001 recommendations for integrating mental health into primary health care: a situation analysis of three African countries: Ghana, South Africa and Uganda. Int Rev Psychiatry. 2010;22(6):599-610. Kane JC, Adaku A, Nakku J, Odokonyero R, Okello J, Musisi S, et al. Challenges for the implementation of World Health Organization guidelines for acute stress, PTSD, and bereavement: a qualitative study in Uganda. Implementation Sci. 2015;11:36. Oseni TIA, Mensah-Bonsu M, Damagun FM, Salam TO, Sonny KJ, Opare-Lokko EBA, et al. Ability and Preparedness of Family Physicians to Recognise and Treat Adolescent Mental Health Disorders in Nigeria and Ghana. Health Serv Insights 2023;16:11786329231166366. Adepoju P. Africa turns to telemedicine to close mental health gap. Lancet Digit Health. 2020;2(11):e571-e572. Bashshur RL, Shannon GW, Bashshur N, Yellowlees PMJT, e-Health. The empirical evidence for telemedicine interventions in mental disorders. Telemed J E Health. 2016;22(2):87-113. Ajike PT, Ariyo EA, Ariyo AM, Adubi KJPIftB, Sciences B. Emerging adults’ awareness and perceptions of mental health problems and services in Nigeria. Int Rev Psychiatry. 2022;9(1):44-8. Corrigan PW, Druss BG, Perlick DAJPSitPI. The impact of mental illness stigma on seeking and participating in mental health care. Psychol Sci Public Interest. 2014;15(2):37-70. Gureje O, Lasebikan VO, Ephraim-Oluwanuga O, Olley BO, Kola LJTBJoP. Community study of knowledge of and attitude to mental illness in Nigeria. Br J Psychiatry 2005;186(5):436-41. Abdulmalik J, Kola L, Gureje OJGMH. Mental health system governance in Nigeria: challenges, opportunities and strategies for improvement. Glob Ment Health (Camb). 2016;3:e9. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6001960","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":443381876,"identity":"8e958ec9-a71a-4617-ba9a-aaee59f61683","order_by":0,"name":"Thomas Olumide Adeleke","email":"","orcid":"","institution":"Bowen University Teaching Hospital, Iwo","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"Olumide","lastName":"Adeleke","suffix":""},{"id":443381877,"identity":"56c8f095-0c5b-4870-b71d-56ff771a5414","order_by":1,"name":"Wulaimat Abimbolanle Adekunle","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABE0lEQVRIiWNgGAWjYFCCBGYgYQHEzA0MCUCKHyxYQFCLBBAzgrVISDaABA2I1QJiGRwAUXi08LcnHzbm3SEhZ3AjsfHDwxy7OuPzqxM/PDBgkOcXO4BVi8SZZ8nJvGckjIFamiUStyVLmN14u1kC6DDDmbMTsFtzI8f4MG8bUPGNxAYgyQzUcnYDSEuCwW3sWuRv5H8GaakHamn+kbitXsJ4xtnNP/BpMbiRw5wM1JJgdiMRZNdhCQP+3m14bTE888zYcG6bhOH+Mw/bLBK3HZeccYN3m0WCgQROv8gdT34s8bbNRl4SGHQ3f26r5ufvP7v55o8KG3l+aRzexwQSYJUSxCoHAf4DpKgeBaNgFIyCEQAATPtjhbOi2VIAAAAASUVORK5CYII=","orcid":"","institution":"Jericho Specialist Hospital, Ibadan","correspondingAuthor":true,"prefix":"","firstName":"Wulaimat","middleName":"Abimbolanle","lastName":"Adekunle","suffix":""},{"id":443381878,"identity":"3fc60f25-9db6-42ed-bb37-7ab04918a0b3","order_by":2,"name":"Oludaisi Adeshina Oduniyi","email":"","orcid":"","institution":"Lagos State University Teaching Hospital, Lagos","correspondingAuthor":false,"prefix":"","firstName":"Oludaisi","middleName":"Adeshina","lastName":"Oduniyi","suffix":""},{"id":443381879,"identity":"31cf2f2c-b744-4b14-9426-4d6fbbccec42","order_by":3,"name":"Akeem Opeyemi Akinbode","email":"","orcid":"","institution":"Federal Teaching Hospital, Birnin-Kebbi","correspondingAuthor":false,"prefix":"","firstName":"Akeem","middleName":"Opeyemi","lastName":"Akinbode","suffix":""},{"id":443381880,"identity":"43062dcb-0c8b-4e9a-b7b1-24b6beef38b8","order_by":4,"name":"Alarape Naomi Oluwasanya","email":"","orcid":"","institution":"Olabisi Onabanjo University Teaching Hospital, Sagamu","correspondingAuthor":false,"prefix":"","firstName":"Alarape","middleName":"Naomi","lastName":"Oluwasanya","suffix":""},{"id":443381881,"identity":"8662409f-4e0e-479f-aa13-1d9f8597e183","order_by":5,"name":"Omorovbiye Aibangbee","email":"","orcid":"","institution":"General Hospital, Otu Jeremi","correspondingAuthor":false,"prefix":"","firstName":"Omorovbiye","middleName":"","lastName":"Aibangbee","suffix":""},{"id":443381882,"identity":"f8f27f77-494e-4581-9506-c23979ddfd21","order_by":6,"name":"Eloho Joy Orji","email":"","orcid":"","institution":"Federal Medical Centre, Owo","correspondingAuthor":false,"prefix":"","firstName":"Eloho","middleName":"Joy","lastName":"Orji","suffix":""},{"id":443381883,"identity":"a82d3118-dadf-41f1-9172-3e0d456f0cad","order_by":7,"name":"Aderemi Temitayo Olabode","email":"","orcid":"","institution":"Fountain University, Osogbo","correspondingAuthor":false,"prefix":"","firstName":"Aderemi","middleName":"Temitayo","lastName":"Olabode","suffix":""},{"id":443381884,"identity":"fc82cc72-99a1-4410-af49-309d892d322e","order_by":8,"name":"Adekunle Joseph Ariba","email":"","orcid":"","institution":"Olabisi Onabanjo University Teaching Hospital, Sagamu","correspondingAuthor":false,"prefix":"","firstName":"Adekunle","middleName":"Joseph","lastName":"Ariba","suffix":""}],"badges":[],"createdAt":"2025-02-10 20:23:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6001960/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6001960/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82097582,"identity":"2ab1d34f-a8d1-4a08-aad5-841c2d7e7504","added_by":"auto","created_at":"2025-05-06 17:53:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":169081,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA chart showing the interviewees’ responses on the use of WHO Guide on MHS Treatment Support\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6001960/v1/9a4b487d723a7819585388fa.png"},{"id":82097616,"identity":"edccdc6c-cb31-4192-a534-49e63706ae69","added_by":"auto","created_at":"2025-05-06 17:53:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":255889,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA chart illustrating the innovative ways of integration of MHS into PHCs suggested by the interviewees.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6001960/v1/13434fd4546d43efd00706f2.png"},{"id":82098534,"identity":"f55ceb3c-ff5e-4bd3-93ed-5b3ba146364f","added_by":"auto","created_at":"2025-05-06 18:09:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1418170,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6001960/v1/7f02fe83-2841-460f-9dd9-d66155ad5c14.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eFamily Physicians' Experience of the WHO Mental Health Gap Action Programme in Nigeria: A qualitative enquiry\u003c/p\u003e","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eMental health service provision is one of the significant global health issues gaining attention with nearly 90% of untreated cases of mental health conditions residing in low- and middle-income countries (LMICs) where 80% of people have been reported to battle with one case of mental health or the other [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Evidence from the World Mental Health Surveys suggested that in Nigeria, less than 1% of persons with anxiety disorders and 6% of those with mood disorders made any treatment contact in the year of the illness [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The majority of Nigerians who sought treatment did so at primary or general healthcare settings where the service provision is nearly unavailable [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecognizing this critical gap, the World Health Organization (WHO) launched the Mental Health Gap Action Programme (mhGAP) in 2008 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This initiative strives to expand and improve mental health services in LMICs. A key component of mhGAP is the mhGAP Intervention Guide (IG), released in 2010 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The IG aims to integrate mental health care into primary care and community settings by equipping non-specialist healthcare providers with the necessary tools, training, and support to deliver evidence-based interventions. The focus is on priority mental, neurological, and substance use (MNS) disorders as defined by the WHO for LMICs.\u003c/p\u003e \u003cp\u003eThe mhGAP-IG has been adopted in over 100 countries, including Nigeria, and has demonstrated effectiveness in delivering evidence-based mental health services within primary healthcare systems in resource-constrained settings [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The core objective is to enhance the capacity of non-specialists in the identification, treatment, and management of MNS conditions through a model of stepped care and collaborative task-sharing. The mhGAP-IG covers a range of modules, including introductory material, essential care practices, and specific guidance on conditions such as depression, psychosis/mania, epilepsy, child and adolescent mental health, dementia, substance use disorders, self-harm/suicide, and other significant mental health complaints. While mhGAP doesn't have dedicated anti-stigma modules, it emphasizes the importance of using non-stigmatizing language, demonstrating empathy, and promoting community awareness about mental illness. Evidence suggests that mhGAP training itself can contribute to reducing stigma among trainees.\u003c/p\u003e \u003cp\u003eFamily physicians, as primary care physicians are crucial in providing effective healthcare at first contact. Beyond offering comprehensive and continuous care for various health issues, they must also be equipped to facilitate timely referrals to specialized care when necessary. While mhGAP-IG implementation has been evaluated in numerous contexts, a comprehensive review of 162 studies by Keynejad and colleagues highlighted the need for further research on its implementation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Therefore, this study aimed to investigate the awareness and engagement of family physicians in implementing mental health interventions within the framework of the mhGAP. The study also sought to identify factors that either facilitate or impede their involvement, contributing to a better understanding of how to bridge the mental health action gap.\u003c/p\u003e\n\u003ch3\u003eAwareness levels of mhGAP in Nigeria\u003c/h3\u003e\n\u003cp\u003eMental health awareness in Nigeria is a growing concern, with a significant gap between the demand for mental health services and the available resources. Research has shown that primary care workers in Nigeria lack the necessary training and support to provide adequate mental health care [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The Mental Health Gap Action Programme (mhGAP) has been implemented in Nigeria to address this gap. The programme provides training for primary care workers on mental health care, with a focus on community-based care. Physicians in Nigeria are involved in mhGAP, primarily through training and capacity building, clinical supervision and mentorship, program evaluation and monitoring, policy development and advocacy, and community engagement and awareness [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFamily physicians\u0026rsquo; awareness levels of the mhGAP in Nigeria are crucial for effective mental health care delivery. Physicians' awareness levels of the Mental Health Gap Action Programme (mhGAP) in Nigeria varies. A study done in Nigeria to assess knowledge and attitude towards mental health among primary health care workers reported that knowledge of PHC workers about psychopharmacology was low. Most of them reported negative attitude towards mental illness [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eFactors Influencing Awareness\u003c/h2\u003e \u003cp\u003eTraining and education: Research has shown that primary care workers in Nigeria lack the necessary training and support to provide adequate mental health care [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Physicians who received training on the mhGAP were more likely to be aware of the programme [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A study found that primary care workers need further training to manage the mental health needs of their patients. This study also identified a need for peer support and supervision from experienced clinicians [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. An overall 25% improvement in knowledge about MNS disorders following mhGAP-IG training in Iraq shows the effectiveness of training and education [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Hughes et al also reported that in-person training of 52 participants, 25 of whom were primary care physicians, with country-specific and needs-led mhGAP-IG training, showed an 8.5% improvement in post-training test scores [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eProfessional experience: More experienced physicians were more likely to be aware of the mhGAP [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccess to resources: The key strategy for increasing awareness is providing training programmes for primary care physicians on mhGAP-IG, with a focus on community-based care. This will help inform PCP on mhGAP and thus increase their involvement and implementation of its use. Physicians with access to the internet and other resources were more likely to be aware of the mhGAP [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Reiss et al found that participants improved their knowledge and skills from training on the mhGAP online course [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePhysicians’ involvement levels in the implementation of the mental health gap action plan\u003c/h3\u003e\n\u003cp\u003ePhysicians' involvement in the Mental Health Gap Action Programme (mhGAP) in Nigeria is crucial for effective mental health care delivery. The involvement levels of physician on mental health action gap in Nigeria are a pressing concern. This gap is further exacerbated by the limited availability of mental health professionals, particularly in rural areas.\u003c/p\u003e \u003cp\u003eInadequate training of primary care providers, which results in poor mental health condition recognition and treatment, lack of support and supervision for their work, an uncoordinated referral pathway through the various health service tiers, and policy neglect\u0026mdash;which frequently takes the form of inadequate funding, irregular medication supply for MNS conditions, and weak health systems\u0026mdash;are the reasons for this gap [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Additionally, Wakida et al. identified the following barriers: (a) a lack of mental health care in-service training, combined with no formal discussions about mental health disorders with higher level supervisors; (b) a lack of coordination between mental health specialists and general health workers; and (c) a lack of support from the district medical team [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Majority of healthcare providers 236 (58.7%) in Ethiopia had stated that there was poor implementation level of mental health integration [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The experience from other SSA countries have also raised concerns about challenges of integration such as poor policy implementation, insufficient numbers of mental health professionals to drive and support the process, poor community engagement and mobilization, and the non-availability of medications [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eInnovative ways of Integration of MHS into PHC care (Key Physicians’ Involvement Levels)\u003c/h3\u003e\n\u003cp\u003eTo bridge this gap, it is essential to increase awareness and education about mental health issues in Nigeria. This can be achieved through community-based initiatives, public awareness campaigns, and training programs for primary care workers.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMental Health Gap Action Programme (mhGAP) training and supervision\u003c/b\u003e: This program provides competency-based training for primary care workers, focusing on mental health care. The mhGAP-IG and a carefully monitored cascade-training methodology make it possible to expand mental health services in Nigerian primary care settings. This teaching approach is practical, economical, and promising, particularly in environments with a shortage of experts [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Primary care workers require more comprehensive training and ongoing support to effectively address mental health issues with the use of WHO guide in MHS treatment support. Physicians should act as Master Trainers, providing training and supervision to non-physician primary care workers. A pilot project in Osun State, Nigeria demonstrated the feasibility of scaling up mental health services through a cascade training model, where Master Trainers trained Facilitators, who then trained primary care workers [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The following obstacles were noted: (a) insufficient mental health care in-service training, in addition to the absence of formal conversations regarding mental health disorders with higher-level supervisors; (b) insufficient coordination between mental health specialists and general health workers; and (c) insufficient assistance from the district medical team [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eClinical Support\u003c/strong\u003e \u003cp\u003eMental illness is often stigmatized, leading to delayed or inadequate treatment [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Physicians should offer clinical support to patients and guidance to primary care workers, ensuring conformity to the mhGAP-IG and ease of referral to mental health specialist. Mental health facilities and resources are scarce, particularly in rural areas. Limited resources for mental health treatment provision (eg medicines and staff) in remote areas like Edawu, Nigeria can create challenges in implementing mhGAP treatment plans in the long run [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Hence, the need for physicians to be more involved in the implementation of mhGAP-IG and to maximize the use of the available scarce resources. Encouraging peer learning and support among primary care workers can help bridge the mental health action gap.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eMonitoring and Evaluation\u003c/b\u003e: The purpose of the monitoring exercise was to encourage integrity in the application of the mhGAP standards and to reinforce skills learnt during training. In order to determine the training program's efficacy and pinpoint areas for development, doctors should take part in monitoring and evaluation activities. The monitoring activities may include: 1) going over clinical notes to make sure that all clinical encounters are properly documented; 2) having a supervisor observe the health providers' clinical assessment of patients using the mhGAP-IG in a non-intrusive manner; and 3) holding debriefing meetings with the clinical staff to go over the observations or notes made in (1) and (2) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Evaluations can be carried out in an organised manner and include comprehensive details regarding patient flow, clinical documentation, fidelity, and the referral process.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDigital solutions\u003c/strong\u003e \u003cp\u003eLeveraging digital platforms and telemedicine can increase access to mental health services, particularly in rural areas [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e \u003cstrong\u003eStudy Design\u003c/strong\u003e \u003cp\u003eA descriptive cross-sectional qualitative study using key-informant interview semi-structured questionnaire to obtain information from 23 Family Physicians across the country (cutting across the six geopolitical zones).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStudy Population\u003c/strong\u003e \u003cp\u003e The study was conducted among specialist primary care physicians (Family Physician) distributed across all the six geopolitical zones in Nigeria. Family Physicians (FPs) treat all patients irrespective of the age, sex or disease entity. Also, FPs co-ordinate care of patients by interacting with other specialist including mental health physicians. Thus, knowledge of their awareness and involvement levels in mhGAP implementation will help mental health service delivery. FPs are in strategic position to give their perception on the situation of mental health services in the country. The cadres of the PCPs used were those who are specialist Family Physicians either as consultants or specialist registrars who were in active service. Exclusion criteria were sick physicians and retired PCPs.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStudy Site\u003c/strong\u003e \u003cp\u003ePrimary care physicians are first contact doctors encountered at different levels of health care delivery centers. A virtual/on-phone location was utilized for data collection during the interview.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSampling Size\u003c/strong\u003e \u003cp\u003eAn a priori estimation was made, with a purposive sampling size of 24 was used. Although one interviewee could not complete the interviewee due to an emergency midway, indicating a response rate of 95.8%.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStudy Procedure\u003c/strong\u003e \u003cp\u003eA stratified sampling technique was used to select PCPs from the six (6) geo-political zones of the country. From each zone, two (2) health facilities were selected from a list of the health facilities in each zone using a simple random method. From each health facility, two (2) interviewees were selected by balloting / picking at random from a list of PCPs obtained from the heads of the Family Medicine units.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData Collection\u003c/strong\u003e \u003cp\u003eA semi-structured questionnaire to guide the interview was used. The questionnaire consisted of the participant\u0026rsquo;s socio-demographic data and their knowledge and involvement in mhGAP implementation in Nigeria was obtained. Probes were used for clarification and to obtain in-depth information as needed. The interview guide was piloted among three (3) facilities outside the selected training centres. The interview guide was administered to three participants who met the inclusion criteria and their responses were used to further improve the guide before utilizing it for the main study. English language was the medium of communication throughout the study period.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eParticipants were informed of the study via message or phone call and their consent obtained, then the interview date, time and mode was fixed. A virtual in-depth interview was conducted for each consenting participant after information was given and consent sought. The interviews were audio-recorded and data were stored in a password protected device.\u003c/p\u003e \u003cp\u003eTo ensure methodological rigour, the following steps was taken: The credibility of this study was ensured through sampling, piloting and member checking. Transferability was ensured through the provision of a clear description of the participants\u0026rsquo; characteristics, settings of the study and methodology. The transcriptions were also stored to serve as references. Dependability was ensured through detailed descriptions of the methodologies to enable others to repeat the study if needed. Data collection was guided by the principle of data saturation which ensured that data collection continued until there was no new themes or insights emerging from the analysis. The a priori was adopted from the study by Chu et al on \u0026ldquo;Integrating Mental Health into primary care: evaluation of the Health Action for psychiatric problems in Nigeria\u0026rdquo; [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData Analysis\u003c/strong\u003e \u003cp\u003eData were transcribed using a thematic analysis. This study adopted a participatory action research (PAR) design where family physicians and the interviewer actively collaborated at all the stages of the interview. Recorded interviews were transcribed verbatim and typeset for ease of analysis as transcripts were reviewed against audio files seeking clarifications from participants when necessary. Adequate data storage plan was adopted by ensuring that the transcribed data was backed up on an external drive for future use of at least five (5) years. Content analysis was used for analyzing the data and presented using thematic representation of the findings, with themes developed and merged into categories. Responses were coded and entered into a spreadsheet, and relationships within the data were examined. New themes and categories were added gradually as obtained from the recordings until all transcripts were analyzed. Conclusions were drawn to depict the participants' perspectives, with all the researchers meeting to ensure agreement on the representation of views.\u003c/p\u003e \u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThis qualitative study's findings are based on twenty-four (24) in-depth interviews with ten female and fourteen male family physicians from the six (6) geo-political zones of the country\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eExperience in Dealing with Mental Health Issues\u003c/h2\u003e \u003cp\u003ePhysicians encounter various challenges when dealing with mental health issues, which are often seen as unique and complex cases. Respondents reported that managing these cases is both challenging and time-consuming. One major issue highlighted was the unavailability of mental health medications, which are often not stocked in pharmacies, forcing patients to seek alternatives at nearby psychiatric hospitals. Additionally, self-medication and poor follow-up were identified as significant concerns, with patients frequently unwilling to continue treatment or accept diagnoses.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026rdquo;Some of the barriers we have are actually the availability of drugs, because they are not cases we often see most times; the pharmacists stocked those drugs as in mental health medications. Because the new psychiatry hospital is also close to us, sometimes they will have to go over there and purchase some of the drugs, so that we can stabilize patients. access to medications is one of the major issues that we have; accepting diagnosis is also another issue, as some of the patients or the relatives may not want to accept that those diagnoses are true and then, embark on self-medication; follow up is also a challenge, but most times when we are able to counsel properly, since we have a liaising center in our facilities, they sometimes agree to come for follow up in our facilities.\u0026rsquo;\u0026rsquo;\u003c/em\u003e(Female, Consultant, Ogun State).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eRespondents also pointed out that managing mental health conditions is highly time-consuming and requires substantial energy, as family involvement is often necessary for effective treatment. Results are gradual, and progress can be slow.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;it's really time-consuming and it needs a lot of energy in terms of you having to involve the family or supporter. It's something that you can't just do on your own so it's really challenging. Sometimes I get results, but the results are very slow and gradual.\u0026rsquo;\u0026rsquo;\u003c/em\u003e (Female, Consultant, Edo State).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eUse of the WHO Guide in MHS Treatment Support\u003c/h3\u003e\n\u003cp\u003eResponses from interviewees reveal that they have limited familiarity and usage of the World Health Organization's Mental Health Gap Action Program Intervention Guide, which aims to integrate mental health into primary care. Many respondents expressed a lack of awareness or experience with the tool, with some stating that they have never used it or are only familiar with it in theory.\u003c/p\u003e \u003cp\u003eThe key points from the interviewees\u0026rsquo; responses as depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e include:\u003c/p\u003e\n\n\u003cdiv class=\"Heading\"\u003e\u003cb\u003eLack of Familiarity and Usage\u003c/b\u003e:\u003c/div\u003e \u003cp\u003eMultiple interviewees explicitly mentioned that they are not familiar with the WHO Intervention Guide or have never used it before. Some respondents remarked that they only have theoretical knowledge of it and have not put it into practice.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I\u0026rsquo;ve not used it before I know there's something by WHO but I've not really explored it.\u0026rdquo;\u003c/em\u003e (Male, Senior Registrar, Oyo State).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLimited Awareness\u003c/h2\u003e \u003cp\u003eSeveral participants acknowledge hearing about the tools but are not well-versed in their application or specific policies related to mental health. A few interviewees mentioned that they are hearing about the tools for the first time during the interview.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Well, I think it's just an awareness theme. I\u0026rsquo;m not sure, um \u0026hellip; well how do I put it now; well, maybe, also part of the curriculum. If it was part of the curriculum training I think I'll probably have seen it in some way so the integration will definitely be helpful at a given curriculum level. .. um of course on personal use and personal study there are a few others that wouldn't know when exactly the gap to by the WHO was initiated but because a few of us people are already so conversant so most people just tend to um get to use that so I think it's an awareness thing\u0026rdquo;\u003c/em\u003e (Male, Senior Registrar, Oyo State)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eChallenges in Implementation\u003c/h2\u003e \u003cp\u003eOne respondent suggests that the tools should be institutionalized and made more accessible at the primary care level, similar to other basic medical tools. Another participant highlights that while they may be aware of the tools, they rarely use them in practice.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;well probably because they are not really, as I said earlier, it depends on, if these things, if they are not institutionalized, for example, you have a primary care clinic. So, these materials should actually be part of the tools that are available to you. For example, just like you have your thermometer, I think that these tools should actually be handy. Maybe you print them, they are pasted on the wall, I mean, they are there, I leave them on the table. I mean, this is what I think, because these are really lacking.\u0026rdquo;\u003c/em\u003e (Male, Consultant, Ogun State).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePotential Benefits\u003c/h2\u003e \u003cp\u003eDespite the limited use, some respondents acknowledge that these tools could improve diagnosis, treatment, and referral processes if they were more widely implemented and used correctly. The overall sentiment indicates a gap between the availability of the WHO guide tools and their practical application in community-based and primary care settings. This highlights the need for more widespread training, awareness, and integration of these tools to enhance mental health care at the primary level.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Well, the impact, if it's used well, it's going to help in making diagnosis. And it will help in classifying patients to a degree of severity.\u0026rdquo;\u003c/em\u003e (Male, Consultant, Ogun State)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eInnovative ways of Integration of MHS into PHC care\u003c/h2\u003e \u003cp\u003eThe interviewees discussed various innovative strategies for integrating mental health services into primary healthcare. Their suggestions are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. A common suggestion was enhancing the training of family physicians in mental health. They proposed that, just as family physicians receive postings in other specialties, they should also spend more time in mental health rotations. This would allow them to gain a deeper understanding of psychiatric issues, ultimately enabling them to manage common mental health conditions effectively at the primary care level.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;the issue is to use the modular training at the primary care level, and to allow more people to be involved in mental health training. And both colleges now that train family physicians should inculcate mental health posting. So, this posting should be looked at regularly, and there may be need to review curriculum from time to time\u0026rdquo;\u003c/em\u003e (Male, Consultant, Kano State).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother approach highlighted was the integration of telemedicine and virtual platforms for mental health consultations. This method would facilitate communication between patients and healthcare providers, allowing for case discussions and experience-sharing among colleagues. However, interviewees noted challenges such as inadequate technical infrastructure, insufficient manpower, and poor telecommunications systems in Nigeria, which could hinder the effectiveness of telemedicine.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;well maybe just as you're having this zoom now; okay that is the telemedicine and communication with the patients and not just update but gatherings where we can share and communicate with the patients and with colleagues, and we can share cases and experiences together; it may help us to be able to take care of the patients more or the clients more you know.\u0026rdquo;\u003c/em\u003e (Female, Consultant, Edo State)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eInterviewees also emphasized the need for increased public awareness of mental health issues. They pointed out that many people lack knowledge about mental health conditions and their risk factors. Additionally, they criticized the government's lack of proactive measures in addressing mental health and drug addiction, highlighting the insufficient number of psychiatric specialists and the poor funding of mental health services\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The knowledge and awareness of our people in mental health as regards public awareness is still very much lacking. We need awareness in that regard because a lot of people do not really know what are the issues that can predispose someone to mental health.\u003c/em\u003e (Male, Specialist Registrar, Oyo State)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFurthermore, interviewees discussed the importance of collaboration between primary healthcare centers and tertiary facilities with mental health specialists. They shared experiences of referring patients to specialists when their conditions exceeded the capacity of primary care providers. Such collaborations, they suggested, could reduce stigmatization and cultural barriers to mental healthcare.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;So, we refer to the psychiatrist. So, we actually refer our patient to the psychiatrist. We don't have a non-psychiatrist like a clinical psychologist. We don't have that facility in my centre. So, we do our referral to the psychiatrist. And so far, we've been able to have a good rapport with the psychiatrist\u0026rdquo;.\u003c/em\u003e (Male, Consultant, Ogun State)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eLastly, the interviewees advocated for a holistic approach in primary care, integrating mental health into the scope of family physicians' work. This approach would involve expanding the family physician's role to include managing common mental health issues, particularly those frequently encountered in primary care, such as depression and other mood disorders. The integration of a psychosocial model into family medicine was also seen as a foundational step toward this goal.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;So, all we need to do is to kind of widen the scope of family physician and ensure that basic mental health issues are introduced into a family physician's scheme of work more especially in cases that are commonly encountered for example depression or mood disorders and maternal psychiatric conditions\u0026rdquo;.\u003c/em\u003e (Male, Specialist trainer, Oyo State).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study explored Family Physicians\u0026rsquo; awareness and involvement levels in the implementation of mental health interventions and identified facilitators and barriers to this engagement in order to contribute to the Mental Health Gap Action Programme. This study was conducted among family physicians in the six geopolitical zones of Nigeria.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eExperience in Dealing with Mental Health Issues\u003c/h2\u003e \u003cp\u003eThis study found that Family Physicians encounter different challenges when dealing with mental health issues, which are both challenging and time-consuming and is similar to the findings of a qualitative study of primary care physicians in California that reported physicians often feel challenged due to insufficient time, difficulty in accessing and communicating with specialists, low reimbursement, poor connections with community social service agencies, and lack of interdisciplinary teams [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Likewise, limited availability of psychotropic medication and specialist mental health personnel, were reported in Uganda as challenges that resulted in a referral bottleneck which is similar to our findings [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Furthermore, in the situational analysis report of three African countries by WHO, poor or uneven implementation of policy, inadequate access to essential drugs and lack of mental health specialists are some of the reasons that significant challenges remain in integrating mental health care into primary health care [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eUse of the WHO Guide in MHS Treatment Support\u003c/h2\u003e \u003cp\u003eMany respondents express a lack of awareness or experience with the tool, with some stating that they have never used it or are only familiar with it in theory. Similar to our findings is the report that inadequate training in the use of mental health screening tools and current evidence-based treatment were identified as reasons for non-usage of skills with regard to integration of mental health services into PHC [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This is corroborated by the findings that PCPs were unsatisfied with the level of knowledge they had in mental health [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Multiple interviewees explicitly mentioned that they are not familiar with the WHO Intervention Guide or have never used it before which is similar to some of our respondents\u0026rsquo; remarks that they only have theoretical knowledge of it and have not put it into practice.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimited Awareness: S\u003c/b\u003eeveral participants acknowledge hearing about the tools but are not well-versed in their application or specific policies related to mental health. A few interviewees mentioned that they are hearing about the tools for the first time during the interview\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eChallenges in Implementation\u003c/strong\u003e \u003cp\u003eOne respondent suggested that the tools should be institutionalized and made more accessible at the primary care level, similar to other basic medical tools. A participant highlights that while they may be aware of the tools, they rarely use them in practice due to lack of time. This is similar to the finding of a study on the evaluation of implementing mhGAP guidelines in Uganda which cited the lack of time for the addition of mental health evaluation to existing clinical work and a high level of ethno cultural diversity in patient populations as underlying barriers to adaptation and adoption [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003eIn LMIC, where specialists are few and often engrossed in the daily routine of providing care for the teeming persons in need, such specialists are hardly available to provide training for the large number of end users (primary care workers) who need to be so trained in order for effective impact to be made on service delivery.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePotential Benefits\u003c/strong\u003e \u003cp\u003eDespite the limited use, some respondents acknowledge that these tools could improve diagnosis, treatment, and referral processes if they were more widely implemented and used correctly. The overall sentiment indicates a gap between the availability of the WHO guide tools and their practical application in community-based and primary care settings. This highlights the need for more widespread training, awareness, and integration of these tools to enhance mental health care at the primary level.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eInnovative ways of Integration of MHS into PHC care\u003c/h2\u003e \u003cp\u003eInterviewees discussed various innovative strategies for integrating mental health services into primary healthcare and a common suggestion was enhancing the training of family physicians in mental health. This corroborate the findings of Oseni et al that almost all the physicians studied said the medical education sessions they had on mental health enhanced their knowledge of mental health, and many said the sessions enhanced their abilities and preparedness to attend to patients with mental disorders [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Similarly, The Health Action for Psychiatric Problems In Nigeria including Epilepsy and SubstanceS (HAPPINESS) project in Imo State enhanced trainees\u0026rsquo; diagnostic and treatment abilities, mental health awareness, and empathy towards patients [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTelemedicine for mental healthcare as an emerging platform for general healthcare delivery allows physicians to deliver counselling services to patients in any part of the world in real time [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Healthcare professionals can use telehealth and virtual services to provide mental healthcare as highlighted in this study. There are substantially supporting evidences from various studies to support the use of telemedicine interventions in patients with mental disorders although with its attendant pros and cons as noted by participants in this study [\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Although, there are challenges to its use as highlighted in most studies, there are consistent evidence of the feasibility of this modality of care and its acceptance by its intended users, as well as uniform indication of improvement case and quality of life among patients across a broad range of demographic and diagnostic groups [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Technology with its continuous advancement has great potential to transform Nigeria's overwhelmed mental healthcare landscape [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn a nation like Nigeria, where mental health services are scarce and health gaps and disparities abound, the value of mental health awareness and realistic health policies cannot be overstated [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. There is still a significant lack of awareness about mental health issues in Nigeria. Stigma and misconceptions about mental illness are prevalent, and many people are reluctant to seek help due to fear of being labeled as \"mad\" [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Hence, the need for increased public awareness of mental health issues as noted in this study. Poor knowledge of causation, negative views of mental illness and beliefs that people with mental illness are dangerous because of their violent behaviour are causality factors. Additionally, the government's lack of proactive measures in addressing mental health issues as identified by the participants can be addressed by a strong and functional mental health system governance (HSG) structure which should translate into a more efficient, integrated, accessible and affordable mental health care services for the generality of Nigerians and result in a decrease in the treatment gap for mental disorders [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIntegrating mental health services into primary health care (PHC) is the most viable way of closing the treatment gap and ensuring that people get the mental health care they need [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The importance of collaboration between primary healthcare centers and tertiary facilities with mental health specialists was stated by interviewees. They shared experiences of referring patients to specialists when their conditions exceeded the capacity of primary care providers. Such collaborations, they suggested, could reduce stigmatization and cultural barriers to mental healthcare.\u003c/p\u003e \u003cp\u003eThe interviewees also advocated for a holistic approach in primary care, integrating mental health into the scope of family physicians' work. This is similar to the factors identified by Wakila et al which included (a) team collaboration with an adequate record system that is connected with primary care and mental health services (b) improved training and recruitment of specialized and other allied health workers (c) the use of stepped-care model (screening, therapeutic interventions, referrals to higher levels of care) (d) the presence of communication between the various services and (e) patient and provider education opportunities to increase patient awareness and screening [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The integration of a psychosocial model into family medicine was also seen as a foundational step toward this goal.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eOverall, family physicians have a vital role to play in the successful implementation of the mhGAP in Nigeria, demonstrating their understanding of the significance of this vital tool for effective mental health care delivery in the country. Areas highlighted to enhance this outcome were; 1) Need for training: There is a need for increased training and education on the mhGAP for physicians in Nigeria, 2) Improved access to resources: Efforts should be made to improve access to resources, such as the internet, to increase knowledge hence the awareness and implementation of the mhGAP and 3) Increased awareness: Raising awareness of the mhGAP among physicians in Nigeria is crucial for improving mental health care delivery and integrating mental health services into primary care.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eRecommendations\u003c/strong\u003e \u003cp\u003eBased on the findings of this study, we recommend comprehensive mhGAP training sessions for family physicians, focusing on practical application. There should be launching of stigma reduction campaigns targeting both the public and healthcare professionals. Adequate integration of mental health services into primary care through collaborative models and clear referral pathways are also highly recommended. We also advocate for policy changes and resource allocation to address systemic barriers like time constraints and inadequate infrastructure. Further research is also needed to evaluate the effectiveness of the above recommendations.\u003c/p\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePCP: Primary care physicians\u003c/p\u003e\n\u003cp\u003ePHC: Primary health care\u003c/p\u003e\n\u003cp\u003eFP: Family physician\u003c/p\u003e\n\u003cp\u003emhGAP-IG: Mental health gap action plan \u0026ndash; intervention guide\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to thank all the participants for partaking in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eATO conceived and designed the study, approved the design and implementation, coordinated and supervised data collection, and drafted the initial Article. AWA contributed to the study design and was responsible for data collection. OOA contributed to study design and data collection. AOA coordinated and supervised data collection. OAN supervised data collection. AO contributed to the study design and participated in the data collection. OEJ contributed to the study design and data collection. AAJ approved the design and implementation of the study and coordinated and supervised data collection. OAT was the study statistician and created and managed the database. ATO drafted the initial Article with input from AWA. All authors critically reviewed and revised the draft.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no funding for the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Ethical approval was obtained from the National Health Research Committee, Nigeria. Approval was also sought from the management of the selected training centres. Confidentiality was ensured throughout the study period as all the interview records were passworded and only the researchers had access. Also, anonymity was maintained with the use of codes and pseudonyms. A written consent was read and explained to each participant and it was made clear to them that consent could be withdrawn at any time even if previously given. The participants provided informed consent to participate. The authors confirm that all study procedures were performed in accordance with relevant guidelines and regulations including the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003eAuthors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number:\u003c/strong\u003e Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eJames SL, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, et al. 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Research Square 2021;1-31\u003c/li\u003e\n\u003cli\u003eKeynejad RC, Spagnolo J, Thornicroft GJBMH. WHO mental health gap action programme (mhGAP) intervention guide: updated systematic review on evidence and impact. Evid Based Ment Health 2021;24(3):124-130.\u003c/li\u003e\n\u003cli\u003eWakida EK, Akena D, Okello ES, Kinengyere A, Kamoga R, Mindra A, et al. Barriers and facilitators to the integration of mental health services into primary health care: a systematic review protocol. Syst Rev. 2017;6(1):171.\u003c/li\u003e\n\u003cli\u003eAbiodun OJIJoSP. Knowledge and attitude concerning mental health of primary health care workers in Nigeria. Int J Soc Psyhiatry 1991;37(2):113-20.\u003c/li\u003e\n\u003cli\u003eAdebowale T, Umukoro OL, Gater R, Akinhanmi A, Ogunlesi A, Helme C, et al. Evaluation of a mental health training course for primary health care workers in Ogun State, South West, Nigeria. J Psychiatry 2014;17(5):14-25. \u003c/li\u003e\n\u003cli\u003eAli A, Chakraborty N. Mental Health Gap Action Programme training in Nigeria: reflections for progressive learning among primary care workers. BJPsych Int 2022;19(2):41-44.\u003c/li\u003e\n\u003cli\u003eAl-Uzri M, Al-Taiar H, Abdulghani EA, Abbas YA, Suleman MJBI. Impact of mhGAP-IG training on primary care physicians\u0026rsquo; knowledge of mental, neurological and substance use disorders in Iraq. BJPsych Int 2024;21(1):14-16.\u003c/li\u003e\n\u003cli\u003eHughes P, Hijazi Z, Saeed KJBI. Improving access to mental healthcare for displaced Syrians: case studies from Syria, Iraq and Turkey. BJPsych Int 2016;13(4):84-86.\u003c/li\u003e\n\u003cli\u003eReiss M. Primary Care Physician (PCP) Treatment of Mental Illness: Bridging the Knowledge Gap: University of Hartford; 2017.\u003c/li\u003e\n\u003cli\u003eWakida EK, Talib ZM, Akena D, Okello ES, Kinengyere A, Mindra A, et al. Barriers and facilitators to the integration of mental health services into primary health care: a systematic review. 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Integrating mental health into primary care: evaluation of the Health Action for Psychiatric Problems In Nigeria including Epilepsy and SubstanceS (HAPPINESS) pilot project. BMC Health Serv Res. 2022;22(1):333.\u003c/li\u003e\n\u003cli\u003eHinton L, Franz CE, Reddy G, Flores Y, Kravitz RL, Barker JCJJogim. Practice constraints, behavioral problems, and dementia care: primary care physicians\u0026rsquo; perspectives. J Gen Intern Med. 2007;22(11):1487-92.\u003c/li\u003e\n\u003cli\u003ePetersen I, Ssebunnya J, Bhana A, Baillie K, Mha PPRPC. Lessons from case studies of integrating mental health into primary health care in South Africa and Uganda. International Journal of Mental Health Systems. 2011;5(1):8.\u003c/li\u003e\n\u003cli\u003eBhana A, Petersen I, Baillie KL, Flisher AJ. Implementing the World Health Report 2001 recommendations for integrating mental health into primary health care: a situation analysis of three African countries: Ghana, South Africa and Uganda. Int Rev Psychiatry. 2010;22(6):599-610.\u003c/li\u003e\n\u003cli\u003eKane JC, Adaku A, Nakku J, Odokonyero R, Okello J, Musisi S, et al. Challenges for the implementation of World Health Organization guidelines for acute stress, PTSD, and bereavement: a qualitative study in Uganda. Implementation Sci. 2015;11:36.\u003c/li\u003e\n\u003cli\u003eOseni TIA, Mensah-Bonsu M, Damagun FM, Salam TO, Sonny KJ, Opare-Lokko EBA, et al. Ability and Preparedness of Family Physicians to Recognise and Treat Adolescent Mental Health Disorders in Nigeria and Ghana. Health Serv Insights 2023;16:11786329231166366.\u003c/li\u003e\n\u003cli\u003eAdepoju P. Africa turns to telemedicine to close mental health gap. Lancet Digit Health. 2020;2(11):e571-e572. \u003c/li\u003e\n\u003cli\u003eBashshur RL, Shannon GW, Bashshur N, Yellowlees PMJT, e-Health. The empirical evidence for telemedicine interventions in mental disorders. Telemed J E Health. 2016;22(2):87-113.\u003c/li\u003e\n\u003cli\u003eAjike PT, Ariyo EA, Ariyo AM, Adubi KJPIftB, Sciences B. Emerging adults\u0026rsquo; awareness and perceptions of mental health problems and services in Nigeria. Int Rev Psychiatry. 2022;9(1):44-8.\u003c/li\u003e\n\u003cli\u003eCorrigan PW, Druss BG, Perlick DAJPSitPI. The impact of mental illness stigma on seeking and participating in mental health care. Psychol Sci Public Interest. 2014;15(2):37-70.\u003c/li\u003e\n\u003cli\u003eGureje O, Lasebikan VO, Ephraim-Oluwanuga O, Olley BO, Kola LJTBJoP. Community study of knowledge of and attitude to mental illness in Nigeria. Br J Psychiatry 2005;186(5):436-41.\u003c/li\u003e\n\u003cli\u003eAbdulmalik J, Kola L, Gureje OJGMH. Mental health system governance in Nigeria: challenges, opportunities and strategies for improvement. Glob Ment Health (Camb). 2016;3:e9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-mental-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dimh","sideBox":"Learn more about [Discover Mental Health](https://www.springer.com/44192)","snPcode":"","submissionUrl":"","title":"Discover Mental Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mental health gap action programme (mhGAP), Primary care mental health, mental health integration, Family physicians, Nigeria","lastPublishedDoi":"10.21203/rs.3.rs-6001960/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6001960/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe World Health Organization\u0026rsquo;s Mental Health Gap Action Programme (mhGAP) intervention guide (IG), provides evidence-based guidance and tools for assessment and integrated management of priority disorders. It is aimed to bridge the mental health gap but this gap still persists, with significant disparities in care access and quality. Family physicians play a crucial role in addressing this gap, but their awareness and involvement levels in the implementation of mhGAP remain unclear. This study explored family physicians\u0026rsquo; awareness and involvement levels in the implementation of mental health service in Nigeria and also explored the perceived facilitators and barriers influencing their level of engagement in contributing to the \u0026ldquo;Mental Health Gap Action Programme\u0026rdquo;.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA descriptive cross-sectional qualitative study using key-informant interview semi-structured questionnaire to obtain information from 23 Family Physicians across the country (cutting across the six geopolitical zones). Responses were transcribed verbatim, typeset and coded inductively and analysed using content analysis process. The findings were presented using thematic representation (by identifying the key themes and patterns).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e Family physicians demonstrated varying awareness of mental health guidelines and interventions. Involvement levels ranged from minimal to proactive as there were no national unified guide. Facilitators to mhGAP involvement and implementation included training of physicians, patient relationships, and multidisciplinary collaboration while barriers included time constraints, stigma, and systemic gaps.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study reveals the varying levels of mhGAP awareness and involvement among Nigerian family physicians. While some are proactive, many show limited engagement. Training, patient relationships, and collaboration facilitate involvement, while time constraints, stigma, and systemic gaps hinder it. Targeted interventions are needed to bridge the mental health action gap.\u003c/p\u003e","manuscriptTitle":"Family Physicians' Experience of the WHO Mental Health Gap Action Programme in Nigeria: A qualitative enquiry","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 17:53:23","doi":"10.21203/rs.3.rs-6001960/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-22T16:39:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-15T15:30:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-15T12:09:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201240054497029766041204732812555873287","date":"2025-04-14T18:19:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"311829572836544517342894037682842146892","date":"2025-04-14T14:16:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-09T06:38:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"117121996225315748267670323225401346507","date":"2025-04-02T11:43:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-01T15:36:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-24T14:09:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-24T14:05:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Mental Health","date":"2025-02-10T20:19:20+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-mental-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dimh","sideBox":"Learn more about [Discover Mental Health](https://www.springer.com/44192)","snPcode":"","submissionUrl":"","title":"Discover Mental Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b0d6fb58-5dd8-4177-be36-72cd4f27b2d1","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-05-28T21:38:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-06 17:53:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6001960","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6001960","identity":"rs-6001960","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}