TITLE: CAN A SHORT-TERM TRAINING COURSE IMPROVE THE PRIMARY-CARE PHYSICIANS’ ATTITUDES TOWARD MENTAL HEALTH PROBLEMS?

  ABSTRACT.OBJECTIVE:
To measure changes in the attitude of Primary Health Care (PHC) physicians towards mental illnesses after a short-term training course. In addition, to ascertain if this change would persist 6 months after the training course.

ABSTRACT.METHOD:
This is an intervention type study. Out of 296 PHC physicians working in Eastern Saudi Arabia, 191 were randomly selected and divided randomly into two groups. The Study groups were tested for pre and post exposure (immediate and 6months later), to the psychiatric training course. The Control group was not involved in the intervention. The course was run over a 4-day period in June 1999. A 26-item self-administered questionnaire to assess the PHC physicians' attitudes was used.

ABSTRACT.RESULTS:
The study group consisted of 45 trainees, 24 (53%) of whom were men. The control group, 121 out of 166 physicians, responded to the questionnaire, with an 83% response rate, men forming 49%. The data analysis indicated a significant improvement in the PHC physicians' attitude after the course (P<0.0001). Six months later, as compared with their immediate post-test, the positive attitudes persisted within the study group (p-value=0.274). Multiple regressions indicated that the duration of undergraduate psychiatric training was the only contributor factor.

ABSTRACT.CONCLUSION:
This training course resulted in a positive change in the trainees' attitudes. Besides, it showed that the undergraduate psychiatric training had a favourable effect on the PHC physicians' attitude. Therefore, there should be frequent mental health training programs for PHC physicians. Moreover, physicians who spent longer period in undergraduate psychiatric training should be given the priority to work in PHC settings.

BODY.INTRODUCTION:
The attitude of PHC physicians toward mental health problems is an important factor in dealing with such disorders. According to Gagne and Briggs, "attitudes are internal states that influence the individual's choice of personal action."1 Thus, increasing the awareness of PHC physicians towards mental problems and developing a positive attitude may be important in the successful recognition of mental disorders in PHC settings.2  Most mental health training interventions demonstrated not only a significant improvement in the physician's ability to identify and treat psychiatric disorders but also positively changed their attitudes toward mental illness.3–5 However, exposing medical students to clinical practice in psychiatry during undergraduate training was shown to have a favourable effect on their attitude toward mental health issues.67  To the researchers' knowledge, no study has been done to explore the changes in the participants′ attitudes that persisted. The present study was carried out during a short training course. Its purpose was to establish how far the attitudes of PHC physicians, working in Eastern Saudi Arabia, would change towards mental health problems after the training course. In addition, this study was to ascertain if this change would persist for 6 months after the training course. It was also designed to assess the relationship between the change in attitudes and the characteristics of PHC physicians.

BODY.METHOD:
This is a cross-sectional intervention study. All PHC physicians working in the Eastern Province, KSA were the target population. Al-Hassa, Naaria, Khafjee and Hafer-Albatten were excluded due to shortage of resources and time. The study area was served by a total of 296 PHC physicians and formed the target population. General practitioners without previous exposure to post-graduate psychiatric training and those who had not worked in a psychiatric clinic were included. One hundred ninety-one (191) PHC physicians were randomly selected. They were divided randomly into two groups (study and control). The study group was composed of 45 PHC physicians, who were tested in psychiatry pre and post exposure to the intervention training program. Their attitudes also were assessed six months after the program. The control group was composed of 146 PHC physicians who were not involved in the intervention training course.  The training course was held in June 1999 for four days. It was designed to focus on the recognition and management of common mental health problems presented in primary care such as: depression, anxiety, somatoform, eating and sleep disorders, as well as common childhood and adolescent problems. Introduction to basic psychotherapy, psychotropic treatments, and referral procedures were also covered. A variety of teaching methods were employed including, audiovisual presentations, role-play and group discussions.  A 26-item self-administered questionnaire to assess the PHC physicians' attitudes toward mental illnesses was used. The questionnaire was based on 35-items, used by Chinnayya H. et al (1990).4 Basic knowledge, such as the nature of mental illness, and popular misconceptions on mental illness were taken into consideration in developing this questionnaire. For each item, the individual was required to state whether he/she strongly agreed, agreed, was not sure, disagreed or strongly disagreed. These responses were made on a five-point interval scale ranging from complete misconception (scoring one) to complete confidence in the area (scoring five). The attitude questionnaire was used to measure the change in each item of attitude separately, and also to generate a total score of positive, desirable attitudes and to measure the change in them as an outcome of the training course.  It was hypothesized that by the end of the training course the candidates should have developed a more enlightened and humane understanding of the nature and causes of mental illness. It was also postulated that they would understand the needs of those who suffer from mental illness and the role of the PHC physicians in managing these cases with the involvement of their families and their community.

BODY.METHOD.DATA ANALYSIS:
The data was analyzed using the Statistical Package of Social Science (SPSS for Window) version 10. Attitude score values were compared by means and their standard deviations, and were tested by t-Student test. Multiple linear regression was used to estimate the effect of the studied independent variables in explaining the variance in attitude scores. A p-value of less than 0.05 was considered as the statistical level of significance.

BODY.RESULT:
The study group consisted of 45 trainees, 24 (53%) of whom were men. Saudis formed 58% (26), other Arab nationals 31% (14), and 5 (11%) were non-Arab. Their ages ranged from 26 to 50 years with a mean ± standard deviation (SD) of 36.50 ± 6.36. Their professional service in PHC settings ranged from 1 to 20 years, with a mean ± SD of 5.21 ± 4.44. Two of the trainees, one male and one female, were not available for follow up attitude assessment. They had been transferred out of the study area.  Eighty three percent of the control group (121 PHC physicians) responded to the questionnaire. Fifty-nine were men (49%). Saudi formed 64% (77), other Arab nationals 32 (26%), and 12 (10%) were non-Arab. Their ages ranged from 25-56 years, with a mean ± SD of 37.8 ± 8.07. The period of their professional service in PHC settings was 1-15 years with a mean ± SD of 5.74 ± 5.19.  Table 1 shows that there was no statistically significant difference in physicians′ attitudes towards mental health issues between the study group in the pre-intervention period and the control group, [p-value = 0.866]. But within the study group, there were significantly higher scores of positive attitudes in the post-test than in the pre-test evaluations, (p-value< 0.0001). Six month after the intervention, the positive attitudes persisted within the study group as compared with their immediate post-test, (p-value=0.274).   Table 1 The effect of mental training course on Primary Care Physicians’ attitudes (study and control), Eastern Province, Saudi Arabia (n=166)   Table 2 demonstrates the variance in mean positive attitude scores by the main characteristics of the participants (i.e. age, sex, nationality, year of graduation, medical school, PHC service period and undergraduate psychiatric training) on the PHC physicians' attitudes toward mental illness. In the Attitudes evaluation of the studied physicians, the post-intervention group scored a mean ± SD of 102.0 ± 6.78. The highest mark was 109 and the lowest 77. The high score in the attitudes test appeared to be significantly associated with the longer period of more than 4 weeks of undergraduate psychiatric training.  Table 2 The effect of a mental training course on Primary Care Physicians’ attitudes (study group) at different demographic and professional characteristics, Eastern Province, Saudi Arabia (n=45)   Multiple regression analysis showed that the duration of the undergraduate psychiatric training course was the only independent variable that contributed to the variance in attitude scores. In this regard, those who had more than four weeks clinical rotation in psychiatry had significantly higher scores of positive attitudes towards mental health issues, (p =0.0334). R square = 0.163, which meant that 16.3% of the variation was explained by the undergraduate psychiatric training.

BODY.DISCUSSION:
Our findings demonstrated similar conclusions as several studies have shown, that of significant positive effect of the mental health training courses in changing the attitudes of PHC physicians towards mental illness .45  The importance of this research lies in using Pre- and Post-tests as indicators of a positive effect as well as an assessment of long-term positive changes in the attitudes toward mental health problems. This would allow us, to measure the immediate and the long-term effects of the program on the PHC physicians' attitudes towards mental illness. From these findings, we concluded that, there was a consistent positive change in PHC physicians' attitudes immediately after, which lasted for 6 months after the training course. These improvements would hopefully influence the mental health services in PHC settings.  Mental health training courses for PHC physicians have been documented as cost-effective, fostening favourable attitudes towards mental health.89 Given the current status of our health care system, PHC physicians should play a more active role in the provision of mental health services.  The study group in the pre-intervention and the control group revealed a low score on the items related to the nature of mental illness and its management in PHC settings. This finding agrees with common misconceptions of mental illness that exist in the community and even among physicians.  The undergraduate psychiatric training had a significant relationship with the PHC physicians' attitudes towards mental illnesses. On the contrary, other PHC physicians' characteristics such as age, sex, nationality, medical school and provisional PHC work did not contribute to the PHC physicians' attitudes as proved by the multiple regression analysis. This is consistent with the inability of Qureshi et al and Chinnayya et al, to find a significant association between attitudes and PHC physicians' age, sex, and duration of their professional service.45 Therefore, the undergraduate psychiatry courses do not only improve the students' attitudes toward mental illness but also play a role in their future career as mental health service providers. Longer exposure to mental health especially in clinical practice does have an influence on attitudes.10 Besides, there were similarities in the findings of Ghadirian and Engelsmann who studied the attitudes of medical students toward mental illness. In that study, the length of clinical exposure led to a more positive attitude in the students.11

BODY.CONCLUSIONS:
This structured-training course resulted in positive changes in the trainee's attitudes. It also indicated a favorable effect of the undergraduate psychiatry training on the PHC physicians' attitudes. The authors recommend that continuous mental health training courses should be offered for PHC physicians. Moreover, those physicians who had long psychiatric training in their undergraduate period should be given the priority to work in PHC settings.

Question: Compared to control group what was the result of study group on attitudes towards mental health issues in pre-intervention period?
Evidence: But within the study group, there were significantly higher scores of positive attitudes in the post-test than in the pre-test evaluations, (p-value< 0.0001).
Answer: no significant difference