Integrating mental health screening into routine community maternal and child health activity: experience from Prevention of Mother-to-child HIV transmission (PMTCT) trial in Nigeria

  • Theddeus Iheanacho
  • Michael Obiefune
  • Chinenye O. Ezeanolue
  • Gbenga Ogedegbe
  • Okey C. Nwanyanwu
  • John E. Ehiri
  • Jude Ohaeri
  • Echezona E. Ezeanolue
Open Access
Original Paper

Abstract

Purpose

Although the prevalence of mental health disorders in Nigeria is comparable to most developed countries, access to mental health care in Nigeria is limited. Improving access to care requires innovative approaches that deliver mental health interventions at the community level. The aim of this study was to determine the feasibility and acceptability of integrating mental health screening into an existing community-based program for prevention of mother-to-child transmission of HIV targeted at pregnant women and their male partners.

Methods

Pregnant women and their male partners from 117 churches enrolled in the healthy beginning initiative (HBI) in southeast Nigeria participated in the mental health screening project. Two members from each church were trained as church-based health advisors to administer the 12-item general health questionnaire.

Results

Ninety-three percent of the pregnant women and their male partners agreed to participate and fully completed the questionnaire. Overall, 21.7 % of the respondents scored above the threshold of 11 indicating significant psychological distress, with women having significantly higher scores than men.

Conclusion

Mental health screening is feasible and well accepted among a cohort of pregnant women and their male partners. Church members can be trained as health advisors to administer mental health screening. Mental health interventions can be developed on the framework of the HBI.

Keywords

Mental health screening General Health Questionnaire 12 Community and church-based screening Adult Nigerians Low- and middle-income countries (LMIC) PMTCT Maternal and child health 

Introduction

Burden of mental health in Nigeria

Nigeria exemplifies the severe gap in mental health care common in low- and middle-income countries (LMIC) [1] with an estimated 150 psychiatrists available in a country of 160 million people. Published studies show that up to 26 % of adult Nigerians had a lifetime prevalence of at least one DSM IV disorder [2, 3, 4]. An estimated 10 % of Nigerian women experience depression during pregnancy while approximately 20 % of women experience post-natal depression [5, 6]. Poor maternal mental has been shown to negatively impact a child’s physiological, emotional and cognitive development [6, 7] and is a major contributor to maternal mortality [8, 9, 10].

Access to mental health in Nigeria

There are limited data from Nigeria on maternal access to mental health care during and after pregnancy. However, available studies indicate that only about 10 % of adults with mental illness in Nigeria receive any care irrespective of severity [2]. Mental health care during pregnancy is scarce and is limited to major urban hospitals. However, more than 50 % of pregnant women in urban areas and more so in rural parts of Nigeria seek perinatal services in non-hospital settings; usually from untrained and unregulated traditional birth attendants [11, 12]. Conversely, most pregnant women and their families get support from their religious organizations during pregnancy [11, 13]. Religious organizations offer special prayer sessions for pregnant couples and celebrate with the families at special services after childbirth [14].

The healthy beginning initiative

The Healthy Beginning Initiative (HBI), funded by the United States National Institute of Health (NIH), was designed to assess the effectiveness of a church-based program that uses prayer sessions to recruit pregnant women early in their pregnancy, utilizes baby shower activities to deliver multiple health interventions (including health education and integrated laboratory testing), and baby receptions to follow up with the women and link them to continuing care after delivery [15]. The rational to use congregation-based approach was based on several reasons: first, Nigeria has extensive penetration of faith-based institutions and faith plays a significant role in the social life of Nigerians. Second, Nigeria is ranked #1 among 53 other nations in church attendance with 89 % of sampled Christian population reporting at least once a week attendance [16, 17, 18]. Third, the use of a family-centered, culturally appropriate approach that relies on a widely distributed infrastructure (religious institutions), if effective, could easily become an attractive model for other maternal and child health interventions in settings that provide interventions to prevent mother-to-child transmission of HIV under the Presidents Emergency Plan for AIDS Relief (PEPFAR) [22]. Finally, the collaborative, community-based approach could strengthen trust between faith-based organizations (FBOs) and researchers at treatment centers, which could make it easier to track enrolled pregnant women and reduce loss to follow-up.

Recent studies estimated that 69 % of adults surveyed in southern Nigeria sought help from their churches, mosques or traditional healers before going to see a healthcare provider [19, 20]. Finding innovative ways to utilize these widely available institutions to enhance access to mental health care that is culturally appropriate is essential to reach the WHO Millennium Development Goals [21, 22]. There is little evidence, however, on the feasibility, acceptability or effectiveness of integrating mental health screening, assessment or treatment into routine religious activities in Nigeria.

Purpose of study

This pilot study was designed to test the feasibility of integrating mental health screening into a routine community health program. The primary aim was to assess the acceptability of mental health screening among pregnant women and their male partners during the HBI to prevent mother-to-child transmission of HIV. The secondary aim was to assess the feasibility of using trained church-based health advisors to administer a mental health screening instrument. The study was approved by the Institutional Review Board of the University of Nevada, Reno and the Nigerian National Health Research Ethics Committee.

Methods

Study setting

Self-identified pregnant women and their partners who attended churches participating in the HBI were approached to participate.

Study procedure

A detailed study procedure has been described elsewhere [23]. In summary, we recruited and trained 144 mostly female church-based health advisors (CHAs) with an average age of 30 years and a minimum of high school education to administer an investigator-assisted questionnaire to HBI participants. CHAs first received specific training on completing the 12-item General Health Questionnaire (GHQ-12) and translating the questions to the local Ibo language so they can provide assistance and respond appropriately to participants’ inquiries while completing the questionnaire. In addition to providing assistance to the participants in completing the GHQ-12, the CHAs provided education to the families on medical screening, breastfeeding, mother–child bonding, mental health and nutrition.

All the bishops who oversaw churches in the proposed study areas agreed to participate in this study following detailed discussions and explanations from the research team. Recruitment occurred at the level of the churches and participants (in that order). Participant’s recruitment followed four steps: (1) potential participants were approached and provided with detailed explanation of the study and its objectives. (2) Those who expressed interest were asked to read the written consent form, allowed to ask questions and were assured of confidentiality. (3) Participants were then asked to sign the written consent form as a confirmation of their voluntary participation in the study. (4) For participants who are unable to read and write, the consent was read to them in the native language, by the CHA and research assistant. After all their questions about the study had been addressed, those who volunteered to participate were asked to give their thumb print as a confirmation of their informed consent.

Participants were clearly informed that HBI is not a substitute for prenatal care and were encouraged to follow up with their healthcare provider for regular care during pregnancy.

Questionnaire administration and completion

The English version of the GHQ-12 questionnaire was used for this study. We decided against translation to the local language (Ibo) after it was noted that although participants were able to speak the local language, majority of the participants were unable to read the local language and preferred to complete the questionnaire in English. Trained research assistants and church-based health advisors selected from participating churches assisted participants with completion of the questionnaire. For participants who could not read, the trained church-based health advisor will read out the questions to them. For participants who do not understand Standard English, the church-based health advisor will first read out the question in English and translate to the local language.

Data analysis

Measures

The GHQ-12 is a validated and reliable 12-question screening instrument that detects general psychological distress and has been used in multiple studies in Nigeria [24]. Each item on the scale has four responses from “better than usual” to “much less than usual”. There are several ways of scoring this measure none being particularly better than the others [25]. For the purpose of this study, we choose the Likert scoring (0–1–2–3) method which gives a possible score range of 0–36. Likert scoring produces superior score distribution to assess severity when psychiatric disorders are considered as dimensions rather than categories [26]. Due to population variations in thresholds for the GHQ-12, the mean GHQ score for a population of respondents is suggested as a rough estimator of the best cut-off point [27]. Higher scores on the GHQ-12 indicate greater levels of general psychological distress [28]. The mean GHQ-12 score for this sample was 8.71 (SD = 5.0) and the threshold score for a high probability of significant psychological distress was 11 (75th Percentile) [26, 27]. This threshold was chosen based on previous studies using GHQ-12 among adult populations in Nigeria [29, 30].

Statistical analysis

Descriptive statistics was used to examine the demographic characteristics of the sample as well as their GHQ-12 scores. Chi square and independent T tests were used to determine if there were any significant gender differences. Fisher’s exact test was used when Chi square tests were inappropriate because of small expected frequencies. P values less than .05 were considered significant. All analysis was performed using SAS software version 9.1 (SAS Institute Inc., NC).

Results

In all, 93 % (n = 4,747) of the pregnant women and their male partners who consented to participate in this study completed the GHQ-12 questionnaire. Most of those who did not complete the questionnaire were the male partners who anecdotally reported to field staff that they felt that this survey was more “for the women”. To assess whether completers differed significantly from non-completers, we followed up a sample of 20 non-completers. Our review of their socio-demographic characteristics did not suggest that non-completers were markedly different from completers. A majority of the participants were married (96.4 %), had post-primary education (66.8 %) and some form of employment (52.7 %). A larger proportion were female n = 2,796 (55.2 %) with the mean age of 28.68 (SD = 6.5). Women participants were younger (28.68 vs. 37.07 years old), less likely to be married (93.5.9 vs. 99.9 %), more likely to be unemployed (58.3 vs. 33.7 %), more likely to have secondary education (56.7 vs. 44.3 %) and more likely to be living in rural areas (71.3 vs. 67.9 %). There were no significant gender differences in the number of people in the household, distance to closest health facility, awareness of sickle cell trait status or HIV status. The mean GHQ-12 score for the sample was 8.71 (SD = 5.0) (Table 1).
Table 1

Sample demographics and characteristics

Variable

Female n (%)

Male n (%)

Total n (%)

Significance

Marital status

 Married

2,615 (93.5 %)

2,305 (99.9 %)

4,920 (96.4 %)

χ 2 (2) = 149.13, p <0.001

 Single

179 (6.4 %)

2 (0.1 %)

181 (3.5 %)

 

 Divorced

2 (0.1 %)

0 (0.0 %)

2 (0.0 %)

 

Education

 None

50 (1.8 %)

70 (3.1 %)

120 (2.3 %)

χ 2 (3) = 146.49, p <0.001

 Primary

688 (24.2 %)

891 (38.9 %)

1,579 (30.8 %)

 

 Secondary

1,608 (56.7 %)

1,013 (44.3 %)

2,621 (51.1 %)

 

 Tertiary

492 (17.3 %)

314 (13.7 %)

806 (15.7 %)

 

Employment

 Full time

769 (28.0 %)

1,131 (50.7 %)

1,900 (38.2 %)

χ 2 (2) = 326.65, p <0.001

 Part time

374 (13.6 %)

348 (15.6 %)

722 (14.5 %)

 

 Unemployed

1,599 (58.3 %)

751 (33.7 %)

2,350 (47.3 %)

 

Area of residence

 Urban

813 (28.7 %)

737 (32.1 %)

1,550 (30.2 %)

χ 2 (1) = 7.04, p <0.01

 Rural

2,023 (71.3 %)

1,560 (67.9 %)

3,583 (69.8 %)

 

Closest health facility

 0–5 km

943 (33.9 %)

838 (37.6 %)

1,781 (35.6 %)

χ 2 (3) = 146.49, p <0.001

 5–10 km

1,072 (38.5 %)

829 (37.2 %)

1,901 (38.0 %)

 

 10–15 km

477 (17.1 %)

333 (15.0 %)

810 (16.2 %)

 

 15+ km

290 (10.4 %)

226 (10.2 %)

516 (10.3 %)

 

Age

Female

Male

Total

Significance

 Mean

28.68

37.07

32.68

F (1, 4,628) = 302.50,

 SD

6.5

22.7

16.9

 p < 0.001, η 2 =0.061

 N

2,424

2,206

4,630

 

GHQ score

 Mean

9.10

8.23

8.71

F (1, 4,745) = 36.07,

 SD

5.1

4.8

5.0

p <0 .001, η 2 = 0.008

 N

2,620

2,127

4,747

 
Overall, 21.7 % of the respondents scored above the threshold of 11 indicating significant psychological distress (Table 2). About 3 % scored 20 or over, indicating severe psychological distress. The level of psychological distress in the pregnant women was higher than in their male partners as shown by a significantly higher mean score (9.10 vs. 8.23 p < 0.0001) (Table 1). These findings seemed to indicate that the women were slightly more vulnerable to develop and experience psychiatric disorders perhaps related to pregnancy. In general, higher scores on the GHQ-12 were significantly correlated with being single (χ 2 (2) = 23.67, p < 0.001), having only primary education (χ 2 (3) = 16.29, p < 0.01), being unemployed (χ 2 (2) = 15.04, p < 0.01) and not knowing their sickle cell trait status (χ 2 (1) = 8.42, p < 0.01). There were no significant associations between high scores on the GHQ-12 and HIV status, sickle cell trait status, age or number of children in the household (Table 3).
Table 2

Frequency of distribution of GHQ-12 scores for the total sample

 

n

%

Less than 4

449

8.6

4

342

6.5

5

422

8.1

6

785

15.0

7

381

7.3

8

368

7.0

9

338

6.4

10

272

5.2

11

251

4.8

12

217

4.1

13

157

3.0

14

147

2.8

15

119

2.3

16

97

1.9

17

86

1.6

18

71

1.4

19

55

1.0

20

46

0.9

21 and greater

144

2.7

Missing

495

9.4

Total

5,242

100.0

Table 3

Correlates of high and low GHQ-12 scores

Variable

GHQ-12 Score below 11

GHQ-12 Score above 11

Significance

N

%

N

%

HIV status

 Negative

996

64.4

550

35.6

χ 2 (1) = 0.333

 Positive

26

72.2

10

27.8

p > 0.05

Aware SC trait status

 No

994

67.8

471

32.2

χ 2 (1) = 8.42

 Yes

2,363

72.0

919

28.0

p <0.01

SC trait

 AA normal

1,993

72.6

754

27.4

χ 2 (3) = 3.04

 AS carrier

369

69.1

165

30.9

 

 SS disease

3

75.0

1

25.0

p > 0.05

 Other

5

62.5

3

37.5

 

Marital status

 Married

3,197

71.3

1,289

28.7

χ 2 (2) = 23.67

 Single

93

55.7

74

44.3

p < 0.001 

 Divorced

0

0.0

2

100.0

 

Education

 None

77

72.6

29

27.4

χ 2 (3) = 16.29

 Primary

995

68.3

462

31.7

p <0.01

 Secondary

1,677

70.3

708

29.7

 

 Tertiary

568

76.4

175

23.6

 

Employment

 Full time

1,296

73.8

461

26.2

χ 2 (2) = 15.04

 Part time

466

70.2

198

29.8

p < 0.01 

 Unemployed

1,457

68.1

683

31.9

 

# of children

 Mean

2.93

3.53

F (1,105) = 2.54

 SD

1.8

1.7

p >0.05

 N

71

34

 

Age

 Mean

32.90

32.16

F (1, 4,226) = 1.53

 SD

20.0

8.5

p > 0.05

 N

3,026

1,202

 

A proportion of respondents either did not answer all the 12 items or provided more than one choice for each question. These were grouped under missing data (9.4 %, Table 2).

Discussion

This pilot study focused primarily on testing the feasibility and acceptability of conducting mental health screening during routine church-based programs for pregnant women in Enugu, southeastern Nigeria. Having a mental health problem in Nigeria remains a taboo and its acknowledgment is fraught with stigmatization. This limits health seeking from psychiatric professionals [31, 32, 33, 34]. The result is that most Nigerians with emotional distress and common mental health disorders seek help and support from their churches, spiritual healers and traditional medicine men [19, 35]. Introducing mental health screening as part of a holistic approach to wellness through this faith-based approach goes a long way to both raising awareness and de-stigmatizing mental illness and can make mental health interventions more accessible and acceptable. There were very few women who declined to complete the screening questionnaire. We interviewed a random sample of participants and although a detailed qualitative analysis of respondents is being done at this time, initial analysis and anecdotal reports show a reasonably high uptake of the program and surveys. One important aspect of this program was the buy-in by the church leaders who viewed it as a significant support for their parishioners at a happy but vulnerable time. They also believed that it was a capacity building process for their church-based lay workers. In addition, integrating the screening with other laboratory tests done in the church was normalizing and reduced the stigma otherwise attached to seeing a psychiatric specialist or going to a psychiatric clinic. The rate of psychological distress reflected in these findings is in keeping with the rate in previous surveys and studies which were primarily conducted in medical settings [36, 37, 38].

Some limitations of this pilot study are worth pointing out. The initial protocol did not include a second screener or assessment after this initial GHQ-12 test for those who scored above the 25th percentile to determine the true prevalence of psychological distress or psychiatric disorder. At the beginning of the study, we concluded with the church leadership that participants will be referred to the nearest medical facility for pregnancy care. Participants who were identified with high GHQ-12 scores were referred for evaluation with their regular provider or to the closest psychiatric facility at the University of Nigeria Teaching Hospital. However, during the study, we noted an acute shortage of psychiatric clinicians and have initiated a process with the psychiatric department at the University of Nigeria to train priests as first-line counselors with a referral mechanism with the University teaching hospital.

Another limitation is the absence of a formal evaluation of the CHA’s competence in administering the survey and respondents’ rating of their experiences in this innovative program. However, as shown by the very high level of response from participants and anecdotal field reports, participants and staff alike had a generally positive view of the process. Moreover, the most important question for this pilot study was whether these mental health screenings can be done during routine church-based activities and whether this cohort of women and their partners would be willing to complete a mental health screening questionnaire during these routine church activities. The authors are currently completing qualitative analysis of respondents’ satisfaction surveys and exit interviews and plan to add evaluation tools including pre and post tests, for CHAs and clergy training in subsequent proposals.

Conclusion

Findings from this pilot study indicate that mental health screening can be integrated into a community-based program designed to improve health outcomes for pregnant women. It also showed that lay church-based health advisors with no previous psychiatric training can be trained to deliver mental health screening survey instruments in church settings. Community-based approaches such as the HBI can become platforms for developing interventions to integrate mental health assessment into community program and linkage to care at primary-care centers.

Notes

Acknowledgments

The authors would like to thank the Catholic Bishops of Enugu and Awgu; the Anglican Bishop of Enugu and Archbishop of Oji-River. Their feedback was very instrumental to the development of this protocol. We are also grateful to the team of research assistants, program coordinators and educators for their work on this project: Dina Patel; Aaron Hunt; Alice Osuji; Amaka Ogidi; Annuli Ike; Nnabundo Musei, Benedicta Ozonweke and the many volunteers of PeTR-GS; The study was co-funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the National Institute of Mental Health (NIMH), the President’s Emergency Plan for AIDS Relief (PEPFAR) under award number R01HD075050 and HealthySunrise Foundation. The funding agencies played no role in the study conception, design, data collection, data analysis, data interpretation or writing of the report.

Conflict of interest

The authors declare that they have no competing interests.

References

  1. 1.
    Kakuma R, Minas H, van Ginneken N, Dal Poz MR, Desiraju K, Morris JE et al (2011) Human resources for mental health care: current situation and strategies for action. Lancet 378(9803):1654–1663PubMedCrossRefGoogle Scholar
  2. 2.
    Gureje O, Lasebikan VO, Kola L, Makanjuola VA (2006) Lifetime and 12-month prevalence of mental disorders in the Nigerian Survey of Mental Health and Well-Being. Br J Psychiatry 188:465–471PubMedCrossRefGoogle Scholar
  3. 3.
    Gureje O, Kola L, Afolabi E (2007) Epidemiology of major depressive disorder in elderly Nigerians in the Ibadan Study of Ageing: a community-based survey. Lancet 370(9591):957–964PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Organization WH. World health statistics 2013: a wealth of information on global public health. 2013Google Scholar
  5. 5.
    Adewuya AO, Ola BA, Aloba OO, Dada AO, Fasoto OO (2007) Prevalence and correlates of depression in late pregnancy among Nigerian women. Depress Anxiety 24(1):15–21PubMedCrossRefGoogle Scholar
  6. 6.
    Adewuya AO, Ola BO, Aloba OO, Mapayi BM, Okeniyi JA (2008) Impact of postnatal depression on infants’ growth in Nigeria. J Affect Disord 108(1–2):191–193PubMedCrossRefGoogle Scholar
  7. 7.
    Ibanez G, Charles MA, Forhan A, Magnin G, Thiebaugeorges O, Kaminski M et al (2012) Depression and anxiety in women during pregnancy and neonatal outcome: data from the EDEN mother–child cohort. Early Human Dev 88(8):643–649CrossRefGoogle Scholar
  8. 8.
    Cook JA, Grey D, Burke J, Cohen MH, Gurtman AC, Richardson JL et al (2004) Depressive symptoms and AIDS-related mortality among a multisite cohort of HIV-positive women. Am J Public Health 94(7):1133–1140PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM et al (2010) Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 375(9726):1609–1623PubMedCrossRefGoogle Scholar
  10. 10.
    Austin MP, Kildea S, Sullivan E (2007) Maternal mortality and psychiatric morbidity in the perinatal period: challenges and opportunities for prevention in the Australian setting. Med J Aus 186(7):364–367Google Scholar
  11. 11.
    Onah HE, Ikeako LC, Iloabachie GC (2006) Factors associated with the use of maternity services in Enugu, southeastern Nigeria. Soc Sci Med 63(7):1870–1878PubMedCrossRefGoogle Scholar
  12. 12.
    Olusanya BO, Alakija OP, Inem VA (2010) Non-uptake of facility-based maternity services in an inner-city community in Lagos, Nigeria: an observational study. J Biosoc Sci 42(3):341–358PubMedCrossRefGoogle Scholar
  13. 13.
    Udoma EJ, Asuquo EE, Ekott MI (1999) Maternal mortality from obstructed labor in south-eastern Nigeria: the role of spiritual churches. Int J Gynaecol Obstet 67(2):103–105PubMedCrossRefGoogle Scholar
  14. 14.
    Adetunji JA (1992) Church-based obstetric care in a Yoruba community Nigeria. Soc Sci Med 35(9):1171–1178PubMedCrossRefGoogle Scholar
  15. 15.
    Ezeanolue EE, Obiefune MC, Yang W, Obaro SK, Ezeanolue CO, Ogedegbe GG (2013) Comparative effectiveness of congregation- versus clinic-based approach to prevention of mother-to-child HIV transmission: study protocol for a cluster randomized controlled trial. Implement Sci 8:62PubMedCentralPubMedCrossRefGoogle Scholar
  16. 16.
    Inglehart R, de Estudios Sociales A. World values surveys and European values surveys, 1981–1984, 1990–1993, and 1995–1997. Inter-University Consortium for for Political and Social Research; 2000Google Scholar
  17. 17.
    Norris P, Inglehart R (2011) Sacred and secular: Religion and politics worldwide. Cambridge University Press, New YorkCrossRefGoogle Scholar
  18. 18.
    Swanbrow D. Study of worldwide rates of religiosity, church attendance. The University of Michigan; 1997 [cited 2014 1/13/2014]; Available from: http://www.ns.umich.edu/Releases/1997/Dec97/chr121097a.html
  19. 19.
    Abiodun OA (1995) Pathways to mental health care in Nigeria. Psychiatr Serv 46(8):823–826PubMedCrossRefGoogle Scholar
  20. 20.
    Aghukwa CN (2012) Care seeking and beliefs about the cause of mental illness among Nigerian psychiatric patients and their families. Psychiatr Serv 63(6):616–618PubMedCrossRefGoogle Scholar
  21. 21.
    Miranda JJ, Patel V (2005) Achieving the Millennium Development Goals: does mental health play a role? PLoS Med 2(10):e291PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Sachs SE, Sachs JD (2007) Mental health in the millennium development goals: not ignored. PLoS medicine 4(1):e56 (author reply e7)PubMedCentralPubMedCrossRefGoogle Scholar
  23. 23.
    Ezeanolue EE, Obiefune MC, Yang W, Obaro SK, Ezeanolue CO, Ogedegbe GG (2013) Comparative effectiveness of congregation-versus clinic-based approach to prevention of mother-to-child HIV transmission: study protocol for a cluster randomized controlled trial. Implement Sci 8:62–69 Google Scholar
  24. 24.
    Abiodun OA (1994) A validity study of the Hospital Anxiety and Depression Scale in general hospital units and a community sample in Nigeria. Br J Psychiatry 165(5):669–672PubMedCrossRefGoogle Scholar
  25. 25.
    Schmitz N, Kruse J, Heckrath C, Alberti L, Trees W (1999) Diagnosing mental disorders in primary care: the General Health Questionnaire (GHQ) and the Symptom Check List (SCL-90-R) as screening instruments. Soc Psychiatry Psychiatr Epidemiol 34(7):360–366PubMedCrossRefGoogle Scholar
  26. 26.
    Goldberg DP, Gater R, Sartorius N, Ustun TB, Piccinelli M, Gureje O et al (1997) The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychol Med 27(1):191–197PubMedCrossRefGoogle Scholar
  27. 27.
    Goldberg D, Oldehinkel T, Ormel J (1998) Why GHQ threshold varies from one place to another. Psychol Med 28(4):915–921PubMedCrossRefGoogle Scholar
  28. 28.
    Goldberg DP, Williams P (1988) A user’s guide to the General Health Questionnaire. Nfer-Nelson, WindsorGoogle Scholar
  29. 29.
    Amoran O, Lawoyin T, Lasebikan V (2007) Prevalence of depression among adults in Oyo State, Nigeria: a comparative study of rural and urban communities. Aust J Rural Health 15(3):211–215PubMedCrossRefGoogle Scholar
  30. 30.
    Ohaeri JU, Campbell OB, Ilesanmil AO, Ohaeri BM (1998) Psychosocial concerns of Nigerian women with breast and cervical cancer. Psycho-Oncology 7(6):494–501PubMedCrossRefGoogle Scholar
  31. 31.
    Saraceno B, van Ommeren M, Batniji R, Cohen A, Gureje O, Mahoney J et al (2007) Barriers to improvement of mental health services in low-income and middle-income countries. Lancet 370(9593):1164–1174PubMedCrossRefGoogle Scholar
  32. 32.
    Organization WH (2009) Mental health systems in selected low-and middle-income countries: a WHO-AIMS cross-national analysis. World Health Organization, GenevaGoogle Scholar
  33. 33.
    Gureje O, Lasebikan VO (2006) Use of mental health services in a developing country. Soc Psychiatry Psychiatr Epidemiol 41(1):44–49PubMedCrossRefGoogle Scholar
  34. 34.
    Klecha D, Barke A, Gureje O (2004) Mental health care in developing countries: the example of Nigeria. Der Nervenarzt 75(11):1118–1122PubMedCrossRefGoogle Scholar
  35. 35.
    Lasebikan VO, Owoaje ET, Asuzu MC (2012) Social network as a determinant of pathway to mental health service utilization among psychotic patients in a Nigerian hospital. Ann Afr Med 11(1):12–20Google Scholar
  36. 36.
    Adewuya AO, Ola BA, Dada AO, Fasoto OO (2006) Validation of the Edinburgh Postnatal Depression Scale as a screening tool for depression in late pregnancy among Nigerian women. J Psychosom Obstet Gynecol 27(4):267–272CrossRefGoogle Scholar
  37. 37.
    Abiodun O (2006) Postnatal depression in primary care populations in Nigeria. Gen Hosp Psychiatry 28(2):133–136PubMedCrossRefGoogle Scholar
  38. 38.
    Fisher J, Mello MC, Patel V, Rahman A, Tran T, Holton S et al (2012) Prevalence and determinants of common perinatal mental disorders in women in low-and lower-middle-income countries: a systematic review. Bull World Health Organ 90(2):139–149PubMedCentralCrossRefGoogle Scholar

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© The Author(s) 2014

Open AccessThis article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

Authors and Affiliations

  • Theddeus Iheanacho
    • 1
  • Michael Obiefune
    • 2
  • Chinenye O. Ezeanolue
    • 3
  • Gbenga Ogedegbe
    • 4
  • Okey C. Nwanyanwu
    • 5
  • John E. Ehiri
    • 6
  • Jude Ohaeri
    • 7
  • Echezona E. Ezeanolue
    • 3
    • 8
  1. 1.Department of PsychiatryYale Univeristy School of MedicineNew HavenUSA
  2. 2.Prevention, Education, Treatment, Training and Research-Global Solutions-PeTR-GSEnuguNigeria
  3. 3.Sunrise FoundationEnuguNigeria
  4. 4.School of MedicineNew York UniversityNew YorkUSA
  5. 5.United States Center for Diseases Control and Prevention, Country OfficeAbujaNigeria
  6. 6.Division of Health Promotion Sciences/Global Health Institute, Mel and Enid Zuckerman College of Public HealthUniversity of ArizonaTucsonUSA
  7. 7.Department of Psychological MedicineUniversity of Nigeria Teaching HospitalEnuguNigeria
  8. 8.Department of PediatricsUniversity of Nevada School of MedicineLas VegasUSA

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