Mental Health First Aid Training for Health Care Workers in the Primary Health Care Center in Surabaya

Article history: The limitation of number of mental health professionals practicing at the primary health care center requires health care workers to be able to identify and intervene early in cases of mental disorders. Therefore, mental health first aid training for health care workers is needed. This research aims to examine the effectiveness of mental health first aid training to improve mental health literacy of the health care workers in the primary health care center. This was a simple randomized design with one group. The intervention was mental health first aid training which includes six sessions, namely mental health, mental health first aid, depression, anxiety, psychotics, and action plan. The training was attended by 58 health care workers and 1 staff from the Health Office of Surabaya. The instruments used were Mental Illness: Clinicians' Attitude Scale (MICA-4) to measure attitudes towards people with mental disorders and true-false questions to measure knowledge about mental health. The result of data analysis with paired-samples t-test showed that the mental health first aid training was effective in increasing the mental health literacy of health workers. Participants showed a significant increase in understanding of mental health (t = 3.575; p = 0.000). However, the limited opportunities for practice and direct interaction with mental patients affects the insignificant impact of training on changing attitudes towards people with mental disorders (t = -0.371; p = 0.753). Finally, this study recommends training methods that involve more practice in the future.


INTRODUCTION
The ratio of the incidence and prevalence of mental health disorders to the number of mental health personnel and services available in developing countries is disproportionate (World Health Organization, 2008). This condition creates a mental health gap where mental health cases often do not get the services they need or get services that are less than optimal. To minimize this gap, a strategy of scaling up services in the form of providing mental health services at the first level of health care has been recommended (World Health Organization, 2007). This strategy is reported to have succeeded in reducing the number of mental health service disparities in several developing countries (World Health Organization & World Organization of Family Doctors, 2008); although there are no published reports on this in Indonesia.
Service integration of mental and physical health at primary health care level consists of the diagnosis and intervention of mental health problems, prevention of the disorder from getting worse or widespread, as well as ensuring that health workers of primary health care center have adequate skills to take early action for mental health problems (World Health Organization, 2007). As the front line of delivering health services, health care workers have a very important role to play in ensuring the success of this strategy. The fact that not all primary health care center has psychologists or psychiatrists also emphasizes the importance of the role of health workers in being able to carry out appropriate initial treatment for mental health disorders. On the other hand, the various educational backgrounds and competencies of health workers are one of the challenges that need special attention.
There is no dedicated management procedure for mental cases at the primary health care center to date.
Health care workers usually carry out psychoeducation efforts to the community to make efforts to promote mental health. If there is a mental patient visit, the procedure that is most often done is to make referral to the only mental hospital in Surabaya. As a result, the number of mental patients in the mental hospital has accumulated. Thus, the strategy of integrating strategy to provide mental health services at the primary health care level has not been able to run in accordance with the objectives. This indicates the need to improve the literacy of mental health of health care workers at the primary health care center to ensure that the objectives of the strategy for integrating services are achieved. The level of mental health literacy of health care workers is relatively low even though their attitudes tend to be empathetic towards people with mental disorders (Ariana, 2013). This shows the lack of competence of health care workers in the primary health care center to provide mental health services. Specifically, health care workers of the primary health care center do not understand how to identify mental health disorders, what to do if they encounter symptoms of mental health disorders, and the opportunities for mental patients to recover if they receive appropriate treatment.
One solution that can be done to support the strategy to integrate services at the primary health care level is to provide mental health first aid training to health care workers in the primary health care center. This mental health first aid training aims to improve the literacy of mental health of health care workers. Mental health literacy includes the understanding of mental health and attitudes towards people with mental health problems (Kitchener & Jorm, 2002a). This research is a part of community development program from Universitas Airlangga that aims to examine the effectiveness of mental health first aid training to improve mental health literacy of health care workers working in the primary health care centers in Surabaya.

THEORITICAL FRAMEWORK
Mental health literacy is a set of knowledge and attitude towards mental health problems (Jorm, et al., 1997). Specifically, mental health literacy consists of the ability to recognize types of mental health problem, determinant factors, self-help interventions, professional help, help-seeking behavior, and mental health information.
Mental health literacy is influenced by health literacy in general. Health literacy is the ability to understand basic or general information in the health care setting, for example to understand information conveyed by doctors, the ability to understand and agree to informed consent, and follow drug dosage labels (Kickbush, 2001). Specifically, several factors that are known to have a relationship with attitudes toward people with mental health problems include lack of knowledge of mental health (Kumar, Kumar, Singh, & Bhandari, 2012); limited contact or unfamiliarity with people with mental health disorders (Corrigan, Edwards, Qreen, Thwart, & Perm, 2001); sociodemographic and cultural factors (Papadopoulos, Leavey, & Vincent, 2002). The low level of health literacy is often regarded as the cause of the emergence of stigma towards people with mental health problems. Therefore, the process of forming stigma towards people with mental health problems in health care workers becomes more complicated to study (Corrigan, 2004).
Research on health care workers shows that this group also has stigma towards people with mental health problems. Compared to attitudes towards general (physical) health disorders, the attitude of health workers towards mental disorders is more negative or stigmatic (Minas, Zamzam, Midin, & Cohen, 2011). It is feared that the stigmatic attitude of health workers will affect the quality of their services and become discriminatory towards patients with mental disorders. To explain this finding, lack of knowledge about mental health and infrequent interaction with people with mental disorders from non-specialist health professionals are often cited as predictors of stigmatic attitudes towards mental disorders. Thus, it is assumed that mental health professionals (e.g., psychiatrists and psychologists) or those working in specialist mental health settings (e.g., mental health clinics and mental hospitals) have positive and supportive attitudes toward mental disorders. This assumption is not supported by empirical data with the publication of several studies showing that stigma against mental disorders is also found in professionals who work in mental health, such as psychiatrists, psychologists, and mental health specialist nurses (Loch, et al., 2013;Lauber, Anthony, Ajdacic-Gross, & Rossler, 2004;Lauber, Nordt, Braunschweig, & Rçssler, 2006). This is of course a challenge for both mental health service providers and health policy makers. As anticipation, anti-stigma efforts targeting health workers can be recommended.

RESEARCH METHODOLOGY
This is an experiment study with simple randomized design. One group or the same group is participated in this study, that are 58 health workers and 1 health office staff. Participants are recruited purposively; each primary health care center was invited to send one representative. The number of participants covered 92% of the total number of primary health care in Surabaya.
Mental health first aid training curriculum was adapted from the mental health first aid manual (Kitchener & Jorm, 2002b). In addition to general insight into mental health and the importance of providing first aid to people with mental disorders, this training also taught practical skills in providing mental health first aid in cases of mental health problems with the high incidence rate in the primary health care center, namely depression, anxiety, and psychotic. At the end of the training, participants were requested to design an action plan for delivering mental health first aid at the primary health care center.
Knowledge of mental health was measured by 20 true and false questions developing by researchers.
Measurement of stigma against mental disorders will be measured by Mental Illness: Clinicians' Attitudes Scale (Kassam, Glozier, Leese, Henderson, & Thornicroft, 2010). Mental Illness: Clinicians' Attitudes Scale (MICA) is a scale for measuring attitudes towards mental disorders developed for a group of professionals (including trainees) in the health field. This scale is reported to have good internal consistency (alpha = 0.79) and test-retest reliability of 0.80 (95% CI 0.68-0.91) (Kassam, Glozier, Leese, Henderson, & Thornicroft, 2010). In accordance with the Manual for Researcher (Updated September 2010), the measuring instrument to be used is MICA v4 which is intended for professional groups in the field of health and social services outside of medicine.

Mental Health First Aid Training and the Knowledge of Mental Health
The main objective of the mental health first aid training is to improve the literacy of mental health of the participants as indicated by an increase in knowledge about mental health and a decrease in negative attitudes towards mental health problems. Data tabulation of pre-test and post-test scores showed that there were 44 complete data sets. That is, 44 participants took part in the pre-test and post-test and filled out all the questions. This data was then processed using paired-samples t-test statistical analysis to determine differences in the knowledge and attitudes of participants before and after the training.
Analysis of the knowledge aspect scores showed a significant difference in the level of mental health knowledge (t = 3.575; p = 0.000). The difference is positive, so the training increased the participants' mental health knowledge. This result is in line with the research by Kitchener and Jorm (2002a) where mental health first aid training can improve a person's ability to identify symptoms of mental disorders, change attitudes towards mental disorders, reduce social distance from people with mental disorders, increase confidence in aiding people with mental disorders, and increase the amount of assistance that can be provided to people with psychological complaints.
Integrating mental health services into primary health care services is a WHO recommendation that cannot be avoided. The high demand for mental health services and the lack of available mental health professionals are the main driving factors for this strategy. However, this strategy needs to be accompanied by the readiness of the primary health care center to be able to provide mental health services needed by the community. In other words, health care workers in the primary health care center need to have adequate understanding and skills to provide mental health services. Furthermore, the attitude shown to the patient should also be an aspect that is improved so that mental health services at the primary health care are optimal.

Mental Health First Aid Training and the Attitudes Toward Mental Illness
Further statistical analysis showed that there was no significant difference in stigmatic attitudes towards people with mental disorders (t = -0.371; p = 0.753). Although there is a trend of decreasing stigma, the insignificant difference does not support the conclusion. Mental health first aid training apparently has not been able to change participants' attitudes towards mental disorders. This can be caused by the short duration of the training. In addition, this year's training focuses on providing education to health workers of primary health care center where participants have various working periods. For health workers who have just worked or have worked for less than 1 month, the opportunity to interact directly with mental patients is still very limited compared to those who are more senior. This can affect how they develop attitudes toward people with mental disorders.
A systematic review of previous research found that there are at least three intervention approaches to stigma against mental disorders, namely education, contact, and protest (Corrigan, Morris, Michaels, Rafacz, & Rusch, 2012). Interventions with an educational approach aim to replace inaccurate stereotypes about mental disorders with more information. The contact-based approach aims to direct individuals to build relationships with people with mental disorders so that they can refute existing stereotypes. And, lastly, the anti-stigma intervention with a protest approach underscores the injustices and losses experienced by people with mental disorders so that it can urge policy makers to formulate rules that are more accommodating to the needs of people with mental disorders.
The not significant influence of this mental health first aid training on changes in the attitude of the health care workers is also an input for improving mental health first aid training. In the following year, training needs to involve teaching methods that allow participants to contact mental patients.

CONCLUSION
Mental health first aid training for health care workers in the primary health care centers is effective in increasing mental health literacy. After attending the training, participants showed increased knowledge about mental health and mental disorders. Unfortunately, the limited opportunities for practice and direct interaction with mental patients affects the insignificant impact of training on changing attitudes towards people with mental disorders. This result recommends the health workers to improve mental health literacy, either by attending formal education or by conducting an independent learning. Primary health care center, on the other hand, need to monitor and evaluate the mental health service as an integrative part of health services. Eventually, the future mental health first aid training need to design a method that does not only focus on in-class training but also provides opportunities for the participants to make direct contact with mental patients so that the main objective of mental health first aid training is optimally achieved.