1 Background

Mental disorders continue to be a serious global public health concern [1]. Globally, nearly one billion individuals, or one in every eight, suffer from a mental illness based on a recent estimate [1]. A mental disorder is a discernible deviation in an individual's cognitive functioning, affective state, or behaviour. Mental disorders exist in a variety of forms, the most prevalent being anxiety and depression [2]. However, the global burden of mental problems grew worse in 2020 following the COVID-19 pandemic [3]. Mental disorders are associated with high rates of morbidity, lost productivity, disability, and death [4, 5]

Nigeria has a high prevalence of mental disorders, including schizophrenia, depression, anxiety disorders, and substance misuse [6]. The World Health Organization (WHO) estimates that 20% of Nigerians suffer from mental illnesses, with depression being the most common cause of disability. Furthermore, the stigma associated with mental illness persists as a significant issue in Nigeria, resulting in prejudice, social exclusion, and obstacles to obtaining assistance [7, 8]. Cultural stereotypes and preconceived notions about mental health frequently play a role in the stigmatization of people with mental illnesses, which discourages them from seeking treatment and results in underreporting [9].

Nigeria has a lot of obstacles when it comes to providing appropriate mental health services because of things like inadequate infrastructure, a lack of mental health experts, underfunding, and poor integration of mental health services with primary healthcare [8]. Disparities in the availability of mental health care are exacerbated in rural areas by the lack of access to providers [10]. The prevalence of mental illnesses in Nigeria is influenced by socioeconomic factors such as urbanization, violence, unemployment, and poverty. These elements may worsen pre-existing mental health issues, raise stress levels, and make it more difficult to get therapy and other supports. Given Nigeria’s unique challenges, particularly the shortage of mental health professionals [11], there is a need for adopting a holistic care approach such as the pharmaceutical care (PC) model involving community pharmacists [12], who seem closer to the patients and often the first point of contact because of their strategic locations within the community.

Hepler and Strand described PC as the responsible provision of medication therapy to attain measurable outcomes that enhance a patient's quality of life [13]. With the use of this PC model, pharmacists can easily collaborate with mental health professionals in creating comprehensive treatment regimens that are tailored to each patient's needs [14]. Community pharmacists have the potential to provide patient-centred services by upholding the fundamentals of PC in mental health. It has been demonstrated that PC offers many advantages when applied in the management of individuals with mental illnesses [15, 16]. First of all, by creating tailored therapies and optimizing drug selection and dosage to reduce side effects and improve therapeutic results, it guarantees the safe and efficient use of medications [16, 17]. Second, PC lowers the likelihood of treatment discontinuation and relapse by promoting medication adherence through the provision of information, counselling, and support [15, 16]. Even while community pharmacists are increasingly seen as having the ability to help people with mental diseases, there is evidence that they stigmatize, are undertrained, and lack confidence when it comes to meeting the special needs of their clients who have mental disorders [18,19,20]. To improve the delivery of mental health services and the outcomes for Nigerians suffering from mental diseases, it is imperative to recognize and address these attitudes. Therefore, this study aimed to assess the community pharmacists’ attitudes and barriers toward providing PC services for clients with confirmed or suspected mental disorders in Enugu, Nigeria.

2 Methods

2.1 Study design

This study was a quantitative descriptive cross-sectional survey among community pharmacists in Enugu, Nigeria.

2.2 Sample size, sampling procedure, and selection criteria

The sample size of this study was determined using the Raosoft online calculator [21]. According to Raosoft online calculator, the minimum sample size for the study was 120, assuming a 5% margin of error, 95% confidence level, and a population of 174 community pharmacists in Enugu. All eligible community pharmacists in Enugu metropolis were given the opportunity to participate in the survey. The participants were recruited if they are community pharmacists currently licensed by the Pharmacy Council of Nigeria (PCN), offer retail pharmacy services to clients, and are willing to participate in the study.

2.3 Survey instrument

The community pharmacists’ attitudes and barriers toward providing PC for patients with mental illness were measured using a questionnaire adapted from a previously published study [22]. The questionnaires were validated and pilot-tested among fifteen eligible respondents before use in the present study, yielding a Cronbach’s alpha of 0.76. The questionnaire had four domains. The domains were (1) Collection of medication history, (2) Screening for pharmacotherapy problems, (3) Monitoring of drug efficacy and adverse effects, and (4) Provision of medication counselling. The questionnaire has 16 items rated on a four-point Likert scale (Not at all = 0, Less = 1, More = 2, Much More = 3). The possible aggregate score ranged from 0 to 48. The higher the aggregate score, the more favourable the pharmacists' attitudes toward providing PC for patients with depression. Additionally, the respondents were asked to provide information on perceived barriers to the provision of PC for patients with mental illness. This section of the questionnaire has 13 items with a response scale of “Yes”, “No”, and “Not sure.”

The respondents’ sociodemographic information was obtained using an attached data collection form designed for the purpose. The sociodemographic information obtained included gender, age, years of practice experience, pharmacist status, and number of pharmacist employees on the premises. The pharmacists were also asked questions about their familiarity with mental illness. Specifically, the questions that were asked to ascertain familiarity with mental disorders included: (1) Have you ever experienced mental illness? (2) Do you know a family member with mental illness? and (3) How would you rate your knowledge of mental illness?

2.4 Data collection

The study respondents were initially briefed on the research after accepting to participate. The self-administered paper-based questionnaires were given to the respondents to complete. Most of the respondents completed the questionnaire immediately and returned it to the researchers or their assistants. However, some pharmacists who were busy at the time of the visit had their questionnaires retrieved on a follow-up visit by a member of the research team. The research team provided further clarification when needed by any of the respondents. The data collection lasted from March 2 to April 26, 2023.

2.5 Data analysis

The data obtained were coded and entered into Microsoft Excel. Thereafter, the data were cleaned and exported to the IBM Statistical Products and Services Solution (SPSS) version 20 for Windows software for statistical analysis. Descriptive statistics, including frequency and percent were used to summarize the respondents’ sociodemographic characteristics. The mean population score of the attitudinal scale was used to group the respondents as having either a positive or a negative attitude toward providing PC for patients with mental illness. The mean score is a valid and reliable cutoff point for categorizing attitude scores obtained in surveys if the data is normally distributed [23, 24]. Scores above the population mean (> 26.25) were considered to be a positive (or favourable) attitude, whereas scores below the mean population (< 26.25) represented a negative (or unfavourable) attitude. The Chi-square/Fisher’s Exact test was used to determine the association between pharmacists' attitudes toward providing PC for patients with mental illness and their sociodemographic characteristics. The level of significance was predefined as probability values less than 0.05.

2.6 Ethical considerations

Ethical approval for the study was granted by the Health Research Ethics Committee of the University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria on February 15, 2022, with reference number NHREC/05/01/2008B-FWA00002458-IRB00002323. Written informed consent was obtained from all the study respondents. The respondents were assured that their responses would be handled with utmost confidentiality and in harmony with applicable national laws on data handling and protection. No financial incentives were given to the respondents for participating in the study. The study was generally conducted in accordance with relevant guidelines and regulations.

3 Results

3.1 Respondents’ sociodemographic characteristics

The sociodemographic characteristics of the study respondents are contained in Table 1. A total of 155 community pharmacists took part in the survey. One hundred and sixty-two community pharmacists were invited for the study, but only 155 provided valid responses, thus giving a response rate of 95.6%. More than half of the respondents were male (n = 87, 56.1%). The majority of the respondents were aged 25 to 45 (n = 125, 80.7%). More than half of the pharmacists had zero to five years of practice experience (n = 87, 56.1%). Most of the pharmacy premises visited had one or two pharmacist employees (n = 113, 72.9%). Eleven per cent of the respondents (n = 17) acknowledged that they had personally experienced a mental illness issue. Nearly a quarter of the respondents (n = 36, 23.2%) admitted knowing a family member or friend with mental illness. Regarding self-reported knowledge of mental illness, more than half of the pharmacists stated that they had “fair knowledge” of the mental disorders (n = 81, 52.3%), with fewer than four percent admitting they had poor knowledge.

Table 1 Pharmacists’ sociodemographic characteristics (n = 155)
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Table 2 shows the attitudes of pharmacists toward providing PC for patients with mental illness. The findings show that a little above half of the pharmacists (n = 80, 51.6%) had positive attitudes toward providing PC services for patients with mental illness. Specifically, nearly half of the respondents were more confident (n = 73, 47.1%), comfortable (n = 74, 47.7%), and interested (n = 75, 48.4%) in obtaining taking medication history of patients with mental illness, but only about 12.9% (n = 20) were much more likely to obtain patients’ medication history. Approximately 47% of the pharmacists were more confident in screening for pharmacotherapy problems in patients with mental illness. More than a quarter of the pharmacists (n = 53, 34.2%) were more likely to monitor for efficacy and adverse effects of psychotropic medications prescribed for patients with mental illness.

Table 2 Attitudes of Community Pharmacists’ toward Providing Pharmaceutical Care for Patients with Mental illness
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Table 3 shows sociodemographic factors associated with pharmacists' attitudes toward providing PC for patients with mental illness. The results revealed that having a family member with mental illness (p = 0.038) and self-reported knowledge of mental illness (p < 0.001) were significantly associated with pharmacists’ attitudes toward providing PC for patients with mental illness. Pharmacists who had a family member with a mental illness have a more favourable attitude toward providing PC for patients with mental illness. A higher proportion of pharmacists with self-rated good or excellent knowledge of mental illness had more favourable or positive attitudes toward providing PC for patients with mental illness.

Table 3 Factors associated with pharmacists’ attitudes toward providing pharmaceutical care for patients with mental illness
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Table 4 contained community pharmacists’ perceived barriers toward providing PC for patients with mental illness. More than half of the pharmacists agreed that a lack of patient understanding of PC (n = 80, 51.6%), a lack of knowledge of mental disorders (n = 72, 46.5%), fear or discomfort of dealing with psychiatric patients (n = 81, 52.3%, a lack of patient information (n = 82, 52.9%), and patient factors associated with their symptoms (n = 92, 59.4%). The lack of documentation skills (n = 30, 19.4%), private counselling area (n = 36, 23.2%), initiative (n = 33, 21.3%), and time constraint (n = 36, 23.2%) were among the least reported challenges for pharmacists in providing PC for patients with mental disorders.

Table 4 Barriers toward provision of pharmaceutical care
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4 Discussion

The current study sought to evaluate the attitudes and barriers of community pharmacists toward providing PC for clients with mental disorders in Enugu, South-Eastern Nigeria. The findings revealed that a little above half of the pharmacists had positive attitudes toward providing PC for mentally ill patients. A similar study in Belgium among community pharmacists reported that about 75% of the respondents had positive attitudes toward providing PC for patients with depression [25]. Another survey among 89 licensed community pharmacists in Egypt revealed that the respondents had generally positive attitudes toward providing PC for patients with depression [18]. Even so, the Egyptian study showed that pharmacists had more favourable attitudes toward providing PC for patients with physical ailments than for those with mental illnesses such as depression [18]. Comparable positive attitudes to the provision of PC for mentally ill patients were equally reported in studies among community pharmacists in Saudi Arabia, Malaysia, United States of America [22, 26, 27]. However, a study in the United Arab Emirates found that pharmacists were largely reluctant in providing PC for patients with mental illness [28].

Positive attitudes towards providing PC for patients with mental disorders were significantly associated with having a family member diagnosed with mental illness and better self-rated knowledge of mental illness. The finding that having a family member with a mental illness and having greater knowledge about mental illness are linked to positive attitudes toward providing PC for patients with mental disorders is consistent with previous research on the influence of professional expertise and personal experiences on the attitudes and perceptions of healthcare providers [29]. Research has repeatedly shown how an individual’s attitudes and behaviours toward people with psychiatric disorders are influenced by personal ties to mental illness, whether they come from personal or familial experiences [30, 31] Experiencing a family member's diagnosis of mental illness can increase compassion, knowledge, and a feeling of duty towards this patient group, which may result in more patient-centred and compassionate care methods. Moreover, the association between a better understanding of mental disease and favourable attitudes towards patient treatment highlights the significance of education and training in augmenting the proficiency and self-assurance of healthcare practitioners in handling mental health issues. Research indicates that having a sufficient understanding of mental illness helps healthcare practitioners make better clinical decisions and achieve better treatment outcomes. It also helps to dispel stigma and misconceptions about psychiatric disorders. Promoting positive attitudes and creating a supportive healthcare environment for people with mental illness can be greatly aided by educational interventions that increase awareness, knowledge, and skills linked to mental health. By bridging the knowledge gap and familiarity with mental illnesses, community pharmacists would be empowered to provide high-quality PC for patients with mental disorders.

In the current study, the most frequently cited obstacles to providing PC for mentally ill patients were: lack of patient information, poor knowledge of mental disorders, fear of working with psychiatric patients, a lack of understanding of PC, and patient factors linked to their symptoms (e.g., hostility and irritability). The current findings are consistent with those of previous studies in which pharmacists frequently cited poor knowledge of mental disorders and a lack of patient understanding of PC as major impedance towards providing PC for patients with mental illness [18, 25, 32]. Similarly, poor knowledge of mental disorders and a lack of patient information were identified as the primary obstacles to pharmacists in providing PC for persons with mental illness in a Malaysian study [27]. Community pharmacists would find it challenging to tailor interventions to patients' specific needs if they do not have a good understanding of psychiatric disorders and available pharmacotherapeutic options, thus leading to suboptimal health outcomes. The issue of patient factors associated with their symptoms and a lack of patient understanding of PC can significantly impair effective communication and cooperation between pharmacists and patients. These challenges underscore the need for some form of specialized training and continuing education to ensure that pharmacists are well-equipped to administer PC for mentally ill patients. Furthermore, Soliman similarly reported that about 54% of the pharmacists who took part in a survey felt that insufficient patient data poses a serious challenge in providing PC for patients with mental illness [18]. In the case of mental disorders, where treatment response might vary greatly among patients, the ability to tailor pharmaceutical interventions to individual needs depends critically on the accuracy and comprehensiveness of patient data. Pharmacists have expressed concern about the current systems' inadequacy or fragmentation in gathering and disseminating patient data, which could compromise patient safety and outcomes and create gaps in clinical decision-making.

4.1 Implications for practice

The results of the study emphasize the necessity of focused interventions to improve pharmacist expertise and participation in providing mental health care. Because community pharmacists are essential to the healthcare system, their optimistic outlooks are critical to increasing medication adherence among patients with psychiatric diseases and facilitating better access to mental health treatments. Policymakers and other stakeholders in the healthcare industry should give priority to programs that increase public awareness, offer education, and create supportive environments in community pharmacy settings to fully realize this potential. Community pharmacists can provide patient-centred PC by participating in training programs that address stigma reduction, communication skills, and the special pharmacotherapeutic needs of people with mental illness. This will ultimately improve patient outcomes and support holistic care for this vulnerable population.

4.2 Strengths and limitations of the study

This study provided insight into the barriers and attitudes of community pharmacists toward providing PC for patients with mental illness in a resource-limited setting with grossly inadequate mental health professionals. However, the study had a few limitations that should be considered while interpreting and applying its findings. First, the survey was conducted among community pharmacists practising in a single south-eastern state of Nigeria, although the respondents included almost all registered community pharmacy premises in the Enugu metropolis. Hence, the generalizability of the study findings to pharmacists in other states of the country may be limited due to possible variations in practice regarding caring for mentally ill persons based on culture, religion, ethnicity, and socioeconomic status. Secondly, there was a possibility of social desirability bias among the respondents, as some pharmacists might have responded in a manner to protect the image of their pharmacy premises. However, the questionnaire was anonymized to minimize this form of bias.

5 Conclusion

The findings of this study suggested that a little over half of the community pharmacists have positive attitudes toward providing PC services for patients with mental illness. Community pharmacists who had a family member with mental illness and good knowledge of mental disorders had more positive attitudes toward providing PC for patients with mental illness than those without these characteristics. However, the most commonly reported barriers to providing PC for mentally ill patients included a lack of patient information, poor knowledge of mental illness, fear of working with psychiatric patients, a lack of understanding of PC, and patient factors related to their symptoms. Therefore, this study underscored the need for increased public awareness, education and training, and the creation of a supportive environment to enable community pharmacists to thrive by fulfilling their potential to care for patients with mental disorders in Nigeria.