Mental Health.

In Nigeria, the disparity between available healthcare services and the need for mental health services is palpable. Although the country has made significant advances in challenging public health problems, health-related policy development, and legislation in trying to achieve health for all policy, there have been challenges concerning mental health services including that policy development and legislation, financing, research, training, and integration of mental health care into primary health care. We consulted relevant publications, official documents, policy statements, blueprints, and working plans of the relevant organizations responsible for mental care and services locally and globally. We identify and highlight challenges faced in mental.

INTRODUCTION  

Mental health is an integral part of health and well-being, and yet it's been neglected in this part of the world. Furthermore, the World Health Organization (WHO) estimates that worldwide, 450 million people have a mental disorder and 25% of the population will suffer from mental illness at some time in their lives. According to the WHO, mental health is; "a state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and can make a contribution to his or her community" In 2019, a survey on mental health in Nigeria, by Africa Polling Institute (API) and EpiAFRIC shows how awareness of mental health is low in Nigeria, with most respondents been aware that they have mental health disorder, recognized it and commonly caused.

WHAT IS MENTAL HEALTH? 

     Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make healthy choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood. Although the terms are often used interchangeably, poor mental health and mental illness are not the same. A person can experience poor mental health and not be diagnosed with a mental illness. Likewise, a person diagnosed with a mental illness can experience periods of physical, mental, and social well-being.

    According to the World Health Organization (WHO)Trusted Source: "Mental health is a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community." The WHO states that mental health is "more than just the absence of mental disorders or disabilities." Peak mental health is not only about managing active conditions but also looking after ongoing wellness and happiness. 

IS MENTAL HEALTH IMPORTANT FOR OVERALL HEALTH?

      Mental and physical health are equally important components of overall health. For example, depression increases the risk of many types of physical health problems, particularly long-lasting conditions like diabetes, heart disease, and stroke. Similarly, the presence of chronic conditions can increase the risk of mental illness. 

CAUSES OF MENTAL HEALTH 

     Research has shown that there is no single cause for mental illness. Several factors can contribute to the risk for mental illness, such as;

Early adverse life experiences, such as trauma, or a history of abuse (for example, child abuse, sexual assault, witnessing violence, etc.)

 Experiences related to other ongoing (chronic) medical conditions, such as cancer or diabetes.

 Biological factors or chemical imbalances in the brain.

Use of alcohol or drugs.

Having feelings of loneliness or isolation.

MEDICATION

Some people take prescribed medications, such as antidepressants, antipsychotics, and anxiolytic drugs. Although these cannot cure mental disorders, some medications can improve symptoms and help a person resume social interaction and a routine while working on their mental health. Some of these medications boost the body's absorption of feel-good chemicals, such as serotonin, from the brain. Other drugs either boost the overall levels of these chemicals or prevent their degradation or destruction. 

SELF HELP

 A person coping with mental health difficulties may need to change their lifestyle to facilitate wellness. Such changes can include reducing alcohol intake, sleeping more, and eating a balanced, nutritious diet. People may need to take time away from work or resolve issues with personal relationships that may be causing damage to their mental health. People with conditions such as anxiety or depressive disorder may benefit from relaxation techniques, which include deep breathing.

PUBLIC HEALTH APPROACHES TO VIOLENCE PREVENTION IN NIGERIA.

 

1.0 INTRODUCTION

Nigeria has a reputation for being a very violent country. In 2014, it was considered to be the seventeenth most fragile state in the world, and it was ranked 151 out of 162 countries in the Global Peace Index, a multidimensional report on violence, security, and criminality (Marc- Antonies, 2014). Literature on causes of violence in Nigeria identifies many factors among them selfishness, greed, injustice, do-or-die politics, love of money, wealth, accumulation of wealth, revolt, repression, immorality, and ignorance, etc. Violence in Nigeria in its various forms has evolved over the decades; from the use of traditional weapons, charms, and hamlets, violence in Nigeria has taken a sophisticated dimension. Political, electoral, religious, ethnic/tribal, cultism, and other forms of violence are dominant in Nigerian society, at varying degrees. Each region in Nigeria has its peculiar form of violence; in northern Nigeria, religious violence and extremist attacks are peculiar, in the South-South, militancy is popular and like extremist attacks in northern Nigeria, it has received global attention. In the Southeast, cultism ferocity, and robbery attacks are common forms of violence, while in the Southwest, political violence and thuggery are intrinsic. However, this doesn’t mean other forms of violence such as gender-based violence (rape, abuse, intimidation), and tribal clashes among others still exist across the regions of Nigeria (Rotimi, 2019).

2.0 DISCUSSION

 Accordance to the World Health Organization’s Violence Prevention Alliance1,

 ‘violence’ is the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either result in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation. This includes neglect, physical, sexual, and psychological violence, and can be interpersonal (towards a family member, partner, acquaintance, or stranger), self-directed, or committed by larger groups such as nation-states and terrorist organizations (WHO 2017c).

Addressing violence is not a single-agency issue, as it is the culmination of many different issues. It is only by pursuing a strategic, coordinated approach involving a range of agencies, including partnerships between statutory and voluntary organizations, that violent crime can be effectively addressed. Therefore, it is imperative to look into the topic of the public health approach to violence prevention in Nigeria.

     The World Health Organization (WHO) (2017a) defines a public health approach to reducing violence as one that: ‘Seeks to improve the health and safety of all individuals by addressing underlying risk factors that increase the likelihood that an individual will become a victim or perpetrator of violence. By definition, public health aims to provide the maximum benefit for the largest number of people. Programs for primary prevention of violence based on the public health approach are designed to expose a broad segment of a population to prevention measures and to reduce and prevent violence at a population level.’

  Public health approaches can be identified by the following characteristics:

• defining and monitoring the problem

• identifying causes of the problem, the factors that increase or decrease the risk of violence, and the factors that could be modified through interventions

• designing, implementing, and evaluating interventions to find out what works

• implementing effective and promising interventions on a wider scale, while continuing to monitor their effects, impact, and cost-effectiveness (WHO, 2017a).

   According to Anikweze( 1998), the perspective of public health on the Violence Prevention Alliance revolves around three theoretical models: the typology of violence, the public health approach, and the ecological framework. These models guide understanding, research, and action for violence prevention. The typology is a tool to help organize thinking about the types of violence and how violence occurs. The public health approach offers practitioners, policymakers, and researchers a stepwise guide that can be applied to planning programs, policies, and investigations. Finally, the ecological framework bridges these two models, giving a structure to understanding the contexts within which violence occurs and the interactions between risk factors in each of these contexts and between them. The ecological framework shows where and how to apply the public health approach and is useful for categorizing planned or existing interventions to help understand the mechanisms by which they might be working, John et al (2001).

 2.1 Public health approach to violence?

Public health approaches work by providing a framework that seeks to understand what causes violence and respond with interventions to prevent or reduce violence, at the population level, informed by the best available evidence. Public health approaches undertake robust research and analysis to identify risk and protective factors that are associated with violence. Definitions of risk and protective factors are presented below.

• Risk factors are those which can usefully predict an increased likelihood of violence. For example, communities with high levels of unemployment may be at higher risk of experiencing increased levels of violence.

• Protective factors are factors that reduce the likelihood of violence. For example, communities with low levels of unemployment may be at less risk of experiencing high levels of violence. 

2.2 Effectiveness of public health approaches in reducing violence?

The public health approach outlined above provides a useful framework for taking an evidenced-led approach to violence reduction. As well as approaches to generating evidence concerning the causes of violence in populations, a public health approach can also deploy a range of interventions aimed at reducing violence at the population level (CDC,2006).

2.3 Interventions aimed at supporting parents and families

• The Family Nurse Partnership

• Incredible Years of Preschool

• Family Foundations

• Triple P

• Empowering Parents

Empowering Communities

Developing life skills in children and young people

• The Good Behaviour Game

• Incredible Years Child Training (Dinosaur School)

• Incredible Years of Teacher Classroom Management

• Promoting Alternative Thinking Strategies (PATHS)

• Let’s Play in Tandem

Working with high-risk youth and gangs/community interventions

• Community Initiative to Reduce Violence (CIRV)

Identification, care, and support

• Identification and referral to improve safety (IRIS)

Multi-component interventions

• Multisystemic therapy Obi (2007).

2.3 Steps of the public health approach

Adapted from CDC (2015)

When considering public health approaches and the implementation of interventions to reduce violence, we consider the following:

1. Surveillance. What is the problem?

• Define the issue. This includes conducting a robust needs assessment concerning violence, including types of violence as well as gaining a clear understanding of risk and protective factors that can be targeted in individuals, families, communities, and populations to address and reduce violence at a population level.

2. Identify risk and protective factors. What are the causes?

• Understand the causes of violence.

This includes taking an evidence-led approach to understanding which risk and/or protective factors cause the violence issue and how they interplay. Through achieving this understanding, local areas are more likely to be successful in implementing public health interventions that effectively moderate and address risk factors and strengthen protective factors, ultimately reducing violence at a population level.

3. Develop and identify interventions. What works for whom?

• Develop an anti-violence or reducing violence strategy. Critically, this strategy should respond to an identified need in the population under consideration and focus on addressing the causes of violence. The strategy should be developed and agreed upon between stakeholders and be Specific, Measurable, Achievable, Relevant, and Timebound. The strategy should link to the wider strategic and policy context and include collaborative and co-productive development with local partners, including the local community, which should ensure local ownership of the strategy and help to ensure that it is implemented as intended.

• Commission and fund evidence-based interventions that have been shown to reduce violence. Where possible, local areas should consider commissioning and funding evidence-based interventions that have been shown to reduce violence.

• Don’t be afraid to innovate.

If there are no off-the-shelf’ evidence-based interventions available, then interventions should be developed based on existing evidence for what works in modifying risk and protective factors for the particular kinds of violence problem that the area is aiming to address.

4. Implementation. Scaling up effective programs and interventions

• Implement interventions ensuring that fidelity is maintained in line with what has been demonstrated to work.

Model fidelity means ensuring that the model implemented stays loyal and is delivered as close to the original model as possible. This requires careful consideration when taking into account the context into which the intervention is being rolled out. Not ensuring model fidelity is one of the key reasons why the implementation of interventions that have been evidenced to work in one area do not work in another.

• The implementation of interventions takes time to embed in practice and to achieve outcomes.

Local decision-makers need to provide sufficient time for programs and interventions to impact desired outcomes. It can sometimes take over five years for programs to achieve outcomes.

• Evaluate and monitor the success of public health interventions.

This review shows that there is still work to be done in developing and evaluating public health interventions aimed at reducing violence at a population level. Although resources are often tight, you should aim to contribute to the evidence base by ensuring robust evaluation of public health interventions that are commissioned and funded. Robust evaluation can save money by clearly identifying models and practices that work, but also showing what does not work. Knowing this can save money and use scarce resources more effectively in the long term.

Public health interventions operate by modifying the risk factors that make an individual, family, or community vulnerable to violence (as victims, perpetrators, or both) and by promoting protective factors. 

2.4 The ecological framework

The ecological framework is based on evidence that no single factor can explain why some people or groups are at higher risk of interpersonal violence, while others are more protected from it. This framework views interpersonal violence as the outcome of interaction among many factors at four levels—the individual, the relationship, the community, and the societal.

1. At the individual level, personal history and biological factors influence how individuals behave and increase their likelihood of becoming a victim or a perpetrator of violence. Among these factors are being a victim of child maltreatment, psychological or personality disorders, alcohol and/or substance abuse, and a history of behaving aggressively or having experienced abuse.
2. Personal relationships such as family, friends, intimate partners, and peers may influence the risks of becoming a victim or perpetrator of violence. For example, having violent friends may influence whether a young person engages in or becomes a victim of violence.
3. Community contexts in which social relationships occur, such as schools, neighborhoods, and workplaces, also influence violence. Risk factors here may include the level of unemployment, population density, mobility, and the existence of a local drug or gun trade.
4. Societal factors influence whether violence is encouraged or inhibited. These include economic and social policies that maintain socioeconomic inequalities between people, the availability of weapons, social and cultural norms such as those around male dominance over women, parental dominance over children, and cultural norms that endorse violence as an acceptable method to resolve conflicts.

The ecological framework treats the interaction between factors at different levels with equal importance to the influence of factors within a single level. For example, longitudinal studies suggest that complications associated with pregnancy and delivery, perhaps because they lead to neurological damage and psychological or personality disorder, seem to predict violence in youth and young adulthood mainly when they occur in combination with other problems within the family, such as poor parenting practices. The ecological framework helps explain the result—violence later in life—as the interaction of an individual risk factor, the consequences of complications during birth, and a related risk factor, the experience of poor parenting. This framework is also useful to identify and cluster intervention strategies based on the ecological level in which they act. For example, home visitation interventions act at the relationship level to strengthen the bond between parent and child by supporting positive parenting practices.

The ecological framework: examples of risk factors at each level

Adapted from WHO (2017b)

2.5 Types of public health interventions for violence prevention/reduction

Central to an effective public health approach to reducing violence is the implementation of interventions that successfully address risk and protective factors in individuals, families, communities, and populations to reduce violence at a community and/or population level.

However, definitions varied and there was no clear consensus or definition as to what constitutes a public health intervention to reduce violence, apart from that it should reduce violence at the community and/or population level.

Conaglen and Gallimore (2014) describe violence prevention interventions as operating on various levels (primary, secondary or tertiary) and define interventions to address violence as universal, selected, or indicated.

  2.6 Levels of violence prevention

Adapted from WHO (2019)

Primary – preventing violence before it happens, i.e., reducing the number of new cases of violence in the population.

Secondary – immediate responses to incidents of violence to decrease prevalence after early signs of the problem, i.e. to reduce the prevalence of violence in the population.

Tertiary – to intervene once the violence problem is evident and causing harm.

Types of intervention to address violence

Universal – aimed at a general population

Targeted selected – targeted at those more at risk

Targeted indicated – targeted at those who use violence

While the WHO, Bellis et al. (2012) and others provide clear definitions of public health approaches, there is less clarity in the literature about what kinds of interventions fall within the scope of a public health approach. This is complicated by the fact that the position of an intervention in the matrix (i.e., primary, secondary, tertiary, universal, targeted selected, targeted indicated) is rarely explicit. However, public health interventions, like public health approaches should seek to reduce violence at a community and/or population level. 

3.0 CONCLUSION

     The preceding discussions have shown that violence is an ill wind of social phenomenon, which blows no one any good. In its aftermath both its perpetrators and victims are losers. As a way out of the mess, Nigerian policymakers should imbibe the public health approach while working on violence prevention and reduction in the country.

 

 

References

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 CDC (2006) Intimate Partner Violence – fact sheet. Retrieved Oct. 2008

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 Richie, O. N. 8 Straus, M. (1994) Beating the devil out of them; Corporal Punishment in American families. New York. Lexington Books   

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 UNICEF (2005) Violence at home (archive) Voices of Youth Forum. Retrieved Oct. 2008

 Dahlberg LL, Krug EG. Violence: a global public health problem. In: Krug E, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, eds.

World Report on Violence and Health. Geneva, Switzerland: World Health Organization; 2002:1-21.