Study setting

Nigeria is made up of 36 states and the Federal Capital Territory. The states which serve as the second tier of government are distributed among the six geo-political zones of the country. This research took place in three states, two of which are in southeast geo-political zone, (Enugu and Anambra states) and one state in north-central geo-political zone, (Nasarawa state). Nigeria has a total of 774 local government areas (LGAs) which are the third tier of government. The study was conducted in 10 local government areas; four are in Anambra state (Awka North, Awka South, Nnewi North and Onitsha South); another four in Enugu state (Awgu, Enugu East, Enugu North and Igboeze North) while two LGAs (Eggon and Keffi) were included from Nasarawa state. The three states were selected because they have similar TB case notification rates and the availability of tertiary health institutions for the referral and management of issues related to mental health. Anambra and Enugu states are in the tropical rain forest while Nasarawa state lies in the Guinea savannah. Igbo language is the main local language in Enugu and Anambra states while in Nasarawa state, the common local languages include Agatu, Basa, Eggon and Gbayi.

In the current standard of care, the patient pathways for TB and MH/SUD services in Nigeria are unlinked and totally independent. While the siloed delivery of TB services is provided at community and primary, secondary and tertiary facility levels in all the states, only specialized entry points like psychiatric hospitals and psychological medicine departments in tertiary health facilities currently offer MH/SUD services where all types of mental health disorders are taken care of. In the context of this study, integrated service delivery was provided at the health facility and community levels. In the health facility level, it meant screening all presumptive TB cases for MH/SUD and also screening individuals presenting at MH/SUD clinics for TB. All the screenings were also carried out at the community level and all individuals who were positive for any of the three disease entities received treatment services.

Study design, participants and sampling

This was a community-based cross-sectional study design using a qualitative data collection method.

Study population

One hundred and sixteen individuals participated in twelve focus group discussions (FGDs). Half of the participants were patients who were beneficiaries of the integrated delivery of TB/MH/SUD services in the project states while the other half were their relatives and caregivers during the period of management. Four FGDs were conducted in each of the three states selected for the study. The FGDs were conducted separately for patients and their relatives and for each of the groups, there were separate FGDs for the male and female participants.

Sampling

Purposive sampling was used for the selection of the participants for the study. Each of the selected beneficiaries of the integrated service delivery program was requested to come for the interview with the caregiver that accompanied him/her during the period he/she benefitted from the program. None of the participants selected for the study declined to participate.

Study instrument and data collection method

Information from the participants was obtained with the use of a pre-tested FGD guide which included questions on the advantages and disadvantages of integrated service delivery and their acceptability of community-based integration by lay health workers. The pre-testing was done in a community not selected for the study. The intention in pre-testing the study tool was to identify and correct ambiguities in the study instrument where they do exist. The FGDs were conducted using English language or the prevailing local language in the community as the case may be. The discussions took place in public places in the communities including town halls and primary schools. All the discussions were recorded digitally. A note taker was also available to take notes manually. Healthcare workers working in the facilities that were used for the integrated service delivery and community guides assisted the research team in the selection of the participants for the study. They related between the research team and the participants all through the study and were also involved in the selection of a suitable date for the discussion. Follow-up questions using probes were applied during the FGDs as way of obtaining more detailed explanations from the participants. The average duration of the discussions was 55 minutes. No FGD was repeated. Data saturation was reached during the FGDs as no new information was obtained.

Two Authors moderated the FGDs. Both are Fellows of the West African College of Physicians (WACP), Faculty of Community Health. They are both Senior Lecturers, one at Ebonyi State University Abakaliki, Nigeria while the second is a staff of Alex Ekwueme Federal University Ndufu-Alike, Ikwo, Ebonyi State, Nigeria. Both are male and have some experience in qualitative studies [24–27].

Data management

The recorded discussions of FGDs were transcribed verbatim after each session. In cases where the discussion was done using the local language, translation into English language was done. For quality assurance purposes, the scripts were compared with the written notes for completeness and accuracy. Then each script was checked against the audiotape by an independent reviewer. As a way of verifying the quality of transcriptions, the recordings were doubly transcribed. The scripts were then checked for similarity and where differences existed, these were reconciled by the transcribers. Data was analyzed thematically. Coding of transcripts was done by two of the researchers and based on pre-determined and emergent themes during the coding process. The pre-determined themes were derived from the study objectives. The process of thematic analysis included familiarization with data, generating initial codes, searching for themes, reviewing, defining and naming themes and report writing [28]. QDA Miner Lite v2.0.6 was used in the analysis of the data.

Ethical consideration

Ethical approval for the study was obtained from the Health Research Ethics Committee of University of Nigeria Teaching Hospital Ituku Ozalla, Enugu, Nigeria (Reference number, NHREC/05/01/2008B-FWA00002458–1RB00002323). The recruitment of participants and data collection for the study took place from August to October 2024. Before the participants were recruited into the study, they were required to sign a written informed consent form. The nature of the study, its relevance and the level of their involvement were made known to them. Participation in the study was voluntary, and participants were informed that they were free to withdraw from the study even after giving consent to participate. The participants were also informed and assured that information provided during the discussion is strictly for research purposes and will be kept confidential and treated anonymously.

Participants’ profile

The age of the participants ranged from 29 to 61 years with a mean age of 45 years. Half of the participants were male. Half of the participants were patients treated during the integrated delivery of TB/MH/SUD services while the remaining half were their relatives/caregivers. Most of the participants, 58% had secondary education. Most of the participants, 64% were self-employed.

Themes

Three themes emerged from the FGDs including perceived value of integrated TB/MH/SUD service delivery, perceived benefits and barriers to integrated service delivery and the acceptability of community-based Integration through lay health workers.

a.Perceived value of integrated TB/MH.SUD service delivery

Almost all the participants perceived integrated service delivery of TB/MH/ SUD to be a good program. This was based on the wonderful results they have seen from the implementation of the program and their understanding that the three disease conditions are linked to one another hence it may not be the best to manage each condition in isolation. The participants largely opined that it made sense for the three health services to be delivered together in an integrated approach.

‘The three diseases do not occur in isolation, by taking care of the three diseases together you have given the person complete treatment’. (Male/PT/03/06).

‘Most of the people that have TB, they do have mental health issues because of the marginalization that is associated with the disease. Some people if they find out you have TB, the way they even treat you will affect your mental health’. (Female/PL/02/04).

‘What I like the most in this combination (referring to ISD) is that TB may lead to mental disorder, mental disorder has a connection with addiction. So, if you place the diseases properly, it helps to explain that you cannot separate TB from mental health and substance abuse disorder’. (Male/PT/02/07).

There were some remarkable comments about the health workers and their activities during the period of the integrated service delivery. The participants affirmed the good provider attitude of the healthcare workers that were involved in the implementation of TB/MH/SUD service delivery. These were how the participants exemplified their thoughts:

‘I like the program and it is acceptable to me because of the counselling. I was a drug addict but have stopped. I will continue to go to the health facility so that I can know more about the effects of drug abuse & mental disorder. The counselling I received from the health workers changed my life for good.’ (Male/PT/01/02).

What made the service delivery good was the encouragement they (referring to the healthcare workers) provided. Like me, when I started my own treatment, I thought there was no hope, but they kept on encouraging me. Through their help, I got better and today, I am well.’ (Female/PT/03/09).

One of the participants who was pleased with the integrated service delivery pleaded that the services, especially the management of mental health disorder should be extended to all primary health centers in the state.

b.Perceived benefits and barriers to integrated service delivery

bi. Benefits

Most of the participants were of the impression that the integrated service delivery had more advantages than disadvantages. The major advantage of the integrated service delivery as expressed by the participants was the reduction in cost especially that of transportation. Also, a reduction in stress of moving from one health facility to another especially when one is seriously ill. There was a remark that stress is also part of mental health disorder. It was also said to save time. These were how the participants made their views known.

‘The benefit is first of all less expenses on transportation and less stress because moving from one hospital to another will add more stress to the person who is sick already. Then, staying in the same hospital to treat three diseases is like using one stone to kill three birds.’ (Female/PT/03/03).

‘We prefer to receive the treatment for the three diseases in one place because a seriously ill patient will not be able to move from place to place accessing isolated services for TB, mental health and substance use disorder.’ (Male/PT/01/10).

‘The advantage is that it saved time and resources receiving the treatment in one place instead of going to three different places. If you receive treatment in one place, it saves time and also resources because of transportation.’ (Male/PL/02/21).

The next advantage from the views of the participants was that all the treatment they received in the integrated service delivery approach was free.

‘It is free treatment for the treatment of three diseases in one place. It is a good thing and I am happy about it. The only cost that we had to bear was that of transportation only.’ (Male/PT/03/14).

There were observations among the participants that the integrated service delivery has increased the awareness of tuberculosis, mental health and substance use disorders among the people. This was seen as a way of reducing the spread of the diseases.

‘Another advantage is the increase in public awareness of these three diseases. This approach has made us know that these three disease conditions could exist together. So, the increase in public awareness is one of the advantages and when you have good public awareness of a disease, the rate of occurrence of the disease condition will be reduced’. (Male/PT/03/12).

There was the affirmation of good treatment outcome from the integrated service delivery approach. One of the participants viewed the integrated service delivery as a form of balanced diet.

‘One is that it will gave good results because the diseases were followed up one after the other. It’s like what is called balanced diet. Because when you are able to get treated for this, this and that, at the same time you get maximum benefit and result.’ (Male/PL/02/19).

The participants also viewed the integrated service approach as an opportunity for being screened for other disease conditions which the person may not be aware of.

‘The arrangement gave one the opportunity of being tested for the three disease conditions at the same time. For example, some people had TB and mental health issues at the same time without knowing it.’ (Female/PL/01/16).

Based on the observation that the three diseases are linked there was agreement among the participants that the treatment of the three disease conditions should not be in isolation.

‘If one goes to different places for the treatment, the health workers will manage mental health in isolation and tuberculosis in isolation so the linkage will not be there. But when the individual is managed in the same place, the health workers will be able to link the three diseases together and make a better treatment’. (Male/PT/03/11).

Two of the participants noted that even if the patients are managed by different doctors in the same health facility, that the doctors will put their knowledge together for the good of the patient. Thus, it was concluded that the patients will recover faster if integrated service delivery is in place.

bii. Barriers

Even though a number of participants insisted that the integrated service delivery had no disadvantages, some of the participants expressed some disadvantages. Most of the participants who spoke on the disadvantages were concerned about the safety of persons with mental health disorder since TB is infectious. This was how one of the participants made his views known:

‘Mental health is not an infectious disease but tuberculosis is infectious. If the individuals that have the two diseases are treated in one place, someone with mental health might be infected with tuberculosis which is now a disadvantage.’ (Male/PL/03/09).

One of the participants also pointed out that someone with TB moving from one health facility to another perhaps for treatment of mental disorder could also spread TB infection to others. Some of the participants were concerned about the specialization of the medical personnel who will be attending to people with TB, mental health and substance use disorders. There was a remark that each doctor should focus on his own specialty instead of being jack of all trade. It was said that in a teaching hospital, each doctor stays in his/her department and takes care of people in his/her own chosen field.

‘There are doctors that treat TB and may not treat one with mental health condition and doctor that treats a mental disorder cannot see someone with eye problems and treat it, so everyone has an area of specialization. So, let everyone stay in his own side, let them separate i. If you are depressed you go to doctor for depression and if you are suffering from TB, the doctor for TB will take care of you.’ (Female/PT/02/06).

A few of the participants who spoke on the disadvantages of integrated service delivery pointed out that it increased the waiting time in the health facilities.

‘The disadvantage is that this approach increased the time spent in the health facilities unlike before and some people do not want to stay long when they come to the hospital, they will say they are wasting their time in the queue. Iif the services are provided in different places, if you have this condition you can go to this place and if you have the other condition you can go to the other place that will ensure that people do not waste time in the health facilities.’ (Female/PL/01/18).

In the light that there may be more work for the healthcare workers based on the integrated service delivery approach which may lead to an increase in waiting time, one of the participants who supported the integrated service delivery recommended that the government should employ more healthcare workers so as to reduce the waiting time in the hospitals designated for such services.

It is important to point out that the perception of mental health by the participants influenced their decision on integrated service delivery. The participants who viewed patients with mental health disorder as ‘mad’ or ‘one whose head is not good’ wondered how such group of people should be kept in the same area with TB patients. One of the participants pointed out that patients with mental health disorders may require to be chained and as such should be managed separately. However, the participants who viewed mental health differently were of the opinion that integrated service delivery is ideal since most TB patients because of the disease may have mental health issues. There was also a position by the participants that a good mental health is necessary to achieve a good adherence to treatment.

c.Acceptability of community-based integration through lay health workers

Most of the participants were in support of patronizing integrated service delivery at the community level from trained lay health workers. Most of them who expressed willingness to patronize the services of the lay health workers said they will do so only if the government is involved in establishing such treatment centers in the communities. The participants were sure that if the government is involved in the program, the lay workers will be adequately trained and equipped with the requisite laboratory tests and medicines. They were certain that government would create the needed awareness among the people of the existence of such treatment centers. Furthermore, the services will be free of charge or at least affordable. There was an affirmation that the government cannot harm its own citizens and that providing such services at the community level is the responsibility of government and also the right of the citizens. These were how the participants expressed their views:

‘Such a community-based program is good because it is a thing like this that government should do for the people in rural communities because if you go there, you will see that the people are really suffering there. Some of them don’t even have good drinking water. So, it is good because it will help them. It is a good idea.’(Female/PL/01/07)

‘Government will not do harm to anyone and it is also our right as citizens to have access to healthcare. Anything that government is doing will be of good quality, the drugs that they will provide will be for the benefit of the members of the community. So I will go there for treatment.’ (Female/PT/02/09).

The next major reason for patronizing the community lay health workers by the participants is that it is an opportunity to bring such services closer to the people and that will help save lives, time, transportation cost and stress among the rural dwellers.

‘What makes it good is that, it will save time, if they decide to treat the diseases in the rural communities. It will also save the people the stress of moving to the urban areas every time they are sick.’ (Male/PT/ 03/15).

‘Yes, the idea is good, because anyone that knows that they have such a facility in the village, will go to the village. You stay there and take your medication; it will save you the stress of coming down to the township, it will save you the cost of transportation and stress.’(Female/PL/01/14).

One of the participants made known the steps he will take to find out if the lay health workers are trained before he will patronize their services. He said this bearing in mind his experience as someone who has been treated for TB.

‘I will go the community center. My reason is that, when I get there, if I tell them what is wrong with me and if they bring out drugs to give me, I will tell them no— they should do a lab test. When they do the lab test, I will know that they know what they are doing. If they say no and insist that I should take the drug, if I collect the drug, I will throw it away on the road’. (Male/PT/03/07).

Two of the participants were of the opinion that the government should provide the lay workers with uniforms or aprons like the ones worn by individuals who take part in house-to-house immunization services. The impression is that the uniform or apron will make the community members know that they are sent by the government and they have received the necessary training to enable them to perform their duties.

‘They should be on uniform even if it is an apron like these people that go to give immunization. Then we can say it is government that sent them. If they did not give them uniform or apron maybe people will not allow them to treat their children.’ (Male/PL/03/10).

One of the participants suggested that the duty of the lay health workers should be to help create awareness of the three diseases including TB, mental health and substance use disorders among the people and not to offer treatment services to individuals.

The few participants who have in mind not to patronize the services of the lay health workers said they will not go there because they are not doctors.

‘It is not a good idea because they are not doctors, they didn’t go to any school. If they give you medicine, it won’t work; they may in a bid to give you drugs, give you an overdose.’ (Male/PT/03/08).

Another concern raised by the participants is why the government will not use the opportunity of the community-based program to employ health workers instead of using lay health workers.

‘There are many health workers looking for work, why not pick them instead of using lay health workers. The health workers went to school but are neglected and their job given to others to do. Why? Let health workers do their job. For me, if anyone didn’t go to school, I will not allow him to treat me.’ (Male/PT/01/09).

Two of the participants pointed out that the lay health workers will collect money from the people even if the government instructs them not to do so. One of the participants said when a community person is involved in matters related to health in the same community, they tend to focus on their own family members instead of everyone.