CHAPTER 1

INTRODUCTION

According to the World Health Organization (2014), mental health is defined as a

state of well-being in which every individual realizes his or her own potential, can cope

with the normal stresses of life, can work productively and fruitfully, and is able to make

a contribution to her or his community. Mental illness refers to a wide range of mental

health conditions — disorders that affect your mood, thinking and behaviour (Mayo

Clinic, 2015).

The World Health Organization (2017) estimated that between 35 percent and 50

percent of people with severe mental health problems in developed countries, and 76 – 85

percent in developing countries, receive no treatment. According to the WHO fact

sheet for 2017, suicide is the second leading cause of death among 15 to 29-year-olds,

and 78 percent of global suicides occur in low and middle-income countries. WHO

(2013) mentioned that the 66th World Health Assembly adopted the WHO’s

Comprehensive Mental Health Action Plan 2013-2020 in May 2013.

In a 2017 report by WHO, the age-standardized suicide rate in the Philippines is

5.8 for male, 1.9 for females, and 3.8 for both sexes. The rate is based from the number of

cases affected per sample size of 100,000 people. The Department of Health (2007)

issued an administrative order on mental health program. The objective of this mental

health program is to provide general guidelines for stakeholders in the government and

Assessment of the Implementation of Mental Health Programs in the Selected Barangays in Cotabato City 1
private sector on the development and implementation of the National Policy on Mental

Health through plans and programs, in order to protect the rights and freedom of persons

with mental disease, thereby reducing the burden of mental and neurological disorders in

the country.

As a lone psychiatrist in the Cotabato City, Dr. Apostol (2017) claimed that she

encounters patients suffering from mental health problems every day. She further said

that the mental health illnesses are alarming in Cotabato City due to the increase of

patients that she encounters every day. An interview done to one of the nurses in Office

of City Health in Cotabato City, accordingly they had a training last 2016 about Mental

Health Gap Action Programme (mhGAP), and it was started last 2017, however it was

not activated fully.

Engaging in an invisible war to combat an invisible illness requires patience. Thus

this program was initiated by the Department of Health (DOH) which has the primary goal

of quality mental health care. But the question is, is the program properly disseminated to

the public? Are they aware of its existence? Are they availing on these service? Grounded

on these premises, merit the need to conduct the study. It will shed light to all these queries

and help improve mental/psychologic well-being of many residents in Cotabato City.

Review of Related Literature

This chapter contains relevant literature and concepts providing insights and

comprehensive background to the present investigation.

Assessment of the Implementation of Mental Health Programs in the Selected Barangays in Cotabato City 2
Mental Health

Mental health is defined as a state of well-being in which every individual realizes

his or her own potential, can cope with the normal stresses of life, can work productively

and fruitfully, and is able to make a contribution to her or his community (WHO, 2014).

The positive dimension of mental health is stressed in WHO's definition of health as

contained in its constitution: "Health is a state of complete physical, mental and social

well-being and not merely the absence of disease or infirmity".

Therefore, WHO (2016) agreed that mental health and well-being are

fundamental to our collective and individual ability as humans to think, emote, interact

with each other, earn a living and enjoy life. Hence, on this basis, the promotion,

protection and restoration of mental health can be regarded as a vital concern of

individuals, communities and societies throughout the world.

According to Nordqvist (2017), mental health refers to our cognitive, behavioral,

and emotional wellbeing - it is all about how we think, feel, and behave. The term 'mental

health' is sometimes used to mean an absence of a mental disorder. Likewise, he believed

that mental health can affect daily life, relationships, and even physical health. Mental

health also includes a person's ability to enjoy life - to attain a balance between life

activities and efforts to achieve psychological resilience.

Mental Health Illness

Mayo Clinic (2015) discussed that mental illness refers to a wide range of mental

health conditions — disorders that affect the mood, thinking and behavior. Examples of

mental illness include depression, anxiety disorders, schizophrenia, eating disorders and
Assessment of the Implementation of Mental Health Programs in the Selected Barangays in Cotabato City 3
addictive behaviors. Many people have mental health concerns from time to time. But a

mental health concern becomes a mental illness when ongoing signs and symptoms cause

frequent stress and affect your ability to function (Mayo Clinic, 2015).

According to Center for Disease Control and Prevention (CDC), mental illnesses

refer to disorders generally characterized by dysregulation of mood, thought, and/or

behavior, as recognized by the Diagnostic and Statistical Manual, 4th edition, of the

American Psychiatric Association (DSM-IV). Mood disorders are among the most

pervasive of all mental disorders and include major depression, in which the individual

commonly reports feeling, for a time period of two weeks or more, sad or blue,

uninterested in things previously of interest, psychomotor retardation or agitation, and

increased or decreased appetite since the depressive episode ensued (CDC, 2016).

WHO (2014) stated in its report “Health for the World’s Adolescents"

that depression is the predominant cause of illness and disability for both boys and girls

aged 10 to 19 years old. Further, Mayo Clinic (2016) pointed out that women are nearly

twice as likely as men to be diagnosed with depression. Some mood changes and

depressed feelings occur with normal hormonal changes. But hormonal changes alone do

not cause depression. Other biological factors, inherited traits, and personal life

circumstances and experiences are associated with a higher risk of depression.

Furthermore, Makvana (2016) reported that 44 percent of college students have

one or more symptoms of depression. This startling statistic shows that hits depression

faced by nearly half of all college students could lead to more complex mental health

issues without the proper counseling to help them identify the source of their depression.

Assessment of the Implementation of Mental Health Programs in the Selected Barangays in Cotabato City 4
 According to Goldberg (2012), the causes of mental illnesses include heredity or

genetics. He also mentioned biology as another reason since some mental illnesses have

been linked to an abnormal balance of brain chemicals called neurotransmitters. Some

mental illnesses may be triggered by another factor, the psychological trauma suffered as

a child, such as severe emotional, physical, or sexual abuse. Lastly, he added

environmental stressors wherein a death or divorce, a dysfunctional family life, changing

jobs or schools, and substance abuse.

Gender is a critical determinant of mental health and mental illness. The

morbidity associated with mental illness has received substantially more attention than

the gender specific determinants and mechanisms that promote and protect mental health

and foster resilience to stress and adversity. WHO further added that gender determines

the differential power and control men and women have over the socioeconomic

determinants of their mental health and lives, their social position, status and treatment in

society and their susceptibility and exposure to specific mental health risks (WHO, 2014).

In most parts of the world, unfortunately, mental health and mental disorders are not

regarded with anything like the same importance as physical health. Indeed, they have

been largely ignored or neglected (WHO, 2003).

A report made by WHO in 2012 that misunderstanding and stigma surrounding

mental ill health are widespread. Despite the existence of effective treatments for mental

disorders, there is a belief that they are untreatable or mentally-ill people are

dysfunctional to the community. This stigma can lead to abuse, rejection and isolation

and exclude people from health care or support. In the Philippines, Francisco (2017)

addressed the concern regarding mental health issue which still remains a misunderstood

Assessment of the Implementation of Mental Health Programs in the Selected Barangays in Cotabato City 5
topic for some Filipinos. Ferrolino (2017) added that people with mental illness are often

discriminated. Likewise, this stigma in the local setting only shows that a lot of Filipinos

lack proper information about mental health. Thus, the social distance between the public

and mentally ill people is getting farther. He claimed that in the Philippines, access to

mental health facilities and institutions remains uneven throughout the country. Within

the health system, people are too often treated in institutions which resemble human

warehouses rather than places of healing. In addition, they claimed that human rights

violations of people with mental and psychosocial disability are routinely reported in

most countries. These include physical restraint, seclusion and denial of basic needs and

privacy. Few countries have a legal framework that adequately protects the rights of

people with mental disorders.

According to Cabrido (2017), with the sudden increase in suicide rates in South

Cotabato, the Integrated Provincial Health Office capacitates its health workers to create

strategies, benefitting those suffering from mental illness. The Mental Health Program

Coordinator, Jade Javellana said a private partner collaborates with the Lake Sebu

Municipal Health Officer Dr. Jospehine Bayquin to capacitate health workers and build

up efforts for potential medical actions. South Cotabato recorded 21 incidents of suicide,

15 are males and six are females (Cabrido, 2017).

Hopeline, a 24/7 suicide prevention hotline was launched last 2016. Online,

concerned citizens pass around hotlines and resources to refer psychiatrists and mental

health resources to each other both an indication of how much of a problem it is in the

Philippines, and how Filipinos are now starting to openly seek help (Francisco, 2017).

Assessment of the Implementation of Mental Health Programs in the Selected Barangays in Cotabato City 6
Mental Health Program

The Department of Health (2007) issued an administrative order on mental health

program. The objective of this mental health program is to provide general guidelines for

stakeholders in the government and private sector on the development and

implementation of the National Policy on Mental Health through plans and programs, in

order to protect the rights and freedom of persons with mental disease, thereby reducing

the burden of mental and neurological disorders in the country.

The program which the DOH has implemented has general guidelines which

composes of 3 areas. First is the National Objectives for Health and F1 encompasses

mental health and applies to the promotion of mental health. The goals of the mental

health program as follow: reduce mental health prevalence; reduce mortality from suicide

and intentional harm, and reduce the risk for mental disorder. This area also comprises

the service delivery which summarizes the enhancement of the mental health services and

facilities, improvement of the healthcare providers’ competencies, and strengthening of

the program in school and workplace. In terms of financing, it primarily focused on the

benefit package and funding for resources. As for the regulation, there will a coordination

with the Bureau of Health Facilities Services. For the governance, it tackles more on their

goals on the sustainability and enhancement of the program. Next area is the National

Mental Health Program focuses on four sub-programs. First is the Wellness of Daily

Living which is done by promoting the healthy lifestyle giving emphasis on coping with

stress and other psychological issues. Second is the Extreme Life Experience that focuses

on addressing the mental health needs of the people who experience catastrophes. Third

is the Substance Abuse and Other Forms of Addiction. Fourth is the mental disorder

Assessment of the Implementation of Mental Health Programs in the Selected Barangays in Cotabato City 7
which focuses on the promotion of mental health and prevention of mental illness (DOH,

2007).

Santos (2016) reported that Health Secretary Paulyn Ubial signed an

administrative order (AO) on the implementation of the agency’s mental health program.

In an interview, Ubial said that the administrative order contains a comprehensive

framework of how the mental health program will be implemented at all levels of the

health system, like health rural unit, the barangay health station, and even in the

community.

In May 2013, the WHO’s Comprehensive Mental Health Action Plan 2013-2020

was initiated. The Action Plan recognizes the essential role of mental health in achieving

health for all people (WHO, 2015). It indicates, as one of its principles that mental health

strategies and interventions for treatment, prevention and promotion need to be based on

scientific evidence and/or best practice, taking cultural considerations into account. As a

consequence, the WHO launched Mental Health Gap Action Programme (mhGAP) in

2008 with the primary goal of increasing the services for mental, neurological and

substance use (MNS) disorders for countries with low- and middle- income (WHO,

2015). Its implementation is based on mhGAP products, including the evidence based

guideline for MNS disorders, Mental Health Gap Action Programme Intervention Guide

(mhGAP-IG) and accompanying training and implementation materials (WHO, 2015).

These are the objectives of mhGAP guideline: (1) to provide latest WHO guidance to

facilitate delivery of interventions; (2) to assist with the increasing of care for MNS

disorders identified with high priority in Low- and Middle-Income Countries (LAMICs);

Assessment of the Implementation of Mental Health Programs in the Selected Barangays in Cotabato City 8
(3) to provide latest WHO guidance that will ease the implementation of WHO

Comprehensive Mental Health Action Plan 2013-2020.

According to WHO (2010), the mhGAP-IG is a model guide wherein the users

may select a subset of the priority conditions or interventions to adapt and implement,

depending on the context (WHO, 2016). It includes guidance on evidence-based

interventions to identify and manage a number of priority conditions. The priority

conditions included are depression, psychosis, bipolar disorders, epilepsy, developmental

and behavioural disorders in children and adolescents, dementia, alcohol use disorders,

drug use disorders, self-harm / suicide and other significant emotional or medically

unexplained complaints. The mhGAP-IG contains modules that serve as toll for clinical

decision-making and management. Each module contains three section: Assessment,

Management, and Follow-up. In the assessment section, it starts with common

presentations of the suspected condition, from which there are a series of clinical

assessment questions one should move down answering yes or no, which directs the user

to move on for further instructions to reach a final clinical assessment. Next, the

Management section consists of intervention details which provide information on how to

manage the specific conditions that have been assessed. Lastly, the Follow-up section

provides detailed information on how to continue the clinical relationship and detailed

instructions for follow-up management (WHO, 2016).

WHO (2017) acknowledged the mhGAP training as it is a training which is being

collaborated between the World Health Organization, the Department of Health, and

local government units to strengthen the mental health services in local communities in

the Philippines. Furthermore, over a few years, non-specialized health workers in all 18

Assessment of the Implementation of Mental Health Programs in the Selected Barangays in Cotabato City 9
regions in the country have participated in the training, empowering them to make

decisions and manage mental health patients close to where it is most needed.

Effectiveness of the Program

One of the extents of the mental health program to be measured is its

effectiveness. Itulid (2017) discussed in his article that the Chairman of the Department

of Psychiatry and Behavioral Medicine of the Philippine General Hospital, Dr. Anselmo

Tronco presented the six principles of an effective mental health program: (1) Address

stigma for it has negative effects to the patients as it deteriorates self-esteem, disrupts

family relationships and limits patient’s function in his community. (2) Create

relationship with the stakeholders for mental health since they have important roles in

integrating a mental health program in the community. (3) Experience a process of

sharing, validation, and problem-solving by building support groups where communities

can share difficulties, identify common reactions, validate good stories of coping, and

facilitate plans for action. (4) Involve the family in the program since services such as

family education and training, support, and counseling on mental health should be

available and accessible to them. (5) Harness Community Resilience on Mental Health,

and it requires human resource that can effectively mobilize community services and

infrastructure for mental health. Lastly, (6) Grab opportunities from crisis and disasters in

order to highlight emotional and social needs since disasters creates a context of shared

grief and recovery. Furthermore, in community-based interventions, Thornicroft, Deb,

and Henderson (2016) enlisted the known effectiveness of the program which include: (1)

integrating mental health promotion strategies (e.g. stress reduction and awareness of

alcohol and drug misuse) into occupational health and safety policies; (2) universal and

Assessment of the Implementation of Mental Health Programs in the Selected Barangays in Cotabato City 10
targeted socio‐emotional learning school programs for vulnerable children; (3) mental

health awareness school programs; (4) methods for the identification and case detection

of children with mental disorders in schools; (5) early child enrichment/preschool

educational programs; (6) parenting programs for children aged 2‐14 years; (7) gender

equity and/or economic empowerment programs for vulnerable groups; and (8) training

of gatekeepers (including community health workers, police and social workers) in

identification of young people with mental disorders, including self‐harm.

Availability of the Program

Secondly is the availability of the mental health program. In the study of Jagodic,

Rokavec, Aguis, and Pregelj (2013), they obtained a data from the Institute of Public

Health of the Republic of Slovenia that mental health service availability data including

the number of psychiatrists working at outpatients clinic, the availability of psychological

services, and the availability of primary care doctors. However, Sahu (2014) stated that

there is a huge gap between mental health service availability and needs of people in the

community. Likewise, in the study of Thornicroft, et al. (2016), they enumerated some

obstacles and challenges of community-oriented mental health care in organization of

health system as follow: (1) lack of a feasible mental health program or non-

implementation of mental health program; (2) Need to include non-medical services; (3)

poor availability of psychotropic medication. In South Africa, there’s a midst of mental

health care crisis because the country does not have enough psychologists or funding to

support mentally disabled citizens, and stigma is still rampant in the country.

Additionally, studies suggest over half of South Africans who live with mental illness

Assessment of the Implementation of Mental Health Programs in the Selected Barangays in Cotabato City 11
consult a faith or traditional healer as a form of counseling, despite healers' lack of

training in psychology (Cayro, 2017).

Accessibility of the Program

Lastly is the accessibility of the mental health program. Walker, Cummings, and

Druss (2015) concluded in their study that the challenges experienced in mental health

care include structural barriers, such as cost and uninsurance, as well as attitudinal

barriers, such as mental health stigma and misconceptions about the effectiveness of

treatments. They added that changing attitudes toward mental health care will need to

target multiple sectors of the population and involve a variety of approaches, such as

public education and awareness of mental disorders and effective treatments, addressing

social norms and cultural factors, and empowering people with mental disorders to

overcome barriers to treatment. On the study of Knaak, Mantler, and Szeto (2017),

mental illness-related stigma, including that which exists in the healthcare system and

among healthcare providers, creates serious barriers to access and quality care. They

identified the key ingredients for effective stigma reduction in healthcare contexts. These

include teaching skills that help healthcare providers know “what to say” and “what to

do,” ensuring program facilitators are modelling person-first behaviours and making

ample use of social contact. Other ingredients namely providing interventions that

include myth busting or a transformative learning focus to target unconscious biases and

correct false beliefs that may be negatively impacting care. The second is

demonstrating/emphasizing recovery from a mental illness and showing ways in which

healthcare providers play an impactful role in that process.

Assessment of the Implementation of Mental Health Programs in the Selected Barangays in Cotabato City 12
 Theoretical Framework

This study will be anchored on the theory of Hildegard Peplau’s “Interpersonal

Relations Theory”.

Firstly, Peplau defined Nursing as “An interpersonal process of therapeutic

interactions between an individual who is sick or in need of health services, and a nurse

especially educated to recognize, respond to the need for help”. The theory explains the

purpose of nursing is to help others identify their felt difficulties and that nurses should

apply principles of human relations to the problems that arise at all levels of experience.

Likewise, Peplau saw a major goal of nursing as helping patients reduce their anxiety and

convert it to constructive action. This theory has significant connection to this study

because there are people who are suffering or experiencing mental health illness. They

are fighting in an invisible war wherein the people around them are not aware of. They

are afraid to open up because of discrimination and stigmatism.

One of the roles of nurses is being advocate. Given the theory of Peplau, upon the

assessment of the implementation of mental health program in the selected barangays in

Cotabato City, this will describe the status and extent of the program.

Being member of health care team, nurses are constantly exposed to people

experiencing problem –listening attentively, showing genuine concern, and respecting the

preference of how these people express themselves. People are secretly fighting for

invisible wars. They are overthinking problems which can greatly affect their mental

health. This theory points out that as healthcare workers, nurses have to provide

appropriate and essential plans, and interventions which are based on their unique

Assessment of the Implementation of Mental Health Programs in the Selected Barangays in Cotabato City 13
experiences. Nurses should never judge them by their stories. Instead, help them as much

as we could.

Statement of the Problem

The study aims to focus on Assessment of the Implementation of Mental Health

Programs in the Selected Barangays in Cotabato City.

Specifically, this study seeks to answer the following questions:

1. What are the Mental Health Program available in the barangay?

2. What is the extent of the program implementation in terms of:

a. effectiveness;

b. availability; and

c. accessibility?

3. What are challenges and difficulties encountered during the implementation?

4. What are the recommendations for the improvement or enhancement of the

service of mental health program?

Significance of the Study

The useful and relevant information that will be acquired from the study will

benefit the following:

Barangay. They will see the benefits and advantages of mental health program in

relation on helping them with mental health issues of for counselling.

Assessment of the Implementation of Mental Health Programs in the Selected Barangays in Cotabato City 14
 Department of Health. The study will be a form of assessment on the extent on the

implementation of mental health program, thus this will gain knowledge to the DOH to

help the barangay health workers enhance the program.

Nursing Education. The academe will gain additional knowledge and updates on

the extent and status of mental health program in the community especially that the

barangay is using mhGAP.

Nursing Practice. The nurses will gain additional knowledge and updates on the

extent and status of mental health program in the community especially that the barangay

is using mhGAP.

Nursing Research. The findings of the study shall serve as baseline data

specifically the outcome of the research for their future studies.

Scope and Limitation

The study mainly focuses on the assessment of the implementation of mental

health programs in the selected barangays in Cotabato City. In the preliminary census, all

barangays in Cotabato City shall be included in the study which involves two (2)

participants: one (1) barangay official and one (1) barangay healthcare worker. On the

actual data gathering, the five (5) mother barangays of Cotabato City will be involved

namely Mother Bagua, Mother Poblacion, Mother Rosary Heights, Mother Tamontaka,

and Mother Kalanganan. The participants shall be fifteen (15): two (2) barangay

healthcare workers, three (3) barangay officials, and ten (10) residents of the barangay.

Assessment of the Implementation of Mental Health Programs in the Selected Barangays in Cotabato City 15
 The study will be limited to the mental health program which the Department of

Health (DOH) implemented in the barangay, and the assessment of the participants in the

implementation of mental health programs in the selected barangay in Cotabato City.

Furthermore, challenges and difficulties encountered in the implementation of the mental

health program, and recommendations for its enhancement will also be considered in the

study.

Definition of Terms

The following terms are defined as they are used in the study:

Accessibility. This refers to the extent of the mental health program of which

entering or receiving the services is easily accessible specifically in terms of distance,

financial, and information.

Assessment. This refers to the appraisal or analysis of the mental health program

implementation in the community in terms of effectiveness, availability, and

accessibility.

Availability. This refers to the extent of mental health program in terms of the

availability of services in the barangay wherein there is the presence of the staff to render

the services.

Challenges. This refers to the obstacles or struggles that the participants observed

or experienced in the implementation of mental health program of their barangay.

Assessment of the Implementation of Mental Health Programs in the Selected Barangays in Cotabato City 16
 Effectiveness. This refers to the extent of the mental health program in which the

intervention, regimen, and service done have beneficial effect to the barangay and its

people.

Extent of Program Implementation. This refers to the degree or amount of the

implementation of the mental health program in the community.

Mental Health Program. This refers to the program that the DOH initiated

which has a primary goal of Quality Mental Health Care by addressing the needs of the

people in the barangay.

Mental Health. This refers to the wellness of mental state of the barangay

officials, barangay health workers and residents of selected barangay in Cotabato City,

wherein they are free from alterations of mental status for they have the capability to

cope up with stresses in life, and function normally in community.

Mental Illness. This refers to the diagnosed or undiagnosed mental health

conditions of the people of Cotabato City, which include depression, schizophrenia,

anxiety disorder, addictive behaviors, mood disorders and others regardless of the

severity.

Assessment of the Implementation of Mental Health Programs in the Selected Barangays in Cotabato City 17