Training the Extended Health Workforce: A Controlled Quasi-Experimental Study on Pre-School Teachers’ Attitudes Toward Autism Using the WHO mhGAP Framework

Hassan Hassan Murtala; Fatima Balarabe; Emmanuel Ejembi Anyebe

doi:10.58418/ijni.v5i1.236

Authors

Hassan Hassan Murtala Bayero University Kano
Fatima Balarabe Ahmadu Bello University
Emmanuel Ejembi Anyebe University of Ilorin

DOI:

https://doi.org/10.58418/ijni.v5i1.236

Keywords:

Educational Intervention, Autism Spectrum Disorder, Preschool Teachers, WHO mhGAP, Task-Shifting, Extended Health Workforce

Abstract

In low- and middle-income countries, a critical shortage of child mental health specialists necessitates innovative task-shifting strategies. This study evaluated the effectiveness of an adapted World Health Organization Mental Health Gap Action Programme (WHO mhGAP) educational intervention on preschool teachers’ attitudes toward Autism Spectrum Disorder (ASD) in Kano, Nigeria. Utilizing a controlled quasi-experimental design, 140 preschool teachers were systematically allocated to an intervention group (n = 70) or a control group (n = 70). The intervention cohort received an eight-week training adapted from WHO mhGAP guidelines, whereas controls received no training. Attitudes were evaluated using the Autism Attitude Scale for Teachers across baseline, mid-intervention, and 16-week post-baseline phases, with data analyzed via Chi-square tests and Multivariate Analysis of Covariance (ANCOVA). At baseline, negative attitudes predominated across both study arms (71.4% study vs 75.7% control; p = 0.565). Post-intervention, positive attitudes in the study group surged to 98.6%, compared to 22.9% in the control group (χ² = 84.120, p < 0.001). ANCOVA confirmed a statistically significant primary treatment effect (F(1, 137) = 345.11, p < 0.001, η²_p = 0.716), explaining 71.6% of adjusted post-training attitude variance. This study provides a novel empirical contribution by establishing that adapting clinical WHO mhGAP guidelines for early childhood educators creates a scalable, task-shifting interprofessional framework. This approach directly bridges the child mental health treatment gap and advances community nursing practice in resource-constrained environments.

References

Al Jaffal, M. (2022). Barriers general education teachers face regarding the inclusion of students with autism. Frontiers in Psychology, 13, 873248. https://doi.org/10.3389/fpsyg.2022.873248

Andrade, C. (2021). The Limitations of Quasi-Experimental Studies, and Methods for Data Analysis When a Quasi-Experimental Research Design Is Unavoidable. Indian Journal of Psychological Medicine, 43(5), 451–452. https://doi.org/10.1177/02537176211034707

Azad, G., McClain, M. B., Haverkamp, C., Maxwell, B., & Shahidullah, J. D. (2021). Interagency collaboration for pediatric autism spectrum disorder: Perspectives of community-based providers. Journal of Interprofessional Education & Practice, 24, 100433. https://doi.org/10.1016/j.xjep.2021.100433

Bowman, K. S., Suarez, V. D., & Weiss, M. J. (2021). Standards for Interprofessional Collaboration in the Treatment of Individuals With Autism. Behavior Analysis in Practice, 14(4), 1191–1208. https://doi.org/10.1007/s40617-021-00560-0

Derguy, C., Aubé, B., Rohmer, O., & Loyal, D. (2023). Evaluation of teachers’ knowledge and attitudes regarding the school inclusion of autistic children: Validation of a brief assessment toolkit. British Journal of Educational Psychology, 93(2), 467–481. https://doi.org/10.1111/bjep.12569

Fang, Z., Liu, X., Zhang, C., & Qiao, D. (2023). Early childhood interventions in educational settings that promote school readiness for children with autism and other developmental disabilities: Systematic review. Research in Autism Spectrum Disorders, 108, 102257. https://doi.org/10.1016/j.rasd.2023.102257

Genovesi, E., Jakobsson, C., Nugent, L., Hanlon, C., & Hoekstra, R. A. (2022). Stakeholder experiences, attitudes and perspectives on inclusive education for children with developmental disabilities in sub-Saharan Africa: A systematic review of qualitative studies. Autism, 26(7), 1606–1625. https://doi.org/10.1177/13623613221096208

Gómez-Marí, I., Sanz-Cervera, P., & Tárraga-Mínguez, R. (2021). Teachers’ Knowledge Regarding Autism Spectrum Disorder (ASD): A Systematic Review. Sustainability, 13(9), 5097. https://doi.org/10.3390/su13095097

Gómez-Marí, I., Sanz-Cervera, P., & Tárraga-Mínguez, R. (2022). Teachers’ Attitudes toward Autism Spectrum Disorder: A Systematic Review. Education Sciences, 12(2), 138. https://doi.org/10.3390/educsci12020138

Goodwin, J., Behan, L., & O’Brien, N. (2021). Teachers’ views and experiences of student mental health and well-being programmes: A systematic review. Journal of Child & Adolescent Mental Health, 33(1–3), 55–74. https://doi.org/10.2989/17280583.2023.2229876

Green, J. (2023). Debate: Neurodiversity, autism and healthcare. Child and Adolescent Mental Health, 28(3), 438–442. https://doi.org/10.1111/camh.12663

Haynes, A. B., Haukoos, J. S., & Dimick, J. B. (2021). TREND Reporting Guidelines for Nonrandomized/Quasi-Experimental Study Designs. JAMA Surgery, 156(9), 879. https://doi.org/10.1001/jamasurg.2021.0552

Holmes, S. C. (2024). Inclusion, autism spectrum, students’ experiences. International Journal of Developmental Disabilities, 70(1), 59–73. https://doi.org/10.1080/20473869.2022.2056403

Johnson, C. L., Gross, M. A., Jorm, A. F., & Hart, L. M. (2023). Mental Health Literacy for Supporting Children: A Systematic Review of Teacher and Parent/Carer Knowledge and Recognition of Mental Health Problems in Childhood. Clinical Child and Family Psychology Review, 26(2), 569–591. https://doi.org/10.1007/s10567-023-00426-7

Jury, M., Perrin, A.-L., Desombre, C., & Rohmer, O. (2021). Teachers’ attitudes toward the inclusion of students with autism spectrum disorder: Impact of students’ difficulties. Research in Autism Spectrum Disorders, 83, 101746. https://doi.org/10.1016/j.rasd.2021.101746

Kang, H. (2021). Sample size determination and power analysis using the G*Power software. Journal of Educational Evaluation for Health Professions, 18, 17. https://doi.org/10.3352/jeehp.2021.18.17

Keynejad, R., Spagnolo, J., & Thornicroft, G. (2021). WHO mental health gap action programme (mhGAP) intervention guide: updated systematic review on evidence and impact. Evidence Based Mental Health, 24(3), 124–130. https://doi.org/10.1136/ebmental-2021-300254

Kumar, M., Bhat, A., Unützer, J., & Saxena, S. (2021). Editorial: Strengthening Child and Adolescent Mental Health (CAMH) Services and Systems in Lower-and-Middle-Income Countries (LMICs). Frontiers in Psychiatry, 12, 645073. https://doi.org/10.3389/fpsyt.2021.645073

Lasisi, D., Ani, C., Lasebikan, V., Sheikh, L., & Omigbodun, O. (2017). Effect of attention-deficit–hyperactivity-disorder training program on the knowledge and attitudes of primary school teachers in Kaduna, North West Nigeria. Child and Adolescent Psychiatry and Mental Health, 11(1), 15. https://doi.org/10.1186/s13034-017-0153-8

Leonard, N. M., & Smyth, S. (2022). Does training matter? Exploring teachers’ attitudes towards the inclusion of children with autism spectrum disorder in mainstream education in Ireland. International Journal of Inclusive Education, 26(7), 737–751. https://doi.org/10.1080/13603116.2020.1718221

Lord, C., Charman, T., Havdahl, A., Carbone, P., Anagnostou, E., Boyd, B., Carr, T., de Vries, P. J., Dissanayake, C., Divan, G., Freitag, C. M., Gotelli, M. M., Kasari, C., Knapp, M., Mundy, P., Plank, A., Scahill, L., Servili, C., Shattuck, P., … McCauley, J. B. (2022). The Lancet Commission on the future of care and clinical research in autism. The Lancet, 399(10321), 271–334. https://doi.org/10.1016/S0140-6736(21)01541-5

Low, H. M., Wong, T. P., Lee, L. W., Makesavanh, S., Vongsouangtham, B., Phannalath, V., Che Ahmad, A., & Lee, A. S. S. (2021). Can pictorial narration offer a solution to teacher training on the effective inclusion of students with autism spectrum disorder in low-resource settings? Investigation on knowledge and stigma change. Autism, 25(5), 1216–1233. https://doi.org/10.1177/1362361320984899

Mabrouk, A., Mbithi, G., Chongwo, E., Too, E., Sarki, A., Namuguzi, M., Atukwatse, J., Ssewanyana, D., & Abubakar, A. (2022). Mental health interventions for adolescents in sub-Saharan Africa: A scoping review. Frontiers in Psychiatry, 13, 937723. https://doi.org/10.3389/fpsyt.2022.937723

Ndetei, D. M., Mutiso, V., & Osborn, T. (2023). Moving away from the scarcity fallacy: three strategies to reduce the mental health treatment gap in LMICs. World Psychiatry, 22(1), 163–164. https://doi.org/10.1002/wps.21054

Ogba, F. N., Onyishi, C. N., Victor-Aigbodion, V., Abada, I. M., Eze, U. N., Obiweluozo, P. E., Ugodulunwa, C. N., Igu, N. C. N., Okorie, C. O., Onu, J. C., Eze, A., Ezeani, E. O., Ebizie, E. N., & Onwu, A. O. (2020). Managing job stress in teachers of children with autism. Medicine, 99(36), e21651. https://doi.org/10.1097/MD.0000000000021651

Olley, J. G., Devellis, R. F., Devellis, B. M., Wall, A. J., & Long, C. E. (1981). The Autism Attitude Scale for Teachers. Exceptional Children, 47(5), 371–372. https://doi.org/10.1177/001440298104700509

Petagna, M., Marley, C., Guerra, C., Calia, C., & Reid, C. (2023). Mental Health Gap Action Programme intervention Guide (mhGAP-IG) for Child and Adolescent Mental Health in Low- and Middle-Income Countries (LMIC): A Systematic Review. Community Mental Health Journal, 59(1), 192–204. https://doi.org/10.1007/s10597-022-00981-3

Pumariega, A. J., Aneja, J., Sharma, P., Breton, K., Thornton, K., Gann, S., & Rothe, E. (2024). Access to Child Psychotherapy in High- and Low/Middle-income Nations: A Cross-national Perspective and Potential Approaches. Journal of Indian Association for Child and Adolescent Mental Health, 20(2), 111–120. https://doi.org/10.1177/09731342241236297

Raj, V., Raykar, V., Robinson, A. M., & Islam, M. R. (2022). Child and Adolescent Mental Health Training Programs for Non-specialist Mental Health Professionals in Low and Middle Income Countries: A Scoping Review of Literature. Community Mental Health Journal, 58(1), 154–165. https://doi.org/10.1007/s10597-021-00805-w

Ramaswamy, S., Sagar, J. V., & Seshadri, S. (2022). A transdisciplinary public health model for child and adolescent mental healthcare in low- and middle-income countries. The Lancet Regional Health - Southeast Asia, 3, 100024. https://doi.org/10.1016/j.lansea.2022.100024

Russell, A., Scriney, A., & Smyth, S. (2023). Educator Attitudes Towards the Inclusion of Students with Autism Spectrum Disorders in Mainstream Education: a Systematic Review. Review Journal of Autism and Developmental Disorders, 10(3), 477–491. https://doi.org/10.1007/s40489-022-00303-z

Sequeira, M., Singh, S., Fernandes, L., Gaikwad, L., Gupta, D., Chibanda, D., & Nadkarni, A. (2022). Adolescent Health Series: The status of adolescent mental health research, practice and policy in sub‐Saharan Africa: A narrative review. Tropical Medicine & International Health, 27(9), 758–766. https://doi.org/10.1111/tmi.13802

Shi, Y. R., & Sin, K. F. K. (2024). Exploring the effects of web-based psychological capitals training on teachers’ PsyCap development, emotional stability, and support: Evidence from Chinese inclusive education. PLOS ONE, 19(9), e0306453. https://doi.org/10.1371/journal.pone.0306453

Simelane, S. R. N., & de Vries, P. J. (2021). Child and adolescent mental health services and systems in low and middle-income countries: from mapping to strengthening. Current Opinion in Psychiatry, 34(6), 608–616. https://doi.org/10.1097/YCO.0000000000000740

Spagnolo, J., & Lal, S. (2021). Implementation and use of the Mental Health Gap Action Programme Intervention Guide (mhGAP-IG): A review of the grey literature. Journal of Global Health, 11, 04022. https://doi.org/10.7189/jogh.11.04022

Taresh, S. M., Morett, L. M., Zaid, S. M., Roslan, S., Taresh Taleb, M., Song, P., Ahmad, N. A., & Noman, S. (2024). Preschool teachers’ knowledge, beliefs, and self-efficacy concerning autism: A parallel mixed-methods study of an intervention to improve autism identification. Autism, 28(1), 239–253. https://doi.org/10.1177/13623613231211850

Vincent, J., & Ralston, K. (2020). Trainee teachers’ knowledge of autism: implications for understanding and inclusive practice. Oxford Review of Education, 46(2), 202–221. https://doi.org/10.1080/03054985.2019.1645651

World Health Organization. (2016). mhGAP Intervention guide for mental, neurological and substance-use disorders in non-specialized health settings. Version 2.0. https://www.who.int/publications/b/31377

World Health Organization. (2023). Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders. https://www.ncbi.nlm.nih.gov/books/NBK598414/

Zeidan, J., Fombonne, E., Scorah, J., Ibrahim, A., Durkin, M. S., Saxena, S., Yusuf, A., Shih, A., & Elsabbagh, M. (2022). Global prevalence of autism: A systematic review update. Autism Research, 15(5), 778–790. https://doi.org/10.1002/aur.2696

Zhou, W., Ouyang, F., Nergui, O.-E., Bangura, J. B., Acheampong, K., Massey, I. Y., & Xiao, S. (2020). Child and Adolescent Mental Health Policy in Low- and Middle-Income Countries: Challenges and Lessons for Policy Development and Implementation. Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00150