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Bangladeshi Health Practitioner Knowledge, Confidence in Diagnosis, and Treatment of Mental Health Disorders in People with Intellectual Disabilities

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Title: Bangladeshi Health Practitioner Knowledge, Confidence in Diagnosis, and Treatment of Mental Health Disorders in People with Intellectual Disabilities
Language: English
Authors: Hinde, Kylie (ORCID 0000-0001-8707-1618), Mason, Jonathan, Kannis-Dymand, Lee (ORCID 0000-0002-1882-6121), Millear, Prue, Sultana, Razia
Source: Journal of Mental Health Research in Intellectual Disabilities. 2023 16(3):205-225.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 21
Publication Date: 2023
Document Type: Journal Articles
Reports - Research
Descriptors: Foreign Countries, Intellectual Disability, Mental Disorders, Knowledge Level, Clinical Diagnosis, Intervention, Self Efficacy, Allied Health Personnel, Symptoms (Individual Disorders)
Geographic Terms: Bangladesh
DOI: 10.1080/19315864.2022.2098432
ISSN: 1931-5864
1931-5872
Abstract: Background: Intellectual disability and mental health disorders constitute a major health problem globally with higher economic burden in low- and middle-income countries such as Bangladesh. In 2017, the World Bank estimated that 85% of the global population lived in low-middle-income countries. Limited research has explored health practitioner knowledge and/or confidence in the diagnosis and treatment of mental health issues in persons with intellectual disabilities (IDs) in low-income countries such as Bangladesh. Method: One hundred and ninety-seven Bangladeshi-based health practitioners were grouped into 7 main professional groups according the current Bangladeshi health hierarchy (psychiatrists; traditional healers and community workers; medical doctors; nurses; psychologists; allied health: speech therapists, occupational therapists, social workers; and others: teachers physiotherapists, administration staff). A 34-item online survey was completed, which included questions measuring symptoms of common mental health disorders with reference to the Psychiatric Assessment Schedule for Adults with Developmental Disabilities, and questions measuring confidence working with persons with IDs from the Therapy Confidence Scale-Intellectual Disabilities. Results: Participants demonstrated low knowledge of symptomology but were "confident" working with people with IDs. Kruskal-Wallis H tests indicated a significant effect of professional group on both overall knowledge and confidence levels, respectively. Traditional healers and community health workers had significantly more knowledge of symptoms than all other practitioners for obsessive-compulsive disorder, depression, psychosis, and hypomania. Conclusion: Participants demonstrated confidence, but low knowledge, in treating individuals with IDs. The development of training programs to address specific deficits in knowledge of mental health symptoms, and confidence in using assessment and assessment-based communication, is recommended.
Abstractor: As Provided
Entry Date: 2023
Accession Number: EJ1392904
Database: ERIC
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  Value: <anid>AN0164492932;[5ew6]01jul.23;2023Jun27.06:27;v2.2.500</anid> <title id="AN0164492932-1">Bangladeshi Health Practitioner Knowledge, Confidence in Diagnosis, and Treatment of Mental Health Disorders in People with Intellectual Disabilities </title> <p>Intellectual disability and mental health disorders constitute a major health problem globally with higher economic burden in low- and middle-income countries such as Bangladesh. In 2017, the World Bank estimated that 85% of the global population lived in low-middle-income countries. Limited research has explored health practitioner knowledge and/or confidence in the diagnosis and treatment of mental health issues in persons with intellectual disabilities (IDs) in low-income countries such as Bangladesh. One hundred and ninety-seven Bangladeshi-based health practitioners were grouped into 7 main professional groups according the current Bangladeshi health hierarchy (psychiatrists; traditional healers and community workers; medical doctors; nurses; psychologists; allied health: speech therapists, occupational therapists, social workers; and others: teachers physiotherapists, administration staff). A 34-item online survey was completed, which included questions measuring symptoms of common mental health disorders with reference to the Psychiatric Assessment Schedule for Adults with Developmental Disabilities, and questions measuring confidence working with persons with IDs from the Therapy Confidence Scale-Intellectual Disabilities. Participants demonstrated low knowledge of symptomology but were "confident" working with people with IDs. Kruskal–Wallis H tests indicated a significant effect of professional group on both overall knowledge and confidence levels, respectively. Traditional healers and community health workers had significantly more knowledge of symptoms than all other practitioners for obsessive-compulsive disorder, depression, psychosis, and hypomania. Participants demonstrated confidence, but low knowledge, in treating individuals with IDs. The development of training programs to address specific deficits in knowledge of mental health symptoms, and confidence in using assessment and assessment-based communication, is recommended.</p> <p>Keywords: Confidence; knowledge; intellectual disability; mental disorder; Bangladesh</p> <p>Intellectual disability (ID) is characterized by significant limitations in intellectual function and adaptive behavior that occurs during the developmental period (before age of 22; Schalock et al., [<reflink idref="bib35" id="ref1">35</reflink>]). Almost 2% of the 164+ million people in Bangladesh are estimated to have an intellectual disability (ID) (Maulik, Mascarenhas, Mathers, Dua, & Saxena, [<reflink idref="bib24" id="ref2">24</reflink>]). Studies report that approximately 16–57% of people with an ID have an additional mental health disorder (Australian Institute of Health and Welfare, [<reflink idref="bib2" id="ref3">2</reflink>]; Cooper, Smiley, Morrison, Williamson, & Allan, [<reflink idref="bib6" id="ref4">6</reflink>]). In Bangladesh, a densely populated low-to-middle-income country, this poses a major public health challenge due to increased strain on public health expenditure and resources, economic costing relating to workforce productivity, and greater social system pressure (Nuri et al., [<reflink idref="bib29" id="ref5">29</reflink>]).</p> <p>Empirical evidence of current confidence and knowledge of Bangladeshi practitioners working with persons with an ID and mental health disorders is limited. It is important that mental health professionals who are able to cater to the needs of people with an ID are available and accessible; however, in Bangladesh, there is an ongoing shortage of health professionals trained to provide assessment and treatment to these individuals (Hinde et al., [<reflink idref="bib14" id="ref6">14</reflink>]; WHO, [<reflink idref="bib43" id="ref7">43</reflink>]). Traditional healers, community health workers and doctors are considered to be the front line of diagnosis and intervention for individuals with an ID and/or mental health disorder (Giasuddin et al., [<reflink idref="bib10" id="ref8">10</reflink>]; Hinde et al., [<reflink idref="bib14" id="ref9">14</reflink>]), and are often responsible for referring patients to psychiatrists and specialist medical doctors.</p> <p>Investigating current practitioner confidence and knowledge in Bangladesh will give much-needed insight into the specific challenges faced by these practitioners who care for persons with an ID and mental health disorder. A greater understanding of current practitioner knowledge and confidence will aid the development of capacity-building resources (e.g., training and national policy development) within the context of diagnosis and treatment of mental health issues in people with ID, whilst improving the outcomes for this population within Bangladesh. The present study will explore current Bangladesh health service provision, and health practitioner confidence and knowledge in working with people with mental health issues and ID.</p> <hd id="AN0164492932-2">Service Provision in Bangladesh</hd> <p>The health service model in Bangladesh is unique, and starkly different than that of most Westernized countries. In Westernized countries such as Australia, United Kingdom, and USA, medical doctors, psychiatrists, and psychologists are often the first point of care in the diagnosis and treatment of persons with mental health issues and ID. Comparatively in Bangladesh, traditional healers and community health workers provide up to 90% of care for those with mental health disorders and disabilities in Bangladesh, despite having limited to no specialist mental health or disability training (Abdullah et al., [<reflink idref="bib1" id="ref10">1</reflink>]; Haque et al., [<reflink idref="bib11" id="ref11">11</reflink>]; Mullick et al., [<reflink idref="bib27" id="ref12">27</reflink>]; WHO, [<reflink idref="bib41" id="ref13">41</reflink>]). These professionals are often trusted members of the community, are easily accessible, and are often more affordable (Giasussin et al., 2012; Haque et al., [<reflink idref="bib11" id="ref14">11</reflink>]).</p> <p>Psychiatrists and medical doctors are the most preferred professions to treat persons with mental health disorders (Rawal et al., [<reflink idref="bib32" id="ref15">32</reflink>]); however, these professions are the least accessible in Bangladesh (World Health Organisation. Regional Office for South-East Asia, [<reflink idref="bib42" id="ref16">42</reflink>]). A 2020 world mental health day address by the director of the National Institute of Mental Health (Bangladesh) indicated that there was a total of 260 psychiatrists servicing a population of 164+ million (Roy Podder, [<reflink idref="bib33" id="ref17">33</reflink>]), which had increased from 73 psychiatrists in 2007 (World Health Organisation. Regional Office for South-East Asia, [<reflink idref="bib42" id="ref18">42</reflink>]). In comparison, the Australian Institute of Health and Welfare indicated that in 2019 there were 3615 psychiatrists providing care to an Australian population of 25.69 million people (Australian Institute of Health and Welfare, [<reflink idref="bib4" id="ref19">4</reflink>]), and an estimated 12.7 thousand psychiatrists providing care to a population of 67.22 million in 2020 in the UK (Royal College of Psychiatrists, [<reflink idref="bib34" id="ref20">34</reflink>]). Figure 1 provides a breakdown of health care professions in Bangladesh including the educational prerequisites for each profession, and their respective roles in mental health care.</p> <p>Graph: Figure 1. Breakdown of health professions including study requirements and role in mental health care.</p> <p>Accessibility of health care is impacted by issues such as poverty, limited availability of adequately trained health-care professionals, no government subsidized health care and high health-care costs, with a majority of the population living rurally whilst skilled health professionals mostly work from main cities (World Health Organisation. Regional Office for South-East Asia, [<reflink idref="bib42" id="ref21">42</reflink>]). To our knowledge, there are no Bangladeshi tertiary healthcare and medical courses that explicitly train students on the assessment, diagnosis, and/or treatment of mental health disorders in persons with an ID.</p> <hd id="AN0164492932-3">Mental Health Symptom Knowledge</hd> <p>A combination of explicit knowledge and tacit knowledge is required in most tasks involving client care in health fields (Kothari et al., [<reflink idref="bib20" id="ref22">20</reflink>]; Nonaka & Krogh, [<reflink idref="bib28" id="ref23">28</reflink>]). Explicit knowledge is that which can be codified and/or is based on written word, and tacit knowledge refers to a form of subconscious expertise, and is largely developed through experience (Nonaka & Krogh, [<reflink idref="bib28" id="ref24">28</reflink>]). Nonaka and Krogh ([<reflink idref="bib28" id="ref25">28</reflink>]) stated that moving knowledge from the tacit to the explicit domain facilitated quick and easy conveyance of meaning to the self and others in the workplace, and aided the detection and correction of unconscious errors. In the detection and diagnosis of mental health conditions, practitioner knowledge and ability to recognize disorder symptoms is key to making accurate diagnoses, and subsequently providing the best treatment (Werner & Stawski, [<reflink idref="bib40" id="ref26">40</reflink>]). Limited research has examined the role and impact knowledge may have on patient care in the field of ID and mental health (Kothari et al., [<reflink idref="bib20" id="ref27">20</reflink>]; Werner & Stawski, [<reflink idref="bib40" id="ref28">40</reflink>]).</p> <p>Hinde and Mason ([<reflink idref="bib13" id="ref29">13</reflink>]) examined explicit knowledge by asking Australian-based practitioners to identify the symptomology of specific mental health disorders in people with an ID. Participant answers were compared to symptom scales in the Mini Psychiatric Assessment Schedules for Adults with Developmental Disabilities (MPAS-ADD). The MPS-ADD is a tool derived from the original gold standard Psychiatric Assessment Schedules for Adults with Developmental Disabilities (PAS-ADD) semi-structured clinical interview. Hinde and Mason also compared practitioner-identified mental health symptoms to MPAS-ADD disorder criteria and reported significant deficits in knowledge of mental illness symptoms in people with IDs. This research indicated that it may be important for practitioners across health disciplines to have adequate knowledge of symptoms for mental health disorders, as people with an ID and mental health disorders often access multiple health practitioners for diagnosis and treatment.</p> <p>To our knowledge, no existing research has examined Bangladeshi health practitioner knowledge, and/or health practitioners in other low-middle-income countries, in identification of mental health symptoms of those with an ID.</p> <hd id="AN0164492932-4">Confidence</hd> <p>Confidence in a clinical context is defined as the degree of certainty a practitioner has in their ability to deliver and achieve valuable service outcomes, and greatly impacts behavior in performing actions or procedures (Hendrick et al., [<reflink idref="bib12" id="ref30">12</reflink>]; Owens & Keller, [<reflink idref="bib30" id="ref31">30</reflink>]). Research suggests that the level of confidence in one's ability to diagnose, treat, or manage mental health concerns of persons with an ID may be positively correlated with the quality of care received (Hinde & Mason, [<reflink idref="bib13" id="ref32">13</reflink>]; Owens & Keller, [<reflink idref="bib30" id="ref33">30</reflink>]). A health professional's response to a patient presenting with an ID and comorbid mental health disorders is therefore not only influenced by their knowledge and skill base, but also their confidence in performing a diagnosis, to treating and to assisting in the management of care.</p> <p>Several studies (Hinde & Mason, [<reflink idref="bib13" id="ref34">13</reflink>]; Hronis et al., [<reflink idref="bib17" id="ref35">17</reflink>]; Jess et al., [<reflink idref="bib19" id="ref36">19</reflink>]; Lennox & Chaplin, [<reflink idref="bib21" id="ref37">21</reflink>]; Man et al., [<reflink idref="bib22" id="ref38">22</reflink>]; Torr et al., [<reflink idref="bib37" id="ref39">37</reflink>]; Weise & Trollor, [<reflink idref="bib39" id="ref40">39</reflink>]) have explored confidence within a sample of health practitioners, but only four of these studies have been completed within the last 10 years. For example, Hronis et al. ([<reflink idref="bib17" id="ref41">17</reflink>]) surveyed 152 Australian psychologists and counselors to explore their confidence in providing therapy to people with an ID. Results indicated that Australian clinicians experienced significantly lower confidence when using assessments and interventions for people with an ID and mental health disorders, compared to IQ-typical patients.</p> <p>Few studies have explored the concept of health practitioner confidence using a valid and reliable instrument. Dagnan et al. ([<reflink idref="bib9" id="ref42">9</reflink>]) developed the Therapy Confidence Scale – Intellectual Disabilities (TCS-ID); a robust and psychometrically sound scale aimed at identifying therapeutic-based practitioner (e.g., psychologists, counselors) confidence levels at key stages in therapeutic relationship development, assessment, intervention and therapy ending. The TCS-ID is the only published scale of its kind to measure the confidence levels of healthcare professionals working in the context of persons with IDs.</p> <p>Despite its suitability for the task of studying practitioner confidence with IDs, the TSC-ID has been under-utilized Only three studies (Cooper et al., [<reflink idref="bib7" id="ref43">7</reflink>]; Hinde & Mason, [<reflink idref="bib13" id="ref44">13</reflink>]; Hronis et al., [<reflink idref="bib17" id="ref45">17</reflink>]) have used the TSC-ID to examine health practitioner confidence, and no studies to date have examined a sample of health practitioners from a low- or middle-income country. Furthermore, delivering assessment, determining diagnoses and building therapeutic relationships are an important part of the treatment delivered by diagnostic-based practitioners (e.g., doctors and nurses). This warrants administration of the TCS-ID to non-therapeutic-based practitioners.</p> <hd id="AN0164492932-5">The Present Study</hd> <p>No existing research has explored current health practitioner knowledge and confidence in the diagnosis and treatment of people with both ID and mental health disorders in Bangladesh. The aims of the present study are to investigate and report current Bangladeshi health practitioner mental health symptom knowledge, and confidence levels in the context of persons with and ID. We hypothesize that our results will demonstrate low levels of practitioner symptom knowledge of five of the most commonly experienced mental health disorders by people with an ID – depression, anxiety, psychosis, hypomania, and OCD.</p> <p>Medical doctors, psychiatrists, and nurses were identified as professions that may demonstrate higher knowledge (i.e., diagnostic processes and pathology), than practitioners from treatment-based professions (i.e. psychologists, community health workers and traditional healers, social workers, speech therapists and occupational therapists) due to having diagnostic components in their respective training and education. In addition, psychologists, community health workers and traditional healers, social workers, speech therapists and occupational therapists were identified as being more treatment-based professions in Bangladesh, and as such, it was anticipated that these professionals would demonstrate higher confidence in therapeutic processes and less knowledge in diagnostic processes (i.e. client pathology). Due to their more advanced training, it was anticipated that doctors, psychiatrists, and nurses would demonstrate high confidence and high knowledge.</p> <p>Finally, in acknowledging existing earlier Australian research that reported low levels of practitioner confidence (Jess et al., [<reflink idref="bib19" id="ref46">19</reflink>]; Weise & Trollor, [<reflink idref="bib39" id="ref47">39</reflink>]), we anticipate that our study will demonstrate similar findings of low confidence scores through the use of the TCS-ID with a Bangladeshi sample.</p> <hd id="AN0164492932-6">Method</hd> <p></p> <hd id="AN0164492932-7">Procedure</hd> <p>A cross-sectional survey design was utilized in the study. Ethics approval was granted through the Human Research Ethics Committee of a regional Australian university and through the Ethics Committee of a regional hospital in Bangladesh. Administrators of professional associations, hospitals, community organizations, and health facilities were contacted via e-mail to invite their members to participate in the survey. The recruitment methods, factors influencing recruitment, and baseline characteristics of the sample, have been reported in an earlier article by (Hinde et al., [<reflink idref="bib14" id="ref48">14</reflink>]). A snowball sampling technique was used, whereby recruited participants extended the details of the study to their colleagues.</p> <p>An e-mail to potential participants included a link to the Project Information Sheet, consent form, and survey, located on an electronic survey website (SurveyMonkey). All participant materials including the invitation e-mail were first written in English and then translated to the national language of Bangladesh, Bengali, before dissemination. A Bangladeshi national with a Master in Applied Linguistics and English Language provided all translations. Two independent Bangladeshi health professionals proficient in English cross-checked translated documents for consistency in meaning of health terminology. All survey answers recorded in Bengali were translated to English before analysis, with the assistance of the project's Bengali-speaking researcher.</p> <hd id="AN0164492932-8">Participants</hd> <p>One hundred and fifty-eight participants completed the survey. Of these, 121 participants were males (61.4%), 75 were females (39.5%), and 1 non-binary person (0.5%). The average age was 33.39 years, with a range from 20 to 73 years. As recommended by Giasuddin et al. ([<reflink idref="bib10" id="ref49">10</reflink>]), Hossain et al. ([<reflink idref="bib15" id="ref50">15</reflink>]) and Islam ([<reflink idref="bib18" id="ref51">18</reflink>]), participants were grouped according to role description and hierarchy in mental health care in Bangladesh. These were as follows: (<reflink idref="bib1" id="ref52">1</reflink>) psychiatrists (<emph>n</emph> = 13, 6.6%), (<reflink idref="bib2" id="ref53">2</reflink>) traditional healers and community workers (<emph>n</emph> = 23, 11.7%), (<reflink idref="bib3" id="ref54">3</reflink>) medical doctors (<emph>n</emph> =61, 31%), (<reflink idref="bib4" id="ref55">4</reflink>) nurses (<emph>n</emph> = 23, 11.7%), (<reflink idref="bib5" id="ref56">5</reflink>) psychologists (<emph>n</emph> = 32, 16.2%), (<reflink idref="bib6" id="ref57">6</reflink>) allied health (speech therapists, occupational therapists, social workers) (<emph>n</emph> = 26, 13.2%), and (<reflink idref="bib7" id="ref58">7</reflink>) "other" (i.e., teachers, physiotherapists, 1x administration staff) (<emph>n</emph> = 19, 9.6%). Teachers, physiotherapists, and administration staff were not directly targeted for inclusion in this study; however, use of snowball sampling dissemination of the survey meant that 3 of these professions were captured in the final sample. Participants had practiced in their profession for a mean of 12.6 years (<emph>SD =</emph> 10.2) and indicated that in the last 5 years, they had worked with a mean of 30.7 clients (<emph>SD =</emph> 50.5) in the field of ID. The range of clients in the field of mental health, had a mean of 414.7 clients (<emph>SD =</emph> 1159.7) indicating a wide range in experience with mental health.</p> <hd id="AN0164492932-9">Measures</hd> <p></p> <hd id="AN0164492932-10">Mini Psychiatric Assessment Schedules for Adults with Developmental Disabilities (MPAS-ADD)</hd> <p>The MPAS-ADD measures knowledge of symptoms of obsessive-compulsive disorder (OCD), depression, hypomania, psychosis, and anxiety, within the context of ID (Beail et al., [<reflink idref="bib5" id="ref59">5</reflink>]). The scoring procedure and use of interrater reliability in Hinde and Mason ([<reflink idref="bib13" id="ref60">13</reflink>]) was used. The survey consisted of five MPAS-ADD related questions such as "In your experience, what are the main symptoms of a client with an ID suffering from anxiety?" Participants recorded their answers in open text. The MPAS-ADD is comprised of the following number of symptoms for each disorder: OCD: 4; depression: 20; hypomania: 11; psychosis: 8; and anxiety: 16.</p> <p>To assess inter-rater reliability, a second experienced independent rater was used to code responses and provide frequency counts. Spearman correlation coefficients were calculated between the two raters for the questions requiring participants to record symptoms for mental health disorders. Scores between both raters for all five questions were significantly (<emph>p</emph>s <.001) correlated, with very strong Spearman's coefficients ranging from <emph>r</emph>s(<reflink idref="bib90" id="ref61">90</reflink>) =.85,.82,.95,.93,.97. The five mental health disorders (OCD, depression, hypomania, psychosis and anxiety) included in the subscale related to knowledge of symptoms were derived from the MPAS-ADD, and was found moderately reliable (α = 0.70).</p> <hd id="AN0164492932-11">Therapy Confidence Scale-Intellectual Disabilities (TCS-ID)</hd> <p>The TCS-ID (Dagnan et al., [<reflink idref="bib9" id="ref62">9</reflink>]) was used to measure confidence relating to therapeutic relationship development, assessment, intervention and therapy-ending with persons with an ID. The scale consists of 14 questions such as "How confident are you that you can listen carefully to concerns presented by a client with a learning disability?" No adaptions beyond the language translation described earlier were made to the 14 TCS-ID items in this study. Participants rated their response on a five-point Likert scale from 1 (<emph>Not confident</emph>) to 5 (<emph>Highly confident</emph>) for each item. An overall mean for the total scale score was calculated for each profession grouping and for the total participant sample (i.e. item mean scores were added for each professional group and then divided by total number of scale items). No reverse scoring was used. Dagnan et al. ([<reflink idref="bib9" id="ref63">9</reflink>]) reported the TCS-ID single-factor structure as accounting for 62% of variance with Cronbach's α = 0.93. In the current study, the internal consistency of the TCS-ID was examined and found to be reliable (α = 0.80).</p> <hd id="AN0164492932-12">Data Analysis</hd> <p>Statistical analyses were conducted using SPSS version 26 (SPSS Inc., Chicago, IL, USA). Univariate normality was assessed and could be not be assumed. Descriptive statistics and frequencies were calculated for quantitative variables. Kruskal–Wallis testing was used to compare levels of confidence and knowledge reported by the professional groups, with practitioner type (psychiatrists, traditional healers and community workers, doctors, nurses, psychologists, allied health, other) entered as fixed between-group factors, and confidence level and knowledge level as the dependent variables. As there were seven profession groups, a Bonferroni adjustment was made to account for multiple comparisons to maintain the family-wise error rate at.05.</p> <hd id="AN0164492932-13">Results</hd> <p></p> <hd id="AN0164492932-14">Attrition</hd> <p>One hundred and ninety-seven participants attempted the survey; however, only 158 participants completed all survey items. Participant attrition occurred after confidence-related questions (item 16 out of total 24 survey items), and only 158 participants responded to both confidence and knowledge-related survey items. T-tests indicated a significant difference in mean confidence level between participants that completed the confidence-related questions only in comparison to those participants that completed all items (t(<reflink idref="bib195" id="ref64">195</reflink>) = −2.81, <emph>p</emph> =.005). A significant difference was also noted for anxiety (t(<reflink idref="bib156" id="ref65">156</reflink>) = −2.67, <emph>p</emph> =.08). There was no significant mean difference between attrition categories for; OCD, psychosis, depression and hypomania, (<emph>p</emph> = >0.05).</p> <hd id="AN0164492932-15">Knowledge</hd> <p>Table 1 shows the mean and standard deviations of mental health condition (anxiety, OCD, psychosis, depression, hypomania) symptom knowledge for each of the professions (psychiatrists, traditional healers and community workers, doctors, nurses, psychologists, allied health, other i.e., teachers, physiotherapists, administration staff). The results of these Kruskal–Wallis H tests are reported for each mental health condition in separate sections below.</p> <p>Table 1. Means and SDs for the mental health conditions reported by each type of health practitioners.</p> <p> <ephtml> <table><thead><tr><td /><td /><td>Professions</td><td /></tr><tr><td>Mental Health Condition</td><td>Total Symptoms</td><td>Psychiatrist <italic>M (SD)</italic></td><td>Traditional healer/ Community Health <italic>M (SD)</italic></td><td>Medical Doctor <italic>M (SD)</italic></td><td>Nurse M (SD)</td><td>Psychologist M (SD)</td><td>Allied Health M (SD)</td><td>Other M (SD)</td><td>Total</td></tr></thead><tbody><tr><td>OCD</td><td>4</td><td>1.58 (0.36)</td><td>1.93 (0.17)</td><td>1.68 (0.39)</td><td>1.67 (0.43)</td><td>1.57 (0.38)</td><td>1.69 (0.35)</td><td>1.73 (0.44)</td><td>1.69 (0.36)</td></tr><tr><td>Depression</td><td>20</td><td>1.63 (0.41)</td><td>1.89 (0.23)</td><td>1.79 (0.37)</td><td>1.80 (0.36)</td><td>1.53 (0.39)</td><td>1.77 (0.33)</td><td>1.82 (0.35)</td><td>1.75 (0.34)</td></tr><tr><td>Hypomania</td><td>11</td><td>1.69 (0.39)</td><td>1.95 (0.16)</td><td>1.88 (0.32)</td><td>1.93 (0.21)</td><td>1.86 (0.46)</td><td>1.94 (0.18)</td><td>1.89 (0.24)</td><td>1.88 (0.28)</td></tr><tr><td>Psychosis</td><td>8</td><td>1.60 (0.31)</td><td>2.00 (0.00)</td><td>1.76 (0.36)</td><td>1.77 (0.31)</td><td>1.73 (0.31)</td><td>1.81 (0.29)</td><td>1.90 (0.23)</td><td>1.80 (0.26)</td></tr><tr><td>Anxiety</td><td>16</td><td>1.72 (0.40)</td><td>1.88 (0.27)</td><td>1.83 (0.45)</td><td>1.84 (0.30)</td><td>2.30 (0.97)</td><td>1.88 (0.25)</td><td>1.91 (0.22)</td><td>1.90 (0.41)</td></tr></tbody></table> </ephtml> </p> <hd id="AN0164492932-16">OCD</hd> <p>There was a statistically significant difference in identification of OCD symptoms among the different profession groups (χ<sups>2</sups> (<reflink idref="bib6" id="ref66">6</reflink>) = 28, <emph>p</emph> <.01). Post hoc tests using Bonferroni correction showed that traditional healers and community health workers were significantly better at identifying OCD symptoms than psychologists (χ<sups>2</sups> (<reflink idref="bib6" id="ref67">6</reflink>) = 60.15, <emph>p</emph> <.01), medical doctors (χ<sups>2</sups> (<reflink idref="bib6" id="ref68">6</reflink>) = 44.21, <emph>p</emph> <.01), allied health professionals (χ<sups>2</sups> (<reflink idref="bib6" id="ref69">6</reflink>) = −42.18, <emph>p</emph> =.029), psychiatrists (χ<sups>2</sups> (<reflink idref="bib6" id="ref70">6</reflink>) = −60.84, <emph>p</emph> <.01), and nurses (χ<sups>2</sups> (<reflink idref="bib6" id="ref71">6</reflink>) = −44.67, <emph>p</emph> =.017).</p> <hd id="AN0164492932-17">Depression</hd> <p>There was a statistically significant difference in identification of symptoms of depression among the different profession groups (χ<sups>2</sups> (<reflink idref="bib6" id="ref72">6</reflink>) = 24, <emph>p</emph> <.01). Post hoc tests using Bonferroni correction showed that traditional healers and community health workers were significantly better at identifying symptoms of depression than both and psychologists (χ<sups>2</sups> (<reflink idref="bib6" id="ref73">6</reflink>) =52.42, <emph>p</emph> <.01) and psychiatrists (χ<sups>2</sups> (<reflink idref="bib6" id="ref74">6</reflink>) = −54.71, <emph>p</emph> =.01).</p> <hd id="AN0164492932-18">Hypomania</hd> <p>There was a statistically significant difference in identification of symptoms of hypomania among the different profession groups (χ<sups>2</sups> (<reflink idref="bib6" id="ref75">6</reflink>) = 19, <emph>p</emph> <.01). Post hoc tests using Bonferroni correction showed that traditional healers and community health workers were significantly better at identifying symptoms of hypomania than psychiatrists (χ<sups>2</sups> (<reflink idref="bib6" id="ref76">6</reflink>) = −49.24, <emph>p</emph> =.01), nurses were significantly better than psychiatrists (χ<sups>2</sups> (<reflink idref="bib6" id="ref77">6</reflink>) = 48.05, <emph>p</emph> =.02), and allied health professionals significantly better than psychiatrists (χ<sups>2</sups> (<reflink idref="bib6" id="ref78">6</reflink>) = −45.05, <emph>p</emph> =.04).</p> <hd id="AN0164492932-19">Psychosis</hd> <p>There was a statistically significant difference in identification of psychosis symptoms among the different profession groups (χ<sups>2</sups> (<reflink idref="bib6" id="ref79">6</reflink>) = 27, <emph>p</emph> <.01). Post hoc tests using Bonferroni correction showed that traditional healers and community health workers were significantly better at identifying symptoms of psychosis than and psychologists (χ<sups>2</sups> (<reflink idref="bib6" id="ref80">6</reflink>) = 47.79, <emph>p</emph> <.01), medical doctor (χ<sups>2</sups> (<reflink idref="bib6" id="ref81">6</reflink>) = 36.46, <emph>p</emph> <.013), and psychiatrists (χ<sups>2</sups> (<reflink idref="bib6" id="ref82">6</reflink>) = −60.31, <emph>p</emph> <.01).</p> <hd id="AN0164492932-20">Anxiety</hd> <p>There was a statistically significant difference in identification of anxiety symptoms among the different profession groups (χ<sups>2</sups> (<reflink idref="bib6" id="ref83">6</reflink>) = 14.15, <emph>p</emph> =.028). There was no significant difference across the professions for identification of anxiety symptoms when adjusting for Bonferroni correction, although Post hoc tests without Bonferroni correction showed that medical doctors (χ<sups>2</sups> (<reflink idref="bib6" id="ref84">6</reflink>) = 14.76, <emph>p</emph> =.045), psychologists (χ<sups>2</sups> (<reflink idref="bib6" id="ref85">6</reflink>) = 15.73, <emph>p</emph> =.009), and psychiatrists (χ<sups>2</sups> (<reflink idref="bib6" id="ref86">6</reflink>) = 50.60, <emph>p</emph> =.005) were significantly better than the "other" profession group in identifying symptoms of anxiety. In addition, traditional healers and community health workers were significantly better at identifying anxiety symptoms than psychologists (χ<sups>2</sups> (<reflink idref="bib6" id="ref87">6</reflink>) = 28.13, <emph>p</emph> =.031) and psychiatrists (χ<sups>2</sups> (<reflink idref="bib6" id="ref88">6</reflink>) = −37.67, <emph>p</emph> =.017); and allied health professionals were significantly better at identifying anxiety symptoms than psychologists (χ<sups>2</sups> (<reflink idref="bib6" id="ref89">6</reflink>) = 14.01, <emph>p</emph> =.048), and psychiatrists (χ<sups>2</sups> (<reflink idref="bib6" id="ref90">6</reflink>) = 23.55, <emph>p</emph> =.025).</p> <hd id="AN0164492932-21">Symptoms Reported that Did Not Fit into the MPAS-ADD Criteria</hd> <p>Table 2 shows the most frequently reported symptom for three diagnoses that could not be coded according to MPAS-ADD criteria.</p> <p>Table 2. Most frequently reported symptoms for depression, anxiety and psychosis that could not be coded according to MPAS-ADD criteria.</p> <p> <ephtml> <table><thead><tr><td>Disorder</td><td>Symptom</td><td>% reported*</td></tr></thead><tbody><tr><td><italic>Depression</italic></td><td>Withdrawal from prayer and/or mosque attendance, and reduction of faith in Allah Lazy Negative or bad attitude</td><td>13.2 7.3 2.5</td></tr><tr><td><italic>Anxiety</italic></td><td>Communication and speaking problems Changes in eating pattern Hot anger</td><td>9.2 5.6 2.1</td></tr><tr><td><italic>Psychosis</italic></td><td>Increased attendance and hypervigilance to prayer and mosque attendance Discourteous behavior Snake-like eyes</td><td>15.7 6.2 2.3</td></tr></tbody></table> </ephtml> </p> <p>1 *% = percentage of participants who reported the corresponding symptom</p> <hd id="AN0164492932-22">Confidence in Diagnosis and Treatment</hd> <p>Table 3 shows the means and standard deviations for each of the aspects of Therapy Confidence Scale-Intellectual Disabilities (TCD-ID), where higher scores were more confident in doing these actions. The mean confidence score across all 14 confidence-related items was 4.11 (<emph>SD </emph>= 1.03), indicating that respondents were, on average, "confident" in working with persons with an intellectual disability. Participants were most confident in listening carefully to concerns presented by a client with an ID (<emph>M = </emph>4.68, <emph>SD = </emph>0.76), and in being empathetic toward a client with an ID (<emph>M = </emph>4.62, <emph>SD = </emph>0.75). Confidence was lowest for identifying therapeutic approaches that would be effective for a client with an ID (<emph>M = </emph>3.84, <emph>SD = </emph>1.41), and explaining the results of an assessment to a client with an ID (<emph>M = </emph>3.87, <emph>SD = </emph>1.31).</p> <p>Table 3. Means and SDs for each aspect of the Therapy Confidence Scale-Intellectual Disabilities (TCD-ID) as reported by each of the groups of health professionals.</p> <p> <ephtml> <table><thead><tr><td>Confidence for using this action in therapy:</td><td>Psychiatrist</td><td>Psychologist</td><td>Doctor</td><td>Nurse</td><td>Allied Health</td><td>Traditional. Healer/ Community Health</td><td>Other</td><td>Total for each aspect</td></tr><tr><td><italic>M(SD)</italic></td><td><italic>M(SD)</italic></td><td><italic>M(SD)</italic></td><td><italic>M(SD)</italic></td><td><italic>M(SD)</italic></td><td><italic>M(SD)</italic></td><td><italic>M(SD)</italic></td><td><italic>M(SD)</italic></td></tr></thead><tbody><tr><td>Listen carefully to concerns presented by a client with an intellectual disability</td><td>5.00 (0.00)</td><td>4.75 (0.76)</td><td>4.68 (0.96)</td><td>4.70 (0.63)</td><td>4.71 (0.69)</td><td>4.36 (1.34)</td><td>4.58 (0.96)</td><td>4.68 (0.76)</td></tr><tr><td>Be empathetic toward a client with an intellectual disability</td><td>4.77 (0.60)</td><td>4.53 (0.76)</td><td>4.67 (1.08)</td><td>4.30 (0.93)</td><td>4.47 (0.94)</td><td>4.71 (0.73)</td><td>4.95 (0.23)</td><td>4.62 (0.75)</td></tr><tr><td>Understand special issues related to heaving an intellectual disability and their impact on a person's life</td><td>4.23 (0.73)</td><td>4.19 (1.26)</td><td>4.28 (1.51)</td><td>4.04 (1.15)</td><td>4.12 (1.27)</td><td>4.21 (1.48)</td><td>4.63 (0.50)</td><td>4.24 (1.13)</td></tr><tr><td>Communicate with a client who has an intellectual disability</td><td>3.77 (1.48)</td><td>3.88 (1.39)</td><td>4.31 (1.50)</td><td>4.04 (1.33)</td><td>3.53 (1.70)</td><td>4.36 (1.34)</td><td>4.53 (0.70)</td><td>4.06 (1.35)</td></tr><tr><td>Develop a therapeutic relationship with a client who has an intellectual disability?</td><td>3.62 (1.26)</td><td>3.66 (1.47)</td><td>4.23 (1.54)</td><td>4.04 (1.36)</td><td>3.47 (1.66)</td><td>4.64 (0.63)</td><td>4.26 (1.28)</td><td>3.99 (1.54)</td></tr><tr><td>Gather information from a client with an intellectual disability so that their difficulties can be better understood</td><td>4.15 (1.07)</td><td>3.97 (1.33)</td><td>4.23 (1.43)</td><td>3.57 (1.47)</td><td>3.71 (1.49)</td><td>4.57 (1.09)</td><td>4.58 (0.77)</td><td>4.11 (1.24)</td></tr><tr><td>Use assessments in a way that a client with an intellectual disability will understand</td><td>3.92 (1.44)</td><td>3.72 (1.37)</td><td>4.28 (1.32)</td><td>3.48 (1.59)</td><td>3.29 (1.57)</td><td>4.86 (0.77)</td><td>4.21 (1.13)</td><td>3.97 (1.31)</td></tr><tr><td>Explain results of an assessment process to a client with an intellectual disability</td><td>3.85 (1.46)</td><td>3.59 (1.54)</td><td>4.23 (1.37)</td><td>3.52 (1.73)</td><td>3.18 (1.63)</td><td>4.43 (1.28)</td><td>4.32 (0.89)</td><td>3.87 (1.41)</td></tr><tr><td>Use knowledge about mental health issues in formulating the problems of a client with an intellectual disability</td><td>4.15 (1.28)</td><td>3.69 (1.49)</td><td>4.16 (1.52)</td><td>3.65 (1.58)</td><td>3.29 (1.49)</td><td>4.14 (1.46)</td><td>4.21 (1.08)</td><td>3.90 (1.41)</td></tr><tr><td>Help a client with an intellectual disability to identify issues that need to be considered in sessions</td><td>3.69 (1.25)</td><td>3.72 (1.46)</td><td>4.21 (1.47)</td><td>3.65 (1.64)</td><td>3.53 (1.50)</td><td>4.36 (1.22)</td><td>4.58 (0.69)</td><td>3.96 (1.32)</td></tr><tr><td>Use knowledge of mental health interventions to work effectively with a client who has an intellectual disability</td><td>3.85 (1.46)</td><td>3.72 (1.54)</td><td>4.15 (1.46)</td><td>3.52 (1.50)</td><td>4.12 (1.32)</td><td>4.93 (0.27)</td><td>4.05 (1.22)</td><td>4.04 (1.25)</td></tr><tr><td>Identify therapeutic approaches that will be effective for a client with intellectual disability</td><td>4.08 (1.38)</td><td>3.56 (1.66)</td><td>3.84 (1.59)</td><td>3.61 (1.47)</td><td>3.29 (1.79)</td><td>4.79 (0.58)</td><td>3.74 (1.41)</td><td>3.84 (1.41)</td></tr><tr><td>Work with care-givers and other important people in the lives of people with an intellectual disability</td><td>4.23 (1.36)</td><td>4.13 (1.26)</td><td>4.41 (1.26)</td><td>3.57 (1.50)</td><td>3.94 (1.25)</td><td>4.29 (1.54)</td><td>4.58 (0.77)</td><td>4.16 (1.28)</td></tr><tr><td>End intervention with a client who has an intellectual disability in an effective manner</td><td>4.54 (0.66)</td><td>3.69 (1.35)</td><td>4.16 (1.45)</td><td>3.78 (1.35)</td><td>4.00 (1.50)</td><td>4.50 (1.29)</td><td>4.00 (1.29)</td><td>4.09 (1.27)</td></tr><tr><td>Total M (SD) for occupational group</td><td>4.13 (0.94)</td><td>3.91 (1.12)</td><td>4.28 (1.02)</td><td>3.82 (1.19)</td><td>3.73 (1.06)</td><td>4.42 (0.90)</td><td>4.37 (0.66)</td><td>4.11 (1.03)</td></tr></tbody></table> </ephtml> </p> <p>A Kruskal–Wallis H test was conducted to examine the differences of levels of the total confidence score and the individual 14 confidence item scores among the 7 professional groups, with practitioner type (psychiatrists, traditional healers and community workers, doctors, nurses, psychologists, allied health, other. When confidence for all aspects of therapy were combined, there were no statistically significant difference in the total confidence scale score among the different profession groups (χ<sups>2</sups> (<reflink idref="bib6" id="ref91">6</reflink>) = 9.780, <emph>p</emph> =.134). Interestingly, when comparing confidence levels at an item level, results showed a statistically significant difference across professions for four aspects of therapy: "<emph>being empathetic towards a client with an ID</emph>" (χ<sups>2</sups> (<reflink idref="bib6" id="ref92">6</reflink>) = 13.97. <emph>p</emph> =.03), "<emph>using assessments in a way that a client with ID will understand"</emph> (χ<sups>2</sups> (<reflink idref="bib6" id="ref93">6</reflink>) = 18.11, <emph>p</emph> =.006), "<emph>explain results of an assessment process to a client with an ID"</emph> (χ<sups>2</sups> (<reflink idref="bib6" id="ref94">6</reflink>) = 15.18, <emph>p</emph> =.02), and "<emph>help a client with an ID to identify issues that need to be considered in sessions"</emph> (χ<sups>2</sups> (<reflink idref="bib6" id="ref95">6</reflink>) = 12.78, <emph>p</emph> =.05).</p> <p>Post hoc tests using a Bonferroni correction showed that compared to allied health professionals, traditional healers and community health workers were significantly more confident (χ<sups>2</sups> (<reflink idref="bib6" id="ref96">6</reflink>) = 50.99, <emph>p = </emph>.022) in using assessments in a way that clients with IDs would understand. Similarly, compared to allied health professionals, medical doctors were significantly more confident (χ<sups>2</sups> (<reflink idref="bib6" id="ref97">6</reflink>) = 39.35, <emph>p</emph> =.044) in helping a client with an ID to identify issues that need to be considered in sessions. Post hoc tests showed no significant difference in confidence level between professions in explaining results of an assessment process to a client with an ID, or in being empathetic toward a client with an ID.</p> <hd id="AN0164492932-23">Discussion</hd> <p></p> <hd id="AN0164492932-24">Knowledge</hd> <p>As predicted, participants in this study demonstrated low symptom knowledge of five common mental health disorders experienced by persons with an ID (OCD, Depression, Hypomania, Psychosis, Anxiety). This expected result was based on prior findings using similar methodology conducted in developed countries (Hinde & Mason, [<reflink idref="bib13" id="ref98">13</reflink>]; Quigley et al., [<reflink idref="bib31" id="ref99">31</reflink>]), and an overall paucity of research exploring both mental health prevalence across Bangladesh, and Bangladeshi health practitioner knowledge of mental health symptoms in persons with an ID. Interestingly, diagnostic-based professions (medical doctors and psychiatrists) demonstrated limited symptom knowledge. This is important to note given that these professions are often responsible for mental health diagnoses, and have greater training with diagnostic and assessment-based content than the other professions in Bangladesh. It may be that Bangladeshi health practitioners learn diagnostic and assessment protocols for mainstream populations (not ID specific populations) and are unable to easily modify training to conceptualize mental health presentations of those with an ID. This may reflect traditional rote-based pedagogical styles of medical training delivered by Bangladeshi medical educational institutes (Amin & Greenwood, 2018). In addition, this may also reflect limited research in the field and limited training opportunities for medical-based practitioners regarding mental health presentations in persons with an ID.</p> <p>In contrast, our results indicated that traditional healers and community health workers, whilst still low in knowledge, were most able to identify the majority of mental health condition symptoms. As traditional healers often act as frontline health-care providers for up to 90% of the population, these professions would likely have more exposure to various ailments and symptomatology than other professions (Abdulla et al., 2019; Rawal et al., [<reflink idref="bib32" id="ref100">32</reflink>]). From a treatment provision perspective, this finding is concerning when placed in context of existing research, as Bangladeshi traditional healers may view disability and mental health disorders as afflictions of black magic and jinni possession (Mullick et al., [<reflink idref="bib27" id="ref101">27</reflink>]). Traditional healers may also use herbal remedies and/or traditional and spiritual healing rituals to treat mental illness (Giasuddin et al., [<reflink idref="bib10" id="ref102">10</reflink>]). Haque et al. ([<reflink idref="bib11" id="ref103">11</reflink>]) found that those from a middle socioeconomic status were less likely to access or continue treatment with traditional healers after treatment was deemed ineffective, partially due to financial and logistical difficulties in accessing other treatments, and would often use these practitioners as a first point of care only. However, those of lower socioeconomic status continue to seek traditional healing despite low efficacy of treatment (Haque et al., [<reflink idref="bib11" id="ref104">11</reflink>]). Poor treatment effectiveness may instead be seen as an individual's own failure to believe in the efficacy of treatment, or low adherence to prescribed religious rituals in the home (Haque et al., [<reflink idref="bib11" id="ref105">11</reflink>]). However, Hinde et al. ([<reflink idref="bib14" id="ref106">14</reflink>]) reported that on the front line, traditional healers may be useful in detecting some mental health disorders such as depression and anxiety. Given those from lower socioeconomic backgrounds tend to prefer accessing these services, targeted ID and mental health training for these professions may be helpful in improving quality of care, with a function of providing information and referrals to medical professionals.</p> <p>Our data also revealed some participant-reported symptoms and terminology that did not fit into MPAS-ADD criteria for the specified mental health conditions. A common symptom identified across mental health conditions was change to religious activity (i.e., engagement in prayer and mosque attendance). For example, 13.2% of participant answers included withdrawal from prayer and/or mosque attendance, and reduction of faith in Allah, as a key symptom of depression. Further, 15.7% indicated <emph>increased</emph> attendance and hypervigilance to prayer and mosque attendance as a symptom of psychosis. Studies conducted in developing countries describe a common feature of psychotic disorders as being "hyper-religiosity," a psychiatric disturbance in which a person experiences intense religious belief and/or behavior that interfere with normal functioning (Mitrev, [<reflink idref="bib26" id="ref107">26</reflink>]; Van Praag, [<reflink idref="bib38" id="ref108">38</reflink>]). The American Psychiatric Association's Diagnostic and Statistical Manual – Fifth Edition (the DSM-5; American Psychiatric Association, [<reflink idref="bib3" id="ref109">3</reflink>]) descriptive and/or value free way of assessing mental health issues may mean that hyper-religiosity as a symptom of psychosis is often overlooked in Western societies. This highlights the important role of spirituality and religion in Bangladeshi culture, and may also explain the prevalence of and public preference given to traditional healers. Religious and/or spiritual-based symptomology was not explicitly identified in Westernized research measuring similar constructs.</p> <hd id="AN0164492932-25">Confidence</hd> <p>Participants in our study demonstrated higher confidence levels in diagnosis and treatment of persons with an ID than were expected. Mental health and ID are not novel to Bangladeshi health care; however, our results may indicate that practitioners have limited understanding the comorbidity of these presentations. Given this, it is not fully understood how health practitioners in Bangladesh demonstrated such high levels of confidence. It was difficult to predict confidence levels from the outset, due to the paucity of research exploring the health practitioner perspective of working in ID-related fields in Bangladesh and/or other similar developing countries.</p> <p>ID: being empathetic; listening to concerns; understanding special issues that impact on a person's life; using knowledge of mental health interventions to work effectively; working with caregivers and other important figures; and ending treatment in an effective manner. Participant responses on all other items fell between the "moderately confident" to "confident" range, with no items reported below a "moderately confident" level. Interestingly, Bangladeshi health practitioners reported higher confidence levels on the TCS-ID compared to an Australian sample (Hinde & Mason, [<reflink idref="bib13" id="ref110">13</reflink>]). Furthermore, comparison of results indicated that Bangladeshi and Australian health practitioners both had highest confidence levels in listening to a client with an ID and being empathetic, and lowest confidence levels in assessment-based tasks. These findings were also echoed in additional studies conducted in the United Kingdom (Dagnan et al., [<reflink idref="bib8" id="ref111">8</reflink>]; Marwood, Chinn, Gannon & Scior, [<reflink idref="bib23" id="ref112">23</reflink>]) and Australia (Hronis, Roberts & Kneebone, [<reflink idref="bib16" id="ref113">16</reflink>]) using the TCS-ID to explore health practitioner confidence in working with persons with IDs. Collectively, this indicates that while health practitioners in both developing and developed countries may have confidence using some therapeutic skills (i.e., listening and giving empathy), they have lower confidence with assessment-based tasks when working specifically people with an ID, and may benefit from specialized training in this area of ID health care. Inadequate assessment and diagnostic ability may lead to ineffective therapeutic treatments and thus a lack of long-lasting treatment gains (Owens & Keller, [<reflink idref="bib30" id="ref114">30</reflink>]). Further research into confidence levels in health practitioners is needed in Bangladesh, as well as other developing and developed countries, to understand common gaps in health practitioner confidence.</p> <hd id="AN0164492932-26">Strengths and Limitations</hd> <p>Our study is the first to explore health practitioner knowledge, confidence and overall perceptions of working with persons with an ID and mental health issues in Bangladesh. This study is therefore able to provide a preliminary understanding of current confidence and knowledge within a diversity of health practitioners tasked with treating people with ID in Bangladesh, thus creating scope to compare findings to recent Western data. This was important to explore, as past research has focussed on exploring Western health practitioner perspectives of working within the fields of mental health and ID.</p> <p>Both scales used in this study (MPAS-ADD and TCS-ID) had strong psychometric properties, that with appropriate translation, were deemed appropriate for use within a non-Western country such as Bangladesh. Being the first study to use the TCS-ID to measure confidence levels within a Bangladeshi sample, it is difficult to determine if participants, and our findings, were impacted by the overconfidence bias. As recommended by Hinde and Mason ([<reflink idref="bib13" id="ref115">13</reflink>]), future studies may include measures to allow for detection of the bias by including case vignettes (as used by Meyer et al., [<reflink idref="bib25" id="ref116">25</reflink>]) and confidence interval estimates (Soll & Klayman, [<reflink idref="bib36" id="ref117">36</reflink>]). Replication of these findings both in Bangladesh and other developing countries, using both the TCS-ID to measure confidence and the MPAS-ADD to measure knowledge, is recommended.</p> <p>Recruitment via snowball sampling meant that our sample distribution between professions was unequal, which may have reduced overall power and generalizability of results for each profession to the wider population. Future research may address this by targeting specific professions and capping participant numbers for each group. The researchers involved in this study were predominantly Australian, and whilst the local relationships fostered by the lead researchers as well as the inclusion of Bangladeshi advisers, translators, peer reviews and researchers throughout the project is likely to have improved its cultural validity is possible that some cultural differences were missed or unintentionally misinterpreted.</p> <p>Finally, the attrition rate in this study was modest, in that only 158 of the 197 consenting participants completed the survey past item 10. This was attributed to participant fatigue, and the placement of more labor-intensive survey items (i.e. items requiring a written response) toward the end of the survey. Future studies may avoid this by randomizing the order of similar items throughout the survey.</p> <hd id="AN0164492932-27">Future Recommendations</hd> <p>In light of our findings, consideration should be given to improving practitioner knowledge of mental health symptoms in the ID population, and promoting confidence across all health professions working in this population. Existing research suggests that an initial understanding of current knowledge and confidence levels in a population is the first step to inform and change policy and educational institutions (Jess et al., [<reflink idref="bib19" id="ref118">19</reflink>]; Weise & Trollor, [<reflink idref="bib39" id="ref119">39</reflink>]). This study has been the first of its kind to explore current levels of Bangladeshi health practitioner knowledge and confidence in working with people with mental health issues and IDs. These findings can assist both the development of further research and investigation, whilst forming the basis for finding out why Bangladeshi health practitioners have overconfidence in working with persons with an ID.</p> <hd id="AN0164492932-28">Conclusion</hd> <p>This study used two psychometrically valid scales to measure the confidence and knowledge of Bangladeshi health practitioners, and identified knowledge and skill deficits unique to Bangladeshi practitioners. Results indicated that while participants demonstrated high confidence in treating mental health symptoms in people with ID, overall knowledge of symptomology was very low. Traditional healers and community health workers, while still low in knowledge, were able to identify more mental health symptoms for 4 of the 5 mental health conditions than all other medical and therapeutic health practitioners. This was attributed to traditional healers and community health workers being on the frontline of community health care for 90% of the health care seeking population, and having more exposure to various ailments and symptoms than other practitioners.</p> <p>Similar to previous Western studies using the TCS-ID to measure confidence, our sample of Bangladeshi health practitioners demonstrated more confidence in using therapeutic aspects of care (listening and being empathetic) and less confidence with using assessment-based tasks with people with an ID and mental health issue. The development of training programs to address specific deficits in knowledge of mental health symptoms, and confidence in using assessment and assessment-based communication, is recommended. Training design should account for the specific needs and working environments of different medical, therapeutic and community-based practitioners. For example, training for medical practitioners may focus on building skill around diagnosis and assessment, and training for therapeutic and community-based practitioners focus on developing treatment protocol and dissemination of information and referral pathways. This recommendation is consistent with several studies indicating the need for training development to improve knowledge and confidence (Lennox & Chaplin, [<reflink idref="bib21" id="ref120">21</reflink>]; Man et al., [<reflink idref="bib22" id="ref121">22</reflink>]; Torr et al., [<reflink idref="bib37" id="ref122">37</reflink>]). Facilitating the implementation of training and ongoing research will not only enhance the capacity of practitioners in diagnosis and treatment of mental health issues in people with ID, but also improve outcomes for this population within Bangladesh.</p> <hd id="AN0164492932-29">Disclosure Statement</hd> <p>No potential conflict of interest was reported by the author(s).</p> <ref id="AN0164492932-30"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref10" type="bt">1</bibl> <bibtext> This manuscript has not been published elsewhere and has not been submitted simultaneously for publication elsewhere.</bibtext> </blist> </ref> <ref id="AN0164492932-31"> <title> References </title> <blist> <bibtext> Abdullah, A. S., Rawal, L. B., Choudhury, S. R., Baral, S., Jiang, L., & Sha, T. (2019). Use of community health workers to manage and prevent noncommunicative diseases: Policy options based on findings of the COACH study. World Health Organisation. 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  Label: Title
  Group: Ti
  Data: Bangladeshi Health Practitioner Knowledge, Confidence in Diagnosis, and Treatment of Mental Health Disorders in People with Intellectual Disabilities
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Hinde%2C+Kylie%22">Hinde, Kylie</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0001-8707-1618">0000-0001-8707-1618</externalLink>)<br /><searchLink fieldCode="AR" term="%22Mason%2C+Jonathan%22">Mason, Jonathan</searchLink><br /><searchLink fieldCode="AR" term="%22Kannis-Dymand%2C+Lee%22">Kannis-Dymand, Lee</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-1882-6121">0000-0002-1882-6121</externalLink>)<br /><searchLink fieldCode="AR" term="%22Millear%2C+Prue%22">Millear, Prue</searchLink><br /><searchLink fieldCode="AR" term="%22Sultana%2C+Razia%22">Sultana, Razia</searchLink>
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  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Journal+of+Mental+Health+Research+in+Intellectual+Disabilities%22"><i>Journal of Mental Health Research in Intellectual Disabilities</i></searchLink>. 2023 16(3):205-225.
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  Data: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
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  Label: Peer Reviewed
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  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 21
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2023
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Intellectual+Disability%22">Intellectual Disability</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Disorders%22">Mental Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Knowledge+Level%22">Knowledge Level</searchLink><br /><searchLink fieldCode="DE" term="%22Clinical+Diagnosis%22">Clinical Diagnosis</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Self+Efficacy%22">Self Efficacy</searchLink><br /><searchLink fieldCode="DE" term="%22Allied+Health+Personnel%22">Allied Health Personnel</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Bangladesh%22">Bangladesh</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/19315864.2022.2098432
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1931-5864<br />1931-5872
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: Intellectual disability and mental health disorders constitute a major health problem globally with higher economic burden in low- and middle-income countries such as Bangladesh. In 2017, the World Bank estimated that 85% of the global population lived in low-middle-income countries. Limited research has explored health practitioner knowledge and/or confidence in the diagnosis and treatment of mental health issues in persons with intellectual disabilities (IDs) in low-income countries such as Bangladesh. Method: One hundred and ninety-seven Bangladeshi-based health practitioners were grouped into 7 main professional groups according the current Bangladeshi health hierarchy (psychiatrists; traditional healers and community workers; medical doctors; nurses; psychologists; allied health: speech therapists, occupational therapists, social workers; and others: teachers physiotherapists, administration staff). A 34-item online survey was completed, which included questions measuring symptoms of common mental health disorders with reference to the Psychiatric Assessment Schedule for Adults with Developmental Disabilities, and questions measuring confidence working with persons with IDs from the Therapy Confidence Scale-Intellectual Disabilities. Results: Participants demonstrated low knowledge of symptomology but were "confident" working with people with IDs. Kruskal-Wallis H tests indicated a significant effect of professional group on both overall knowledge and confidence levels, respectively. Traditional healers and community health workers had significantly more knowledge of symptoms than all other practitioners for obsessive-compulsive disorder, depression, psychosis, and hypomania. Conclusion: Participants demonstrated confidence, but low knowledge, in treating individuals with IDs. The development of training programs to address specific deficits in knowledge of mental health symptoms, and confidence in using assessment and assessment-based communication, is recommended.
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  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2023
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1392904
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1392904
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1080/19315864.2022.2098432
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 21
        StartPage: 205
    Subjects:
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Intellectual Disability
        Type: general
      – SubjectFull: Mental Disorders
        Type: general
      – SubjectFull: Knowledge Level
        Type: general
      – SubjectFull: Clinical Diagnosis
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Self Efficacy
        Type: general
      – SubjectFull: Allied Health Personnel
        Type: general
      – SubjectFull: Symptoms (Individual Disorders)
        Type: general
      – SubjectFull: Bangladesh
        Type: general
    Titles:
      – TitleFull: Bangladeshi Health Practitioner Knowledge, Confidence in Diagnosis, and Treatment of Mental Health Disorders in People with Intellectual Disabilities
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Hinde, Kylie
      – PersonEntity:
          Name:
            NameFull: Mason, Jonathan
      – PersonEntity:
          Name:
            NameFull: Kannis-Dymand, Lee
      – PersonEntity:
          Name:
            NameFull: Millear, Prue
      – PersonEntity:
          Name:
            NameFull: Sultana, Razia
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 01
              Type: published
              Y: 2023
          Identifiers:
            – Type: issn-print
              Value: 1931-5864
            – Type: issn-electronic
              Value: 1931-5872
          Numbering:
            – Type: volume
              Value: 16
            – Type: issue
              Value: 3
          Titles:
            – TitleFull: Journal of Mental Health Research in Intellectual Disabilities
              Type: main
ResultId 1