Study Design
This pilot study is a three-phase study with descriptive and intervention components. The first phase is a needs assessment and situational analysis using a mixed methods approach to determine the prevalence and factors contributing to stress and mental health outcomes among police officers in four randomly selected states in four out of the six geo-political zones of the country. This phase will be conducted in four randomly selected states in the four geo-political regions of Nigeria. The states are Bauchi (North East), Nasarawa (North Central), Akwa-Ibom (South-South), and Oyo (South West). The second phase is a pilot study that will utilize a parallel cluster randomized trial to assess a peer-led intervention for stress prevention, management, and coping mechanisms among 200 police officers. The pilot trial will be conducted in only one state (Oyo). The third is the preliminary evaluation of the intervention based on knowledge about stress management and mental disorders and reduction in stress levels. These measures will be obtained at baseline, immediate, and six months post-intervention. Feasibility will be determined based on enrollment rate, attendance, and completion of the group sessions.
Study setting
The Nigeria Police Force (NPF) was established in 1820. Staff of the NPF are distributed across the 36 states of the federation and Abuja, Federal Capital Territory (FCT). NPF staff are also involved in international policing and peacekeeping assignments on behalf of the Economic Commission for West Africa, the African Union, the United Nations, and Interpol. The Inspector General of Police commands and supervises the NPF. There are 17 operational zonal commands (usually composed of two to four state commands) headed by an Assistant Inspector-General of Police; and 37 state commands, including the FCT.
The study will be conducted in Bauchi, Nassarawa, Akwa Ibom, and Oyo states. Each state has a Command led by a Commissioner of Police, Area Commands managed by an Assistant Commissioner of Police, and several Divisions administered by a Chief Superintendent or Superintendent (www.npf.gov.ng). As stated in Section 4 of the Police Act of 2020, the duties of the police are to prevent crime, apprehend offenders, protect public safety, keep the peace, safeguard and protect individuals and their properties. The rank and file of the police personnel need to be in optimal mental health to successfully perform these duties. The organizational structure of the NPF are: Force Headquarters; Zonal Headquarters; State Command Headquarters; Area Command Headquarters; Divisional Police Headquarters; Police Station; Police post and Village Police post (www.npf.gov.ng). The NPF has seven specialised departments designated as letters A-G which include the police medical services under the “A” department and the Research and Planning under the “E” department.
Study Population
The study population will consist of male and female police officers including Senior officers (Commissioner, Deputy Commissioners, Assistant Commissioners, Chief Superintendent, Deputy Superintendent and Assistant Superintendent of Police) and Junior officers (Inspectors, Sergeants, Corporals and Constables).
Inclusion criteria
The criteria for selection will include:
Informed consent
1. and willingness to participate in the study.
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Serving as a full-time police officer in the division
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Attachment to a defined police formation.
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Schedule that involves direct interactions with the community members.
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Availability throughout the period of the research work.
Exclusion criteria
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Police officers who are ill and unavailable during the conduct of the study
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Posting to duty stations outside Nigeria
Phase One of the study: Needs assessment and situation analysis
Sample size determination
The sample size for the needs assessment and situation analysis will be derived using the following assumptions: α = 0.05, β = 0.8, a design effect of 1.0, 95% CI and the proportion of police officers (93.4%) who had experienced stress from a recent study [7]. The calculated sample size for the quantitative component of the study will also include 20% non-response resulting in approximately 300 police officers per state (total 1,200). The sample for the qualitative component is 40 police officers. Together 1,240 police officers will be recruited into the study (see Table 1 for details). In selecting respondents for the survey component, the plan is to recruit police officers in the ratio of 1:4 senior and junior officers based on the preponderance of junior officers in the Nigeria Police Force.
Table 1
Method of data collection and sample size by states
| Site | Method and sample | Total |
| Quantitative | Qualitative |
| Survey Questionnaire | Informant/in-depth interviews |
| North east (Bauchi) | 300 | 10 | 310 |
| North central (Nasarawa) | 300 | 10 | 310 |
| South-South (Akwa Ibom) | 300 | 10 | 310 |
| Southwest(Oyo) | 300 | 10 | 310 |
| Total | 1, 200 | 40 | 1, 240 |
Instruments for quantitative data collection
We will use stress-related police-specific tools and other tools to collect quantitative data (Supplementary file 1). These include the Perceived Stress Scale, [13], Operational Police Stress Questionnaire (PSQ-Op) and Organizational Police Stress Questionnaire (PSQ- Org) [14], Burn out using the Maslach Burnout Inventory (MBI-22 item) [15], Sleep disorders using the Pittsburgh sleep quality index (PSQI) [16], Psychological wellbeing using the 12-Item General Health Questionnaire [17], common mental disorders using the Patient health questionnaire (PHQ-9) for depression [18] and the generalized anxiety disorder (GAD-7) for anxiety [19], alcohol and substance use disorders using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) [20]. The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) is a screening tool developed by the World Health Organization [20]. It assesses lifetime and past three-month use of psychoactive substances, problems related to substance use, risk of current or future harm and level of dependence. Substances assessed include tobacco, alcohol, cannabis, cocaine, amphetamine-type stimulants, sedatives, hallucinogens, inhalants, opioids, and other drugs. The CIDI short-form suicidality module will be used to assess the presence of suicidal behaviours including suicidal ideas, suicidal plans, and suicide attempts in the last 12 months [21]. The CIDI is a lay-administered structured diagnostic instrument designed to ascertain the diagnosis of mental disorders based on either the DSM or WHO International Classification of Diseases and Related Health Problems (ICD) diagnostic criteria.
Instrument for qualitative data collection
Key informants guide will be used to conduct the interviews. The plan is to interview 40 police officers to document their personal experiences and coping with stress-related issues and existing services to manage stress and related mental health issues (Supplementary File 2).
Measures
The combination of quantitative and qualitative methods is aimed at triangulation, which will yield breadth and depth of data needed for both diagnosis and planning of appropriate interventions. The variables of interest are knowledge about stress, the experience of stress, the severity of stress, reported coping mechanisms, level of depression, sleep disorder, anxiety disorder, and substance use.
Procedure for data collection
Before the data collection, advocacy visits will be paid to the Police Headquarters in Abuja as well as to each of the State Police Commands to obtain official permission to conduct the study. In each selected states, contact will be made with either the state Commissioner of police or State Police Medical officer who will send a signal/directive to all the selected divisions in the state.
There are not less than 40 police divisions in each state. A minimum of 10 divisions will be randomly selected from two out of the three senatorial districts in each state to reflect the potential diversity in each state. Members of the research team and trained research assistants will obtain consent from Police officers who are willing to participate in the study. Efforts will be made to select female and male police officers in a ratio of 1 to 3. We will also ensure that the selection of the different police cadres (ranks) takes into cognizance the proportion of junior and senior officers in the police force.
The quantitative data will be interviewer-administered by trained research assistants (RAs) using the KoboCollect. The interviews will take place at a time and place convenient for each participant. Privacy will be maintained throughout the period. We envisage that the tool will take approximately 50–60 minutes to administer. Each interviewer is expected to interview 30 police officers (per state) in total (1,200) and they are expected to conduct the interviews for 6 days making a total of 5 interviews per day.
For key informant interviews, we envisage that 40 interviews will be needed to reach saturation, a situation where a researcher stops data collection because no new information is received. The categories of persons to be interviewed will include senior officers (Chief Superintendent of Police, Superintendent of Police, Deputy Superintendent of Police) and junior officers (inspectors, corporal, and constables). All interviews will be recorded on a digital recorder after consent has been obtained from each study participant. The state research team will designate a time and location for interviews that is convenient for the participants. The interviews are anticipated to take between 45 and 60 minutes to elicit rich details about the topics covered while conscious of the participants' time. Trained RA will conduct interviews including taking notes, operating the recorder, and ensuring that the interviewee is comfortable. The interviewer will inform each prospective respondent that participation in the study is voluntary. The interviewer will provide clarification of any issue the respondent may have regarding the questions.
Quality assurance
During the data collection period, the transcription will occur parallel to data collection and will be shared on an ongoing basis with the study team leader to ensure the quality of the data. State team leaders will be in constant communication while on the field to respond to any issues that arise during data collection. To ensure good quality data, adequate training will be conducted to capacitate all the field staff through a well-developed training manual. This training manual will serve as a guide to all the field staff to consult in case they encounter any issues relating to the field activities.
Data analysis
Quantitative Data
The analysis will be performed using SPSS version 25.0. Descriptive statistics will be used to summarize the data to present the prevalence of stress, burnout, and mental disorders (depression, anxiety, alcohol use disorder and substance use disorders. The associations between demographic variables and stress with mental disorders and suicidal behaviour will be explored using T-Test and ANOVA for continuous variables and Chi-square for categorical variables. Linear regression models will be used to assess the correlates of severity of mental disorders based on the scores on the instruments for those who meet the diagnostic criteria for the different conditions. The level of significance will be set at 0.05 two-tailed.
Each of the tools to be administered is a standardized scale with specified cut points for each condition. For example, the PSQ-Op has 20 items that measure the prevalence of stress with categories that range from ‘no stress at all’ to ‘a lot of stress’. The PHQ-9 and the GAD-7 are derived from the full patient health questionnaire. The PHQ-9 is a 9-item screening instrument for depression that has been previously used and validated in earlier studies in Nigeria [22]; a cut-off score of 10 or higher denotes probable depression. The GAD-7 is a 7-item screener for generalized anxiety disorder with probable generalized anxiety disorder indicated by a score of 10. Further questions derived from the CIDI short form will be administered to participants who screen positive on the PHQ-9 and the GAD-7 to ascertain whether they meet the Diagnostic and Statistical Manual (DSM-V) diagnostic criteria for depression or anxiety disorder [21].
Qualitative data
Transcription
All digitally recorded interviews will first be transcribed verbatim using a structured transcription format. Verbatim transcription will be performed close to the time of completion of the interviews/discussions to maintain the originality of the information without loss of themes. Transcriptions will be conducted by the interviewers. Data transcription will be performed under the supervision of the team leader who will review it for completeness. Transcripts will be de-identified and participants will be identifiable only by a unique identifier code. Participant’s names and personal information will not be recorded. The transcript will be uploaded into the qualitative data management software Atlas.ti. The code book will be developed by the team members to guide coding and ensure consistent classification of themes. Thematic analysis will also be used to code the documents and transcripts, pointed out by the major research questions. We will adopt the Consolidated Criteria for Conducting and Reporting Qualitative Studies (COREQ) (Tong et al, 2007) for presenting and reporting the qualitative data.
Phase two: Pilot parallel cluster randomized trial
Trial Design
We will pilot test this intervention using a cluster randomized controlled trial (cRCT) design (See Fig. 3). While the police formation will be the unit for randomization, outcome assessment will be conducted on individual participants (police officers). cRCT is justified based on the format for the delivery of the interventions to groups of police officers selected based on the usual team/ office-based distribution of police officers (police formation).
General sensitization on stress management
A general sensitization meeting will be held in the intervention and control arms with the rank and file of police officers. The sensitization will include a general discussion of the cause of stress, prevention, and management. The sensitization meeting will be held during one of the monthly meetings convened by the Commissioner of Police which all police personnel in the state typically attend. We envisage that approximately 100 police personnel will attend the meeting.
Description of the intervention, adaptation, and development
Intervention group
Participants will be exposed to an evidence-based peer-led team-based format adapted from an earlier programme of safety and health improvement for law-enforcement officers (The SHIELD) study carried out in the US [23]. The intervention was implemented among individuals who worked in the same location and the same shift schedule and they were organised into groups. One participant was selected per group to serve as the team leader and they received a 20-minute orientation session and a scripted manual to guide each session. Other group members used a corresponding workbook. The curriculum had 12 modules, scripted, peer-led, team-based sessions. Sessions were delivered weekly during work hours. Each session comprised three or four brief interactive activities focusing on lifestyle factors such as stress management, exercise, healthy eating, body weight, and sleep. The peer-led, team format fosters support and accountability at the workplace. Participants were encouraged to support one another with the achievement of weekly goals and scripted discussion prompts facilitated the sharing of suggestions and tips [24].
A peer-led intervention is proposed because interventions delivered by peers are credible and can be sustained. The SHIELD intervention and a relevant publication by the World Health Organisation [25] will be adapted by stakeholders consisting of representatives of the junior and senior police officers and the research team at different adaptation meetings. The details of the specific contents of the pilot intervention to be implemented will be derived from the analysis of the results of the survey and interviews. We will aim to have no more than 8 modules that can be delivered in fortnightly sessions over a period of two months with each session lasting approximately 30 minutes.
Control group
A general sensitization meeting on the causes of stress, prevention, and management will be held in the control arm.
Sample size estimation
We aim to recruit 100 participants for each study arm. The sample size was determined based on the findings of a simulation study by [26] which suggests that a sample size of between 60–100 participants per arm in a pilot trial provides a reliable estimate of recruitment parameters.
Participant Recruitment and retention
There will be an announcement for participation using the police radio services, bulletins, and signals. Trained research assistants will help to recruit interested participants. Recruited participants will complete the surveys at enrollment. Participant recruitment will be conducted in the two study arms and will span 6 weeks. Eligible police formations (that is formations with a team of officers made up of a minimum of 10 men/women) will be stratified based on location (rural versus urban) to reflect the distribution of the State police command. Twenty of these eligible formations will be randomly selected for the pilot and these will be randomly assigned by an independent researcher who is not a member of the research team to the intervention (peer-led group support n = 10) and control groups (n = 10) using a computer generated table of random numbers.
Each of the teams assigned to the intervention arm will be requested to nominate 2 members each to be trained as Volunteer Peer Champions (VPC) for stress and mental health promotion (total of 20). The criteria for nomination/selection of VPC will include availability for the period of the intervention
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Availability for the period of the intervention.
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Willingness to participate in the intervention phase.
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Commitment to implement prevention activities after training.
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Possession of leadership and communication skills.
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Approachability.
To promote participant retention, there will be monthly text messages and phone call reminders to participate in the intervention and data collection activities. We will provide a small incentive to all participants regardless of the treatment arm enrollment and we will aim for at least 80% retention at the 6-month follow-up.
Intervention delivery/implementation
The peer-led group sessions will comprise 20 peer leaders working together in a team; this approach is aimed at helping police officers collectively address identified modifiable stressors within their team as well as develop relevant coping strategies that have the potential to build resilience and improve mental well-being. The role of VPC will be to (1) help police officers identify stress and stress manifestations in their personal lives (2) provide an understanding of the relationship between stress and work performance/ health (3) teach adaptive coping strategies and (4) improve police officer’s awareness of mental health conditions and promote help-seeking behaviour including referral. The peer champions will also be capacitated to identify signs of psychological distress and mental disorders and provide mental health first aid to their peers. Peer champions will have an established protocol for linking team members in need of further evaluation or treatment to the police clinic. The peer champions will deliver these interventions for six months.
Integration of care for mental disorders into the police medical service
The doctors and nurses working in the ten police clinics in Oyo State will be trained using the WHO Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) to identify and treat common mental disorders. Support and supervision will be provided by an identified psychiatrist in the University College Hospital in Ibadan, Oyo state. To ensure that the health workers keep to the agreed protocol for consultations and referrals to specialists, care providers will be provided with recharge cards for telephone calls. In addition, four hotlines to provide anonymous counselling for police officers who require support will be provided by the care providers. Four mobile phones with designated phone numbers will be provided for this purpose
Phase three: Preliminary evaluation of the intervention
Blinding
The outcome assessments will be carried out by blinded assessors (research assistants with qualifications like those who conducted the initial survey) trained in the use of the instruments that does not have any information about the assignment of the police formation or the interventions.
Outcome Measures
The preliminary effectiveness of the intervention will be assessed using a reduction in stress levels (measured on the Perceived Stress Scale (PSS) [13] and the Maslach Burnout Inventory (MBI) [15]), improved knowledge about stress management and mental disorders (based on pre-and post-test questions for each session of the training curriculum) and psychological distress (measured using the World Health Organization 20-item Self-Reporting Questionnaire (SRQ-20) [27].
These measures will be administered at baseline, two months after baseline (after the group sessions), and six months at the end of the intervention sessions to police officers in the intervention and control arms. The baseline characteristics of the participants in both arms and outcome measures at the two-month and six-month follow-up will described. Participation recruitment, retention rate, and compliance assessment will be presented. All recruited participants will be included in the analyses. Linear regression models considering clustering effects will be used to estimate between-group differences in outcome measures.
Implementation measures
Four implementation measures- adaptation, fidelity, feasibility, and acceptability of the intervention will be assessed. Adaptation will be assessed based on the number and mix of stakeholders who participate in the adaptation process, the number of meetings held to adapt/refine the materials and obtain feedback, and qualitative assessment of the quality of the adaptation process.
To assess fidelity, a research team member will sit in to observe about one-third of the sessions delivered by the group leaders using the curriculum. The sessions will be randomly selected. We shall also keep track of referrals to care and contact with specialist services. Feasibility will be assessed based on the proportion of police officers who provide consent and are enrolled in the pilot study and reasons for non-consent, the number of police officers who volunteer as peer educators, records of the group sessions to track the proportion of sessions that were conducted on schedule, the proportion of police officers who attend ≥ 75% of the sessions and reasons for dropouts and engagement of the group members as well as monitoring of performance of practice exercises. Acceptability will be assessed using a self-reported acceptability rating scale. Appropriate descriptive statistics will be used to summarize indicators of feasibility, acceptability, and fidelity.
Monitoring and Evaluation of Pilot Intervention
There will be monthly project review meetings using a team-based approach to assess the project progress in line with the performance indicators. The review meetings will provide an opportunity to track progress and determine outcomes taking into cognisance the project work plan and the indicators. The meetings will also be an opportunity to identify and discuss problems and challenges encountered during project implementation and propose clear recommendations for scale-up and replication of future interventions. In addition, we shall collect information on the number of health workers in the police clinic trained, the number of Volunteer Peer Champions trained, the number of supervisory meetings held with the champions after training, the number of persons that peer champions reached with interventions and number of those referred to the police clinic to receive mental health care.
Ethical Approval
Approval was obtained from the National Health and Research Ethics Committee (NHREC), Federal Ministry of Health, Abuja (NHREC/01/01/2007- 25/04/2023). All study activities will be implemented in line with ethical guidelines. Any amendenment to the protocol will be communicated to the investigators, the ethical review commiittee, trial participants and the trial registry.
Data management
Each participant will be assigned an anonymized identification number (CODE). All information collected will be kept confidential; all electronic data will be stored in encrypted files, and physical copies will be stored in locked cabinets accessible only to the research team. The outcome data will be collected on electronic forms on KoboCollect and will be transferred to the IBM Statistical Package for the Social Sciences (SPSS) database (SPSS version 27, Chicago, IL, USA) for data analysis.
Data sharing
Individual participant data that underlie the results reported in the articles published from the study will be available after deidentification. The study protocol will be published. The deidentified data will available beginning 12 months and ending 36 months following the publication of articles. These data will only be provided to investigators whose proposed use of the data has been approved by an independent review committee. Proposals may be submitted up to 36 months following article publication. After 36 months the data will be available in our University's data warehouse but without investigator support other than deposited metadata. Proposals should be submitted to the Principal Investigator ([email protected])
Dissemination of findings
The research team will convene dissemination workshops where the findings of the project will be presented to stakeholders including policy makers, staff from the Nigeria Police in the intervention sites, Nigeria Police Commission, the National Assembly, academics, journalists, and professionals from the NGO communities. Policy Briefs will be developed highlighting the key findings, lessons learnt and policy implications for prevention and management of stress among police officers. The findings of the study will be published in peer-review journals and the final report will be submitted to TETFund.