Abstract
BackgroundThe provision of mental healthcare through integration into primary care is expected to improve access to care, but not all population groups may benefit equally. The aim of this study was to inform delivery of a new primary care-based mental health service in rural Ethiopia by identifying potential barriers to equitable access to mental healthcare and strategies to overcome them.MethodsA qualitative study was conducted as formative work for the PRogramme for Improving Mental healthcarE (PRIME), a project supporting delivery of mental healthcare integrated into primary care in a rural district in south central Ethiopia. In-depth interviews (n = 21) were carried out with stakeholders selected purposively from mental health service users, caregivers, community leaders and healthcare administrators. A focus group discussion (n = 12) was conducted with community health extension workers. Framework analysis was employed using an adapted version of the access framework developed for use in contexts of livelihood insecurity, which considers (1) availability, (2) accessibility and affordability. and (3) acceptability and adequacy dimensions of access.ResultsPrimary care-based mental healthcare was considered as a positive development, and would increase availability, accessibility and affordability of treatments. Low levels of community awareness, and general preference for traditional and religious healing were raised as potential challenges to the acceptability of integrated mental healthcare. Participants believed integrated mental healthcare would be comprehensive and of satisfactory quality. However, expectations about the effectiveness of treatment for mental disorders were generally low. Threats to equitable access to mental healthcare were identified for perinatal women, persons with physical disability, those living in extreme poverty and people with severe and persistent mental disability.ConclusionEstablishing an affordable service within reach, raising awareness and financial support to families from low socioeconomic backgrounds were suggested to improve equitable access to mental healthcare by vulnerable groups including perinatal women and people with disabilities. Innovative approaches, such as telephone consultations with psychiatric nurses based in nearby towns and home outreach need to be developed and evaluated.
Highlights
The provision of mental healthcare through integration into primary care is expected to improve access to care, but not all population groups may benefit
Sociodemographic characteristics of participants In-depth interviews were conducted with service users (n = 6), religious and faith leaders (n = 4), a district health office representative (n = 1), a herbalist (n = 1), community elders (n = 2), representatives of nongovernmental organisations (n = 2) and caregivers of people with severe mental disorders (n = 5) (Table 1)
Theme I: Availability Most participants spoke of the current absence of a service in the district as one of the biggest barriers to accessing mental healthcare, affecting decisions about where to seek care and when to initiate help seeking
Summary
The provision of mental healthcare through integration into primary care is expected to improve access to care, but not all population groups may benefit . It is estimated that 50 % of people with severe mental disorders remain untreated and the treatment gap in low-income countries (LICs) is as high as 90 % [4, 5]. In response to this high treatment gap, the World Health Organisation (WHO) has introduced the mental health gap action programme (mhGAP); a framework for scale-up of mental health services for selected priority disorders through integration into primary care [6]. The mhGAP intervention guide is a contextually adaptable, evidence-based set of packages of care suitable for delivery by non-specialists in low resource settings
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