Abstract
BackgroundPrimary care physicians (PCPs) working in mental health care in Tunisia often lack knowledge and skills needed to adequately address mental health-related issues. To address these lacunas, a training based on the Mental Health Gap Action Programme (mhGAP) Intervention Guide (IG) was offered to PCPs working in the Greater Tunis area between February and April 2016. While the mhGAP-IG has been used extensively in low- and middle-income countries (LMICs) to help build non-specialists’ mental health capacity, little research has focused on how contextual factors interact with the implemented training program to influence its expected outcomes. This paper’s objective is to fill that lack.MethodsWe conducted a case study with a purposeful sample of 18 trained PCPs. Data was collected by semi-structured interviews between March and April 2016. Qualitative data was analyzed using thematic analysis.ResultsParticipants identified more barriers than facilitators when describing contextual factors influencing the mhGAP-based training’s expected outcomes. Barriers were regrouped into five categories: structural factors (e.g., policies, social context, local workforce development, and physical aspects of the environment), organizational factors (e.g., logistical issues for the provision of care and collaboration within and across healthcare organizations), provider factors (e.g., previous mental health experience and personal characteristics), patient factors (e.g., beliefs about the health system and healthcare professionals, and motivation to seek care), and innovation factors (e.g., training characteristics). These contextual factors interacted with the implemented training to influence knowledge about pharmacological treatments and symptoms of mental illness, confidence in providing treatment, negative beliefs about certain mental health conditions, and the understanding of the role of PCPs in mental health care delivery. In addition, post-training, participants still felt uncomfortable with certain aspects of treatment and the management of some mental health conditions.ConclusionsFindings highlight the complexity of implementing a mhGAP-based training given its interaction with contextual factors to influence the attainment of expected outcomes. Results may be used to tailor structural, organizational, provider, patient, and innovation factors prior to future implementations of the mhGAP-based training in Tunisia. Findings may also be used by decision-makers interested in implementing the mhGAP-IG training in other LMICs.
Highlights
Primary care physicians (PCPs) working in mental health care in Tunisia often lack knowledge and skills needed to adequately address mental health-related issues
Authors have strongly advocated for further integrating mental health in primary care settings [1,2,3,4,5] to address the mental health treatment gap, which is especially alarming in low- and middle-income countries (LMICs) [3, 6,7,8,9]
We developed an exploratory trial [38, 39] that seeks to contextualize, implement, and evaluate a mental health training program for primary care physicians (PCPs) in the Greater Tunis area of Tunisia based on the Mental Health Gap Action Programme (mhGAP)-Intervention Guide (IG) [23] before country-wide implementation
Summary
While the mhGAP-based training, in both of its versions, has been implemented in over 100 countries [26, 27], little research has focused on how factors within specific contexts interact with the implemented training program to influence its expected outcomes [27,28,29,30,31] Such findings highlight real-world challenges to the training’s uptake and scale-up in specific resource-limited settings [32,33,34] and may encourage decision-makers to create a system facilitating non-specialists’ involvement in mental health care [4, 27, 35,36,37]
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