Mental health and psychosocial support services in primary health care in Nepal: perceived facilitating factors, barriers and strategies for improvement

Abstract

Background: The barriers and facilitating factors for integrating mental health into primary health care have been well documented in the literature, but little is known about the perspectives of primary health care workers (who provide integrated mental health care) on barriers and facilitating factors of the health system for scaling up mental health interventions in low and middle income countries. This study aimed to explore these perspectives of primary health care workers within the health system, and identify possible strategies to optimize the integration of mental health in primary health care. Methods: The study was conducted in the Chitwan district of Nepal with 55 purposively selected primary health care workers representing prescribers (N = 35), non-prescribers (N = 12) and Female Community Health Volunteers (N = 8). Using a semi-structured interview guide, experienced qualitative researchers collected data between September 2016 and May 2017. The interviews were audio-taped, transcribed and then translated into English. The transcripts were coded using Nvivo 10 software and themes were generated for the thematic analysis. Results: According to the health workers, the facilitating factors for scaling up mental health services in primary health care setting in Nepal included; (1) availability of guidelines, protocols and awareness raising materials, (2) provision of supervision, (3) referral systems being in place, (4) patient record keeping, (5) community sensitizations and home visits, and (6) provision of psychosocial counseling. The barriers identified included; (1) shortage of psychotropic medicines, (2) lack of private space for counseling, (3) workload and health workers' grievances regarding incentives, and (4) perceived stigma causing dropouts. Conclusions: The findings suggest that implementation of mental health services through primary health care workers in resource-poor setting is possible when health system level barriers are addressed and facilitating factors are strengthened. In order to address these barriers the health workers suggested a few strategies which included; ensuring dedicated staff available at health facility, allocating dedicated and confidential space for counseling, improving on incentives and motivational benefits to existing health staff, organizing policy level advocacy for mental health, improving medicine supply chain management and strengthening systems for supervision, referral and mental health information management.

Task Sharing or Task Dumping: Counsellors Experiences of Delivering a Psychosocial Intervention for Mental Health Problems in South Africa

“…In addition, our findings suggest that intentionally incorporating debriefing into weekly supervision contributed to FBCs' positive views of supervision and helped buffer against the stress associated with counselling in this context. While the importance of providing such support for preventing burnout and improving job satisfaction among mental health providers is well-established (Edwards et al 2006), our findings support claims that debriefing and emotional support services are critical in the context of task-shared mental health services where counsellors do not have extensive training in managing stress and preventing secondary traumatization (Barnett et al 2018;Upadhaya et al 2020). As in other studies (Jain 2010;Wall et al 2020), many of the FBCs in this study were exposed to the same environmental stressors as participants, resulting in psychological distress that was exacerbated by the provision of counselling.…”

Feasibility of implementing a culturally adapted Prolonged Grief Disorder scale in the mental healthcare system in Nepal

“…PRIME developed a district mental healthcare plan (MHCP) for implementation and evaluation based on the Mental Health Gap Action Programme (mhGAP) by the World Health Organization (WHO), a guideline for the detection, diagnosis, and treatment of mental disorders in primary care settings (Lund et al ., 2012; Jordans et al ., 2016; Luitel et al ., 2020). Prescribers were trained on pharmacological treatment of mental disorders, whereas non-prescribers were trained on psychosocial interventions (Upadhaya et al ., 2020). Female community health volunteers (FCHVs) were trained to operate home-based care, community awareness programs, and mental health case detection (Upadhaya et al ., 2020).…”

“…Prescribers were trained on pharmacological treatment of mental disorders, whereas non-prescribers were trained on psychosocial interventions (Upadhaya et al ., 2020). Female community health volunteers (FCHVs) were trained to operate home-based care, community awareness programs, and mental health case detection (Upadhaya et al ., 2020).…”

Perception of service users and their caregivers on primary care-based mental health services: a qualitative study in Nepal

“…In addition to this, perceived stigma and discrimination was also reported as one of the major reasons for not receiving treatment for depression and AUD in Chitwan [34]. Similarly, lack of confidential space has also been reported as one of the most important system-level barriers to integrating mental health services into primary care by the trained health workers [35]. Therefore, a separate and confidential place for consultation and psychological intervention should be made available in each of the health facilities.…”