Elsevier

The Lancet Psychiatry

Volume 7, Issue 1, January 2020, Pages 78-92
The Lancet Psychiatry

Review
Barriers and facilitators of mental health programmes in primary care in low-income and middle-income countries

https://doi.org/10.1016/S2215-0366(19)30125-7Get rights and content

Summary

Integration of services into primary health care for people with common mental disorders is considered a key strategy to improve access to mental health care in low-income and middle-income countries, yet services at the primary care level are largely unavailable. We did a systematic review to understand the barriers and facilitators in the implementation of mental health programmes. We searched five databases and included studies published between Jan 1, 1990, and Sept 1, 2017, that used qualitative methods to assess the implementation of programmes for adults with common mental disorders at primary health-care settings in low-income and middle-income countries. The Critical Appraisal Skills Programme Qualitative Checklist was used to assess the quality of eligible papers. We used the so-called best fit framework approach to synthesise findings according to the Consolidated Framework for Implementation Research. We identified 24 papers for inclusion. These papers described the implementation of nine programmes in 11 countries. Key factors included: the extent to which an organisation is ready for implementation; the attributes, knowledge, and beliefs of providers; complex service user needs; adaptability and perceived advantage of interventions; and the processes of planning and evaluating the implementation. Evidence on implementation of mental health programmes in low-income and middle-income countries is scarce. Synthesising results according to the Consolidated Framework for Implementation Research helped to identify key areas for future action, including investment in primary health-care strengthening, capacity building for health providers, and increased support to address the social needs of service users.

Section snippets

Background

Common mental disorders such as depression and anxiety are among the leading causes of years lived with disability globally.1 In low-income and middle-income countries, estimates indicate that 79–93% of people with depression and 85–95% of people with anxiety do not have access to treatment.2 Low availability of human resources for mental health and poor implementation of mental health programmes at scale contribute to this large, unmet need for mental health care.3, 4 WHO promotes the

Methods

This systematic review is reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses criteria.17 The protocol for this Review was not registered.

To identify relevant literature, we combined search terms related to implementation determinants, primary health-care settings, and common mental disorders. After removing duplicates, GME screened all titles and abstracts, and SH and OQ independently double-screened a 10% random sample of the titles and abstracts. The

Findings

We identified 12 661 records through the databases, internet, and hand searches. 287 papers were eligible for full-text screening. Figure 2 describes the number of papers excluded at each stage. 24 publications that report the findings of 22 studies related to nine mental health-care programme in 11 countries were included in this Review (table 2).

Two of these programmes were in low-income countries,32, 34, 35, 36, 37 four were in lower-middle income countries,33, 38, 39, 40, 41, 42 and one was

Characteristics of the intervention

Strength of evidence, complexity, and cost were reported as barriers. Facilitators included the capacity to adapt the interventions to fit local needs and perceived advantages of using the intervention. No programmes reported information related to the intervention source, trialability, and design quality.

A common implementation challenge was the complexity of interventions for mental health, which require lengthy consultations,31, 43 frequent home visits,37 and considerable coordination

Discussion

This study synthesises stakeholders' perceptions of factors acting as barriers and facilitators to the implementation of programmes for common mental disorders in primary health care in low-income and middle-income countries. To the best of our knowledge, this Review is the first systematic review on this topic. Most frequently discussed were CFIR domains related to contextual factors of the inner and outer setting and characteristics of individuals. Within the inner setting, availability of

Search strategy and selection criteria

We used Boolean operators to combine subject headings and relevant search terms related to implementation determinants, primary health-care settings, and common mental disorders to search Medline, EMBASE, PsycINFO, Global Health, and LILACS. We included peer-reviewed qualitative studies published between Jan 1, 1990, and Sept 1, 2017, in English or Spanish. The complete list of search terms can be found in the appendix. Relevant literature was also identified through searches in Google and

References (82)

  • S Saxena et al.

    Resources for mental health: scarcity, inequity, and inefficiency

    Lancet

    (2007)
  • L Wozniak et al.

    Contextualizing the effectiveness of a collaborative care model for primary care patients with diabetes and depression (TeamCare): a qualitative assessment using RE-AIM

    Can J Diabetes

    (2015)
  • Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

    Lancet

    (2017)
  • PY Collins et al.

    Grand challenges in global mental health

    Nature

    (2011)
  • Integrating mental health into primary care: a global perspective

    (2008)
  • Mental health atlas 2017

    (2018)
  • Mental health atlas 2014

    (2015)
  • V Patel et al.

    Mental, neurological, and substance use disorders: disease control priorities

    (2016)
  • T Adam et al.

    Systems thinking for strengthening health systems in LMICs: need for a paradigm shift

    Health Policy Plan

    (2012)
  • T Luig et al.

    Understanding implementation of complex interventions in primary care teams

    J Am Board Fam Med

    (2018)
  • P Nilsen

    Making sense of implementation theories, models and frameworks

    Implement Sci

    (2015)
  • SA Flottorp et al.

    A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice

    Implement Sci

    (2013)
  • D Moher et al.

    Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

    PLoS Med

    (2009)
  • What is primary care mental health? WHO and Wonca Working Party on Mental Health

    Ment Health Fam Med

    (2008)
  • The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines

    (1992)
  • V Patel et al.

    Poverty and common mental disorders in developing countries

    Bull World Health Organ

    (2003)
  • World Bank Country and Lending Groups

  • CASP Qualitative Checklist

  • C Carroll et al.

    “Best fit” framework synthesis: refining the method

    BMC Med Res Methodol

    (2013)
  • A Booth et al.

    How to build up the actionable knowledge base: the role of ‘best fit’ framework synthesis for studies of improvement in healthcare

    BMJ Qual Saf

    (2015)
  • LJ Damschroder et al.

    Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

    Implement Sci

    (2009)
  • MA Kirk et al.

    A systematic review of the use of the consolidated framework for implementation research

    Implement Sci

    (2016)
  • K Athié et al.

    Perceptions of health managers and professionals about mental health and primary care integration in Rio de Janeiro: a mixed methods study

    BMC Health Serv Res

    (2016)
  • S Soares et al.

    The matrix approach to mental health care: experiences in Florianopolis, Brazil

    J Health Psychol

    (2016)
  • I Petersen et al.

    Strengthening mental health system governance in six low- and middle-income countries in Africa and South Asia: challenges, needs and potential strategies

    Health Policy Plan

    (2017)
  • M Abas et al.

    ‘Opening up the mind’: problem-solving therapy delivered by female lay health workers to improve access to evidence-based care for depression and other common mental disorders through the Friendship Bench Project in Zimbabwe

    Int J Ment Health Syst

    (2016)
  • LS Nasir et al.

    Barriers to the diagnosis and treatment of depression in Jordan. A nationwide qualitative study

    J Am Board Fam Pract

    (2005)
  • R Jenkins et al.

    Health system challenges to integration of mental health delivery in primary care in Kenya—perspectives of primary care health workers

    BMC Health Serv Res

    (2013)
  • R Jenkins et al.

    Exploring the perspectives and experiences of health workers at primary health facilities in Kenya following training

    Int J Ment Health Syst

    (2013)
  • D Kiima et al.

    Mental health policy in Kenya -an integrated approach to scaling up equitable care for poor populations

    Int J Ment Health Syst

    (2010)
  • C Othieno et al.

    Perspectives and concerns of clients at primary health care facilities involved in evaluation of a national mental health training programme for primary care in Kenya

    Int J Ment Health Syst

    (2013)
  • Cited by (59)

    • Socioeconomic and racial/ethnic inequalities in depression prevalence and the treatment gap in Brazil: A decomposition analysis

      2022, SSM - Population Health
      Citation Excerpt :

      On average, countries spend small shares of their health budgets on mental health services and those funds are largely spent on specialized mental health hospitals (Patel et al., 2018). In low- and middle-income countries (LMICs), between 79% and 93% of people with depression do not receive care (Esponda et al., 2020). Countries must expand services for mental health disorders, including depression, as a key step for achieving universal health coverage (World Health Organization, 2019).

    • Barriers and facilitators to treatment seeking behaviors for depression, epilepsy, and schizophrenia in low- and middle-income countries: A systematic review

      2022, Archives of Psychiatric Nursing
      Citation Excerpt :

      Mistrust also was a frequently reported barrier to treatment-seeking across all three disorders. Consistent with other reviews, people with neuropsychiatric disorders have reported that health care providers' lack of mental health training, bias, mistreatment, stigmatization, and lack of support of persons with mental illness affect treatment-seeking (Esponda et al., 2020). Compared to their trust in health care providers, patients and family members report greater trust in traditional or faith healers and thus may be more inclined to seek treatment from them (Esponda et al., 2020; von Gaudecker et al., 2019).

    View all citing articles on Scopus
    View full text