Mental health service delivery in Sierra Leone: Reducing stigma and exploring opportunities for expansion in primary care
Globally, untreated mental illness is a public health crisis that confers preventable suffering. In low- and middle-income countries (LMICs) in particular, the vast majority of individuals with serious mental illness receive no formal treatment. In response to the challenge of a vast treatment gap and limited resources allocated to mental health, best practices have highlighted strategies that utilize existing infrastructure and human resources. Integration of mental health into primary care settings and task-sharing to enable non-specialist health workers to provide mental health services have emerged as key strategies towards reducing the treatment gap. Despite a growing body of evidence illustrating that non-specialists can effectively provide a variety of mental health services in primary care, there has been limited success in expanding these models beyond clinical trials. The present studies explore this challenge in the context of Sierra Leone, a small country on the west coast of Africa. In Sierra Leone, a network of peripheral health units (PHUs) are the core component of first line primary care. The healthcare staff working in these small, decentralized clinics are typically the first, and often only, contact that most community members have with the healthcare system. The present studies focus on these health care workers as key providers of accessible physical health care and as providers who could potentially take on mental health service tasks in an expanded system of mental health care. We focus first on barriers to the integration of mental health care into primary care and utilization of existing services: namely, stigma towards mental illness and a lack of knowledge about mental health. We then shift our focus to a more exploratory look at health care worker’s perspectives on the potential for expanding mental health services within primary health care. Study 1 builds on prior work that identified widespread stigma towards mental illness, commonly held misinformation about mental illness, and a lack of awareness of available resources (namely, mental health nurses within the district hospitals) among PHU staff. Study 1 presents the development and pilot testing of an educational mental health workshop for PHU staff designed to reduce stigma towards mental illness and increase awareness of mental illness and services provided by the local mental health nurse. In particular, this study examines a) the extent to which such an intervention is feasible and the factors that constrain and promote feasibility; b) the extent to which this intervention and its mental health content is viewed as appropriate and relevant to primary health care workers; and c) the impact of the intervention on stigma and knowledge about mental illness. Our mixed-methods data provides evidence for the feasibility and acceptability of an educational mental health workshop for PHU staff, and preliminary support for the effectiveness of these workshops in reducing stigma and improving knowledge. We highlight factors that may promote the feasibility of future interventions, including partnership with local resources such as universities and health districts. Study 2 uses the context of the workshop to investigate health care workers’ perspectives on factors important for the expansion of mental health services in primary care. Specifically, we assess PHU workers’ perspectives on the potential acceptability of mental health services provided in primary care to the local community and the appropriateness of taking on mental health tasks themselves. Lastly, as stigma has been highlighted as a barrier to the uptake of mental health interventions, we investigate whether there is a relationship between stigma towards mental illness and interest in providing mental health care. We consider “mental health tasks” broadly, in order to investigate the factors that should be taken into consideration when designing a mental health initiative in Sierra Leone rather than investigating a specific psychosocial or biomedical intervention. Through qualitative and quantitative methods, primary health workers expressed interest in taking on mental health care tasks such as prescribing medications and providing counseling. Contrary to expectations, we did not find a significant relationship between stigma and interest in taking on mental health tasks. Our qualitative data highlights potential barriers to local acceptability, including extensive community stigma around the word “mental” and expectations of pharmacological treatment, particularly at the district hospitals. Our results also raise the possibility that certain PHU staff who are already highly involved in their patient’s overall wellbeing may be particularly well-suited to taking on mental health counseling tasks without over-emphasizing a biomedical model of mental illness. Both studies prioritize the voices of frontline workers in PHUs and nursing students as key informants and elements of the healthcare system, as the providers who are most accessible to community members. As Sierra Leone and other LMICs move towards the uptake of task-sharing and integrated models of service delivery, it is critical to inform this implementation process with the voices of the stakeholders who serve as front-line healthcare providers and potential providers of task-sharing mental health care.
global mental health, mental health stigma, primary care, Sierra Leone
University of Illinois - Urbana-Champaign
Networked Digital Library of Theses and Dissertations
University of Illinois at Urbana-Champaign