Stakeholder perspectives on integration of mental health services into primary care: a mixed methods study in Northern Iraq

Abstract

BackgroundIntegrating evidence-based mental health services into primary care has been identified as one strategy for overcoming the treatment gap in low and middle-income countries, yet their uptake into standard practice remains poor. The purpose of this study was to understand stakeholder perspectives regarding barriers and facilitators to integration of mental health services into primary care settings in Northern Iraq.MethodsUsing a convergent mixed methods study design, quantitative and qualitative questionnaires assessed respondent perceptions of implementation factors under the domains of Autonomy, Acceptability, Appropriateness, Feasibility, Penetration/Accessibility, Sustainability, and Organizational Climate. We interviewed four types of stakeholders: clients, providers of mental health services, non-mental health (MH) staff working at the centers, and center directors. Interviews were conducted with clients at the completion of services, and with all other stakeholder groups in the latter half of the first year of program implementation, by Kurdish-speaking interviewer pairs. Qualitative and quantitative data were analyzed separately and merged using qualitative data transformation to quantify frequency of theme and integrate with quantitative findings through woven narrative.Results123 clients, 26 providers, 40 non-MH staff, and 12 directors provided data. Positive perceptions of the program’s acceptability, appropriateness, feasibility, and positive impacts were reported across all stakeholder levels. Providers reported that the program length (8–12 sessions) was a challenge. Clients described logistical challenges (e.g.: transportation, childcare, home duties); support from family and friends appeared to be critical. Lack of private space, insufficient staffing, and need for greater government support were also important issues.ConclusionsThis mixed methods study is unique in its inclusion of non-MH staff and director perspectives on integration of mental health services in primary care clinics. Their inclusion proved vital since they included critical human resource barriers to feasibility. Providers reported generally positive integration experiences but that some colleagues (clinic staff not involved in mental health services) were unsupportive. Most non-MH staff were supportive, but some did report negative impacts on their working environment. Future studies of integration of mental health services into other service platforms should include the perspectives of stakeholders not involved in provision of mental health services.

Adaptation, Validity, and Reliability of the Patient Health Questionnaire (PHQ-9) in the Kurdistan Region of Iraq

“…This is consistent with findings of other studies that measured the internal consistency of the PHQ-9 [38,39], and for this reason the PHQ-8 is recommended for public health surveys; however, it has less specificity than the PHQ-9 [40]. Suicide thoughts and attempts are still under-reported; this could be explained by the cultural and religious effects [41], stigma, and mental health literacy level [42,43]. The concurrent validity of the PHQ-9 is supported by the statistically significant association between the PHQ-9 total score and the overall SRQ-20 score and between the PHQ-9 total score and the scores of each SRQ-20 domain (anxiety and depression, cognitive area, somatic disorders).…”

Factors Associated with Implementing the Integrated Behavioral Health Care Model and Iraqi Refugees in the USA

“…Promotion of discretion from family members (e.g., husband or sons) was established as a facilitator, and its lack as a barrier. This is consistent with findings of Nguyen et al (2019) that asserted that lack of childcare and lack of privacy from family members are barriers to engagement with Iraqi women.…”

Is only one cognitive technique also effective? Results from a randomized controlled trial of two different versions of an internet-based cognitive behavioural intervention for post-traumatic stress disorder in Arabic-speaking countries

“…endangerment of female participants due to existing gender norms which do not allow women to visit a doctor on their own) and treatment-related aspects (e.g. length of treatment) remain as barriers and challenges (Ashfaq et al, 2020 ; Nguyen et al, 2019 ).…”

“…The existing writing-based intervention consists of three components with ten writing assignments: 1. written traumatic exposure, 2. cognitive restructuring, and 3. cognitive elaboration in the form of social sharing (Knaevelsrud et al, 2015 ). By shortening the intervention (six assignments and only one of the two cognitive techniques), we intended to reduce the barriers and challenges with respect to existing social restrictions and the preference for short interventions (Nguyen et al, 2019 ), and thus increase the number of patients (i.e. scale up the intervention).…”

“…We also excepted that the dropout rate would be lower in the brief intervention (i.e. proportion of individuals who completed at least six assignments) as the literature shows that shorter approaches tend to be preferred (Nguyen et al, 2019 ). As PTSD is frequently comorbid with other mental disorders and evidence suggested that IBIs for PTSD affect also secondary outcomes (Lewis et al, 2019 ), a similar change in depressive and anxiety symptoms, somatic complaints and quality of life is assumed in both interventions.…”