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Table 2 Levels, domains, barriers, and facilitators to integration

From: Barriers and facilitators to the integration of mental health services into primary health care: a systematic review

Level SURE framework concepts Barriers Facilitators
Providers of care Knowledge and skills Inability to diagnose and treat mental illnesses • Perceived competence in mental health care
• Knowledge of mental disorder symptoms
• Prior training in mental health
Inability to identify either an antipsychotic or antidepressant medication
Lack of knowledge regarding psychosocial interventions
Inadequate training in the use of mental health screening tools
Inadequate training in current evidence-based treatment
Limited mental health awareness in the community
Lack of knowledge about health system structures
Lack of knowledge about processes for management of mental health
Attitudes regarding program acceptability, appropriateness, and credibility Beliefs that mental illness is a strange behavior • Agreement that mental health problems are common and need to be attended to
• Acknowledgement that mental health is a problem and care is important
• Support the idea of providing mental health care within the health center
• Willingness to maintain a relationship with persons with mental illness
• Belief that treating mental illness in the community would better integrate patients into regular life
• Recommend that mental health screening should take place at each visit
• Supported adopting a more tolerant attitude towards the mentally ill
• In support of spending more tax money on the care and treatment of the mentally ill
Beliefs that mental illness is more difficult to diagnose than other illnesses
Beliefs that traditional healers were more effective than modern medicine
Uncomfortable attending to mentally ill people
Beliefs that anyone who had mental health problems should be avoided
Beliefs that it is difficult to work with people with mental illness
Beliefs that people with mental illness should be kept behind locked doors and excluded from public offices
Patients respond to screening in a dishonest manner
Patients would not comply with the provider’s recommendations
Patients would not accept to receive the diagnosis or treatment at the primary care level
Legal liability for charting a wrong diagnosis
Unsatisfied with the level of knowledge in mental health
Do not regard managing mental illnesses as their primary role
Counseling left to the few specialists on ground which in their view tended to be unsuccessful
Negative attitudes towards mental health and mental disorders and limited appreciation of integration into primary health care
Motivation to change Low interest in delivering mental health care • Improved supply system of psychotropic medicines
• Trust from clients
• Ability to understand the patient in a more holistic way
• Convenience of service provision
• Willingness to screen for mental health problems
Increased workload and limited time
Lack of mental health support both at community and district levels
Limited resources for service delivery
Clients attending many clinics leading to inconsistent management of health problems
Health system constraints Management and/or leadership No in-service training in mental health care • Team collaboration
• Adequate record system
• Connected primary care and mental health services
• Improved training and recruitment of specialized and other allied health workers
• Presence of communication between the services
• Patient and provider education opportunities to increase patient awareness and screening
No formal discussions about mental health disorders with higher level supervisors
Inadequate coordination between general health workers and mental health specialists
Inadequate support from the district medical team
Low prioritization of mental health care at the lower levels
Lack of knowledge about system structures and work processes
Inability of the health system to respond to the clients’ broader needs
Restriction on prescription of psychotropic medicines
Challenges managing outreach services
Lack of integrated health professionals’ timetables
Uncoordinated care planning
No clearly defined integrated clinic roles
Disjointed services within a decentralized system
Inadequate numbers of more diverse staff to serve the linguistic minority
Financial resources Inequities in funding • Separate mental health budget line within the Ministry of Health budget
Lack of employee benefits
Lack of reimbursement for services
Uncertainty about continued funding for community programs/services
Mental health budget cuts
Insufficient insurance coverage to meet the treatment option
High cost of hiring nursing and support staff