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

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