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Open Access Highly Accessed Research article

Demand and access to mental health services: a qualitative formative study in Nepal

Natassia F Brenman1, Nagendra P Luitel2*, Sumaya Mall3 and Mark J D Jordans14

Author Affiliations

1 HealthNet TPO, Amsterdam, the Netherlands

2 Transcultural Psychosocial Organization (TPO), Baluwatar Kathmandu, Nepal

3 Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa

4 Centre for Global Mental Health, King’s College London, London, UK

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BMC International Health and Human Rights 2014, 14:22  doi:10.1186/1472-698X-14-22

Published: 2 August 2014

Abstract

Background

Nepal is experiencing a significant ‘treatment gap’ in mental health care. People with mental disorders do not always receive appropriate treatment due to a range of structural and individual issues, including stigma and poverty. The PRIME (Programme for Improving Mental Health Care) programme has developed a mental health care plan to address this issue in Nepal and four other low and middle income countries. This study aims to inform the development of this comprehensive care plan by investigating the perceptions of stakeholders at different levels of the care system in the district of Chitwan in southern Nepal: health professionals, lay workers and community members. It focuses specifically on issues of demand and access to care, and aims to identify barriers and potential solutions for reaching people with priority mental disorders.

Methods

This qualitative study consisted of key informant interviews (33) and focus group discussions (83 participants in 9 groups) at community and health facility levels. Data were analysed using a framework analysis approach.

Results

As well as pragmatic barriers at the health facility level, mental health stigma and certain cultural norms were found to reduce access and demand for services. Respondents perceived the lack of awareness about mental health problems to be a major problem underlying this, even among those with high levels of education or status. They proposed strategies to improve awareness, such as channelling education through trusted and respected community figures, and responding to the need for openness or privacy in educational programmes, depending on the issue at hand. Adapting to local perceptions of stigmatised treatments emerged as another key strategy to improve demand.

Conclusions

This study identifies barriers to accessing care in Nepal that reach beyond the health facility and into the social fabric of the community. Stakeholders in PRIME’s integrated care plan advocate strategic awareness raising initiatives to improve the reach of integrated services in this low-income setting.

Keywords:
Demand; Access; Mental health care; Stigma; Treatment gap; Nepal