title: Demand and access to mental health services: a qualitative formative study in Nepal.
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.
authors.forename: Natassia F
authors.initials: NF
authors.lastname: Brenman
authors.affiliation: Transcultural Psychosocial Organization (TPO), Baluwatar Kathmandu, Nepal. luitelnp@gmail.com.
authors.forename: Nagendra P
authors.initials: NP
authors.lastname: Luitel
authors.forename: Sumaya
authors.initials: S
authors.lastname: Mall
authors.forename: Mark J D
authors.initials: MJ
authors.lastname: Jordans
mesh_terms: D000328:Adult; D001364:Awareness; D003469:Culture; D003906:Developing Countries; D005260:Female; D017144:Focus Groups; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D001523:Mental Disorders / Q000628:therapy*; D008605:Mental Health Services; D008875:Middle Aged; D009390:Nepal; D011203:Poverty; D036301:Qualitative Research; D012111:Residence Characteristics; D057545:Social Stigma; D055815:Young Adult
references.citation: Behav Res Ther. 2011 Sep;49(9):523-8
references.pmid: 21788012
references.citation: Cult Med Psychiatry. 2008 Dec;32(4):462-91
references.pmid: 18784989
references.citation: Lancet. 2007 Oct 6;370(9594):1241-52
references.pmid: 17804059
references.citation: Psychol Med. 2015 Jan;45(1):11-27
references.pmid: 24569086
references.citation: JAMA. 2004 Jun 2;291(21):2581-90
references.pmid: 15173149
references.citation: Epidemiol Psichiatr Soc. 2008 Jan-Mar;17(1):14-9
references.pmid: 18444452
references.citation: PLoS Med. 2007 Jun;4(6):e159
references.pmid: 17579508
references.citation: J Adv Nurs. 2008 Apr;62(2):228-37
references.pmid: 18394035
references.citation: Lancet. 2007 Sep 8;370(9590):841-50
references.pmid: 17826169
references.citation: Int Rev Psychiatry. 2004 Feb-May;16(1-2):142-9
references.pmid: 15276946
references.citation: Int J Ment Health Syst. 2008 Apr 13;2(1):3
references.pmid: 18405393
references.citation: Lancet. 2007 Sep 8;370(9590):878-89
references.pmid: 17804062
references.citation: Int J Soc Psychiatry. 2002 Sep;48(3):163-76
references.pmid: 12413245
references.citation: Cult Med Psychiatry. 2010 Jun;34(2):322-52
references.pmid: 20309724
references.citation: Lancet. 2007 Sep 29;370(9593):1164-74
references.pmid: 17804061
references.citation: Soc Psychiatry Psychiatr Epidemiol. 2013 Feb;48(2):183-93
references.pmid: 22777395
references.citation: PLoS Med. 2012;9(12):e1001359
references.pmid: 23300387
references.citation: Int Health. 2013 Mar;5(1):6-8
references.pmid: 24029838
references.citation: Soc Sci Med. 2010 Aug;71(3):517-528
references.pmid: 20621748
references.citation: Br J Psychiatry. 2012 Oct;201(4):268-75
references.pmid: 22878131
references.citation: Soc Sci Med. 2011 Mar;72(5):763-72
references.pmid: 21272968
references.citation: Int Rev Psychiatry. 2007 Apr;19(2):157-78
references.pmid: 17464793
references.citation: Lancet. 2007 Sep 8;370(9590):806
references.pmid: 17804065
references.citation: Soc Sci Med. 2010 Jan;70(1):35-44
references.pmid: 19833427
references.citation: Health Policy Plan. 2006 May;21(3):157-70
references.pmid: 16522714
references.citation: BMC Psychiatry. 2013 Dec 05;13:332
references.pmid: 24305432
references.citation: Health Transit Rev. 1994 Oct;4(2):151-66
references.pmid: 10150515