title: Equitable access to integrated primary mental healthcare for people with severe mental disorders in Ethiopia: a formative study.
abstract: The provision of mental healthcare through integration into primary care is expected to improve access to care, but not all population groups may benefit equally. The aim of this study was to inform delivery of a new primary care-based mental health service in rural Ethiopia by identifying potential barriers to equitable access to mental healthcare and strategies to overcome them.
  
  
  
  A qualitative study was conducted as formative work for the PRogramme for Improving Mental healthcarE (PRIME), a project supporting delivery of mental healthcare integrated into primary care in a rural district in south central Ethiopia. In-depth interviews (n = 21) were carried out with stakeholders selected purposively from mental health service users, caregivers, community leaders and healthcare administrators. A focus group discussion (n = 12) was conducted with community health extension workers. Framework analysis was employed using an adapted version of the access framework developed for use in contexts of livelihood insecurity, which considers (1) availability, (2) accessibility and affordability. and (3) acceptability and adequacy dimensions of access.
  
  
  
  Primary care-based mental healthcare was considered as a positive development, and would increase availability, accessibility and affordability of treatments. Low levels of community awareness, and general preference for traditional and religious healing were raised as potential challenges to the acceptability of integrated mental healthcare. Participants believed integrated mental healthcare would be comprehensive and of satisfactory quality. However, expectations about the effectiveness of treatment for mental disorders were generally low. Threats to equitable access to mental healthcare were identified for perinatal women, persons with physical disability, those living in extreme poverty and people with severe and persistent mental disability.
  
  
  
  Establishing an affordable service within reach, raising awareness and financial support to families from low socioeconomic backgrounds were suggested to improve equitable access to mental healthcare by vulnerable groups including perinatal women and people with disabilities. Innovative approaches, such as telephone consultations with psychiatric nurses based in nearby towns and home outreach need to be developed and evaluated.
authors.affiliation: College of Health Sciences, School of Medicine, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia. maji.hailemariam@gmail.com.
authors.forename: Maji
authors.identifier: 0000-0003-3730-9637
authors.initials: M
authors.lastname: Hailemariam
authors.affiliation: College of Health Sciences, School of Medicine, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia.|Psychology and Neuroscience, Department of Psychological Medicine, Centre for Affective Disorders, King's College London, Institute of Psychiatry, London, UK.
authors.forename: Abebaw
authors.initials: A
authors.lastname: Fekadu
authors.affiliation: College of Health Sciences, School of Medicine, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Medhin
authors.initials: M
authors.lastname: Selamu
authors.affiliation: Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Girmay
authors.initials: G
authors.lastname: Medhin
authors.affiliation: Population Research Department, Centre for Global Mental Health, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Health Services, London, UK.
authors.forename: Martin
authors.initials: M
authors.lastname: Prince
authors.affiliation: College of Health Sciences, School of Medicine, Department of Psychiatry, Addis Ababa University, Addis Ababa, Ethiopia.|Population Research Department, Centre for Global Mental Health, King's College London, Institute of Psychiatry, Psychology and Neuroscience, Health Services, London, UK.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Hanlon
mesh_terms: D005002:Ethiopia; D006297:Health Services Accessibility / Q000592:standards*; D054625:Healthcare Disparities / Q000592:standards; D006801:Humans; D001523:Mental Disorders / Q000628:therapy*; D008605:Mental Health Services / Q000600:supply & distribution*; D011320:Primary Health Care / Q000706:statistics & numerical data*; D036301:Qualitative Research
keywords: Access to care; Barriers to access; Ethiopia; Mental health care; Primary care; Psychosis