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Challenges and Opportunities for Implementing Integrated Mental Health Care: A District Level Situation Analysis from Five Low- and Middle-Income Countries
Open accessAbstract
BACKGROUND: Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care. METHODS: A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts. RESULTS: The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care. CONCLUSIONS: The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care.
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“but a relative lack of these types of networks made implementation more difficult [78].”
From Barriers and facilitators to implementation of evidence-based task-sharing mental health interventions in low- and middle-income countries: a systematic review using implementation science frameworks (2022) · cites this paper as [78]
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“Several of the papers assessed this issue, in general finding low levels of preparedness 50 .”
From Integrated care for people with long-term mental and physical health conditions in low-income and middle-income countries (2019) · cites this paper as [50]
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“However, in Ethiopia, South Africa, and Uganda, despite the fact that nurses cover many care needs, it is necessary to increase the number of professionals who care for people with mental illnesses (Hanlon et al., 2014), even if they are not health professionals (Mendenhall et al., 2014).”
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Self-citationAvailability, Price and Affordability of Psychotropic Medicines in Addis Ababa, Ethiopia
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“If the result is less than 1 it is affordable, if greater than 1 it is unaffordable.(10) ● Other sector 1: in this study was Red Cross Pharmacies.”
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Njau, T., Mwakawanga, D. L., Sunguya, B. F., Minja, A., Kaaya, S., & Fekadu, A. (2024) · BMC Health Services Research · doi:10.1186/s12913-024-11118-5 · Cited by 9
Self-citationCampion, J. (2018) · Springer eBooks · doi:10.1007/978-3-319-70554-5_31 · Cited by 9
Best Practices in Global Mental Health: An Exploratory Study of Recommendations for Psychologists
Hook, K., & Vera, E. M. (2020) · International Perspectives in Psychology · doi:10.1037/ipp0000125 · Cited by 9
Neuroanthropological Perspectives on Culture, Mind, and Brain
Lende, D. H., & Downey, G. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108695374.014 · Cited by 10
Chisholm, D., Garman, E. C., Breuer, E., Fekadu, A., Hanlon, C., Jordans, M. J. D., Kathree, T., Kigozi, F. N., Luitel, N. P., Medhin, G., et al. (2020) · Health Policy and Planning · doi:10.1093/heapol/czz182 · Cited by 9
Self-citationClinical supervision for clinical psychology students in Uganda: an initial qualitative exploration
Hall, J., Kasujja, R., & Oakes, P. (2015) · International Journal of Mental Health Systems · doi:10.1186/s13033-015-0016-8 · Cited by 8
Mutual Constitution of Culture and the Mind
Kitayama, S., & Yu, Q. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108695374.006 · Cited by 9
Aryal, K. K., Alvik, A., Thapa, N., Mehata, S., Roka, T., Thapa, P., Pandey, P., & Stray‐Pedersen, B. (2018) · Journal of Nepal Health Research Council · doi:10.3126/jnhrc.v16i2.20310 · Cited by 26
Studying the context of psychoses to improve outcomes in Ethiopia (SCOPE): Protocol paper
Hanlon, C., Roberts, T., Misganaw, E., MALLA, A. K., Cohen, A., Shibre, T., Fekadu, W., Teferra, S., Kebede, D., Mulushoa, A., et al. (2024) · PLoS ONE · doi:10.1371/journal.pone.0293232 · Cited by 7
Self-citationKirmayer, L. J., Worthman, C. M., & Kitayama, S. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108695374.028 · Cited by 8
Reliability and validity of a perinatal depression screening instrument in rural Mali
Lasater, M. E., Beebe, M., Warren, N., WINCH, P. J., Souko, F., Keita, M., Doumbia, S., & Murray, S. M. (2022) · SSM - Mental Health · doi:10.1016/j.ssmmh.2021.100059 · Cited by 8
“Multiple challenges, including shortages of providers, impede widespread implementation of screening for CPMDs by providers in primary and maternal healthcare settings even when tools are available (Hanlon et al., 2014; Larsen et al., 2021; Rochat et al., 2013; van Heyningen et al., 2019).”
BackgroundPowell, T. M., & Qushua, N. (2022) · International Journal of Social Psychiatry · doi:10.1177/00207640221074808 · Cited by 7
“…health care in Jordan and neighboring Arab countries include limited awareness of mental health, stigma, co-morbidity with physical health conditions, lack of training for primary healthcare providers, and poverty (Collins et al., 2011; Eaton et al., 2011; Hanlon et al., 2014; Lund et al., 2016).”
BackgroundOwens, C. E., & Hadley, C. (2023) · SSM - Population Health · doi:10.1016/j.ssmph.2023.101382 · Cited by 7
“Previous studies among rural communities in Ethiopia have documented a high prevalence of mental distress driven, in part, by stressful life events and a lack of mental health care integration into primary care practices (Fekadu et al., 2014, 2015; Hanlon et al., 2014).”
BackgroundNeurodiversity as a Conceptual Lens and Topic of Cross-Cultural Study
Cascio, M. A. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108695374.027 · Cited by 7
Mushi, D., Hanlon, C., Francis, J. M., & Teferra, S. (2020) · BMJ Open · doi:10.1136/bmjopen-2020-038615 · Cited by 7
Self-citationOmann, L. R., Dushimiyimana, V., Musoni, E., Arnbjerg, C. J., Niyonkuru, V. U., Iyamuremye, J. D., Gasana, M., Carlsson, J. M., Kallestrup, P., & Kraef, C. (2024) · AIDS and Behavior · doi:10.1007/s10461-024-04358-3 · Cited by 6
“Previous studies have also highlighted the undertreatment of mental health disorders in LMIC [26] due to the lack of specialist mental health care and multidisciplinary work-force providing psychosocial support [27].”
BackgroundPrecision Assignment to Psychosocial Interventions for Late-Life Depression
Solomonov, N., Kerchner, D., Bein, O., Lee, C., Diaz, J. L., Ciarleglio, A., Kim, S., Sirey, J. A., Gunning, F. M., Raue, P. J., et al. (2025) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2025.2518 · Cited by 7
Salehi, M., Hormozi, F., Marvi, A., Seddigh, B., & Zakeri, A. (2025) · BMC Health Services Research · doi:10.1186/s12913-025-13702-9 · Cited by 6
“These include the absence of stable and coordinated mental health policies, a shortage of trained human resources, insufficient funding, weak health information systems, social stigma, limited intersectoral collaboration, and cultural and linguistic challenges [16–19].”
Nanfuka, E. K., Kafuko, A., Nakanjako, R., Ssenfuuma, J. T., & Mafigiri, D. K. (2024) · Journal of the International Association of Providers of AIDS Care (JIAPAC) · doi:10.1177/23259582241298166 · Cited by 6
Unveiling autism spectrum disorder in South East Asia through a public health Lens
Kumar, A., & Bhattacharya, S. (2024) · Frontiers in Child and Adolescent Psychiatry · doi:10.3389/frcha.2024.1489269 · Cited by 8
Kirmayer, L. J., Gómez-Carrillo, A., Langlois‐Thérien, T., Ramstead, M. J. D., & Gold, I. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108695374.012 · Cited by 6
van Rensburg, A. J., Khan, R., Wouters, E., van Rensburg, D. H., Fourie, P., & Bracke, P. (2018) · The International Journal of Health Planning and Management · doi:10.1002/hpm.2593 · Cited by 6
“Hierarchies and budgetary controls as forms of power—not subsisting in any individual or specific institution54—have been suggested elsewhere to be a feature of local health care provision in South Africa.52 Further, it seems prudent to ask whose interests are being served within the stewardship and governance dynamic…”
BackgroundRaeber, F., Haldemann, M. I., Ray, S., Huber, J. P., Firima, E., Fernández, L. G., Amstutz, A., Gerber, F., Labhardt, N. D., & Belus, J. M. (2024) · Frontiers in Psychology · doi:10.3389/fpsyg.2024.1241403 · Cited by 5
Docrat, S., Cleary, S., Chisholm, D., & Lund, C. (2019) · PLoS ONE · doi:10.1371/journal.pone.0224799 · Cited by 5
“KK faces a high prevalence of both HIV (30% of the district population) and Tuberculosis (TB), and a rising burden of concomitant non-communicable disease including diabetes and hypertension [27].”
BackgroundInfluentialSelf-citationCultural Priming Effects and the Human Brain
Han, S., & Northoff, G. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108695374.011 · Cited by 5
Kirmayer, L. J., Worthman, C. M., & Kitayama, S. (2020) · Cambridge University Press eBooks · doi:10.1017/9781108695374.002 · Cited by 6
Njau, T., Ngakongwa, F., Sunguya, B. F., Kaaya, S., & Fekadu, A. (2022) · Healthcare · doi:10.3390/healthcare10122491 · Cited by 5
“The arguments highlight the challenges and risks of applying Western approaches and interventions to other cultures prior to assessing if inherent are socially appropriate, feasible, or effective [26,34,35]; hence, intervention development or good adaptation work needs consideration before going to scale.”
BackgroundSelf-citationNarayan, S., Kishore, M. T., Satyanarayana, V. A., Bhaskarapillai, B., Desai, G., & Chandra, P. S. (2023) · Indian Journal of Psychological Medicine · doi:10.1177/02537176231164732 · Cited by 5
Votruba, N., Praveen, D., Mellers, L., Rajan, E., Thout, S. R., Arora, V., Malik, Y. K., Kashyap, A., Majumdar, S., Hirst, J. E., et al. (2023) · Frontiers in Global Women s Health · doi:10.3389/fgwh.2023.1143880 · Cited by 7
“We will use a standardised situational analysis tool, adapted from the PRIME study/WHO-AIMS (53, 60).”
Method
Metadata
- Authors
- Hanlon, C., Luitel, N. P., Kathree, T., Murhar, V., Shrivasta, S., Medhin, G., Ssebunnya, J., Fekadu, A., Shidhaye, R., Petersen, I., Jordans, M., Kigozi, F., Thornicroft, G., Patel, V., Tomlinson, M., Lund, C., Breuer, E., De Silva, M., & Prince, M.
- Affiliations
- King's College London (GB)
- University of KwaZulu-Natal (ZA)
- Sangath (IN)
- Addis Ababa University (ET)
- Butabika Hospital (UG)
- Public Health Foundation of India (IN)
- London School of Hygiene & Tropical Medicine (GB)
- University of Cape Town (ZA)
- Corresponding author
- Hanlon, Charlotte
- ORCID
- Venue
- PLoS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2014-02-18
- Volume
- 9
- Issue
- 2
- Pages
- e88437
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC3928234
- OpenAlex
- W2151272134
- Cited by
- 339
- References
- 46
- Citations by year
- 2026: 14 · 2025: 22 · 2024: 26 · 2023: 18 · 2022: 33 · 2021: 24 · 2020: 61 · 2019: 27 · 2018: 32 · 2017: 24 · 2016: 23 · 2015: 26 · 2014: 9
- FWCI
- 40.50
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- PLoS ONE (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Research Portal (King's College London) (publishedVersion, cc-by)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Open University of Cape Town (University of Cape Town) (submittedVersion, cc-by)
- Edinburgh Research Explorer (University of Edinburgh) (submittedVersion, cc-by)
- SUNScholar (Stellenbosch University) (submittedVersion, public-domain)
- Greater South Information System
- Funders
- Wellcome Trust (084674, 100714)
- Government of the United Kingdom
- National Institute for Health and Care Research (NF-SI-0611-10053)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
- Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Keywords
- integrated mental health care, primary care integration, health system preparedness, mental health literacy, community health workers, mental health professionals, intersectoral collaboration, low- and middle-income countries, district health planning
- MeSH terms
- Community Health Workers, Community Mental Health Services, Cross-Sectional Studies, Developing Countries, Ethiopia, Health Services Accessibility, Humans, India, Nepal, Poverty, Primary Health Care, Public Health, South Africa, Tuberculosis, Uganda, Program Evaluation, HIV Infections
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