Multilevel Barriers and Facilitators of Mental Health Services: Narratives from Nepal

Background: COVID-19 has exacerbated mental health symptoms and increased mental health service demands across the globe. In low- and-middle-income countries (LMICs), the rise in demand for mental health services is often compounded with multiple barriers including, under-resourced healthcare systems, social unrest, lack of mental health policies, cultural stigma, lack of mental health providers, and gaps in culturally responsive mental health interventions. Current trends in Nepal show an urgent need to expand mental health services by mobilizing professionals and paraprofessionals in the field. Although existing literature has documented challenges for scaling up mental health interventions in LMICs, little is known about mental health service provision from the perspective of mental health providers in in a resource poor setting like Nepal. Drawing on the experiences of mental health counselors working at individual and community settings in Nepal, our study aimed to: (1) explore the lived experiences of Nepali mental health counselors, and (2) identify potential facilitators and barriers to mental health service provision and delivery.

Methods: As a part of a larger mixed methods intervention study that used a community-engaged research approach, qualitative data was collected from participants in the Missing Counselor Project (MCP), a three-month synchronous mental health capacity building intervention provided to mental health professionals and paraprofessionals in Nepal (N=14). Multimodal qualitative data was collected in both Nepali and English using two focus group discussions (FGDs), eight de-briefing sessions, and in-depth interviews at the beginning, during, and at the conclusion of the intervention. All FGDs, de-briefing sessions, and interviews were video recorded on zoom, translated from Nepali to English, and transcribed verbatim. Participants represented diverse demographic strata: age (22 to 37 years); education (master’s degree=10, bachelor’s degree=4), and gender (female=13, male=1). Grounded theory method using open, axial, and selective coding process was followed to analyze the data using thematic analysis approach with two coders independently analyzing the qualitative data throughout the research process. Any disagreements in coding and analysis were resolved through an interactive team approach by a three-person research team.

Results: Findings highlighted facilitators and barriers of mental health service provision, delivery, and utilization across individual, community, and system levels. Identified facilitators included: 1) personal motivation sources including family support and cultural resilience; and 2) increased awareness and decreased stigma around mental health since COVID-19. Identified barriers included: 1) structural barriers: resource deficiency and centralized services; 2) lack of culturally responsive trainings and supervision opportunities 3) gaps in mental health policy, legislation, and implementation, and 4) cultural barriers causing poor compliance and treatment.

Conclusion: Achieving mental health equity, requires understanding the wide range of factors that influence health outcomes at multiple social-ecological levels. In order to overcome structural, systemic, legal, and cultural barriers in mental health service provision, delivery and utilization of services, multi-pronged strategies including improved opportunities and motivational benefits for mental health workers, strengthening systems to provide culturally responsive supervision and trainings, expanding services to sub-urban and rural areas, implementation of national mental health policy, and development of an integrated health system are crucial.