Stakeholder perspectives on integration of mental health services into primary care: a mixed methods study in Northern Iraq

Integrating evidence-based mental health services into primary care has been identified as one strategy for overcoming the treatment gap in low and middle-income countries, yet their uptake into standard practice remains poor. The purpose of this study was to understand stakeholder perspectives regarding barriers and facilitators to integration of mental health services into primary care settings in Northern Iraq. Using a convergent mixed methods study design, quantitative and qualitative questionnaires assessed respondent perceptions of implementation factors under the domains of Autonomy, Acceptability, Appropriateness, Feasibility, Penetration/Accessibility, Sustainability, and Organizational Climate. We interviewed four types of stakeholders: clients, providers of mental health services, non-mental health (MH) staff working at the centers, and center directors. Interviews were conducted with clients at the completion of services, and with all other stakeholder groups in the latter half of the first year of program implementation, by Kurdish-speaking interviewer pairs. Qualitative and quantitative data were analyzed separately and merged using qualitative data transformation to quantify frequency of theme and integrate with quantitative findings through woven narrative. 123 clients, 26 providers, 40 non-MH staff, and 12 directors provided data. Positive perceptions of the program’s acceptability, appropriateness, feasibility, and positive impacts were reported across all stakeholder levels. Providers reported that the program length (8–12 sessions) was a challenge. Clients described logistical challenges (e.g.: transportation, childcare, home duties); support from family and friends appeared to be critical. Lack of private space, insufficient staffing, and need for greater government support were also important issues. This mixed methods study is unique in its inclusion of non-MH staff and director perspectives on integration of mental health services in primary care clinics. Their inclusion proved vital since they included critical human resource barriers to feasibility. Providers reported generally positive integration experiences but that some colleagues (clinic staff not involved in mental health services) were unsupportive. Most non-MH staff were supportive, but some did report negative impacts on their working environment. Future studies of integration of mental health services into other service platforms should include the perspectives of stakeholders not involved in provision of mental health services.