AbstractBackground Nepal is representative of Low and Middle Income Countries LMIC with

AbstractBackground: Nepal is representative of Low and Middle Income Countries (LMIC) with limited availability of mental health services in rural areas, in which the majority of the population resides.Methods: This formative qualitative study explores resources, challenges, and potential barriers to the develop-ment and implementation of evidence-based Comprehensive Community-based Mental Health Services (CCMHS) in accordance with the mental health Gap Action Programme (mhGAP) for persons with severe mental health disorders and epilepsy. Focus Group Discussions (FGDs, n = 9) and Key-Informant Interviews (KIIs, n = 26) were conducted in a rural district in western Nepal. Qualitative data were coded using the Framework Analysis Method employing QSR NVIVO software.Results: Health workers, general community members, and persons living with mental illness typically attributed mental illness to witchcraft, curses, and punishment for sinful acts. Persons with mental illness are often physically bound or locked in structures near their homes. Mental health services in medical settings are not available. Tradi-tional healers are often the first treatment of choice. Primary care workers are limited both by lack of knowledge about mental illness and the inability to prescribe psychotropic medication. Health workers supported upgrading their existing knowledge and skills through mhGAP resources. Health workers lacked familiarity with basic computing and mobile technology, but they supported the introduction of mobile technology for delivering effective mental health services. Persons with mental illness and their family members supported the development of patient sup-port groups for collective organization and advocacy. Stakeholders also supported development of focal community resource persons to aid in mental health service delivery and education.Conclusion: Health workers, persons living with mental illness and their families, and other stakeholders identified current gaps and barriers related to mental health services. However, respondents were generally supportive in devel-oping community-based care in rural Nepal.Keywords: Community mental health, Severe mental disorders, Task shifting, Stigma, Patient support groups, mHealth1 Research Department, Transcultural Psychosocial Organisation (TPO) Nepal, Kathmandu, NepalFull list of author information is available at the end of the article© The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.BackgroundMental disorders are frequently occurring and often seriously impairing in many countries across the world [1]. e burden of mental disorders has significantly increased by 37•6% at the duration of 20 years between 1990 and 2010 accounting for 7.4% of disability adjust-ment life years (DALY), and 22.9% of all years lived with disability [2]. Mental illness is one of the major contribu-tors to global economic burden of non-communicable diseases; it is estimated that the global burden will rise twofold between 2010 and 2030 [3], in part due to the demographic and epidemiological transitions in LMICs [4]. A review study of 174 surveys across 26 high income countries and 37 Low and Middle Income Countries (LMICs) showed that one in five adults (17.6%) expe-rienced a common mental health disorder on average within the past 12 months with a 29.2% chance of expe-riencing a mental health disorder at a point in their life-time [5].According to World Health Organization (WHO), more than 13% of the global burden of disease is due to neuropsychiatric disorders and almost three quarters of this burden lies in low-income and middle-income coun-tries [LMICs] [6]. Nepal is an LMIC that has suffered through a 10-year long conflict (Maoist insurgency), which further increased the mental health burden. Since most LMICs do not routinely conduct their own popu-lation-based surveys, several studies on mental health in the general population during and after the Maoist insurgency in Nepal have shown high prevalence rates of mental illness [7–10]. A recent study revealed a 22.7% prevalence of anxiety and 11.7% prevalence of depression in Nepal’s population [11].e impact of untreated mental disorders results in homelessness, incarceration and violence. It does not only affect the person suffering from the illness but also those close to the person. Studies have shown several adverse consequences of untreated mental illness includ-ing poverty [12], physical health problems [13] and pre-mature death [14]. Mental disorders have a negative impact on education and work productivity when com-pared to persons without mental disorders [15, 16].More than 40% of all countries have no mental health policies and over 30% have no specific mental health pro-grammes [17]. Several studies have estimated that nearly half of all individuals with severe mental disorders are not receiving treatment for their mental illness at any given time [18–20]. In LMICs, only a minor proportion of people with mental disorders receive adequate treat-ment [21–25]. Studies show that nearly 80% of people with mental disorders in developing countries receive no effective treatment [6, 21] In many LMICs, there is often only one psychiatrist or psychologist for over two million people [26].e Government of Nepal has attempted to include mental health services as a basic primary health care component however; services still remain inaccessible to most of the population at the primary care level. e National Health Sector Programme (NHSP-II) of Nepal has included mental health as a part of “essential health care”. However, government policy does not permit pri-mary health care workers to independently diagnose and treat mental disorders within the primary care system. Procedures for referring persons from primary care to secondary/tertiary care also do not exist in the health care system [27].Stigma is strongly embedded in Nepali communities thereby posing a large challenge in the scaling-up of men-tal health services. Lack of awareness of mental health services and related issues among both the marginalized and the privileged is another major hindrance. Families and close relatives/friends are primary detectors and identifiers of mental health problems, and can take a piv-otal role in making mental health services accessible [28]. e already overburdened health workers, unavailability of psychotropic drugs, lack of awareness in the general people, deeply engrained negative attitudes/stigmatized and discriminating behavior towards the mentally ill all pose as challenges in integrating mental health services in primary health care in Nepal [28–30].In order to close the gap between mental health needs and services, activists and researchers have initiated a task-sharing (also referred to as ‘task-shifting’) approach, from specialist mental health professionals to non- spe-cialist health workers in LMIC primary health care set-tings [31–33]. However, the data regarding fidelity of care in task-shifting to community -based services and utiliza-tion of mental health services after community training is limited to a few LMIC settings [34].Integration of mental health services into primary health care is one of most essential health care recom-mendations from WHO [35]. e integrated approach helps to reduce stigma, improve access to mental health services and treatment of co-morbid physical condi-tions, reduce chronicity and improve social integration, human rights protection, better health outcomes for peo-ple treated in primary health care, and improve human resource capacity for mental health [36].ere have been significant efforts made towards the development of a community mental health delivery inte-grated program in Nepal [27]. However, no unified model has been adopted or scaled up. is gap highlights the lack of available single best-practice models, as well as the urgent need to better understand how a comprehensive mental health approach, encompassing services within PHC and the surrounding community, can be developed and implemented [28].MethodsStudy designCross sectional studies involving qualitative methods of data collection and analysis were conducted between December 2012 and May 2013 to portray the prevalent condition of mental disorders, as perceived by district and national levels stakeholders.Settingis formative research was conducted through a pro-gram titled Mental Health Beyond Facilities (mhBeF), funded through a grant awarded to Makerere University School of Public Health from Grand Challenges Canada. e objective of mhBeF is to develop and implement an evidence-based comprehensive community-based men-tal health services (CCMHS) package in accordance with the mental health Gap Action Programme (mhGAP) for persons with severe mental disorders and epilepsy (PWSMDE) in Liberia, Uganda, and Nepal. e CCMHS package integrates three components: (a) strengthening clinical recognition, referral, assessment and manage-ment by health workers and community resource persons (CoRPs) including an electronic mobile health (mHealth) package; (b) establishing psychosocial and socio-eco-nomic support services for PWSMD through patient support groups (PSGs); and (c) conducting stigma reduc-tion targeted activities for health providers, families and PWSMDE.As post-conflict countries, Liberia, Uganda, and Nepal each have a high burden of mental disorders and a lack of community-based mental health services. e mhBeF project is implemented in Nepal by Transcultural Psy-chosocial Organization Nepal (TPO Nepal).As part of the inception phase of the mhBeF project, investigators undertook a formative study with policy level stakeholders at the national level in Kathmandu and other district level stakeholders in Pyuthan district, located in the mid hills of the Rapti zone in the mid-western devel-opment region of Nepal [37] (Fig. 1). e objective of this formative research was to examine domains considered central to the successful development and implementa-tion of a comprehensive community-based mental health services package with a mobile health component.Nepal is a developing country with a low income, ranking at 145 of 187 countries on the Human Develop-ment Index (HDI) in 2015 [38]. Nepal recently endured the People’s War fought between the Communist Party of Nepal (Maoist) and government security forces from 1996 through 2006 causing widespread psychosocial and mental health implications. In rural Nepal, moderate to severe depression symptom prevalence is reported at 33% and anxiety prevalence at 27% [9]. Pyuthan district was among six districts seriously affected by the Maoist insurgency when the first ceasefire was declared on July 21, 2001 and till date there are no mental health and psy-chosocial interventions in the district.Nepal has made significant progress in formulating a Mental Health Policy (1996) and Mental Health Act (2006). However, implementation has been inadequate and needs to be strengthened. e availability of human resources for health is also very scarce; 0.18, 0.04 and 0.25 psychiatrists, psychologists and nurses per 100,000 population in the country [27]. e District health sys-tem in Nepal is based on primary health care, which is more or less a self-contained segment of the national health system. District health system provides preven-tive, promotive and curative services to the people living in the districts through the District Public Health Ofce, District Hospitals, Primary Health Care Centers (PHCC), Health posts (HP), and Sub Health Posts (SHP) at all lev-els of the healthcare system. Pyuthan district has 1-dis-trict hospital, 2-primary health care centers, 11-health posts, and 35-sub health posts, about 40-pharmacies and 3-Ayurvedic health facilities. e peripheral health care system health work force, mainly consist of mid-level health worker groups who are largely paramedical practitioners Health Assistants (HA), Auxiliary Health Workers (AHW) etc. and nursing and nursing associate professional’s group. is includes Staff Nurse (SN) and Auxiliary Nurse Midwives (ANMs). Paramedical prac-titioners are also known as prescribers, as they run the Out -Patient Department (OPD) in health facilities where Nursing and nursing associates are known as non- pre-scribers since they are only involved in patient care and midwifery. Along with these barriers intervention studies are lacking for people with serious mental disease in pri-mary care.

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