Factors influencing primary care access for common mental health conditions among adults in West Africa: A scoping review

doi:10.21203/rs.3.rs-4874948/v1

Background

Mental health conditions are a significant threat to global health and have recently seen increased efforts to tackle them. Despite these efforts, common mental health conditions like stress, anxiety disorders, depression, schizophrenia, bipolar disorder, and substance use disorder continue to affect many people worldwide. In West Africa, the situation is worse because of the many factors that hinder access to primary care for these conditions. Our scoping review explored the factors that influence primary care access for common mental health conditions among adults in West Africa.

Methods

Using the approach for the conduct of scoping reviews described by Arksey and O’Malley in 2005, five electronic databases (PubMed, Embase, PsycINFO, CAIRN INFO, and Google Scholar), were searched for articles published between 1st January 2002 and 31st January 2024. Papers were screened by two independent reviewers and selected based on predetermined inclusion and exclusion criteria. This review adheres to the requirements of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, extension for scoping reviews.

Results

After removing duplicate records titles and abstracts were screened for 1736 articles resulting in 39 articles eligible for full-text screening. After full-text screening, 28 articles were included in the review. Our review revealed that the factors that influence primary care access for common mental health conditions in West Africa act either at the level of the patient, the primary healthcare facility, or outside these two levels at the contextual level. Contextual factors include social norms, cultural beliefs, traditions, and socio-economic status. They influence primary care access for mental health by affecting the patient level and healthcare facility-level factors. Furthermore, the domains of influence at the patient level and facility level are interrelated.

Conclusion

Factors influencing primary care access for common mental health conditions among adults in West Africa are multiple, complex, and interrelated. Effective Interventions to improve primary care access for mental health need to be multi-faceted addressing individual, facility and systems, as well as contextual factors.

Scoping review

mental health

non-communicable diseases

primary care

access

barriers

enablers

West Africa

Although mental health conditions are a significant threat to global health, they have not been public health’s priority in the past (1). This group of conditions is now gaining more attention, especially in areas where it was not given the needed consideration (1). Many countries are showing a keen interest in issues of mental health, with governments recognizing the need to strengthen their mental health strategies and update them where necessary (1). The sector has seen significant advancements in evidence-based research and improvements in learning and practice tools and materials. Mental health advocacy activities have increased, and more importantly, the interests of the ordinary health service user are being given more priority (1).

Nevertheless, mental illnesses continue to affect many people worldwide. Nearly a billion people in the world live with a mental health condition, and about four out of five such people live in a low- or middle-income country (LMIC) (1). Some common mental health conditions include anxiety disorders, depressive disorders, bipolar disorder, and schizophrenia. Globally, in 2019, 301 million people were living with anxiety disorders, 280 million with depressive disorders, 40 million with bipolar disorder, and 24 million had schizophrenia (1). A scoping review by Greene et al. (2). showed that as of 2021, the prevalence of various groups of mental disorders in Africa was between 3.3% and 9.8% for mood disorders; 5.7% and 15.8% for anxiety disorders; and 3.7% and 13.3% for substance use disorders. This is consistent with the 10.9% prevalence of mental illnesses in Africa, reported by the World Mental Health Report (1). Despite this regional prevalence being lower than the global prevalence, gaps in mental health data reporting in Africa could be one reason that accounts for this (3).

The above findings highlight the gap between mental health needs and mental health service provision. There is inequitable distribution of mental health services. Even where they are available, they are sometimes not accessible (1). Access is a major part of the drive to improve mental healthcare across the world (1). While it may be a complex concept to define, it can be conceptualized as “the possibility to identify healthcare needs, to seek healthcare services, to reach the healthcare resources, to obtain or use healthcare services, and to actually be offered services appropriate to the needs for care” (4). This approach, described by Levesque et al. (4), is useful in taking a comprehensive look at the multifaceted dimensions of access.

In West Africa, many factors hinder access to primary care for mental health conditions. Social norms may influence people's views about what may or may not be a mental health condition (5,6). Cultural beliefs and traditional practices play a significant role in the path that sufferers of mental health conditions and their carers choose to address their condition (5,7). Furthermore, perceptions of mental illnesses as those characterized by overt symptoms are still rife in the sub-region, and these notions prevent people from seeking help if symptoms are absent or mild (5,8,9). Also, social networks are critical in the health-seeking period, and in many instances, they choose to send their relative to an alternative care provider rather than to orthodox primary care settings (9). There is also the commonly reported issue of lack of funds hindering access to healthcare (8,9). Especially if the medications are not available at the primary healthcare facility, it deters service users from seeking care there (5). Moreover, the service provided may not be acceptable to most people (5,8), or they may view the management as ineffective and therefore may not adhere to the treatment regimen (9).

On the other hand, although not as abundant as the barriers, certain enablers that have been identified can be maximized to improve access to mental healthcare in the sub-region. Firstly, although social networks sometimes hinder access, empowering these networks with the right information has been shown to increase access to mental healthcare (10). Secondly, task-shifting policies have also shown promising signs of bridging the gap in mental health care, especially in geographically isolated areas (11–13). Thirdly, there have been efforts to integrate mental healthcare into general health services, making it more accessible at the community level (14). Also, considering the significant role played by traditional and spiritual healers in the sub-region (9,15–18), it is encouraging to learn of signs of collaboration being fostered between these alternative providers and primary care providers (19).

This scoping review identified the factors that influence access to primary care for common mental health conditions among adults in West Africa. To the best of our knowledge, this is the foremost review that collated evidence from studies conducted on this topic in West Africa. The findings of our study will be valuable to policymakers and other stakeholders in mental health in co-producing interventions to improve access to mental healthcare. Additionally, our review identified opportunities for further research to bridge the gaps in the literature on access to primary care for mental healthcare in West Africa.

Conceptual framework for enablers and barriers to primary care access for mental health

We adapted a conceptual framework to guide our exploration and analysis of factors influencing access to primary care for mental health, drawing on the work of Levesque et al. (4) and the concept of context from Leichter’s framework of context (20).

The framework (Fig. 1) categorized and explored factors (or enablers and barriers) that influence access to primary care for mental health, further categorized into factors that operate at the level of individual perspectives and the level of the primary healthcare facility. Enablers and barriers influencing access to care related to the primary healthcare facility include (1) approachability; (2) acceptability; (3) availability and accommodation; (4) affordability; and (5) appropriateness of services. Enablers and barriers influencing access to care related to the individual include (1) perceptions of care; (2) care-seeking behaviour; (3) healthcare reaching (4) healthcare payment; and (5) healthcare engagement.

The framework also included specific contextual factors that influence access to primary care for mental health conditions. We defined contextual factors as those elements outside of an individual but within his or her environment that interact with the individual and influence their approach to seeking and utilizing healthcare services (21). Thus, although Leichter (20) subdivided contextual factors into situational, structural, cultural, and environmental factors, we focused on the cultural factors only to meet our third specific objective. These contextual factors include sociocultural and socio-economic factors such as social norms, cultural beliefs, traditions, and income levels (21). These sociocultural and socio-economic enablers and barriers act as background factors in the society of the individual and primary healthcare facility that shape other enablers and barriers to accessing primary care for mental health.

Individuals’ access to primary care for mental health depends on their perceptions of care, their care-seeking behaviour, their ability to reach a primary care facility, and their capacity to pay and engage with the available services. Access also depends on how approachable the primary care facility is, how well the individual accepts the mode of service delivery, the services available, how affordable they are, and how appropriate they are for attending to mental health. These factors are all affected by social constructs of mental health such as the beliefs, norms, traditions, and income levels of that specific society. Therefore, primary care access for common mental health conditions among adults in West Africa is affected by interactions between enablers and barriers to access at the individual and primary healthcare facility level, and these interactions take place within a background of and are shaped by specific contextual factors.

Figure 1: Conceptual framework for access to primary care for common mental health conditions

Objective

The main objective of this review was to identify factors influencing access to primary care for common mental health conditions (depression, bipolar disorders, schizophrenia, anxiety disorders, stress disorders, and substance use disorders) in adults 18 years and above, in West Africa, from 2002 to 2024.

The specific objectives were as follows:

To identify patient-level factors that affect and how they affect access to primary care for common mental health conditions in adults, 18 years and above, in West Africa, from 2002 to 2024.

To identify primary healthcare facility-level factors that affect and how they affect access to primary care for common mental health conditions in adults, 18 years and above, in West Africa, from 2002 to 2024.

To identify specific contextual factors (societal beliefs, norms, and practices) that affect and how they affect access to primary care for common mental health conditions in adults, 18 years and above, in West Africa, from 2002 to 2024.

To synthesize implications for co-design with stakeholders of interventions for primary mental health care, identify gaps in the literature, and suggest areas for further research into primary care for common mental health conditions in adults, 18 years and above, in West Africa.

Our scoping review followed the five-stage approach developed by Arksey and O’Malley who proposed a methodological framework for conducting scoping reviews (22). The full research protocol is available (23).

Identifying the research question

The research question was formulated based on gaps identified in the literature after an initial literature search and in consultation with experts in the field. The main research question was: “What factors influence access to primary care for common mental health conditions (depression, bipolar disorders, schizophrenia, anxiety disorders, stress disorders, and substance use disorders) in adults 18 years and above, in West Africa, and how and why do they work?”

Identifying relevant studies

Inclusion criteria

The search included studies conducted from 1st January 2002 to 31st January 2024. We used the participants, concept, context, and type of study (PCCS) framework to identify studies that were eligible for our review.

Participants: Participants were defined as adults (18 years old and above) living with mental health conditions, and those involved in providing their care or relevant policies and systems for their care. Thus, any studies that involved the following stakeholders in mental health – clients, their caregivers, frontline providers of primary care for mental health, health system managers, policymakers, academics, Civil society, and non-governmental organizations in mental health – were eligible for inclusion.
Concept: (i) We were interested in studies reporting factors that influence primary care of common mental health conditions in adults. The mental health conditions we focused on were depression, bipolar disorders, schizophrenia, anxiety disorders, stress disorders, and substance use disorders. Studies that reported on mental health conditions in general were also included provided they met all other inclusion criteria. (ii) The patient-level factors of interest included those related to perceptions of care, care-seeking behaviour, healthcare reaching, healthcare payment, and healthcare engagement. (iii) Primary healthcare facility-level factors of interest were approachability, acceptability, availability and accommodation, affordability, and appropriateness. (iv) We were also interested in other factors such as social norms, cultural beliefs, traditions, and socio-economic factors.
Context: We included studies that were conducted in one or more of the 15 countries in West Africa that formed the Economic Community of West African States at the time of the review namely: Benin, Burkina Faso, Cabo Verde, Cote d’Ivoire, The Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone, and Togo.
Type of study: Primary studies, systematic reviews, and scoping reviews that met other inclusion criteria were included. Published theses that met our inclusion criteria were also included.

Exclusion criteria

We excluded studies that did not report any data that answered our research question, studies whose participants did not meet our inclusion criteria, studies that were conducted outside of West Africa, papers that were published before 2002, papers that were neither in English nor French, and papers that did not meet our criteria for study type. Case studies, case reports, and anecdotal evidence from grey literature were also excluded.

Conducting the search

We searched for records in PubMed, Embase, PsycINFO, Cairn.info, and Google Scholar using search terms adapted for each database (Table 1). The bibliographies of studies included in the initial search were manually explored for more papers. The search results were then exported to Rayyan, a web-based screening tool. Records that were in French were translated with the help of a bilingual secretary and DeepL Translate, a translation software.

Table 1

Search strategy for PubMed
Search No.	Search terms
#1	(((((((((((((((((((("Mental health"[MeSH]) OR ("Mental health condition")) OR ("Common mental disorder")) OR ("mental disorders"[MeSH])) OR ("mental illness")) OR (stress)) OR ("stress disorder")) OR (anxiety[MeSH])) OR ("anxiety disorders"[MeSH])) OR (depression[MeSH])) OR ("recurrent depression")) OR ("major depression")) OR ("major depressive illness")) OR ("depressive illness")) OR ("depressive disorder"[MeSH])) OR ("mood disorders"[MeSH])) OR ("Substance abuse")) OR ("Substance use disorder")) OR ("bipolar disorder"[MeSH])) OR (schizophrenia[MeSH])) OR ("generalized anxiety disorder")
#2	((((((Hypertension[MeSH]) OR ("High blood pressure")) OR ("Raised blood pressure")) OR ("Increased blood pressure")) OR ("Hypertensive disease")) OR (Hypertensive)) OR ("Hypertensive patient")
#3	(((((((Diabetes) OR ("Diabetes Mellitus"[MeSH])) OR ("High blood glucose")) OR ("High plasma glucose")) OR ("Raised blood glucose")) OR ("Increased blood glucose")) OR (Diabetic)) OR ("Diabetic patient")
#4	((((((((((Influence) OR (Barrier)) OR (hindrance)) OR (hinder)) OR (obstacle)) OR (difficult)) OR (obstruct)) OR (prevent)) OR (limit)) OR (restrain*)) OR (inhibit)
#5	(((((((enable) OR (facilitat)) OR (support)) OR (opportunit)) OR (aid)) OR (ease)) OR (promot)) OR (help)
#6	((((((((((((((((((("Health Education") OR ("Patient counseling")) OR (Psychotherapy[MeSH])) OR (Exercise)) OR ("Cognitive behavioral therapy"[MeSH])) OR ("Behavioral therapy")) OR ("Stress therapy")) OR ("Antidepressive agents"[MeSH])) OR ("Selective serotonin reuptake inhibitors")) OR (SSRIs)) OR ("Tricyclic antidepressants")) OR (TCAs)) OR (Antidepressants)) OR ("anti-anxiety agents"[MeSH])) OR (Anxiolytics)) OR (Rehabilitation)) OR ("Primary care")) OR ("Primary healthcare")) OR ("Health services")) OR (Healthcare)
#7	((((((((((((((((((("West Africa") OR ("Africa, Western"[MeSH])) OR (Benin[MeSH])) OR ("Burkina Faso"[MeSH])) OR ("Cape Verde")) OR ("Cabo Verde"[MeSH])) OR ("Cote d’Ivoire"[MesH])) OR (Gambia[MeSH])) OR (Ghana[MeSH])) OR (Guinea[MeSH])) OR (Guinea-Bissau[MeSH])) OR ("Ivory Coast")) OR (Liberia[MeSH])) OR (Mali[MeSH])) OR (Niger[MeSH])) OR (Nigeria[MeSH])) OR ("Sierra Leone"[MeSH])) OR (Senegal[MeSH])) OR (Togo[MeSH])
#8	((((#1) AND (#2)) AND (#3)) AND (#4)) AND (#6)
#9	((((#1) AND (#2)) AND (#3)) AND (#5)) AND (#6)
#10	(((#1) AND (#2)) AND (#4)) AND (#6)
#11	(((#1) AND (#2)) AND (#5)) AND (#6)
#12	(((#1) AND (#3)) AND (#4)) AND (#6)
#13	(((#1) AND (#3)) AND (#5)) AND (#6)
#14	((#1) AND (#4)) AND (#6)
#15	((#1) AND (#5)) AND (#6)
#16	(#8) AND (#7); Filter- Publication Year: 2002–2024
#17	(#9) AND (#7); Filter- Publication Year: 2002–2024
#18	(#10) AND (#7); Filter- Publication Year: 2002–2024
#19	(#11) AND (#7); Filter- Publication Year: 2002–2024
#18	(#12) AND (#7); Filter- Publication Year: 2002–2024
#19	(#13) AND (#7); Filter- Publication Year: 2002–2024
#20	(#14) AND (#7); Filter- Publication Year: 2002–2024
#21	(#15) AND (#7); Filter- Publication Year: 2002–2024
Final output: #16, #17, #18, #19, #20, #21, #22, #23

Table 1: Search strategy for PubMed

Study selection

Rayyan was used to remove the duplicates and screen the records. A team of six reviewers (NYAB, VR, RNBA, EPKB, KNAAA, MPA,) screened the titles and abstracts of the studies ensuring that each record was independently reviewed by two authors. The full texts of selected studies were then retrieved and screened independently by the same team. Studies that met the inclusion criteria were selected for final analysis. Conflicts were resolved by a third reviewer or discussion where needed. The study selection process followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines (24).

Charting the data

A data extraction tool (Table 2) adopted from the Joanna Briggs Institute Manual for Evidence Synthesis (25) was created using Microsoft Excel. A pair of reviewers independently extracted the following data: publication details, study characteristics, key findings, limitations, and recommendations. The tool that was drafted in the protocol was modified to include the mental illness studied and the study method (qualitative or quantitative) used.

Table 2

Data Extraction Tool
PUBLICATION DETAILS
Title
Author(s)
Year of Publication
Country/Countries
Language
STUDY CHARACTERISTICS
Objective(s)
Mental Illness(es) studied
Study Design
Method (quantitative/qualitative)
Setting
Study Population
Study Participants
Sampling method
Sampling size
Data collection method
Data Analysis
Type of Evidence Source
KEY FINDINGS
Patient-level factors
• Ability to perceive
• Ability to seek
• Ability to reach
• Ability to pay
• Ability to engage
Primary healthcare facility-level factors
• Approachability
• Acceptability
• Availability and accommodation
• Affordability
• Appropriateness
Contextual factors
• Social norms
• Cultural beliefs
• Traditions
• Income Levels
Other findings
Limitations
Recommendations
Reviewer's comments

Collating, summarizing, and reporting the results

The extracted data was summarized and categorized according to themes determined a priori from the conceptual framework for access to primary care described in the protocol. Under each theme, the factors were identified either as enablers or barriers to primary care access. These factors were then categorized according to the level at which they act, be it patient-level, primary healthcare facility-level, or contextual. Additionally, subthemes derived from the literature were placed under the main pre-defined domains in the framework.

The search in the databases yielded 2,918 results. After removing duplicates, 1,736 results were screened by their titles and abstracts. Out of these, the full texts of 39 results were sought for full-text screening. However, two articles could not be accessed despite contacting their corresponding authors. Therefore, the full texts of 37 results were reviewed, of which 28 papers were selected for data extraction and analysis. The review procedure and reasons for exclusion after full-text screening are summarized in the PRISMA flow diagram (Fig. 2).

Figure 2: PRISMA flow diagram

Study characteristics

The characteristics of the studies included are provided in Table 3, and the distribution of included studies by country is shown in Fig. 3. Fourteen studies used a qualitative approach, nine used a quantitative approach, and five used a mixed methods approach. Also, twenty-two studies used a cross-sectional design, three were ethnographies, one used a descriptive design, and two of the studies did not report the study design used. Fifteen studies used one or more non-probability sampling methods (purposive, convenience, snowballing, total), three used probability sampling (multistage), and ten did not report a sampling method. Furthermore, the sample sizes ranged from 15 to 706 participants. Sixteen studies included some form of analysis (thematic, content, framework), eleven used descriptive and/or inferential statistics, and one did not report any data analysis approach. One study each reported on anxiety disorder and stress disorder, two reported on substance use disorders, three each reported on depression and bipolar disorder, eight reported on Schizophrenia, and eighteen studies were on mental illnesses in general (Table 4). The participant groups included mental health service users, their caregivers, mental and general health professionals, traditional and spiritual healers, religious and traditional leaders, health administrators, policymakers, academics, civil society organizations, and the general public. The various pre-defined themes and subthemes derived from the literature are shown in Table 5.

Table 3

Characteristics of included studies
Author	Objective	Method	Study design	Sampling method	Sampling size	Data collection method	Data analysis
Badu et al.(8)	To explore mental health professional’s views on the evidence-based therapeutic process in psychiatric facilities in Ghana.	Qualitative	Cross-sectional	Purposive	30	Semi-structured interviews, surveys, and a review of the literature	Thematic analysis
Ofori-Atta et al.(39)	To conduct a situation analysis of the status of mental health care in Ghana and to propose options for scaling up the provision of mental health care	Qualitative	Cross-sectional	Purposive	122	Semi-structured interviews and focus group discussions	Framework analysis
Elugbadebo et al.(27)	To determine the pattern of clinic attendance among older patients attending outpatient mental health services at the Geriatric Centre of the University College Hospital (UCH), Ibadan, Nigeria, and examine the reasons for drop out and partial non-attendance.	Mixed methods	Cross-sectional	Not reported	201	Review of case records, key informant interviews, semi-structured questionnaire	Descriptive statistics and content analysis
Mosaku and Wallymahmed(35)	To provide information on attitudes of PHC workers towards the mentally ill and determine factors that affect such attitudes	Qualitative	Cross-sectional	Not reported	100	Questionnaire	Descriptive and inferential statistics
Samba(16)	To assess the availability of essential Psychotropic medications at PHC facilities and identify facilitators/barriers to their availability at primary care level.	Quantitative	Descriptive	Total	106	Questionnaire	Descriptive statistics
Barrow and Faerden(17)	To describe local concepts, experiences and knowledge about mental illness and the implications of such beliefs and attitudes for access to mental health services	Qualitative	Cross-sectional	Convenience and purposive	15 for in-depth interviews	Focus group discussions (FGDs) and in-depth interviews	Thematic analysis
Adjorlolo and Aziato(25)	To investigate factors hampering the provision of mental health services by nurses and midwives to childbearing women to assist in the prioritization and distribution of limited mental health resources	Qualitative	Cross-sectional	Convenience	309	Questionnaire	Descriptive and inferential statistics
Jack-Ide and Uys(33)	Explored the barriers to utilization of mental health services by caregivers/clients accessing services at the Rumuigbo Hospital, the aim being to identify key elements in an effort to increase access and improved service utilization	Qualitative	Cross-sectional	Purposive	20	In-depth interviews	Thematic analysis
Anyebe et al.(26)	To identify and explore the real and perceived barriers to the provision of community mental health service in three selected states in northern Nigeria.	Mixed methods	Cross-sectional	Purposive	204	Questionnaire and in-depth interviews	Descriptive and thematic analysis
Jack-Ide et al.(18)	To explore the experiences of living with and caring for persons with serious mental health problems within the context of the mental health policy environment in Port Harcourt, Rivers State, Nigeria.	Qualitative	Cross-sectional	Purposive	20	In-depth interviews	Framework analysis
Gwaikolo et al.(28)	To identify potential barriers to development and uptake of mental health services for an mhGAP-based primary care program in rural Liberia.	Mixed methods	Not reported	Purposive	71	Focus group discussions and key informant interviews	Descriptive statistics and framework analysis
Nonye et al.(19)	To determine the health-seeking behavior of mentally ill patients in Enugu, Nigeria.	Quantitative	Cross-sectional	Not reported	397	Questionnaire	Descriptive and inferential statistics
Read(40)	To provide a qualitative perspective on the limitations of antipsychotic medication as experienced by people with mental illness and their families in rural communities in and around Kintampo, Ghana.	Qualitative	Ethnography	Not reported	114	Key informant interviews and focus group discussions	Not reported
Ikwuka et al.(31)	To establish the relative weight, significance, and determinants of ideological versus instrumental barriers for behavioral policy interventions.	Mixed methods	Cross-sectional	Multistage (random and convenience)	706	Questionnaire	Descriptive statistics, inferential statistics, and content analysis
Agyapong et al.(13)	To examine the perceptions of psychiatrists and health policy directors about the policy to expand mental health care delivery in Ghana through a system of task-shifting from psychiatrists to community mental health workers (CMHWs)	Mixed methods	Cross-sectional	Total	40 (quantitative), 9 (qualitative)	Questionnaire and key informant interviews	Descriptive statistics and thematic analysis
Pigeon-Gagné et al.(7)	To explore the perceptions of care systems and barriers to help-seeking that may be encountered by people with mental disorders in urban areas of Burkina Faso	Qualitative	Ethnography	Not reported	Not reported (69 stakeholders in FGDs, 25 individual interviews)	Individual interviews, focus group discussions, and participant observation	Thematic analysis
Nelson and Abikoye(9)	To investigate barriers to the utilization of drug abuse treatment by female street sex workers in Nigeria.	Qualitative	Not reported	Snowball	27	In-depth interviews	Thematic analysis
Kisa et al.(6)	To assess the different pathways persons with severe mental disorders and epilepsy take when accessing care and identify the barriers to accessing care that patients face.	Qualitative	Cross-sectional	Purposive	Not reported (22 KIIs, 6 FGDs (consisting of 5 to 8 participants each))	Focus group discussions, and key informant interviews	Framework analysis
Ikwuka et al.(32)	To explore the preferred pathways to care for mental illness and dynamics of pathways choices in a non-clinical cross-section of the south-eastern Nigerian population	Quantitative	Cross-sectional	Multistage (random and convenience)	706	Questionnaire	Descriptive and inferential statistics
Ibrahim et al.(30)	To describe the distribution of first pathway contacts for psychiatric care by individuals with mental disorders attending the outpatient unit of a large public psychiatry facility and assess the possible link between socio-demographic factors and patients’ pathways before they sought care at the Pantang Psychiatric Hospital in the Greater Accra Region of Ghana.	Quantitative	Cross-sectional	Purposive	107	Questionnaire	Descriptive and inferential statistics
Odinka et al.(37)	To assess the relationship between the positive and negative symptoms of schizophrenia, help-seeking behavior and duration of untreated psychosis (DUP).	Quantitative	Cross-sectional	Not reported	360	Questionnaire and interviews	Descriptive and inferential statistics
Cohen et al.(11)	To augment our understanding of how SHGs may contribute to the clinical, social, and economic well-being of service users and their families	Qualitative	Ethnography	Not reported	Not reported (18 SHGs, 5 local NGOs, and others)	Observations, discussions, and conversations	Thematic analysis
Lasebikan et al.(34)	To determine the influence of social network on the pathway to formal mental health service use among psychotic patients in a general hospital in a major city in South Western Nigeria.	Quantitative	Cross-sectional	Not reported	652	Questionnaire	Descriptive and inferential statistics
Fitts et al.(20)	To identify challenges and opportunities for mental health system strengthening within each health system building block in Sierra Leone	Qualitative	Cross-sectional	Convenience	43	In-depth interviews	Thematic analysis
Hopwood et al.(29)	To investigate the barriers and facilitators to mental health service provision at service and management levels within Sierra Leone’s district nurse-led mental health units (MHUs).	Qualitative	Cross-sectional	Purposive	13	Key informant interviews and focus group discussions	Thematic analysis
Adeosun et al.(24)	To assess the pathways to mental health care in patients with schizophrenia, at their first contact with a mental health service in Lagos, southwestern Nigeria and determine the association between the pathways to care and certain clinical and sociodemographic characteristics of the patients	Quantitative	Cross-sectional	Not reported	138	Questionnaire and interviews	Descriptive and inferential statistics
Nartey et al.(36)	To explore factors influencing treatment pathways to mental health services among consumers in Ghana.	Quantitative	Cross-sectional	Multistage (cluster and systematic)	542	Questionnaire	Descriptive and inferential statistics
Odinka et al.(38)	To determine the socio-demographic profile of patients with schizophrenia assessing care at a tertiary psychiatric centre, their first points of treatment, and the association of these factors with treatment delay	Quantitative	Cross-sectional	Not reported	360	Questionnaire and interviews	Descriptive and inferential statistics

Table 3: Characteristics of included studies

Figure 3: Distribution of included studies by country

Table 5

Pre-defined themes presented with subthemes derived from the literature
Patient-level factors	Primary healthcare facility-level factors	Other factors
• Perceptions of care o Perceived causes of mental illness o Knowledge of mental health services o Confidence and expectations • Care-seeking behaviour o Social support o Nature and severity of symptoms o Fear of negative consequences • Healthcare reaching o Travel distance o Transportation costs • Healthcare payment o Treatment costs o Family support o Viability of alternative • Healthcare engagement o Perceived symptomatic improvement o Treatment side effects o Treatment privacy o Family support o Experience of services o Self-help groups	• Approachability o Access to information o Awareness creation • Acceptability o Attitudes of health workers o Experience of services • Availability and accommodation o Geographic distribution o Waiting times and processes o Resource capacity • Affordability o Treatment costs o Opportunity costs o Shortage of funds • Appropriateness o Staff adequacy o Staff skill capacity o Working conditions o Supervision, guidance, and regulation o Adequacy of medications and resources o Stakeholder collaboration	• Social norms o Stigmatization o Social condemnation o Maltreatment, discrimination and isolation • Cultural beliefs o Conceptualization of mental illness o Perceived causes o Perceived efficacy • Traditions o Customary approach • Socioeconomic status o Employment status o Educational status

Patient-level factors

Perceptions of care

Ten papers talked about perceptions of care (5,8,9,18,19,26–30). In West Africa, perceptions about the nature, causes, and appropriate treatment of mental illnesses influence access to primary care. The tendency for people to attribute mental illnesses to spiritual causes (9,28,30) and to conceptualize mental illnesses as those characterized by overt disruptions in behaviour results in delays in seeking healthcare (5,9). Insufficient knowledge of mental health and available services also hinders access (18,26,29). However, familiarity with the services available serves as a facilitator to accessing primary care (29). Furthermore, a lack of confidence in the efficacy of treatment and the perception that mental illnesses are untreatable, serve as barriers (8,18,19).

Care-seeking behaviour

Six papers reported on care-seeking behaviour (8,28,30–33). Seeking primary care for mental illnesses is influenced by social support, the nature and severity of symptoms, and the fear of negative consequences. The decision to seek treatment is seen as the responsibility of the family (30). Consequently, contact with family and friends could serve as a barrier or enabler to access depending on the support system’s decision (32). Also, people with less clear symptoms are less likely to seek primary care; they usually prefer alternative medicine (28,33). For persons with substance use disorder, barriers to access include fear of police arrest, partner disapproval, and lack of trust in health workers (8).

Healthcare reaching

Four papers talked about health-reaching (5,17,29,34). The two influencing factors here are travel distances and transportation costs. Unfortunately, most service users must travel long distances to access mental health care (35). However, people who live close to facilities do not face this barrier (29). A closely related barrier is the high transportation cost to primary care facilities (6,18,42). One study in Liberia reports that bicycle parking fees increase this cost burden at care centers (5).

Healthcare payment

Eight studies had information on healthcare payment (5,8,9,17,29,31,35,36). The subthemes derived from the literature include financial constraints, the viability of alternatives, and family support. Service users are financially constrained and unable to afford services (8,17,29,31,35,36). This is compounded by the expectation that the treatment is lifelong, making it economically unfeasible. However, where hospital treatment is free or alternative medicine is more costly, service users resort to formal mental health care (5). Furthermore, payment for mental services is usually the responsibility of family and social networks. If they face financial difficulties, their mentally ill relative may not be able to receive care (9,36).

Healthcare engagement

Eight papers talked about healthcare engagement (9,10,12,17,18,28,29,37). The ability of service users to engage mental health services is influenced by symptomatic relief, unpleasant side effects, previous experiences of primary care, treatment privacy, family support, and self-help groups. When service users experience relief of symptoms, they do not see the reason to continue treatment (37). Also, some service users commonly complain of unpleasant side effects of antipsychotic drugs which make them weak and unable to work (29). Furthermore, patients and caregivers who have had previous undesirable experiences at mental health care facilities are discouraged from continuing care (9). Additionally, caregivers need assurance of privacy to feel free to discuss their relative’s mental health issues with professionals (28). As is the case for earlier phases of the help-seeking journey, family support greatly influences the ability to engage available services (9,29). A notable facilitator of access is the presence of self-help groups reported in a study in Ghana. These groups improve treatment adherence (10).

Primary healthcare facility-level factors

Approachability

Six studies reported on the approachability of services (8–10,28,33,35). The approachability of mental health services depends on the dissemination of information on the location of facilities and awareness creation by health workers about the availability of such services. People with higher access to this information are more likely to seek help for their condition (28), while a lack of it hinders access (8,35). On the other hand, educational campaigns and awareness creation programmes such as “mad pride marches” (38) and self-help groups (10) are enablers of mental health care access.

Acceptability

Five papers talked about the acceptability of care (5,8,10,39,40). Attitudes of health workers and experiences of formal mental health services influence access to primary care. Studies report that negative attitudes of health workers include stigmatizing and passing derogatory comments, calling clients undesirable names, and despising them (5,8). However, a study in Sierra Leone (39) reveals that health worker passion drives access to mental health care. Moreover, service users who have had positive experiences in the hands of these health workers are encouraged to seek help when needed (10).

Availability and accommodation

Thirteen papers talked about availability and accommodation (5,17,19,26–28,30,31,35–37,39,41). Our review found that geographic location, waiting times and processes, and resource capacity of health facilities affect access to mental health care. Mental health facilities are sparsely distributed and mostly confined to urban areas (17,26,30,35). The available facilities therefore serve large catchment areas, making them inaccessible to those who live far off (5,31,39,42). Moreover, service users and caregivers complain of long waiting times and complex procedures at the primary care facilities, discouraging them from seeking care (35,37). Besides, these facilities are bedeviled with resource challenges such as intermittent power supply and inadequate infrastructure (19,27).

Affordability

Seven papers discussed affordability (8,15,17,19,30,35,38). In West Africa, treatment costs, opportunity costs, and availability of facility funds influence the affordability of mental health care. The high cost of treatment hinders people from accessing mental health care (15,19,30). One study in Sierra Leone reported that sometimes, service providers assist with payments out of their pocket (19). Also, health facilities sometimes spend most of their funds on patients’ basic needs, leaving almost nothing for their treatment (38). In addition, service users and caregivers tend to lose time, money, and effort they feel they could have spent on profit-making activities. This discourages them from seeking formal healthcare (8,17,35).

Appropriateness

Thirteen papers reported data on the appropriateness of care (5,8,12,15,19,27–29,35,37–39,42). The subthemes include staff adequacy; staff skill capacity; adequacy of medications and resources; working conditions; supervision, guidance, and regulation; and stakeholder collaboration. In addition to the lack of facilities that provide mental health care, there are not enough mental health professionals (5,27,35,37). In countries like the Gambia, this is worsened by frequent strike actions by health professionals (15). Moreover, some studies report that the available mental health professionals lack sufficient training which is a major barrier to care (38,42). To mitigate these issues, basic mental health training for primary health care workers in the Gambia and task-shifting in some areas of Ghana ease access, despite implementation challenges (12,15). Also, although health workers are willing (27), they are discouraged by poor working conditions like low remuneration, stigmatization of their profession, and a lack of risk protection policies (19,27,39). Furthermore, there are frequent medication shortages (12,15,27,29,39) and inadequate supervision of mental health professionals (12,19). A study in Ghana reported low stakeholder interest in task-shifting policies (12), but in Sierra Leone, stakeholder partnerships have fostered decentralized mental healthcare (39).

Contextual factors

Social norms

Nine papers discussed how social norms may hinder access to mental health care (5,9,15,19,27,28,35,40,42). Social norms such as stigmatization, social condemnation, maltreatment, discrimination, and isolation hinder access to mental health care. Stigma, which is a major barrier across West Africa (15,42), is deeply rooted in the negative societal conceptualization of mental illness (28,35), and is seen in the use of local stigmatizing idioms such as “crazy” (9,27) and avoidance of patients and their families (5,19). Aside from this, not only do people believe mentally ill people should be isolated (40), but some are maltreated by being chained, beaten, or denied jobs (27). Also, the social condemnation associated with seeking primary care for mental illness, and the tendency for society to arbitrarily link mental disorders to substance abuse and moral decadence deter help-seeking (9,28).

Cultural beliefs

Ten papers talked about cultural beliefs (5,15,19,27–31,36,39). Cultural conceptualization of mental illness and beliefs about its causes and treatment influence access to the required care. Culturally derived categorization of illnesses into ‘bodily’ and ‘spiritual’ ones hinder access since mental illnesses are considered spiritual (29). Illnesses such as Schizophrenia are considered ‘strange’ (28), thereby encouraging people to seek care from informal sectors (15). Beliefs that attribute mental illnesses to witchcraft, bad wind, and evil spirits also serve as barriers (5,19,27,30,31,36,39). In effect, these beliefs propose that biomedical treatment is usually ineffective for mental illnesses (30,31). In Ghana, the Twi word for healing is “ayaresa” which literally means to “stop” or “cut off” pain or illness, a concept that might not always agree with biomedical treatment approaches (29).

Traditions

Only one study talked about the role of traditions in hindering access to mental health care services (9). This study in Burkina Faso by Pigeon-Gagné et al. (9), revealed that it is customary for mental illnesses to be treated by traditional healers. In keeping with ancestry practices, traditional medicine may include mixtures of herbs, certain rituals, and communication between healers and ancestors. Despite the emphasis on its effectiveness, many patients who use the traditional approach eventually end up in formal mental health facilities (9).

Socioeconomic status

Five papers talked about the role of socioeconomic status in accessing mental health care (7,36,41,43,44). The factors under this theme include employment status, educational level, and marital status. Skilled employment, self-employment, and working in the health profession enhance access to formal mental health care (36,43,44), but unemployment hinders access to care (43). Furthermore, people with higher education are more likely to access mental health care as compared to less educated people (7,41,44). Moreover, one study in Ghana reported that people with higher education participate more actively in shared treatment plans (7).

This review of factors influencing primary care access for common mental health conditions among adults in West Africa found evidence that people with common mental health conditions in West Africa experience difficulties in accessing primary care for their conditions. There is no previous similar review for West Africa.

Our findings are largely consistent with a similar review in Southeast Asia (45) and another in Australia (46). Similar to our review findings, Andary et al (45) reported that in Southeast Asia facilitators of access to primary care for mental health conditions include self-awareness, resources and information about mental health services, affordability, and accessibility. Furthermore, Kavanagh et al (46) found enablers that include patient-centered care, use of technology, easy accessibility, mental health literacy, and culturally sensitive practice. These represent milestones in mental health care that we can strive to achieve in West Africa. Also, a study on immigrant students in high-income countries (47) highlighted the advantages of mental health literacy, cultural adaptation, and female gender. These are likely to be enablers specific to immigrants in high-income countries.

Our review findings can provide guidance for developing interventions and policies to address the challenges of mental health care access in West Africa. It reveals that solving access problems should consider the entire spectrum of the health-seeking journey, paying attention to both the patient (service-user) and primary healthcare facility (provider) ends. Also, the appropriateness of mental health services and the ability of service users to engage primary care services have to be emphasized as reports of these dominated our findings. Although the preceding phases of access to mental health care are important, there appears to be a greater deficit in these two domains. Furthermore, mental health care access interventions should fit the West African context, addressing barriers existing in social norms, traditions, and cultural beliefs. To respond to our findings, any interventions to improve access to primary mental health care in West Africa need to be multi-faceted addressing individual, health facility and system, and contextual drivers of access.

Our review has a few strengths. Notably, this is the first review that has scoped the literature available on the factors that influence access to primary care for common mental health conditions in West Africa. Also, the data was obtained from many sources including people with mental health conditions, their caregivers, general and mental healthcare professionals, health administrators, alternative healthcare providers, academics, and the general public. This provides important insights from multiple perspectives. Furthermore, including English and French studies prevented missing important papers based on language. Using a comprehensive framework helped us to analyze the relevant factors from the studies using appropriate themes and sub-themes. Also, the review included papers from different literature sources, providing a depth of themes and insights that would not be possible from single studies.

However, considering that most of the studies were from two countries – Ghana and Nigeria – issues unique to other countries are still to be known. Other studies have also found that publications from these two countries are much more than other West African countries, especially francophone West Africa (48). Therefore, there is a need for conscious efforts by governments and institutions to increase research output in the rest of West Africa. Also, only a few studies included vulnerable groups and civil society organizations, underscoring an opportunity for future research. Finally, since the primary data from each study was inaccessible, the review relied on the reports from the authors of the included studies.

The factors influencing access to primary care for common mental health conditions in West Africa include patient-level factors, primary healthcare facility-level factors, and contextual factors that affect primary care. The various domains of access are interrelated, act at various points of the care-seeking pathway, and are significantly shaped by social norms, cultural beliefs, traditions, and the socioeconomic status of individuals. Interventions to improve access to primary care for common mental health conditions in West Africa should target multiple levels of influence and the sociocultural context.

LMIC: Low- or middle-income country

PCCS: Participants, concept, context, and type of study

PRISMA: Preferred reporting items for systematic reviews and meta-analyses

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Availability of data and materials

The datasets generated during the current study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This work received funding from the NIHR (National Institute for Health Research) Global Health Research Center project: Research and Institutional Capacity Strengthening in NCDs. Grant number NIHR203246 – Global Health Research Centre on Strengthening of Capacity for NCD control in West Africa (Stop-NCD).

Authors' contributions

IAA, TM, SO, EA, AM, and NYAB contributed to the conceptualization and design of the study. VR, RNBA, EPKB, KNAAA, MPA, and NYAB screened the titles and abstracts, reviewed full-text articles, agreed on the final selection of included papers, and extracted relevant data from the papers. VR and NYAB analyzed the extracted data. NYAB drafted the manuscript. All authors read, edited, and approved the final manuscript.

Acknowledgments

We acknowledge the contributions of the Ghana College of Physicians and Surgeons, Ashesi University, the London School of Hygiene and Tropical Medicine team, and all members of the STOP NCD project. We also thank the NIHR for its financial support.

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Table 4 is available in the Supplementary Files section.

No competing interests reported.

Table4.docx

Factors influencing primary care access for common mental health conditions among adults in West Africa: A scoping review

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Background

Methods

Inclusion criteria

Exclusion criteria

Results

Perceptions of care

Care-seeking behaviour

Healthcare reaching

Healthcare payment

Healthcare engagement

Approachability

Acceptability

Availability and accommodation

Affordability

Appropriateness

Social norms

Cultural beliefs

Traditions

Socioeconomic status

Discussion

Conclusion

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors' contributions

Acknowledgments

References

Table 4

Additional Declarations

Supplementary Files

Status:

Version 1