Introduction
Methods
Setting
Study participants
Instruments
Quantitative
Qualitative
Data collection procedures
Analysis
Results
Sample description
Client (n = 123a) % | Provider (n = 26) % | Non-MH Staff (n = 40a) % | Director (n = 12) % | |
---|---|---|---|---|
Age; mean (SD) | 30.3 (8.4) | 35.0 (7.1) | 34 (6.8) | 39.7 (7.8) |
Gender | ||||
Men | 28.7 | 42.3 | 60 | 100 |
Women | 71.31 | 57.7 | 40 | 0.0 |
Employment | ||||
Not working | 49.2 | – | – | – |
Irregular/daily work | 12.3 | – | – | – |
Regular/stable work | 30.3 | – | – | – |
Self-employed | 8.2 | – | – | – |
Marital status | ||||
Single | 30.3 | 30.8 | – | – |
Married | 65.6 | 69.2 | – | – |
Divorced | 2.5 | 0.0 | – | – |
Widowed | 1.6 | 0.0 | – | – |
Education | ||||
Secondary | – | 7.7 | – | – |
Institutional degree | – | 34.6 | – | – |
Bachelor’s or higher | – | 57.7 | – | – |
Location | ||||
Erbil | 13.9 | 19.2 | 35.0 | 41.7 |
Sulimaniyah | 77.9 | 65.4 | 42.5 | 33.3 |
Garmyan | 8.2 | 15.4 | 22.5 | 25.0 |
Findings
Domain/item | Client | Provider | Non-MH staff | Director |
---|---|---|---|---|
Autonomy | ||||
Mental health care decisions are made by others in the family | ● | |||
Accessibility | ||||
Service accessibility for most people in the community | ○ | ○ | ○ | |
Service accessibility for the poorest people in the community | ○ | ● | ● | |
Service accessibility for women who need them | ○ | ○ | ● | ○ |
Service accessibility for men who need them | ○ | ○ | ||
There are groups in the community that are unable to access the servicesb | ● | ● | ● | ● |
Acceptability | ||||
Services are a priority for the government | ● | ● | ○ | |
Services are acceptable to the community | ○ | ○ | ○ | |
Your job negatively affects your family life | ○ | |||
Feasibility | ||||
Difficulty attending weekly treatment sessions for 8–12 weeks | ○ | |||
Sufficient access to computer/internet equipment | ● | |||
Sufficient access to private space to meet with clients | ○ | ● | ● | |
Enough counselors to implement step-by-step psychotherapy | ○ | ○ | ||
Enough counselor time to implement step-by-step psychotherapy | ○ | ○ | ||
Sufficient budget to implement step-by-step psychotherapy | ● | ● | ||
Enough other necessary resources (e.g.: support staff, administrative time, transportation money, etc.) | ● | ● | ||
Feasibility of integrating step-by-step psychotherapy into primary health centers | ○ | ○ | ||
Positive organizational structure (not included in client interviews) | ||||
Feeling overworked | ○ | ● | ● | |
Satisfaction with salary | ○ | |||
Enough learning opportunities available | ○ | ○ | ||
Clinic promotes professional growth | ○ | |||
Positive working environment | ○ | |||
Regularly paid on time | ○ | ● | ● |
Examples | Clients (n = 62) N | Providers (n = 26) N | Staff (n = 40) N | Directors (n = 12) N | Total (N = 140) N | |
---|---|---|---|---|---|---|
Cultural barriers | ||||||
Stigma | I am shy, people are very ruthless and make fun of mental illness (C) In our community, whoever suffers from mental illnesses is called crazy (S) | 34 | 12 | 24 | 3 | 73 |
Beliefs, traditions | As long as that old belief circulate among us, we cannot make it feasible (P) Circulated customs, culture and tradition in the society make most challenges for the programme (S) | 11 | 13 | 20 | 8 | 52 |
Predominance of traditional medicine | People believe more in sheik and mullah (C) There are people who believe in religious places to receive treatment and this makes it less acceptable (P) | 9 | 8 | 9 | 2 | 28 |
Lack of organizational resources | ||||||
Center is too crowded, small space | Crowdedness of the place is an obstacle (C) Work condition in such a small hospital is very difficult (D) | 14 | 17 | 22 | 6 | 59 |
Lack of designated/private place | Because of lack of place we would go to the courtyard (C) Lack of private place is a problem (S) | 12 | 18 | 14 | 7 | 50 |
Lack of equipment/infrastructure | We have no access to computers to record files for patients (P) Psychotherapists do not have methods of communication with patients (S) | 4 | 18 | 8 | 3 | 34 |
Center lacks financial resources | Lack of required budget (P) Financial obstacles is the most important (D) | 1 | 8 | 17 | 6 | 32 |
Poor reputation of center | People have bad opinion and do not think it is good (C) They have little treatment and the doctors are not smart (C) | 11 | – | – | – | 11 |
Environmental challenges | ||||||
Distance to facility | The place is far for patient to access (P) Most of the patients are poor and they cannot afford to come from far (S) | 26 | 14 | 26 | 6 | 71 |
Staffing issues | ||||||
Too few staff/lack of time | We do not have sufficient employee for this service (S) Time allocated for seeing patients is short, mentally ill patients need more time (S) The therapist is very tired with patients (D) | 6 | 6 | 19 | 5 | 36 |
Lack of therapists of same gender for clients | Sometimes patients [are] embarrassed talking to female therapist (P) I was shy to talk about everything to my CMHW because he was a male (C) | 8 | 16 | 7 | 3 | 34 |
Lack of specialists | Shortage of psychotherapist makes problem (P) Lack of specialized psychiatrist is problem (S) | 1 | 10 | 12 | 7 | 29 |
Lack of skilled or adequately trained staff | Lack of trained staff (P) This psychotherapist has received only 10 days training it is too early to become a psychotherapist (S) | – | 5 | 7 | 5 | 17 |
Program characteristics | ||||||
Length of program | Duration of sessions is long (P) If allocated time is too long, it will make patients bored and it is less appropriate (S) | 8 | 15 | 14 | 1 | 38 |
Low client adherence, drop-out | Patients are often find[ing] it difficult to continue receiving treatment (P) If patient does not apply recommendation and therapy perfectly, it will not be appropriate (S) | – | 6 | 6 | 4 | 15 |
Inappropriate for context/needs | The religious aspect has not been mentioned in this program, which is the most important thing for treatment (C) This programme cannot be applied in this hospital (D) | 9 | – | – | 2 | 11 |
No drugs | People are used to take drugs which means people are not calm to accept this treatment (S) People mostly believe in drugs than without it (D) | 1 | – | 7 | 1 | 8 |
Program is new, untrusted | It is new, therefore some people do not trust it (P) Not trusting psychotherapist by the people, make[s] problem (S) | – | 4 | 5 | – | 8 |
Dislike memory recall/talk therapy | The treatment is talk and I forget talk (what is said) (C) I do not like the painful memories of this program (C) | 6 | – | – | – | 6 |
Client logistical issues | ||||||
Lack of transportation | [No] provisions [for] transportation methods for patients makes it not continue (P) Transportation for patients is [a] challenge (S) | 13 | 3 | 7 | – | 22 |
Financial difficulties | From financial aspect, some people would like to come but they do not have access to it (C) There are patients who suffer economical problems and may not be able to come for treatment all the time (S) | 5 | 5 | 4 | 1 | 15 |
Work interference | My problem is my work is daily. When I come here I lose it (daily wages) (C) When I ask for leave, I am confronted with many questions that I do not like (C) | 13 | – | – | – | 13 |
Childcare issues | My problem is I have a child and do not know where to take him/her [when at treatment] (C) Because I have children and cannot leave them for a long time, that is my problem (C) | 10 | – | – | – | 10 |
Home duties | And sometimes I was not able to apply the instructions because of domestic daily work (C) Illiterate people can’t apply this program because they miss their home duties (P) | 2 | 4 | 2 | – | 8 |
Low mental health literacy | ||||||
Public unaware of service | It is a hidden thing, nobody knows this treatment is available (C) Lack of people[s] awareness to apply the programme is a problem (S) | 12 | 5 | 19 | 5 | 41 |
Low education | Lack of people’s awareness (education) makes them visit the center with fear (C) [There is a] lack of awareness about mental health problems (P) People[s’] education about mental illnesses is not at required level (D) | 4 | 11 | 6 | 4 | 25 |
Lack of support for the program | ||||||
Potential lack of external support | If international cooperation stops, it will be less sustainable (P) If international support stopped it will hard on the government to handle it (S) | – | 18 | 18 | 1 | 36 |
Lack of government support | Government and concerned authorities do not handle the project as their own (P) The government is not taking this field into consideration, it does not take it seriously (S) | 1 | 6 | 24 | 2 | 34 |
Lack of support from colleagues | Doctors do not help us, they do not refer patients (P) There are no harmony in our works (S) | – | 4 | 15 | – | 20 |
Lack of organizational support | [There is a] lack of supervision (P) Non-cooperative director is a challenge (S) | – | 4 | 2 | 1 | 8 |
Lack of support for clients | ||||||
Unsupportive family | Patients are not cooperated by their families (P) Sometimes my man (husband) is an obstacle saying do not go to the hospital (C) | 27 | 9 | 16 | 4 | 56 |
Unsupportive friends/other supports | My friends say this treatment is ‘not serious’ (C) I was afraid my friends would look at me with a bad eye (think I am doing something bad) (C) | 20 | – | – | 9 | 20 |
Examples | Clients (n = 62) N | Providers (n = 26) N | Staff (n = 40) N | Directors (n = 12) N | Total (N = 140) N | |
---|---|---|---|---|---|---|
Positive perceptions of program | ||||||
Program is good/people like it | I believe it is the best psychotherapy (P) People talk good about this therapy (C) | 58 | 26 | 40 | 11 | 137 |
Program is acceptable/agrees with values | This therapy suits my values, otherwise I could not come (C) It is accepted by [when] explaining the treatment (P) | 51 | 26 | 33 | 6 | 116 |
Program is suitable/appropriate | It suits my needs (C) This treatment is suitable and blessed (D) | 47 | 26 | 29 | 11 | 113 |
Program is feasible | It is feasible and requires no changes (P) It is feasible with the current capacities (D) | – | 18 | 27 | 10 | 55 |
Program is accessible/is for everyone | Everyone and [every] section of the community can have access to it (C) | 7 | – | – | – | 7 |
Program impacts | ||||||
Is useful/effective | I had the feeling that I was getting better session after session (C) We were able to treat most of our patients’ problems (P) Patients get rid of psychological stress and it is useful for the community (D) The good thing is that patients recover to enjoy better normal health status (S) | 58 | 18 | 24 | 5 | 106 |
Increased knowledge/MH literacy | I learned from it that not only I am ill (C) People’s awareness about mental health sicknesses increased (D) | 9 | – | 15 | 4 | 28 |
No harmful impact | It does not have any bad effect for me (C) | 27 | – | – | – | 27 |
Empowers clients | It enables patients to depend upon oneself (P) It teaches people better know their problems and have them solved by themselves (S) I have learned a lot from this treatment that I can control my mental issues (C) | 14 | 5 | 2 | – | 21 |
Prevents suicide | Previously I had suicide idea but now it is no longer in my mind (C) This treatment helps decrease the level of suicide and self-burning (P) | 9 | 1 | 5 | – | 15 |
Gives security, comfort | I had the feeling that I become comfortable when I come here (C) I felt secure (C) | 15 | – | – | – | 15 |
Gives hope | I have regained hope for life (C) This mental health section gave hope to people, influenced them and people took benefit (S) | 5 | – | 3 | – | 8 |
Program attributes | ||||||
Free of drugs | My problem was solved without taking a single pill (C) This treatment is better and more effective than drugs (S) | 34 | 9 | 18 | 5 | 66 |
No cost | The treatment was free of charge (C) If treatment is free of charge, poor people will take benefit from the program (S) | 29 | 13 | 14 | 4 | 60 |
Talk-based treatment | I could talk out what was in my heart (C) I needed someone to listen to me (C) | 36 | – | – | – | 35 |
Simple/easy to follow | The home exercises made it easy (C) We feel the programme is not difficult, patients can apply there, therefore, it is feasible (P) | 16 | 3 | 4 | – | 22 |
Flexible scheduling | They set the appointment according to my time (C) | 16 | – | – | – | 15 |
Protects confidentiality | There was no name recording (C) Patients’ private data kept confidential by us (S) | 12 | 1 | 2 | 1 | 15 |
Providers receive training | We received good trainings (P) In the university, I did not know anything, but here I learned (P) | – | 13 | – | – | 13 |
Step-by-step/session-based | Weekly you sit with a CMHW for an hour or two; possibly you could not do so with someone else (C) This program is step-by-step that is why it will have effect on the patient (C) | 7 | – | – | – | 7 |
Provider attributes | ||||||
Caring/respectful | There is someone who listens to you and trusts your decisions (C) We are always ready for any patient without difference (P) In this treatment, patients are respected and listened to (S) | 54 | 6 | 12 | – | 73 |
Providers are capable/specialized | The CHHW was there ready at the exact time (C) There are capable psychotherapists (D) | 13 | 8 | 11 | 3 | 35 |
Eager/motivated providers | As a psychotherapist, I continue and never quit (P) Staff eagerness and loyalty for the work (D) | – | 10 | – | 3 | 13 |
Service environment | ||||||
Good facilities (large, quiet, clean) | The place was quiet (C) Our building is new and large (D) | 35 | 7 | 17 | 3 | 62 |
Center has good reputation | The say good things about the reputation of the health center (C) The structure of the program is robust (C) | 41 | – | – | – | 41 |
Separate space/MH section | There is a private place where I can talk (C) I have my own room (P) | 10 | 4 | – | 3 | 18 |
Coffee/tea provided | They bring us water, tea and sweets (C) | 12 | – | – | – | 13 |
Conveniently located | The place was very near for me (C) In terms of location, our hospital is suitably located (P) | 8 | 1 | 1 | – | 10 |
Positive work environment | ||||||
Good cooperation among staff | They show readiness for giving their places whenever there is patients or when I ask them (P) Staff are very cooperative to the programme (S) Employees enjoy a good cooperation between them (D) | – | 25 | 37 | 12 | 74 |
Supportive leadership | Supervision is at a very good level (S) The director facilitating a lot of things for us (P) | 1 | 15 | 28 | 4 | 48 |
Client attributes | ||||||
Supportive friends/family | My mother told me many times to use this treatment to get better and this made me continue (C) My friends were happy that I came here (C) | 53 | – | – | – | 53 |
Autonomy for treatment decisions | I come to this treatment based on my decision (C) | 50 | – | – | – | 50 |
Able to arrange work/schedule | I arrange my work ahead of time (C) In my job, they give me permission [to leave] anytime I want (C) | 21 | – | – | – | 21 |
Trust for the program/CMHW | The CMHW can be trusted so you talk about your problem with them (C) Patients tell psychotherapists their stories because they trust them (S) | 10 | 4 | 5 | – | 20 |
Motivation/recognized need | I needed this treatment very much (C) I wanted to get rid of my problem (C) | 19 | – | – | – | 20 |
Sufficient time available | I have time to come here (C) | 12 | – | – | – | 13 |
Childcare available | I take my children to my neighbors (C) | 11 | – | – | – | 11 |
Adequate program resources | ||||||
Financial/material support for clients and program | Paying the transport cost made it easy (C) Help from ‘material’ (Financial) aspect (C) | 12 | 1 | 4 | – | 17 |
Provision of incomes for staff | Provision of incomes make it suitable to continue (S) | – | – | 13 | – | 13 |
Adequate staffing/staff time | I allocate much time for patients (P) In the past, we suffered lack of doctors and social workers but now we have psychotherapist (S) | – | 6 | 3 | – | 8 |
Examples | Clients (n = 62) N | Providers (n = 26) N | Staff (n = 40) N | Directors (n = 12) N | Total (N = 140) N | |
---|---|---|---|---|---|---|
Change/improve facilities | ||||||
Designated space for services | A private place should be allocated for mental health sections (S) A special (private) place be allocated for the CMHW (C) | 16 | 13 | 33 | 9 | 71 |
Larger center | A larger mental health hospital should be available (P) We need a large hospital to be built for us (D) | 6 | 5 | 3 | 2 | 15 |
Beautify facilities | The place [should] be in a garden surrounded by green areas (C) A library to be available in the center (C) | 5 | – | 1 | – | 6 |
Staffing changes | ||||||
Increased specialist/trained staff | More expert psychotherapist and staff should be employed (S) Provision of smart and trained psychotherapist (D) | 9 | 16 | 25 | 3 | 53 |
Increase staff numbers | More staff should be employed in this centre (S) Provide better number of doctors and staff (D) | 3 | 4 | 21 | 8 | 36 |
Providers of matched gender | Both gender staff should be available in mental health section (S) More CMHW be available of both genders (C) | 6 | 8 | 11 | 4 | 29 |
Protected time for providing services | No other jobs imposed on psychotherapists but the service only (P) Staff should carry out only this task in the hospital, not do any other tasks (S) | – | 6 | 3 | – | 8 |
Raise awareness | ||||||
Mental health literacy | Media methods like TV, radio and newspapers should play their role on circulating awareness on mental health and this programme as well (P) To publicize more information about mental illnesses (D) | – | 19 | 29 | 10 | 57 |
Educate about program | This treatment become known through media (C) This service should be introduced through media methods, symposiums and seminars (S) | 9 | 14 | 8 | 2 | 34 |
Increase support for program | ||||||
Increase government support | Government and concerned authorities should take mental health more seriously (P) The government have to have a special plan for paying more attention to this program (C) | 3 | 23 | 29 | 6 | 62 |
Financial/material support | Government and ministry to provide financial and moral support (P) If the government provide transportation means it will make the programme continue (S) | – | 13 | 24 | 5 | 42 |
Formal recognition/integration | Government should recognize it formally (P) This programme to be included within ministry structure (D) | – | 13 | 17 | 5 | 35 |
Expand services | ||||||
To all regions/centers | Now it is only available in one area I wish it was available in districts and sub-districts (C) More centres should be established for those who live far away (S) | 19 | 6 | 17 | 1 | 43 |
Mobile teams | A mobile team to be available to visit remote areas (P) Mobile psychotherapist teams should visit patients in their homes (S) | 2 | 3 | 13 | 3 | 21 |
Embed in schools/offices | Psychotherapist to be employed in schools (P) If they put CMHW in the schools it would make it easy (C) | 1 | 1 | 3 | 1 | 6 |
Program changes | ||||||
Involve family | Family of patient should be talked with to support and cooperate the patient (S) If possible, patients’ families to participate in this treatment (P) | – | 5 | 5 | – | 10 |
Adapt for illiterate clients | It is better to make a CD version for illiterate people (C) I prefer that the program use colors for illiterate people; for example, for something bad use a black color (C) | 9 | – | – | – | 8 |
Treat patients carefully/with respect | Patients should be treated with respect (S) | – | – | 8 | 1 | 8 |
Decrease sessions/time | Lessening the sessions (P) The sessions be reduced because it is difficult that the patient comes every week (C) | 5 | 2 | 1 | – | 8 |
Encourage client adherence | It should be clear for the patient that the programme takes long time (S) In the beginning the programme should be explained for the patient (S) | – | – | 6 | – | 6 |
Financial supports | ||||||
Allocate budget/resources for program | Budgets should be allocated for the programme (S) Money, staff, place, required equipment and transportation methods make continuity (D) | – | 19 | 20 | 7 | 46 |
Accommodations for staff | Transportation and communication methods should provide for psychotherapists (S) | – | – | 9 | – | 8 |
Financial support | Attempt to provide financial facilitation for patients (P) Financial support should be provided for patients (S) | 4 | 6 | 5 | 4 | 20 |
Transportation support | Provide transportation fees for patients (P) It is necessary that means of transport be arranged for patients (C) | 5 | 5 | 8 | 1 | 20 |
Training | ||||||
Provide trainings on the intervention | CETA to be inserted into college studies (P) More training courses should be arranged for the staff (S) | 3 | 14 | 13 | 2 | 32 |