Table 1 Frequencies within challenge domains and related sub-themes

Screening intake

 1. Mistrust of informal health providers

Patients tend to have negative biases towards healers

  1.1 Belief system

Patients’ belief systems are in opposition to those of healers

  1.2 Secondary gain

Patients assume that healers make some form of material gain

  1.3 Mental health credentials

Patients believe healers lack the necessary credentials

  1.4 Suggestions

Informal Health Providers (IHPs) made suggestions as to how to break these biases

 2. Cultural misunderstanding and stigma of mental health

General misunderstandings and often negative associations about mental health

  2.1 Lack of knowledge

No knowledge about mental health

  2.2 Stigma around mental disorders

Negative beliefs about mental illness

  2.3 Social support

Partly because of stigma, families and friends do not support the mentally ill

  2.4 Fear of treatment

Fears about the hospital testing and procedures for mental disorders

  2.5 Suggestions

IHPs provided opportunities that can be used to reduce these negative perceptions

Between screening and treatment

 3. Resource barriers

Lack necessary resources (financial, time, etc.) to travel to hospital for treatment

  3.1 Patient resources

Patients lack funds to pay for public transport to the hospital, or for food (requiring work at time of appointment)

  3.2 IHP resource barriers

IHPs lack resources for themselves and for supporting their patients

  3.3 Suggestions

IHPs suggest ways of dealing with the above barriers

 4. Resistance to treatment

Patients resist treatment in multiple ways (e.g. illness denial, refusal to go to hospital, substance addiction)

  4.1 Suggestions

IHPs identify ways of strengthening the willingness of patient referral for those suffering from mental illnesses

 5. Limitations of the referral system

Lack of recognition on the limit of IHPs’ role in the task-sharing model, resulting in responsibilities outside their role as referrers

  5.1 Suggestions

IHPs emphasized the need for specialized training such as counselling to know how to motivate patients who have lost hope, to seek further treatment without being accompanied by IHPs

During treatment

 6. Treatment infrastructure issues

Many logistical challenges are faced upon arrival to the hospital

  6.1 Procedural issues

Some untrained hospital staff often do not recognize referral forms

  6.2 Drug availability

Drugs are often unavailable at the hospital and patients are forced to purchase elsewhere

  6.3 Limited medical staff

There are often limited medical staff and long queues at the health facilities

  6.4 Suggestions

IHPs suggested how to improve infrastructure issues