We report a study that, as far as we have been able to establish through global literature, is the first qualitative study from a LMIC to report the following all happening concurrently in one study: (1) personal perceptions as captured by narratives of patients and different types of community based non-mental health specialties; (2) the stakeholders working collaboratively and as a team in a community based setting; (3) using the mhGAP-IG as a common tool for all of them; (4) using concerted effort to build collectively owned human resource for mental health and (5) maximizing existing community owned human and financial resources for mental health. This study is not about the outcomes or efficacy of the mhGAP-IG by different health providers—we have already reported these in several quantitative studies and summarized them in the introduction [18,19,20, 26]. Instead, this was on how the application of the mhGAP-IG, using the TEAM model, had personally touched the lives of the patients and on the experiences of the service providers, expressed through verbatim personal narratives. We attach significance to our findings in that personal narratives reflect lived life experiences which are more powerful in the minds of users and service providers than statements of quantitative outcomes without personal touch or relevance. Perceptions can make or break stigma, one of the most important barriers to mental health uptake and one of the main causes of mental health treatment gap as pointed out by WHO [27] and also in some of Kenyan studies [28, 29].
This qualitative study focused on how service users and service providers perceived TEAM and how these corroborated earlier published qualitative outcomes of TEAM. Although we found positive perceptions and corroborations of the findings on the quantitative phase of TEAM, all of these are subject to caveats that place the TEAM model in both theoretical and practical contexts. As pointed out by WHO [10, 30], different contexts vary in terms of culture, practice, policy, human and financial resources that have a bearing on an appropriate health system model. This means different contexts will need to develop their own models or improve on those that they already have. Alternatively they can adopt other models that have been successfully piloted in different but contextually similar settings. Results from different contexts may not be applicable in another given context. In the case for Kenya, we developed the TEAM as an inclusive model of as many stakeholders and players that are already in existence and available.
The TEAM pilot model takes cognizance of the reality of minimal public resources for mental illness [31]. Therefore TEAM sought to maximize the use of the already available financial and human resources in the development of a mental health system. To achieve this, we sought to dovetail in a health system that has both informal (THs, FHs, CHWs) and the formal (nurses and clinical officers) systems. But it is a system that still largely excludes mental health as an ongoing concern, despite the fact that FHs and THs are still extensively consulted out of choice by patients, including those with mental disorders [32].
The TEAM model also borrows from WHO which recognizes and recommends a multi-stakeholder approach to mental health system development that includes both formal and informal systems. This is aptly captured by the WHO Mental Health Action Plan (2013–2020) when talking about multi-stakeholder approach to mental health: “….Greater collaboration with “informal” mental health care providers, including families, as well as religious leaders, faith healers, traditional healers……, is also needed” [30]. If TEAM as pilot model is successful, it could be adopted and piloted in other contexts. With the above caveats, we can now discuss our findings.
That the patients presented with a combination of physical conditions and mental disorders as illustrated by depression and high blood pressure suggests the need to integrate physical and mental health management even at primary health care as was the case in this study. The application of counseling (in this case mhGAP-IG based), not only led to perceived clinical improvement on the physical aspect but also the reduction of the doses of the drugs used for the physical conditions (Narratives 1 and 2). We mention depression and high blood pressure just as an example of the well-known co-morbidity of mental disorders and physical conditions [33]. These qualitative narratives also lend support to our quantitative data on TEAM that a combination of psychoeducation and physical treatment was widely applied by the clinicians in the course of TEAM, leading to multiple positive outcomes on disabilities, quality of life and clinical outcomes in the patients with mental disorders [18].
The shift from the traditional perception of mental illnesses as caused by a curse or by a religious cause (Narrative 3) has implications on paradigm shift on perception to the effect that such patients could be managed as medical cases. This kind of cooperation is indeed anticipated by the mhGAP-IG which states: “…Ask the person to let you know if they are seeing a traditional or a faith healer, showing respect for this, but emphasizing the need for being seen at a healthcare facility….” [10].
This is a potentially significant development given that THs and FHs are a first contact in health seeking behavior in Kenya [11], other countries in Africa [8, 9] and indeed many other countries [10]. This is a major step from stigmatization to acceptance of mental illness. It confirms our earlier quantitative findings that our approach had led to significant positive changes in perceived stigmatization amongst patients with mental illness [26]. A combination of service providers with a less stigmatizing attitude to patients with mental disorders, and patients feeling less discriminated has the potential to reduce the treatment gap from its current high level of about 85% in LMICs [10]. That this is feasible has already been urged in yet another quantitative publication arising from TEAM in which we demonstrated that THs, FHs and CHWs had increased referrals of cases of mental illness to the health facilities [18]. A significant development was the breaking of barriers between TH and clinicians in that the TH were able to recognize mental illness and refer to health facilities (Narratives 4, 6, 18, 20). This confirms our earlier findings that THs, FHs, nurses and clinical offices were willing to collaborate and cooperate and also referred patients to health facilities [19].
The overall impact of this concerted effort by key players in service providers in the community to identify and refer patients towards services including services at health facilities has also the potential to reduce the treatment gap [19]. Our approach (TEAM) suggests enhanced community connection that involved patients, the families and the communities (Narratives 7–12). This enhanced relationship and economic participation (Narrative 10–12) particularly at family level, and community acceptance of people with mental illness happened because they could see they (the patients) improved on treatment. This, in the process, reduced stigmatization. These qualitative narratives support the commonly accepted association between mental illness and poverty [34].
All the service providers appreciated the capacity building, which involved training them on the application of the WHO-mhGAP-IG. All of this is captured in Narratives 13–14 and throughout all the narratives on health system related perceptions (Narratives 17–23). As a result of this enhanced capacity they had more job satisfaction (Narrative 15). They also developed motivation for further training in anticipation for more numbers coming forward for treatment (Narrative 16).
There is the possibility that increased turnover of patients seeking for help from service providers who were empowered with skills could lead to overburdening and fatigue in the service providers [19]. Instead and as was found in this study, it led to enhanced job satisfaction and the desire to provide more help (Narrative 15). There was also a positive expectation to see more (Narratives 16, 23). There was the potential to avoid the revolving door phenomena for patients who would keep on coming back for conditions that were not properly diagnosed and managed (Narrative 17). If anything it would lead to a less burden and also a reduction on unnecessary overuse of services.
The training enhanced self confidence in the primary healthcare providers (Narratives 15, 17). This means they were able to reduce the number of referrals to higher level hospitals for the attention of doctors (Narrative 12). The patient who associated referrals to a hospital rather than a community based facility with high costs can be easily understood in the local context. Hospitals are considerable distances from the homes. Going to hospitals takes time and financial resources from family. It takes just about a day to travel from home to hospital (including waiting time) either walking long distances and/or paying for the expensive public or even private transport. This would normally involve at least two people—the patient and another person to accompany the patient to the hospital—that is two people whose economic activities are interfered with. The service providers were positively encouraged by the improvement of their patients. Noteworthy is that this encouragement led the health providers to want to help more people (Narratives 16, 23) as opposed to complaining about over-burdening. It led to increased interest in mental health training in order to meet the increased demand for services (Narrative 16).
TEAM brought about improvement in the health system that now accommodated mental health, to identify, manage and refer them if need be. It brought out the spirit of team work, where several stakeholders complemented one another and therefore it benefited everybody. In particular, the traditional healers clientele grew (Narrative 14), their incomes increased while at the same time, they referred more patients to the healthcare facilities. Therefore cooperation between traditional healers and the formal sector is feasible as was demonstrated in an earlier paper [24]. It does not necessarily reduce the traditional healers’ incomes; rather it could potentiate their incomes. There was enhanced community awareness which in turn contributed to an increase in seeking for treatment across all categories of community based service providers. The narrative (Narratives 17–23) suggest improvement in health systems in which all key players in the service provision were working together, amongst themselves and with the communities. Overall, the referral system was perceived to have been enhanced.