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Table 3 Barriers to mental health service implementation reported across stakeholder levels

From: Stakeholder perspectives on integration of mental health services into primary care: a mixed methods study in Northern Iraq

(n = 62)
(n = 26)
(n = 40)
(n = 12)
(N = 140)
Cultural barriers
StigmaI 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)
Beliefs, traditionsAs 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)
Predominance of traditional medicinePeople 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)
Lack of organizational resources
Center is too crowded, small spaceCrowdedness of the place is an obstacle (C)
Work condition in such a small hospital is very difficult (D)
Lack of designated/private placeBecause of lack of place we would go to the courtyard (C)
Lack of private place is a problem (S)
Lack of equipment/infrastructureWe have no access to computers to record files for patients (P)
Psychotherapists do not have methods of communication with patients (S)
Center lacks financial resourcesLack of required budget (P)
Financial obstacles is the most important (D)
Poor reputation of centerPeople have bad opinion and do not think it is good (C)
They have little treatment and the doctors are not smart (C)
Environmental challenges
Distance to facilityThe place is far for patient to access (P)
Most of the patients are poor and they cannot afford to come from far (S)
Staffing issues
Too few staff/lack of timeWe 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)
Lack of therapists of same gender for clientsSometimes patients [are] embarrassed talking to female therapist (P)
I was shy to talk about everything to my CMHW because he was a male (C)
Lack of specialistsShortage of psychotherapist makes problem (P)
Lack of specialized psychiatrist is problem (S)
Lack of skilled or adequately trained staffLack of trained staff (P)
This psychotherapist has received only 10 days training it is too early to become a psychotherapist (S)
Program characteristics
Length of programDuration of sessions is long (P)
If allocated time is too long, it will make patients bored and it is less appropriate (S)
Low client adherence, drop-outPatients 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)
Inappropriate for context/needsThe 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)
No drugsPeople 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)
Program is new, untrustedIt is new, therefore some people do not trust it (P)
Not trusting psychotherapist by the people, make[s] problem (S)
Dislike memory recall/talk therapyThe treatment is talk and I forget talk (what is said) (C)
I do not like the painful memories of this program (C)
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)
Financial difficultiesFrom 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)
Work interferenceMy 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)
Childcare issuesMy 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)
Home dutiesAnd 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)
Low mental health literacy
Public unaware of serviceIt is a hidden thing, nobody knows this treatment is available (C)
Lack of people[s] awareness to apply the programme is a problem (S)
Low educationLack 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)
Lack of support for the program
Potential lack of external supportIf international cooperation stops, it will be less sustainable (P)
If international support stopped it will hard on the government to handle it (S)
Lack of government supportGovernment 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)
Lack of support from colleaguesDoctors do not help us, they do not refer patients (P)
There are no harmony in our works (S)
Lack of organizational support[There is a] lack of supervision (P)
Non-cooperative director is a challenge (S)
Lack of support for clients
Unsupportive familyPatients are not cooperated by their families (P)
Sometimes my man (husband) is an obstacle saying do not go to the hospital (C)
Unsupportive friends/other supportsMy 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)
  1. “–” indicates response was not provided at that stakeholder level