A mixed methods study to understand the knowledge, facilitators and barriers to practice of mental health facilitators trained in 2020 in Lira and Kampala, Uganda

Abstract
Background: It is estimated that approximately 35% of all Ugandans have a mental illness, with
at least 15% requiring treatment. However, 90% of those requiring treatment do not receive it.
Under-investment in mental health has resulted in limited availability of providers and services,
as well as increased stigma among the population. The Mental Health Facilitator program trains
non-specialists to identify mental health conditions, assess and make appropriate referrals. This
study aims to understand the knowledge, facilitators, and barriers to practice of MHFs trained in
Uganda.
Methods: Utilizing a cross-sectional convergent merged mixed methods study design, we
assessed the knowledge, facilitators, and barriers to practice of MHFs trained in 2020 in Lira and
Kampala, Uganda. Knowledge was assessed using the NBCC MHF standard curriculum evaluation
test. A structured questionnaire was developed to identify practice levels, and a semi-structured
focus group discussion and in-depth interview guide was used to determine the facilitators and
barriers to MHF practice. The MHFs were matched to untrained community members who were
purposively selected according to matching MHF demographics (i.e., gender, age, education level
and location), at a ratio of 1 MHF: 2 untrained community members.
Results: The study had a total of 64 participants, 22 MHFs and 42 community members. There
was a significant association between knowledge levels and participant type (P= .003), location
(P= .009) and occupation (P= <.001). MHF practice was associated with the MHFs age and the
median number of cases they assessed (P= .027) and referred (P= .034). Furthermore, a
statistically significant association was found between an MHFs location and the median number
of cases they identified (P= .017), assessed (P= .044) and referred (P-= .017). Qualitatively, four
themes were identified as facilitators and barriers to practice of MHFs in Lira and Kampala,
Uganda. These are the contextual environment, interpersonal skills, and personal attributes of
MHFs, community attributes and perceptions, and resource and support systems affect MHFs
practice.
Conclusion & Recommendations: MHFs trained in 2020 in Lira and Kampala were found to have
more knowledge on mental health and facilitation than untrained community members. In
addition, knowledge from the training is sufficiently retained after one year. Still, knowledge was
not a determinant of practice as this was influenced by other factors such as; the mental health
burden within the MHFs practice setting, MHF lived experiences and their medical and mental
health related backgrounds. The MHF program is suitably implemented in high mental health
burden rural settings, where access to alternative mental health care is limited, with established
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collaboration between facility and community based MHFs, available resources and local support
systems