Barriers and Enablers of Retention in Pharmacotherapy among Adult Patients with Mental Illnesses in Kayonza District, Rwanda.

Background:
Mental illnesses total 13% of the global disease burden. Effectively managing mental illnesses requires comprehensive treatment strategies that incorporate pharmaceutical, psychological, and social therapies. Patient retention in pharmacotherapy is one of the main factors that mental illness treatment outcomes depend on. In Rwanda, barriers and enablers for mental illness patient retention in pharmacotherapy among adults treated for mental illnesses have not been systematically synthesized to inform practice and policy. This study aims to quantitatively and qualitatively describe mental illness retention rates, and the experience of barriers, and enablers for patient retention in pharmacotherapy among adults treated for mental illnesses in Kayonza District in Rwanda. The primary outcome was mental illness patient retention to care defined as the attendance of at least four pharmacotherapy visits that were at least 90 days apart between January 1, 2023, and December 31, 2023.

Methods:
This was an explanatory sequential mixed methods study using the data of 343 adult patients with mental illnesses retrospectively extracted from the Electronic Medical Records (EMR) of the Rwinkwavu District Hospital (RDH) and eight health centers in its catchment area between January 1, 2023, and December 31, 2023. Fifteen purposively selected adults with mental illnesses and five conveniently selected mental health care-providers were qualitatively interviewed to describe patient experiences of potential barriers and enablers with patients’ psychiatric diagnosis as well as describe care-providers’ observations of potential barriers and enablers with patients’ experience of the potential barriers and enablers in Kayonza District between May – July 2024. Descriptive and thematic analysis was employed for quantitative and qualitative analysis respectively.

Results:
The data of 343 adults with mental illness was analyzed quantitatively. There were 197 (57.4%) females and 146 (42.6%) males with a median age of 33 years (IQR=21). Only 67/343 (19.5%) patient with mental illnesses were retain in pharmacotherapy treatment. 35/67 (52.25%) were female, and 32/67 (47.8%) were males. Patients’ age employment, and health facility had significant impact of patient retention (p-value < 0.05) while living with family had a marginal impact on retention in care (p-value 0.060). Key barriers included patients’ lack of understanding about their mental illnesses, patients’ forgetfulness, financial constraints, lack of family support and social stigma, and negative healthcare experiences. Important enablers were MH service quality, regular follow-ups, social support and active MH CHW services.

Conclusion & recommendation:
Barriers such as patients’ lack of understanding about their mental illnesses, patients’ forgetfulness, financial constraints, lack of family support and social stigma, and negative healthcare experiences and enablers such as MH service quality, regular follow-ups, social support and active MH CHW services are pivotal in improving patient retention rates in Kayonza District, Rwanda. We recommend comprehensive patient, family and societal mental health education program; strengthening community-based support systems; investing in rural healthcare facilities, patient-centered care with a focus on positive patient- provider relationships to improve patient and community understanding of mental illnesses and the importance of consistent pharmacotherapy.