Community Health Workers' Perceptions of Depression and of Barriers and Facilitators in Mental Health Care in Sierra Leone: A Qualitative Study

AIMS: Sierra Leone has a 98% mental health treatment gap. This has been attributed to lack of resources and attitudinal/cultural barriers. Community health workers (CHWs) are the backbone of healthcare delivery in the country, constituting 1,500 of the general health workforce. The government has trained CHWs to improve mental health care. However, evidence have shown that this training is inadequate, leading to poor mental health literacy among CHWs. Sierra Leonean CHWs' perceptions of mental health and experiences of mental healthcare delivery have not been investigated. Therefore, this study aims to assess CHWs' knowledge regarding depression and suicidality, as well as their perceptions of barriers to, and facilitators of, mental health care in Sierra Leone. METHODS: Purposive sampling and snowballing were used in this qualitative descriptive study (N = 10) to recruit CHWs in Kono and Freetown, Sierra Leone. Participants were interviewed remotely using Zoom. A short vignette on depression and suicidality was employed, together with remote semi-structured interviews exploring mental health literacy, perceptions of mental health care, and experiences in providing care during COVID-19. Thematic analysis was utilized. RESULTS: Five themes and 10 subthemes were derived from the thematic analysis. More than two-thirds of the participants viewed the problem as 'depression', while none mentioned suicidal ideation. Life events were the most commonly identified causes of depression, with no mention of spiritual, supernatural or biological attribution as possible causes. The inductively coded themes include the need for change; barriers to mental health care; accessing care; and COVID-19-related mental health care challenges. All participants agree that seeking counselling or speaking with a mental health expert is preferred. Stigma, prejudice, misconceptions, religious and traditional beliefs and insufficient government support were perceived as key impediments to care. Community health workers' experiences during COVID-19 were mixed. Awareness campaigns, training, establishing mental health policies, and integrating mental health into communities were identified as facilitators of mental health care. CONCLUSION: The findings have shown that developing and implementing a comprehensive multi-agency approach is fundamental in dealing with mental health problems in Sierra Leone. In addition, future larger-scale research should be conducted on the underlying cultural principles and traditions regarding mental illness and the status of mental health care provision in Sierra Leone.