Table 2 Barriers and facilitators influencing the implemented training’s expected outcomes
Dimension | Barriers | Facilitators |
|---|---|---|
Structural factors | • PCPs cannot prescribe certain molecules. • Substance use disorders are often managed judicially. • PCPs feel that physical health is valued more than mental health. • Mental health statistics are not taken seriously. • PCPs still use “ancient” mental health tools in practice. • Substance use disorders are stigmatized in Tunisia. • Mental health care within institutions is stigmatized. • There is a lack of continuity in mental health trainings. • There is a lack of obligatory mental health internships after medical school to further develop professional practice. • If there are mental health trainings, not all PCPs can attend. • There is only one mental health hospital in the country, and it is not accessible to all. | • Laws and restrictions are changing to reflect current trends in mental health. • There is increased attention put on mental health statistics. • Mental health is recognized in the country through the development of the national programme for mental health promotion. • Strategies are used to increase awareness of mental health conditions. • There is less stigma towards certain types of mental disorders since the Revolution. • The Ministry adopted a new medical curriculum, encouraging increased teachings and internships in mental health for future family physicians. |
Total | 11 barriers | 6 facilitators |
Organizational factors | • Trained PCPs are not always at the same primary healthcare clinic, affecting continuity in care. • There is a lack of medication in primary healthcare clinics. • If medication is available, it is easily stolen. • If medication is available, it is not evenly distributed. • If medication is available, it runs out quickly. • There is a lack of time to provide adequate mental health care. • There is a high turnover of employees within primary healthcare organizations. • PCPs expressed difficulties working with other health care professionals in the primary healthcare clinic. • Primary healthcare clinics do not encourage staff meetings. • Collaborations with the mental health hospital is difficult. | • Medication is available within primary healthcare clinics. • PCPs engage in case discussions with colleagues about mental health. • Collaborations with PCPs responsible for continuing medication education helps with mental health care. • There are opportunities for collaborations with other healthcare professionals. |
Total | 10 barriers | 4 facilitators |
Provider factors | • PCPs do not have previous mental health training. • PCPs do not like treating certain types of mental illnesses. • PCPs do not get involved with pharmacological treatment. • PCPs are not interested in mental health. | • PCPs have participated in mental health trainings. • PCPs participated in a mental health internship during medical school. • Many years of field experience have equipped PCPs with confidence in their general clinical skills. • PCPs are personally motivated to provide mental health care. • PCPs have personal preferences for certain types of illnesses. • PCPs participate in mental health training during their own time (outside of office hours). |
Total | 4 barriers | 6 facilitators |
Patient factors | • Patients think that receiving care in primary healthcare clinics is sub-par to receiving care by a specialist. • Patients are treated differently once “society” knows they live with mental health issues. • Patients do not seek care because they are afraid of legal issues. • Patients do not seek care because they do not want to be noticed by community members. • In consultation, patients are interrupted by other patients. • Patients are not aware that mental health services are available at primary healthcare clinics. • Patients do not know that mental health services are confidential. | • Patients prefer seeking and receiving care at the primary healthcare clinic because it is less stigmatizing than the mental health hospital. • Patients like receiving care at the primary healthcare clinic because they may go unnoticed. • Patients like receiving care at the primary healthcare clinic because it is offered quickly. • Patients think that the mental health hospital is very stigmatizing. • Patients think that the mental health hospital is too far. • Patients think that receiving services at the mental health hospital takes too long. • Patients are more open about their own mental health. • Patients will seek care at the primary healthcare clinic between appointments with psychiatrists. |
Total | 7 barriers | 8 facilitators |
Innovation factors | • Modules chosen do not correspond to the clientele seen by PCPs. • PCPs did not like all the theory provided during the training. • PCPs did not like that they were not able to learn about all the modules included in the guide. • PCPs did not like role plays. • PCPs found there was not enough time for all the content provided. | • Modules chosen correspond to the reality seen by PCPs. • Modules chosen correspond to the reality of the Greater Tunis area. • PCPs appreciated the clinical discussions during the training as they helped orient practice. • PCPs liked the role plays because they helped learning. • PCPs liked that they could learn from their peers. • PCPs enjoyed the videos shown during the training. • PCPs liked the training guide. |
Total | 5 barriers | 7 facilitators |
TOTAL | 37 barriers | 31 facilitators |