Perceptions of Community Involvement in the Peruvian Mental Health Reform Process Among Clinicians and Policy-Makers: A Qualitative Study

Document Type : Original Article


1 Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, USA

2 Department of Pediatrics, Division of Infectious Diseases, and Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA

3 Department of Health Policy, and Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA

4 CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru


The global burden of mental health conditions has led to the implementation of new models of care for persons with mental illness. Recent mental health reforms in Peru include the implementation of a community mental health model (CMHM) that, among its core objectives, aims to provide care in the community through specialized facilities, the community mental health centers (CMHCs). Community involvement is a key component of this model. This study aims to describe perceptions of community engagement activities in the current model of care in three CMHCs and identify barriers and potential solutions to implementation.
A qualitative research study using in-depth semi-structured interviews with clinicians from three CMHCs and with policy-makers involved in the implementation of the mental health reforms was conducted in two regions of Peru. The interviews, conducted in Spanish, were digitally recorded with consent, transcribed and analyzed using principles of grounded theory applying a framework approach. Community engagement activities are described at different stages of patient care.
Twenty-five full-time employees (17 women, 8 men) were interviewed, of which 21 were clinicians (diverse health professions) from CMHCs, and 4 were policy-makers. Interviews elucidated community engagement activities currently being utilized including: (1) employing community mental health workers (CMHWs); (2) home visits; (3) psychosocial clubs; (4) mental health workshops and campaigns; and (5) peer support groups. Inadequate infrastructure and financial resources, lack of knowledge about the CMHM, poorly defined catchment areas, stigma, and inadequate productivity approach were identified as barriers to program implementation. Solutions suggested by participants included increasing knowledge and awareness about mental health and the new model, implementation of peer-training, and improving productivity evaluation and research initiatives.
Community engagement activities are being conducted in Peru as part of a new model of care. However, their structure, frequency, and content are perceived by clinicians and policy-makers as highly variable due to a lack of consistent training and resources across CMHCs. Barriers to implementation should be quickly addressed and potential solutions executed, so that scale-up best optimizes the utilization of resources in the implementation process.


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  1. Murray CJL, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2197-2223. doi:10.1016/S0140-6736(12)61689-4
  2. Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2163-2196. doi:10.1016/S0140-6736(12)61729-2
  3. World Health Organization (WHO). Investing in Mental Health: Evidence for Action. Published 2013.
  4. Lund C, De Silva M, Plagerson S, et al. Poverty and mental disorders: breaking the cycle in low-income and middle-income countries. Lancet Lond Engl. 2011;378(9801):1502-1514. doi:10.1016/S0140-6736(11)60754-X
  5. Graham K, Cheng J, Bernards S, Wells S, Rehm J, Kurdyak P. How much do mental health and substance use/addiction affect use of general medical services? Extent of use, reason for use, and associated costs. Can J Psychiatry Rev Can Psychiatr. 2017;62(1):48-56. doi:10.1177/0706743716664884
  6. Genell Andrén K. A study of the relationship between social network, perceived ill health and utilization of emergency care. A case-control study. Scand J Soc Med. 1988;16(2):87-93.
  7. Kne T, Young R, Spillane L. Frequent ED users: patterns of use over time. Am J Emerg Med. 1998;16(7):648-652.
  8. Sun BC, Burstin HR, Brennan TA. Predictors and outcomes of frequent emergency department users. Acad Emerg Med. 2003;10(4):320-328.
  9. Caldas de Almeida JM. Mental health services development in Latin America and the Caribbean: achievements, barriers and facilitating factors. Int Health. 2013;5(1):15-18. doi:10.1093/inthealth/ihs013
  10. Cohen A, Eaton J, Radtke B, et al. Three models of community mental health services in low-income countries. Int J Ment Health Syst. 2011;5(1):3. doi:10.1186/1752-4458-5-3
  11. Kiima D, Jenkins R. Mental health policy in Kenya -an integrated approach to scaling up equitable care for poor populations. Int J Ment Health Syst. 2010;4:19. doi:10.1186/1752-4458-4-19
  12. Jenkins R, Heshmat A, Loza N, Siekkonen I, Sorour E. Mental health policy and development in Egypt - integrating mental health into health sector reforms 2001-9. Int J Ment Health Syst. 2010;4:17. doi:10.1186/1752-4458-4-17
  13. Funk M, Saraceno B, Pathare S, World Health Organization, eds. Organization of Services for Mental Health. Geneva: World Health Organization; 2003.
  14. World Health Organization, ed. Mental Health Atlas 2014. Geneva, Switzerland: World Health Organization; 2015.
  15. Thornicroft G, ed. Oxford Textbook of Community Mental Health. Oxford : Oxford University Press; 2011.
  16. Thornicroft G, Deb T, Henderson C. Community mental health care worldwide: current status and further developments. World Psychiatry. 2016;15(3):276-286. doi:10.1002/wps.20349.
  17. Drake RE, Latimer E. Lessons learned in developing community mental health care in North America. World Psychiatry. 2012;11(1):47-51.
  18. Zitko P, Ramírez J, Markkula N, Norambuena P, Ortiz AM, Sepúlveda R. Implementing a Community Model of Mental Health Care in Chile: Impact on Psychiatric Emergency Visits. Psychiatr Serv Wash DC. 2017;68(8):832-838. doi:10.1176/
  19. Castillo H. Situación de la atención de salud mental en el Perú: Resultados preliminares del Estudio Epidemiológico de Salud Mental en Lima Replicación 2012. Lima, Peru. 2012.
  20. Instituto Nacional de Salud Mental. Estudio Epidemiológico de Salud Mental en la Selva Peruana 2005.  Accessed October 15, 2018. Published 2005.
  21. Instituto Nacional de Salud Mental. Estudio Epidemiológico de Salud Mental en Lima Rural 2007.  Accessed October 15, 2018. Published 2008.
  22. Toyama M, Castillo H, Galea JT, et al. Peruvian Mental Health Reform: A Framework for Scaling-up Mental Health Services. Int J Health Policy Manag. 2017;6(9):501-508. doi:10.15171/ijhpm.2017.07
  23. Miranda JJ, Diez-Canseco F, Araya R, et al. Transitioning mental health into primary care. Lancet Psychiatry. 2017;4(2):90-92. doi:10.1016/S2215-0366(16)30350-9
  24. Ministerio de Salud. Lineamientos y medidas de reforma del sector Salud. Published 2013.
  25. Ministerio de Salud. Salud Mental Comunitaria: Nuevo Modelo de Atencion.  Published 2016.
  26. Ministerio de Salud. Plan Nacional de Fortalecimiento de Servicios de Salud Mental Comunitaria 2018–2021 - Resolucion Ministerial.  Accessed October 26, 2012.
  27. Aprueban el Documento Técnico: “Plan Nacional de Fortalecimiento de Servicios de Salud Mental Comunitaria 2018-2021."  Accessed October 26, 2018. Published April 2018.
  28. Ministerio de Salud. Norma Tecnica de Salud - Centros de Salud Mental comunitarios.  Accessed October 15, 2018.
  29. Odugleh-Kolev A, Parrish-Sprowl J. Universal health coverage and community engagement. Bull World Health Organ. 2018;96(9):660-661. doi:10.2471/BLT.17.202382
  30. Rifkin SB. Lessons from community participation in health programmes: a review of the post Alma-Ata experience. Int Health. 2009;1(1):31-36. doi:10.1016/j.inhe.2009.02.001
  31. Lavery JV, Tinadana PO, Scott TW, et al. Towards a framework for community engagement in global health research. Trends Parasitol. 2010;26(6):279-283. doi:10.1016/
  32. Oakley P. Community Involvement in Health Development: An Examination of the Critical Issues. Geneva: World Health Organization; 1989.
  33. Hennink MM, Hutter I, Bailey A. Qualitative Research Methods. Thousand Oaks, CA: SAGE; 2011.
  34. Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. 4. paperback printing. New Brunswick: Aldine; 2009.
  35. Institute of Medicine (US) Committee on Prevention of Mental Disorders. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research (Mrazek PJ, Haggerty RJ, eds.). Washington (DC): National Academies Press (US); 1994.  Accessed March 30, 2018.
  36. Kohrt B, Asher L, Bhardwaj A, et al. The Role of Communities in Mental Health Care in Low- and Middle-Income Countries: A Meta-Review of Components and Competencies. Int J Environ Res Public Health. 2018;15(6):1279. doi:10.3390/ijerph15061279
  37. Botha UA, Koen L, Joska JA, Hering LM, Oosthuizen PP. Assessing the efficacy of a modified assertive community-based treatment programme in a developing country. BMC Psychiatry. 2010;10(1). doi:10.1186/1471-244X-10-73
  38. Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. The Lancet. 2008;372(9642):902-909. doi:10.1016/S0140-6736(08)61400-2
  39. Chatterjee S, Chowdhary N, Pednekar S, et al. Integrating evidence-based treatments for common mental disorders in routine primary care: feasibility and acceptability of the MANAS intervention in Goa, India. World Psychiatry Off J World Psychiatr Assoc WPA. 2008;7(1):39-46.
  40. Rao S, Raguram A, Gangadhar B, Hegde S. Addition of home-based cognitive retraining to treatment as usual in first episode schizophrenia patients: A randomized controlled study. Indian J Psychiatry. 2012;54(1):15. doi:10.4103/0019-5545.94640
  41. Chatterjee S, Patel V, Chatterjee A, Weiss HA. Evaluation of a community-based rehabilitation model for chronic schizophrenia in rural India. Br J Psychiatry. 2003;182(1):57-62. doi:10.1192/bjp.182.1.57
  42. Ghadiri Vasfi M, Moradi-Lakeh M, Esmaeili N, Soleimani N, Hajebi A. Efficacy of Aftercare Services for People With Severe Mental Disorders in Iran: A Randomized Controlled Trial. Psychiatr Serv. 2015;66(4):373-380. doi:10.1176/
  43. Witmer A, Seifer SD, Finocchio L, Leslie J, O’Neil EH. Community health workers: integral members of the health care work force. Am J Public Health. 1995;85(8 Pt 1):1055-1058.
  44. Perry HB, Zulliger R, Rogers MM. Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness. Annu Rev Public Health. 2014;35:399-421. doi:10.1146/annurev-publhealth-032013-182354
  45. Hill Z, Dumbaugh M, Benton L, et al. Supervising community health workers in low-income countries--a review of impact and implementation issues. Glob Health Action. 2014;7:24085.
  46. Mutamba BB, van Ginneken N, Smith Paintain L, Wandiembe S, Schellenberg D. Roles and effectiveness of lay community health workers in the prevention of mental, neurological and substance use disorders in low and middle income countries: a systematic review. BMC Health Serv Res. 2013;13:412. doi:10.1186/1472-6963-13-412
  47. Weaver A, Lapidos A. Mental Health Interventions with Community Health Workers in the United States: A Systematic Review. J Health Care Poor Underserved. 2018;29(1):159-180. doi:10.1353/hpu.2018.0011
  48. Ozarin LD. The important contribution of community mental health workers. Am J Public Health. 1996;86(9):1319-1320.
  49. Singla DR, Kumbakumba E, Aboud FE. Effects of a parenting intervention to address maternal psychological wellbeing and child development and growth in rural Uganda: a community-based, cluster-randomised trial. Lancet Glob Health. 2015;3(8):e458-e469. doi:10.1016/S2214-109X(15)00099-6
  50. Agyapong VIO, Osei A, Farren CK, McAuliffe E. Factors influencing the career choice and retention of community mental health workers in Ghana. Hum Resour Health. 2015;13:56. doi:10.1186/s12960-015-0050-2
  51. Greenspan JA, McMahon SA, Chebet JJ, Mpunga M, Urassa DP, Winch PJ. Sources of community health worker motivation: a qualitative study in Morogoro Region, Tanzania. Hum Resour Health. 2013;11(1). doi:10.1186/1478-4491-11-52
  52. Arias P, Camps, Claudia. Rehabilitación psicosocial del trastorno mental severo Situación actual y recomendaciones. Published 2002.
  53. McKay C, Nugent KL, Johnsen M, Eaton WW, Lidz CW. A Systematic Review of Evidence for the Clubhouse Model of Psychosocial Rehabilitation. Adm Policy Ment Health Ment Health Serv Res. 2018;45(1):28-47. doi:10.1007/s10488-016-0760-3
  54. Road to recovery: employment and mental illness. Published 2014.
  55. Bouvet C, Battin C, Le Roy-Hatala C. [The Clubhouse model for people with severe mental illnesses: Literature review and French experiment]. L’Encephale. 2015;41(6):477-486. doi:10.1016/j.encep.2014.09.001
  56. Price-Haywood EG, Dunn-Lombard D, Harden-Barrios J, Lefante JJ. Collaborative Depression Care in a Safety Net Medical Home: Facilitators and Barriers to Quality Improvement. Popul Health Manag. 2016;19(1):46-55. doi:10.1089/pop.2015.0016
  57. Naslund JA, Aschbrenner KA, Marsch LA, Bartels SJ. The future of mental health care: peer-to-peer support and social media. Epidemiol Psychiatr Sci. 2016;25(02):113-122. doi:10.1017/S2045796015001067
  58. Cheng J, Benassi P, De Oliveira C, Zaheer J, Collins M, Kurdyak P. Impact of a mass media mental health campaign on psychiatric emergency department visits. Can J Public Health Rev Can Sante Publique. 2016;107(3):e303-e311.
  59. Henderson C, Evans-Lacko S, Thornicroft G. Mental Illness Stigma, Help Seeking, and Public Health Programs. Am J Public Health. 2013;103(5):777-780. doi:10.2105/AJPH.2012.301056
  60. Shidhaye R, Kermode M. Stigma and discrimination as a barrier to mental health service utilization in India. Int Health. 2013;5(1):6-8. doi:10.1093/inthealth/ihs011
  61. Campo-Arias A, Oviedo HC, Herazo E. [Stigma: Barrier to Access to Mental Health Services]. Rev Colomb Psiquiatr. 2014;43(3):162-167. doi:10.1016/j.rcp.2014.07.001
  62. Minoletti A, Sepúlveda R, Horvitz-Lennon M. Twenty Years of Mental Health Policies in Chile: Lessons and Challenges. Int J Ment Health. 2012;41(1):21-37. doi:10.2753/IMH0020-7411410102
  63. Minoletti A, Galea S, Ezra S. Community mental health services in Latin America for people with severe mental disorders. Public Health Rev. 2012;34(2):529–551.
  64. Minoletti A, Alvarado R, Rayo X, Minoletti M. Evaluacion del Sistema de Salud Mental de Chile. Published June 2014.
  65. Gater R, Saeed K. Scaling up action for mental health in the Eastern Mediterranean Region: an overview. Eastern Mediterranean Health Journal. 2015;21(7).
  66. Semrau M, Barley EA, Law A, Thornicroft G. Lessons learned in developing community mental health care in Europe. World Psychiatry. 2011;10(3):217-225.
  67. Scorza P, Cutipe Y, Mendoza M, Arellano C, Galea JT, Wainberg ML. Lessons From Rural Peru in Integrating Mental Health Into Primary Care. Psychiatr Serv. October doi:10.1176/
  68. Pedersen D. Estabilización post-conflicto y rehabilitación psicosocial en comunidades alto-andinas del Perú. 2007.
  69. Fundacion Manantial. Plan de Formacion y Capacitacion en salud mental comunitaria - Peru (PFCSMC - Peru) - Memoria de Actividad 2016-2017.   Accessed September 30, 2018.
  70. Diez-Canseco F, Ipince A, Toyama M, et al. Atendiendo la salud mental de las personas con enfermedades crónicas no transmisibles en el Perú: retos y oportunidades para la integración de cuidados en el primer nivel de atención. Rev Peru Med Exp Salud Pública. 2014;31(1). doi:10.17843/rpmesp.2014.311.19
  71. Cavero V, Diez-Canseco F, Toyama M, et al. Provision of mental health care within primary care in Peru: A qualitative study exploring the perspectives of psychologists, primary health care providers, and patients. Wellcome Open Res. 2018;3:9. doi:10.12688/wellcomeopenres.13746.2
  72. Yamin AE, Rosenthal E. Out of the Shadows: Using Human Rights Approaches to Secure Dignity and Well-Being for People with Mental Disabilities. PLoS Med. 2005;2(4):e71. doi:10.1371/journal.pmed.0020071
  73. United Nations Committee on Economic, Social and Cultural Rights. General comment 14: The right to the highest attainable standard of health.  Accessed April 30, 2019. Published August 2000.
  74. Organizacion Panamericana de la Salud. Encuentro de Representantes de Asociaciones de Usuarios de Servicios de Salud Mental y sus Familiares. Noticias.   Published May 10, 2017. Accessed March 11, 2019.
  75. Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015;10(1). doi:10.1186/s13012-015-0242-0.
  76. Lloyd R. Standardize Before You Improve.  Published July 3, 2018.
Volume 8, Issue 12
December 2019
Pages 711-722
  • Receive Date: 17 September 2018
  • Revise Date: 01 August 2019
  • Accept Date: 03 August 2019
  • First Publish Date: 01 December 2019