research article

 

Abdul Jalloh, School of Health and Wellbeing, College of Medical Veterinary & Life Sciences, University of Glasgow, United Kingdom (UK); Ministry of Health, Western area, Freetown, Sierra Leone; Department of Internal Medicine, College of Medicine and Allied Health Sciences, University of Sierra Leone; https://orcid.org/0000-0001-8756-6848

Augustus Osborne, Institute for Development, Western area, Freetown, Sierra Leone; https://orcid.org/0000-0002-0226-841X

Dimitar Karadzhov, School of Health and Wellbeing, College of Medical Veterinary & Life Sciences, University of Glasgow, United Kingdom (UK); https://orcid.org/0000-0001-8756-6848

Abstract

 

Background: Sierra Leone has a substantial mental health treatment gap, driven by limited resources, stigma, and a shortage of specialised personnel. Community health workers (CHWs) play an important role in frontline care, yet their mental health literacy and preparedness to support people with depression remain underexplored.

Objectives: This study aimed to assess CHWs’ knowledge of depression, examine their perceptions of barriers and facilitators to mental health care in Sierra Leone, and explore their experiences of delivering care during the COVID-19 pandemic.

Methods: A qualitative descriptive study was conducted in 2022 with 10 CHWs recruited through purposive and snowball sampling from Freetown and Kono District, Sierra Leone. Data were collected through remote semi-structured interviews using a vignette describing depression with suicidality. A hybrid deductive–inductive thematic analysis was undertaken using NVivo 12. The study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Results: Most participants (70%) correctly identified the vignette as depression, although none explicitly recognised suicidal ideation as a major clinical risk. Life events were the most commonly identified causes, while biological, spiritual, and supernatural explanations were not mentioned. Five themes were developed: mental health literacy, need for change, barriers to mental health care, accessing care, and the status of mental health care during COVID-19. Key barriers included stigma, misconceptions, poverty, weak planning and coordination, insufficient government support, and limited community awareness. Suggested facilitators included mental health training, community sensitisation, stronger policies, improved service integration, and greater system-level commitment.

Conclusions: CHWs demonstrated partial recognition of depression but important gaps remained in identifying suicide risk and understanding the broader clinical dimensions of depression. Strengthening CHW training, supervision, community engagement, and mental health system coordination may improve access to culturally responsive and effective mental health care in Sierra Leone.

 

Keywords: Mental health, Mental health literacy, Depression, Community health workers

Introduction

 

Depression is a leading cause of disability worldwide and remains a major contributor to the global burden of disease (World Health Organization [WHO], 2019). It can severely impair daily functioning and, when left untreated, may increase the risk of suicide. Suicide is among the leading causes of death among young people aged 15 to 29 years (Khatami & Khodabakhshi-Koolaee, 2021). More broadly, mental disorders affect a substantial proportion of the global population, with recent estimates suggesting that 10.7% of people worldwide live with a mental disorder (Dattani et al., 2021). The burden is especially pronounced in low- and middle-income countries (LMICs), where over 85% of the world’s population resides and where mental disorders account for a significant proportion of years lived with disability and overall disease burden (Rathod et al., 2017).

Despite this burden, access to mental health care remains profoundly limited in many LMICs. More than 90% of people with mental health conditions in these settings do not receive appropriate care (Chibanda et al., 2020). Closing this treatment gap requires coordinated leadership, workforce development, public engagement, and contextually grounded research (Chibanda et al., 2020). In Africa, the challenge is particularly acute. Between 2000 and 2015, the continent’s population increased by approximately 49%, while years lived with disability due to mental and substance use disorders rose by 52% (Sankoh et al., 2018). However, mental health expenditure has not increased proportionately, contributing to chronic underinvestment in services (WHO, 2018a).

One important explanation for the treatment gap is limited mental health literacy. Mental health literacy refers to knowledge and beliefs about mental disorders that support their recognition, management, and prevention (Jorm et al., 1997; Jorm, 2000). Jorm et al. (1997) conceptualised mental health literacy as including the ability to recognise mental disorders, knowledge of risk factors and causes, beliefs about self-help and professional interventions, attitudes that facilitate recognition and help-seeking, and knowledge of how to access mental health information. Low mental health literacy has been associated with delayed help-seeking, stigma, and poor treatment engagement. In many settings, traditional and religious beliefs also shape understandings of mental illness and pathways to care, sometimes reinforcing non-biomedical explanations and delaying access to formal services (Atilola, 2015, 2016). Negative attitudes and misconceptions among both the general public and health workers can therefore present major barriers to effective care (Muslic et al., 2021).

These issues are particularly relevant in Sierra Leone, where the mental health system operates under severe resource constraints. According to national estimates, Sierra Leone has a mental health treatment gap of approximately 98% (Harris et al., 2020). The country has experienced repeated collective trauma, including an 11-year civil war, the Ebola outbreak, mudslides, and the COVID-19 pandemic, all of which have contributed to increased psychosocial distress and mental health needs. A joint assessment by the WHO and the Ministry of Health and Sanitation (MoHS) reported a significant burden of mental health conditions, including psychosis, depression, and substance use disorders (MoHS, 2019). Yet service delivery remains limited by stigma, inadequate public awareness, insufficient funding, scarce specialist personnel, and the influence of cultural and religious beliefs on illness attribution and care-seeking (Fitts et al., 2020; Sharpe et al., 2021).

Although Sierra Leone introduced the National Mental Health Policy and Strategic Plan 2019–2023 to strengthen governance, build capacity, raise awareness, and decentralise services, specialist resources remain extremely limited (Hopwood et al., 2021). The country has one psychiatric hospital and only a very small number of specialist mental health professionals for a population of approximately 7.5 million, including two psychiatrists, two clinical psychologists, and 27 mental health nurses, of whom only four specialise in child and adolescent mental health (Harris et al., 2020; WHO, 2022). In practice, much of the burden of identifying, supporting, and referring people with mental health problems falls on community health workers (CHWs), who serve as frontline providers in many communities (Harris et al., 2020).

CHWs in Sierra Leone are generally lay workers who provide basic health support, promote access to services, and act as links between communities and the formal health system. Many have received some form of health training, including exposure to the WHO Mental Health Gap Action Programme (mhGAP), but there is no standardised national approach to mental health training for this cadre, and little is known about their preparedness to recognise and respond to common mental health problems such as depression (MoHS, 2016; Yoder et al., 2016). This evidence gap is important because CHWs are increasingly expected to contribute to mental health care in contexts where specialist services are scarce.

Research on mental health literacy among CHWs and primary care workers in sub-Saharan Africa remains limited, and evidence from Sierra Leone is particularly scarce (Marangu et al., 2021; Tekola et al., 2021). There is also limited qualitative evidence on how CHWs understand depression, how they perceive barriers and facilitators to mental health care in their communities, and how they experienced delivering care during the COVID-19 pandemic. Understanding these perspectives is important for informing training, service development, and policy reform in a setting with substantial unmet need.

 

This study therefore aimed to explore CHWs’ understanding of depression and their perceptions of mental health care in Sierra Leone. Specifically, the study sought to:

1. assess CHWs’ knowledge of depression using Jorm’s mental health literacy framework;
2. examine CHWs’ perceptions of barriers and facilitators to mental health care in Sierra Leone; and
3. explore CHWs’ experiences of delivering mental health care during the COVID-19 pandemic.

 

Methodology

 

This section outlines the design, setting, sampling, data collection, and analysis procedures used in the study. The study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007).

 

Study design

 

A qualitative descriptive design was used. This approach was considered appropriate because the study aimed to provide a rich, practice-oriented account of CHWs’ knowledge and experiences in a context where little prior research exists (Sandelowski, 2000). A qualitative descriptive design allowed the researchers to explore participants’ understandings of depression, perceived barriers and facilitators to care, and experiences during the COVID-19 pandemic in their own words.

 

Study setting

 

The study was conducted in Freetown and Kono District, Sierra Leone, in 2022. Freetown is the capital city and represents an urban setting, whereas Kono is a predominantly rural, diamond-producing district in the eastern part of the country (Adams et al., 2020). These sites were selected to capture potentially different experiences and perceptions of mental health care across urban and rural settings.

 

Participants and sampling

 

Participants were recruited using purposive sampling and snowball sampling (Patton, 2002). Eligible participants were CHWs who:

• were aged 18 years or older;
• were based in Freetown or Kono District;
• had worked in a public health facility for at least the previous 12 months;
• were able to communicate in English; and
• had experience of encountering mental health cases in their work.

Visiting CHWs and those without experience of mental health cases were excluded.

Ten CHWs participated in the study, with five recruited from Freetown and five from Kono. In Sierra Leone, CHWs are usually lay community-based workers who support health promotion, facilitate referrals, and accompany community members to care. Although they may receive basic training in different health areas, they do not usually hold formal qualifications in mental health beyond short training courses or workshops (MoHS, 2016).

 

Recruitment procedures

 

Recruitment was facilitated through social workers attached to the Psychiatric Teaching Hospital in Sierra Leone. A study flyer was circulated through CHW WhatsApp groups, inviting interested individuals to contact the first author directly by email. The social workers helped to support local arrangements for interviews, including identifying private spaces and assisting with internet access where needed, but they did not have access to participants’ personal responses or interview data.

The first author screened interested individuals for eligibility through email correspondence. Eligible participants were then sent the participant information sheet and consent form, and a Zoom interview was scheduled. Thirteen CHWs initially expressed interest in participating, including six from Kono and seven from Freetown. The first five eligible respondents from each site were invited to participate. Ten interviews were ultimately conducted. Reasons for non-participation included illness (n = 2) and failure to return the study documents (n = 1).

 

Researcher characteristics and reflexivity

 

The first author conducted all interviews. At the time of the study, he was a psychiatrist and Mental Health Programme Manager at the Ministry of Health in Sierra Leone and was also affiliated with the University of Glasgow. This professional background supported contextual understanding of the mental health system and CHW roles. However, it may also have influenced participant responses, particularly if participants perceived the interviewer as a senior mental health professional or authority figure.

To minimise this risk, the interviewer used open-ended questions, emphasised that there were no right or wrong answers, and encouraged participants to speak freely about both strengths and challenges in service delivery. Reflexive attention was maintained throughout data collection and analysis, and an independent researcher co-coded a sample of transcripts to enhance analytic credibility.

 

Data collection

 

Data were collected in July 2022 through remote semi-structured interviews conducted via Zoom. Remote interviews were selected because of the practical uncertainties associated with the COVID-19 period and the feasibility of online qualitative interviewing across sites (Archibald et al., 2019; Falter et al., 2022; Oliffe et al., 2021). Although the first author was based in Scotland at the time of data collection, participants were interviewed from Sierra Leone.

Once interviews had been scheduled, participants received a Zoom link and a brief demographic questionnaire by email. To support participation, arrangements were made locally to provide a suitable device, internet access, data packages, and a private room where required. Written consent forms were signed electronically and returned before the interview. Oral confirmation of willingness to participate was also obtained at the start of each interview.

At the beginning of each interview, the researcher introduced the study, answered questions, and used brief rapport-building conversation to reduce anxiety. Participants were reminded that participation was voluntary and that they could withdraw at any time without consequence.

 

Interview guide and vignette

 

The interview guide was informed by Jorm’s mental health literacy framework (Jorm et al., 1997) and included a short vignette describing a hypothetical woman, “Yabome”, experiencing depression with suicidality (Reavley & Jorm, 2011; Prior et al., 2003). The vignette has been used internationally in research on mental health literacy and was reproduced with permission from the original authors (Karadzhov & White, 2020; Marangu et al., 2021; Reavley & Jorm, 2011).

After hearing the vignette, participants were asked open-ended questions about:

• what they thought was wrong with Yabome;
• possible causes of her condition;
• appropriate sources of help and likely outcomes;
• similar cases encountered in practice;
• barriers and facilitators to mental health care in their communities; and
• experiences of delivering mental health care during the COVID-19 pandemic.

The diagnostic summary of the vignette was not disclosed until the debriefing stage. Interviews lasted between 30 and 60 minutes, with an average duration of approximately 30 minutes. All interviews were conducted in English, audio- and video-recorded with permission, anonymised, and transcribed verbatim using Zoom’s transcription function, followed by checking and cleaning of transcripts by the researcher.

 

Data analysis

 

The data were analysed using hybrid thematic analysis, combining deductive and inductive coding approaches (Fereday & Muir-Cochrane, 2006). This approach was selected to allow the study both to assess specific components of mental health literacy using a pre-existing framework and to identify broader patterns in participants’ experiences and perceptions emerging from the data.

For the first research objective, a deductive approach was used, drawing on Jorm et al.’s (1997) mental health literacy framework. The predefined coding categories included:

• conceptualisation of the mental health problem;
• aetiological attribution; and
• course of action, including beliefs about professional help and self-help interventions.

For the second and third research objectives, an inductive, data-driven thematic analysis was used to identify themes relating to barriers, facilitators, service experiences, and the effects of the COVID-19 pandemic.

The analysis followed the phases described by Braun and Clarke (2006). First, transcripts were read and re-read to support familiarisation with the data. Second, initial codes were generated in NVivo 12 (QSR International, 2020). Third, conceptually related codes were grouped into candidate themes. Fourth, themes were reviewed and refined in relation to both coded extracts and the full dataset. Fifth, themes and subthemes were defined and named. Finally, the findings were written up with supporting quotations selected to illustrate key patterns in the data.

To enhance credibility, 20% of a random sample of anonymised transcripts was independently co-coded by a second researcher (Campbell et al., 2013). No substantial discrepancies were identified, and the coding process was discussed to confirm consistency in interpretation.

 

Results

 

This section presents participants’ characteristics followed by the five themes generated from the hybrid thematic analysis. The themes were: (1) mental health literacy, (2) need for change, (3) barriers to mental health care delivery, (4) accessing mental health care, and (5) the status of mental health care during COVID-19.

 

Participant characteristics

 

Table 1 summarises the demographic characteristics of the 10 participating CHWs. Six participants (60%) were male and four (40%) were female. Half were aged under 30 years. Five participants (50%) held a university degree, and six (60%) had fewer than five years of experience in community health service. Four participants (40%) reported supervising others, while eight (80%) reported that they themselves had been supervised. Four participants (40%) managed between 21 and 30 patients per month. Seven participants (70%) had received some form of formal mental health training, mainly through short courses or workshops.

 

Table 1. Participant demographic characteristics

Note. Formal mental health training mainly consisted of short-term training sessions and workshops.

 

Overview of themes

 

The thematic map illustrated the interrelationships between the five themes and their subthemes. Across the dataset, participants emphasised that the central need in their communities was equitable access to mental health care. This need was shaped by two broad influences: first, the level of mental health literacy among CHWs and community members; and second, the extent to which health systems, families, and community institutions supported mental health care. The themes therefore reflected both individual-level knowledge and broader structural conditions affecting access, help-seeking, and service delivery.

 

Theme 1: Mental health literacy

 

This theme captured participants’ understanding of the vignette and included three subthemes: conceptualisation of the mental health problem, aetiological attribution, and course of action.

 

Conceptualisation of mental health concerns

Most participants identified the vignette as describing depression. Seven participants (70%) labelled the problem as depression, two (20%) described it as stress, and one (10%) referred to it as anxiety. Although most participants recognised depression, none explicitly identified the suicidal ideation described in the vignette as an immediate clinical risk or marker of severity.

“I think Yabome has depression.” (P004)

“She has an anxiety.” (P002)

“She is stressed.” (P005)

This suggests partial recognition of depression, but a notable gap in recognising suicidality within depressive presentations.

 

Aetiological attribution

When asked about possible causes of Yabome’s condition, participants most commonly referred to social and life circumstances. They attributed her distress to factors such as being unmarried, having no children, loneliness, and a lack of social support.

“Yabome is 30 years of age, and she’s not married, and she doesn’t have any child.” (P003)

“I think as a lady at the age of 30 years and does not have any child puts her in a dilemma which could have contributed to the current situation.” (P004)

“…because of loneliness because you see she is 30 years and no family and no kid.” (P005)

Notably, none of the participants attributed the problem to biological, spiritual, or supernatural causes. Their explanations focused instead on psychosocial stressors and interpersonal circumstances.

 

Course of action

All participants believed that Yabome needed professional help. Counselling and psychosocial support were the most frequently suggested responses, usually involving referral to a mental health facility, counsellor, psychiatrist, or CHW. Some participants also highlighted the importance of family support.

“Well, from previous training I have attended, Yabome needs somebody to talk to so that she can understand that she is not alone. She also needs counselling.” (P006)

“But I believe counselling presents the most appropriate approach to handle her situation. Also seek a psychiatrist service would be appropriate.” (P007)

“You have to get somebody who stays with Yabome to encourage and support her.” (P001)

Although participants recommended professional help, none mentioned medication, formal diagnosis beyond counselling needs, or longer-term treatment planning. However, all participants recognised that failure to seek help could lead to serious consequences, including deterioration and suicide.

“…I think it would degenerate into severe mental illness.” (P006)

“…She might have gone ahead and committed suicide.” (P007)

 

Theme 2: Need for change

 

This theme reflected participants’ experiences of delivering mental health care in the community and their attitudes towards people living with mental illness. Two subthemes were identified: compounded reactions and they are human.

 

Compounded reactions

Participants described their experiences of providing mental health care as mixed, combining rewarding encounters with frequent frustration. Some spoke positively about the opportunity to engage with community members and support people in distress.

“My experience has been good. Having to work in the community addressing mental health builds confidence….” (P004)

“It’s actually a good experience because you get to meet with different people, and then interact with them, know their stories...” (P005)

At the same time, many participants reported resistance, rejection, and difficulty persuading community members to accept mental health information or seek biomedical care.

“People reject mental health. What they do is that when they notice that a person has mental health, they shun them and ignore them. They do not consider them as members of their communities and are unable to listen to you when trying to educate them about mental health and how to care for people with mental health.” (P006)

“It’s quite challenging for the community I live in… I would rate my experience to around 40%. This is because majority are not willing to listen or learn about mental health since they understand that being mentally ill is a supernatural occurrence.” (P007)

Participants also reported mixed experiences with families and religious leaders. Some relatives were supportive and appreciative when patients improved, while others remained disengaged. Similarly, some religious leaders encouraged care-seeking, whereas others framed mental illness exclusively as a spiritual issue.

“Some appreciate our work. Because when their relatives get better, they appreciate, although some do not.” (P001)

“The funniest thing is that some of them do not want the patient to leave their churches to come to the facility, because everything is spiritual.” (P003)

“Yes, the religious leaders are supportive as well because they usually come to the clinic twice a week to help preach to them not to forget about religion and also pray….” (P005)

 

They are human

Despite these challenges, all participants expressed empathy and a strong ethical commitment to treating people with mental illness with dignity and equality. They described people with mental illness as deserving compassion, inclusion, and social connection.

“In the first place, we have to actually think and put ourselves in the position of these people… I have the empathy to be closer to that person.” (P002)

“I feel that mentally ill people in the community should be treated equally just like any other person who falls ill.” (P008)

“Sometimes I feel sorry for them especially how they are treated by those close to them.” (P009)

This subtheme highlighted that, although CHWs worked in stigmatising environments, they generally held supportive attitudes towards service users.

 

Theme 3: Barriers to mental health care delivery

 

Participants identified multiple barriers to effective mental health care in their communities. These barriers were grouped into two subthemes: awareness concerns and structural barriers.

 

Awareness concerns

Participants consistently described poor community awareness, stigma, and misconceptions as major obstacles to care. Mental illness was often poorly understood and associated with social exclusion.

“Stigmatisation is one of the greatest obstacles that we do have. Once they know about someone having mental illness, they isolate you, even those who are well educated.” (P002)

“Stigma and discrimination. These are the key barriers.” (P010)

Cultural beliefs and traditional interpretations of mental illness were also seen as barriers to help-seeking and community acceptance.

“In our communities, people are not accepting. They think that mental health is spiritual or something. People don’t want to listen to you.” (P003)

“Some communities have some kind of culture or beliefs which limit the overall focus on mental health. Some have superstitions regarding mental health where they say that a patient has been bewitched.” (P004)

 

Structural barriers

Alongside social barriers, participants described major system-level constraints. These included poverty, limited service organisation, shortages in human resources, weak planning, and limited support from health authorities. Some participants also perceived differences between Freetown and Kono, suggesting somewhat greater awareness and health-seeking behaviour in urban settings, but greater organisational gaps in rural areas.

“Even though there is higher progress in mental health, there are no specialised systems in place and commitment to mental healthcare.” (P004)

“I think we are faced with massive issues both accessing healthcare and policies, processes and human resource to achieve higher mental health care.” (P010)

Poverty was described as a particularly important barrier, especially for rural patients who struggled to maintain follow-up.

“Poverty is a major issue because majority are lost for follow-up due to poverty. Mental health patients are also marginalised in the community.” (P006)

Participants also felt that institutional bodies responsible for health planning and mental health oversight were insufficiently visible or engaged.

“The district health management team has provided not much help I know of.” (P001)

“This is one of the challenges, the government do not prioritise mental health. Such teams we never see them come to us.” (P006)

“For me, I think this directorate is tasked with many responsibilities which limit mental health. Their support is minimal.” (P007)

 

Theme 4: Accessing mental health care

 

Participants were also asked how mental health care could be improved in Sierra Leone. Their suggestions formed three subthemes: community sensitisation, capacity-building, and priority mental health policies.

 

Community sensitisation

Most participants argued that improving access to mental health care would require stronger community awareness and education. Suggested strategies included community meetings, religious gatherings, and media campaigns.

“We need more awareness campaign. We need to take our relatives to the hospital before the situation becomes serious instead of rushing to traditional medicine.” (P001)

“First, sensitisation about mental health and then medical supply should be enough. Another one, healthcare workers should be trained effectively.” (P004)

 

Capacity-building

Participants also emphasised the need to strengthen the workforce through training, recruitment, and specialist support. This included training CHWs, increasing the number of mental health professionals, and ensuring availability of essential supplies.

“I would think that having professionals in those areas could help improve the status of mental health. Professionals can also help in sensitisation of mental health across communities.” (P007)

“Sensitisation and ensuring that provision of supplies is available is integral in achieving high level of success in the efforts to improve mental health.” (P010)

 

Priority mental health policies

Participants called for stronger government commitment and more functional policy implementation. They viewed mental health as insufficiently prioritised and believed that better policy attention could improve coordination, teamwork, and service delivery.

“We need the Government to put more attention to mental health programmes and campaigns.” (P002)

“There are lapses on the side of government. It is high time for the government to prioritise mental health; it would help improve quality of mental care.” (P006)

 

Theme 5: Status of mental health care during COVID-19

 

This theme captured participants’ experiences of providing mental health care during the COVID-19 pandemic. Participants described fear, uncertainty, low preparedness, and disrupted service organisation, although a few also described local adaptations and teamwork.

Many participants reported anxiety about infection and reduced morale during the pandemic.

“We had fear especially when the disease was spreading in isolation centres. It was not easy.” (P001)

“I had fear because sometimes it is difficult to know if someone is affected. But we worked diligently to ensure that they receive quality care.” (P004)

Preparedness was often described as limited, particularly at the system level. Stay-at-home measures and movement restrictions reduced contact with patients and disrupted routine care. Some participants felt unprepared when the pandemic began, although a few noted that they developed personal strategies to protect themselves and maintain some service continuity.

“I was not prepared for that, but when it came, we all had to work together.” (P003)

“I was prepared during this time because I knew how to protect myself, which was integral to having a better level of engagement….” (P004)

A small number of participants described more adaptive responses, including remote communication and local team planning.

“My experience was fairly good since we had a plan among ourselves on how we can continue engaging mentally ill patients. Some of them we engaged through phone calls.” (P009)

Participants also described COVID-19-related stigma, psychological distress after diagnosis, and weak coordination of mental health care during the pandemic. Overall, the findings suggested that mental health care delivery during COVID-19 was uneven, with frontline workers relying heavily on personal initiative in the absence of strong system preparedness.

 

Discussion

 

This section interprets the findings in relation to the existing literature and the wider mental health system context in Sierra Leone. The study showed that CHWs had partial but incomplete mental health literacy, worked within highly stigmatising and resource-constrained environments, and identified community sensitisation, training, and stronger policy support as key priorities for improving care.

 

Mental health literacy and recognition of depression

 

A central finding was that most participants recognised the vignette as describing depression, yet none explicitly identified the suicidal ideation embedded within it as an urgent clinical warning sign. This is an important distinction. The findings suggest that CHWs may be able to recognise depression at a general level while still lacking the confidence or training to identify suicide risk as a core component of assessment.

This partial recognition is notable in a setting where CHWs often serve as the first point of contact for community members with mental health difficulties. The proportion correctly identifying depression in this study (70%) was higher than that reported in some previous studies using similar vignette methods. For example, Karadzhov and White (2020) found that 40% of clergy participants in Scotland identified depression, while Marangu et al. (2021) reported correct identification by 39% of primary healthcare workers in Kenya. In rural Ethiopia, Tekola et al. (2021) found even lower levels of recognition. One possible explanation for the relatively stronger performance in the present study is that most participants had received some supervision and many had received short-term mental health training.

However, the inability to identify suicidality remains a major concern. It may reflect limited training in risk assessment, discomfort discussing suicide, or broader stigma surrounding suicidal thoughts. This gap is especially important because recognising suicide risk is essential for timely referral and prevention. In practical terms, the findings suggest that CHW training in Sierra Leone should move beyond broad awareness of depression to include more explicit content on suicidal ideation, severity assessment, referral pathways, and crisis response.

Participants tended to explain the vignette in terms of life events and social adversity, such as childlessness, relationship status, loneliness, and limited support. This emphasis on psychosocial explanations is understandable in context and may reflect socially embedded understandings of distress. Interestingly, none of the participants mentioned biological, spiritual, or supernatural causes when interpreting the vignette. This differs from studies in some other settings where depression is commonly linked to spiritual or supernatural explanations, or where religious and traditional help-seeking pathways are more explicitly endorsed (Suhail, 2005; Miller et al., 2021). In this study, participants largely endorsed professional help, especially counselling and psychosocial support. Yet the absence of discussion of medication or longer-term recovery planning suggests that their understanding of treatment remained relatively narrow.

 

CHWs’ motivation, empathy, and the need for change

 

Another important finding was the contrast between participants’ empathy towards people with mental illness and the negative social environments in which they worked. Participants consistently described people with mental illness as deserving compassion, equality, and human dignity. This is a significant strength, because supportive provider attitudes are important for trust-building and continuity of care. At the same time, participants reported frustration, rejection, and emotional strain when working in communities where mental illness was stigmatised or interpreted as a spiritual problem.

This tension reflects a broader implementation challenge for community-based mental health services in low-resource settings. CHWs may be willing and motivated to provide care, but their effectiveness can be undermined by low community awareness, lack of family support, weak institutional recognition, and limited resources. Similar patterns have been reported in studies from Kenya and Nigeria, where CHWs experienced workload pressure, social misunderstanding, and low support while delivering care in community settings (Kwobah et al., 2021; Olateju et al., 2022). Such pressures may contribute to frustration, burnout, and reduced retention if not addressed through training, supervision, and system support (Kok et al., 2018; Maslach & Leiter, 2016; Pallas et al., 2015).

The mixed experiences reported with families and religious leaders are particularly important. Some relatives and faith leaders supported care-seeking, while others discouraged biomedical treatment or preferred spiritual responses. This pattern reflects medical pluralism, in which multiple explanatory models and treatment pathways coexist (Patel et al., 2018). In practice, this means that mental health programmes in Sierra Leone cannot assume a purely biomedical pathway to care. Instead, interventions may need to engage families, traditional belief systems, and religious leaders in ways that reduce harm, support referral, and build trust without dismissing local meaning systems.

 

Barriers to mental health care delivery

 

Participants described barriers operating at both community and health-system levels. At the community level, the most prominent barriers were low awareness, stigma, discrimination, and culturally shaped misconceptions about mental illness. These findings are consistent with evidence from Rwanda, Uganda, Mozambique, and other settings where stigma and low mental health literacy reduce help-seeking and delay treatment (Mabunda et al., 2022; Muhorakeye & Biracyaza, 2021; Shah et al., 2017). Participants’ accounts suggest that stigma in Sierra Leone is not only attitudinal but also relational: people with mental illness may be ignored, isolated, or excluded by their families and communities.

At the structural level, participants described poverty, weak service organisation, inadequate workforce capacity, and limited government prioritisation as major barriers. These findings align closely with previous reports on Sierra Leone’s mental health system, which has been characterised by underfunding, shortages of specialists, and weak decentralised service capacity (Fitts et al., 2020; Harris et al., 2020). The perception that key administrative bodies were largely absent from community mental health work further points to gaps in governance, coordination, and accountability.

The contrast drawn by some participants between Freetown and Kono is also noteworthy. Although both settings faced substantial barriers, urban participants appeared to perceive somewhat greater awareness and help-seeking, whereas rural participants more often highlighted organisational weakness and limited access. This suggests that place matters and that mental health system strengthening may require different operational strategies in urban and rural areas.

 

Facilitators of access and implications for service development

 

Participants proposed three main facilitators of improved access: community sensitisation, capacity-building, and stronger policy implementation. These suggestions were closely tied to the barriers they described and provide a practical roadmap for action.

First, participants emphasised community sensitisation through local meetings, religious settings, and media messages. This aligns with broader evidence that anti-stigma campaigns and community education can improve recognition, reduce fear, and promote help-seeking when they are sustained and culturally adapted (Muhorakeye & Biracyaza, 2021; Muslic et al., 2021). In Sierra Leone, such efforts may be especially important if they are delivered through trusted community actors rather than only through formal health channels.

Second, participants highlighted capacity-building, including training CHWs, recruiting more specialists, and improving the availability of supplies. Existing evidence suggests that structured training can improve frontline competence, confidence, and referral practice, even in low-resource settings (Armstrong et al., 2011; Jenkins et al., 2013; Sibeko et al., 2018). In the present study, the gap in suicide risk recognition provides a strong rationale for strengthening mhGAP-informed training and supervision for CHWs.

Third, participants called for more effective and visible mental health policy implementation. This reflects the fact that policy documents alone do not improve access unless they are accompanied by budget allocation, service integration, workforce development, and local accountability mechanisms. A stronger policy environment could improve coordination between CHWs, district health teams, specialist staff, and community stakeholders, thereby reducing fragmentation in care.

 

Mental health care during the COVID-19 pandemic

 

Participants’ accounts of service delivery during COVID-19 showed that the pandemic introduced additional layers of fear, uncertainty, disruption, and stigma. These findings are consistent with studies from Uganda, Nigeria, and India, where frontline workers reported fear of infection, high workload, and difficulty maintaining routine care during the pandemic (Muzyamba et al., 2021; Olateju et al., 2022; Roy et al., 2021). In the present study, participants described weak preparedness, reduced mobility, and poor organisational support, all of which affected mental health care delivery.

At the same time, some participants described adaptive responses, such as phone contact and informal team planning. These examples suggest that even within weak systems, frontline workers can create local workarounds. However, reliance on personal initiative is not a substitute for system preparedness. The findings therefore reinforce the need to integrate mental health into emergency preparedness planning, especially in countries with already fragile health systems.

 

Study limitations

 

This study has several limitations. First, the sample was small and drawn from only two locations, Freetown and Kono, which limits transferability to other parts of Sierra Leone. Second, the vignette and interview materials, although adapted from established sources, were not formally validated in the Sierra Leonean context. Third, data collection was conducted remotely via Zoom, which may have introduced selection bias by favouring CHWs who were more comfortable with digital participation or had better access to connectivity. Nevertheless, efforts were made to support participation through provision of devices, internet access, and private interview spaces.

 

Implications for policy and practice

 

The findings have several implications for policy and practice in Sierra Leone. Most importantly, they suggest that CHWs represent a motivated and potentially valuable workforce for expanding community mental health care, but they require more structured support. Training should place greater emphasis on depression recognition, suicide risk identification, referral pathways, and ongoing supervision. Community awareness campaigns should address stigma and misconceptions while engaging families, religious leaders, and other trusted local actors. At the health-system level, stronger implementation of mental health policy, dedicated funding, workforce expansion, and improved coordination across district and national structures are needed to reduce the treatment gap.

Taken together, the findings support a multi-sectoral and culturally responsive approach to mental health system strengthening in Sierra Leone. Such an approach should integrate community education, CHW capacity-building, governance reform, and stronger links between formal services and community-based support systems.

 

Conclusion

 

This study explored community health workers’ understanding of depression and their perceptions of barriers and facilitators to mental health care in Sierra Leone, including their experiences during the COVID-19 pandemic. The findings suggest that many CHWs were able to recognise depression in a vignette-based scenario and valued professional support, counselling, and family involvement as important responses. However, important gaps remained, particularly in recognising suicidal ideation as a major clinical risk and in understanding the broader treatment and recovery dimensions of depression.

Beyond mental health literacy, the study highlighted wider barriers to care, including stigma, poor community awareness, cultural misconceptions, poverty, limited-service organisation, and insufficient institutional support. At the same time, participants demonstrated empathy towards people living with mental illness and expressed strong motivation to support them. They identified community sensitisation, stronger training and supervision, increased workforce capacity, and more effective policy implementation as key facilitators of improved care.

Taken together, these findings indicate that CHWs represent an important but under-supported resource for expanding mental health care in Sierra Leone. Strengthening their role will require a coordinated, multi-sectoral approach that combines mental health literacy improvement, suicide risk training, anti-stigma efforts, service integration, and stronger health-system commitment. Future research should further examine cultural understandings of mental illness, help-seeking pathways, and the implementation of community-based mental health services across different regions of Sierra Leone.

 

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Ethical Statement

Ethical approval for this study was obtained from the University of Glasgow College of Medical, Veterinary and Life Sciences Research Ethics Committee on 5 June 2022 (Project No. 200210132) and the Sierra Leone Ethics and Scientific Review Committee on 21 June 2022 (SLESRC No. 012/06/2022). Administrative clearance to recruit participants was obtained from the Ministry of Health and Sanitation, Sierra Leone, on 28 June 2022. All participants provided informed consent prior to participation. Participation was voluntary, confidentiality was maintained throughout the study, and participants were informed of their right to withdraw at any stage without consequence.

 

Data Availability Statement

The qualitative data generated and analysed during this study are not publicly available because they contain information that could compromise participant confidentiality and privacy. De-identified excerpts are included in the manuscript. Additional information may be available from the corresponding author on reasonable request, subject to ethical and institutional approval.

 

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

 

Competing Interests

The authors declare no competing interests.

 

Authors’ Contributions

Abdul Jalloh: Conceptualisation, Methodology, Investigation, Data Curation, Formal Analysis, Writing – Original Draft, Project Administration.

Augustus Osborne: Writing – Review & Editing

Dimitar Karadzhov: Conceptualisation, Methodology, Supervision, Validation, Writing – Review & Editing.

 

Use of AI Technologies

No generative artificial intelligence tools were used in the analysis or interpretation of the study data. AI-assisted support was used only for language refinement and manuscript structuring, and all content was reviewed, verified, and approved by the authors. The authors remain fully responsible for the accuracy, originality, and integrity of the manuscript.

 

Acknowledgement

The authors thank the community health workers who participated in this study for sharing their time and experiences. The authors also acknowledge the support of the social workers who assisted with participant coordination and interview logistics in Freetown and Kono. Appreciation is extended to the Ministry of Health and Sanitation, Sierra Leone, and the University of Glasgow for their institutional support.