Key Barriers to the Provision and Utilization of Mental Health Services in Low-and Middle-Income Countries: A Scope Study

Inadequate attention has been given to the provision of mental health (MH) services especially in low-and middle-income countries (LMICs). This study was aimed to identify key barriers to provide and utilize MH services in LMICs. A comprehensive search on7 important online databases was conducted for key barriers to the provision and utilization MH services in LMICs from Jan 2000 to Nov 2019. Five-step Arksey and O’Malley guideline was used for scope study. The extracted data were synthesized using a qualitative content analysis and thematic network. Three main themes identified as barriers to the provision of MH services in LMICs, namely resource and administrative barriers, information and knowledge barriers, as well as policy and legislation barriers. Also attitudinal barriers, structural barriers, knowledge barriers, and treatment-related barriers were four main themes emerged regarding the challenges of utilization of MH services. Equitable access to MH services in LMICs is influenced by many barriers in both provision and utilization sides. In order to alleviate these problems, health systems could adopt some strategies including integration of MH into the general health policy, improvement of public MH awareness, developing anti-stigma programs, reallocation of health resources toward high-priority MH needs, developing community-based insurance, as well as integration of MH services into all levels of health-care systems. The success of intervention strategies depends on the weight of these barriers in different socio-economic contexts.


Introduction
Mental health (MH) is among the leading determinants of people's overall well-being (WHO 2001). Mental disorders are among the main non-fatal causes of burden of diseases in the world (Gong T 2019), so that the burden of mental illnesses has become a great public health concern (GBD 2015 Eastern Mediterranean Region Mental Health Collaborators 2018). A report on global burden of disease show that more than 5 percent of Disability Adjusted Life Years (DALYs) and up to 15.7 percent of Years Lived with Disability(YLDs) in the world are associated with the mental disorders (Kassebaum et al. 2016). Also an economic study estimated that the global cost of mental disorders in 2010 was equal to $2.5 trillion, and it was predicted that in 2020 the cost will increase to more than $6 trillion (Bashshur et al. 2016).
Despite the increasing trend of global burden of mental illnesses, the problem has not been regarded appropriately like physical diseases and to a large extent has been neglected in many parts of the world especially in low-and middle-income countries (LMICs) (Gilbert et al. 2015;Sockalingam et al. 2018;Pearson et al. 2015). This defect leads to limited, inadequate, and inequitable provision of MH services (Gilbert et al. 2015), and would expand treatment gap. This widening gap causes many health, social, and economic complications (Rebello et al. 2014). Studies have shown that key barriers to the provision of MH services include problems related to information systems (Knapp et al. 2006;Petersen et al. 2017), economic and resource barriers (Saraceno et al. 2007;Sulaberidze et al. 2018), defects in evidence-based policy and practice (Jenkins et al. 2011), as well as prevention, integration, and structural challenges (Jenkins et al.2011;Martinez et al. 2016;Wainberg et al. 2017).
In addition to the provision of MH services, utilization of these services has a significant effect on the MH condition of the community. Studies have identified several barriers to the utilization of MH services (Ghanizadeh et al. 2008) such as fear of stigma (Luitel et al. 2017;Salaheddin and Mason 2016;Taghva et al. 2017), transportation problems (Andrade et al. 2014;Brenes et al. 2015;Schierenbeck et al. 2013), cost of services (Andrade et al. 2014;Borba et al. 2012;Mwansisya et al. 2015), and information barriers (Sulaberidze et al. 2018;Ghanizadeh et al. 2008;Luitel et al. 2017).
LMICs face various challenges that have limited access to MH services. These barriers include limited and unsustainable resources (Semrau et al. 2015), shortage of MH workforce (Bruckner et al. 2011), non-integrated services , lack of evidence and information, policy and legislation deficits, and infrastructure constraints . Since equitable access to health care services is affected by both supply and demand sides (Richard et al. 2016), in order to provide a pervasive view of the issue, identifying barriers to the utilization and provision of MH services is essential for evidence-based planning, priority setting for resource allocation, and finally reducing burden of mental disorders (Andrade et al. 2014). Despite the fact that the majority of global burden of MH diseases is in LMICs (WHO 2005), less than 10% of published researches on MH are form these countries (Saxena et al. 2006). Moreover, based on our searches, there is not any comprehensive review in LMICs in which barriers on the both supply and demand sides have been investigated simultaneously. Therefore, this review scopes studies on barriers to the utilization and provision of MH services in LMICs in order to summarize, categorize and then discuss about each of the barriers. Results of this review provide a comprehensive map of the evidence on the barriers to the utilization and provision of MH services in LMICs. These evidence could shed light on policy formulation and implementation in LMICs.

Methods
The main objective of this scoping review was to map the literature about key barriers to the utilization and provision of mental health services in LMICs simultaneously. We have used scoping review because this method allows inclusion of literatures with heterogeneous designs and samples (Arksey and O'Malley 2005). Also This type of review provides the possibility of identifying main aspects and factors related to the concept, building on a comprehensive map of the evidences on the issue, and determining knowledge gaps in the area (Munn et al. 2018).
In this regards, we used scoping review approach developed by Arksey and O'Malley (Arksey and O'Malley 2005).
This methodology is consisted of five distinctive stages: 1-Identifying research question, 2-Finding the relevant studies, 3-Selecting relevant studies, 4-Charting the data, as well as 5-Collating, summarizing and reporting the results.

Identifying the Question
Although research question determines scope of the study, but scoping review has an iterative process. Therefore, the research question of this study was developed gradually through the literature review process. Outcome of interest in our study was key barriers to the utilization and provision of MH services recognized by providers and patients in LMICs. In this study, adult population was considered as care receivers and in the provider side, all levels from individual caregivers to policy sectors were included. Therefore, this study aimed to answer to this question: 'what are the key barriers to the utilization and provision of MH services in LMICs?'

Finding the Relevant Studies
Before carrying out a comprehensive review, we searched Cochrane database to ensure that there is no similar review. In order to find relevant studies, we conducted a systematic search on 7 online databases including PubMed, Scopus, Web of Science, Embase, ProQuest, Wiley online library, and ScienceDirect. We searched these databases for the relevant studies published from January 2000 to November 2019. We determined three categories of search term through an initial literature review and then we refined and completed categories during the systematic search process. Search terms in each category were combined using logical operator 'OR' and the categories were merged applying logical operator 'AND'. The search strategy of the study is shown in Table 1. Using this search strategy, we have retrieved 71,832 reports. After removing duplicates, 50,131 papers were entered into the assessment phase. We used EndNote manager software (EndNote X7.1, by Thomson Reuters) to manage references.

Selecting Relevant Studies
For selecting the studies that were relevant to the research question, we carried out an iterative three-step peer review process, so that in each phase we refined the search strategy, searched literature, and reviewed new papers. For developing the key objective and question of the review and also in all steps of appraisal and inclusion we used three main criteria of scoping review studies. In this regard, adult patients, barriers to the provision and utilization of MH services, as well as LMICs were considered as "Population, Concept, and Context" (PCC) respectively. At the first step, title of 1 3 papers was screened by two reviewers independently based on outcome of interest. In this step, 11,237 studies were accepted for further assessment. After excluding irrelevant titles, abstract of remained papers were reviewed by two reviewers and those that did not meet the aim of the study were removed and 163 full-text articles were selected for further appraisal. Finally, 2 reviewers scanned full-text papers and 35 studies including 20 articles on barriers to the provision of MH services (Knapp et al. 2006;Petersen et al. 2017;Saraceno et al. 2007;Sulaberidze et al. 2018;Martinez et al. 2016;Taghva et al. 2017;Schierenbeck et al. 2013;Ali and Agyapong 2015;McDaid et al. 2008;Rugema et al. 2015;Ssebunnya et al. 2011;Strumpher et al. 2014;Kpobi et al. 2018;Sun et al. 2018;Wakida et al. 2018;Murphy et al. 2018;Wakida et al. 2019;Chisholm et al. 2019;Caplan et al. 2018;Zhang et al. 2019) and 24 studies on challenges of utilization of MH services (Sulaberidze et al. 2018;Ghanizadeh et al. 2008;Luitel et al. 2017;Taghva et al. 2017;Schierenbeck et al. 2013;Borba et al. 2012;Mwansisya et al. 2015;Ali and Agyapong 2015;Rugema et al. 2015;Strumpher et al. 2014;Sun et al. 2018;Murphy et al. 2018;Caplan et al. 2018;Jack-Ide and Uys 2013;Hailemariam et al. 2017;Iseselo and Ambikile 2017;Nickels et al. 2018;Husain 2020;James et al. 2019;Baldisserotto et al. 2020;Rad et al. 2019;Tirintica et al. 2018;Yu et al. 2018;Tristiana et al. 2018) were selected for final analysis. The "Critical Appraisal Skills Programme" (CASP) checklists (Critical Appraisal Skills Programme checklists [Internet] 2019) and the "Strengthening the Reporting of Observational Studies in Epidemiology" (STROBE) tools (Von Elm et al. 2007) were used for quality assessment of selected full-texts. In all steps of selection phase, cases of disagreement were reviewed by a third reviewer for final inclusion. In order to get more familiar with all steps of the research process, two reviewers involved in a pilot project prior to the implementation of main study.

Inclusion/Exclusion Criteria
Due to the language limitations, only studies with full text in English were included. Since healthcare systems have changed remarkably over the recent years, and in order to investigate the latest barriers to the provision and utilization of MH services in LMICs, articles published after 2000 were selected. We included original researches and discussion papers, however commentaries, letters, and reviews of other studies were excluded. Figure 1 shows the process of paper selection for this study in the form of a PRISMA flowchart.

Charting the Data
We applied a content analysis approach for charting the data (Bengtsson 2016). We developed a data-charting form to extract relevant data from included papers. In this regards two reviewers carried out the charting jointly through an iterative process, so that they extracted data and updated the data-charting form continuously.

Collating and Summarizing the Data
We analyzed extracted data using a qualitative thematic analysis (Thomas and Harden 2008). At the first step of thematic analysis, we became familiar with the data through multiple readings of the full-text papers. Then we identified preliminary codes based on research question and outcome of interest. In the third step, we conducted an interpretive analysis of the initial codes and organized them into subthemes and main themes. Reviewing themes was the next step. In this regards, we carried out a deeper review on the identified themes in order to combine, refine, separate, or discard initial themes if it was necessary. In the final step, we defined and labeled themes and their related sub-themes in terms of relevancy of the contents.
The main themes and their related sub-themes are presented in the format of tables. Also, in order to provide a better view of the breadth of the evidence, frequency of studies involved in development of each theme and sub-theme are listed in the tables. Finally, we generated a map of the evidence in order to provide a more comprehensive insight into the issue. We developed the concept map using the results of thematic analysis. Because equitable access to health services is under influence of provision and access aspects at the same time, this map comprises the main themes and their sub-themes in both dimensions.

Results
Our searches resulted in the retrieval of 71,832 publications, of which 35 articles were finally included in the review. Table 2 shows the characteristics of included studies. A large portion of included studies were from Africa and the majority of articles performed using a qualitative or mixedmethod design. Most of the studies on utilization (70%) and provision (50%) conducted with the participation of healthcare professionals. Thematic analysis resulted in development of 3 main themes and 13 sub-themes regarding the barriers to the provision of MH services which are presented in Table 3. Also, results of thematic analysis lead to 4 main themes and 20 sub-themes regarding the barriers to the utilization of MH services which are presented in Table 4.

Resource and Administrative Barriers
This theme explains problems that are related to allocation of resources to MH services. It also shows administrative and organizational challenges that may restrict access to MH services.

Insufficient Resources
Results of the analysis showed that lack of sufficient resources was the most frequent barrier regarding the provision of MH services. Findings indicated that scarcity of resources for MH services in LMICs can  (Caplan et al. 2018), and limited healthcare facilities (Sulaberidze et al. 2018;Rugema et al. 2015;Caplan et al. 2018;Zhang et al. 2019).

Geographical Imbalance in Resource Allocation
Imbalanced geographical distribution of MH services was another frequent barrier to the provision of MH services. Studies indicated that inequality in distribution of MH resources is pertaining to the unequal distribution of budgetary resources (Saraceno et al. 2007;Sulaberidze et al. 2018), centralized MH beds and facilities (Knapp et al. 2006;Saraceno et al. 2007;Chisholm et al. 2019;Zhang et al. 2019), and unbalanced distribution of MH staff (Petersen et al. 2017;Saraceno et al. 2007).

Centralized and Non-integrated Services
This review showed that one of the main barriers to equitable provision of MH services in many LMICs is that these services are usually not integrated into Primary Health Care (PHC) and a major proportion of service facilities are located in the centers of provinces (Knapp et al. 2006;Saraceno et al. 2007;Sulaberidze et al. 2018;Taghva et al. 2017;Ali and Agyapong 2015;Wakida et al. 2018Wakida et al. , 2019.

Inappropriate Service Types
Findings of current study revealed that failure to provision of appropriate MH services is a challenges for health systems in some LMICs. Inappropriateness of MH services is related to the improper allocation of MH services resources (Sulaberidze et al. 2018;Wakida et al. 2019;Tirintica et al. 2018) as well as incongruity between available services and needs or preferences of target population (Martinez et al. 2016;Zhang et al. 2019).
Imperfect Inter-Organizational Collaboration Lack of appropriate cooperation between different parts of the health system associated with MH services was another challenges for provision of MH care in LMICs. Studies reported that this problem has different aspects including lack of cooperation between scientific institutions for development of preventive and treatment programs (Taghva et al. 2017), poor coordination between policy and practice (Petersen et al. 2017), and lack of cooperation between organizations and professionals at different levels of MH services (Knapp et al. 2006;Petersen et al. 2017).

Weakness of Quality Assurance Programs
This review showed that another challenge of health systems in LMICs for provision of MH services is deficiency of quality assurance programs. Quality assurance practices usually focus on professionals' competency, quality of equipment and medications, and provision of evidence-based services (Petersen et al. 2017;Strumpher et al. 2014).

Information and Knowledge Barriers
This themes indicates those barriers that limit access to information and evidence needed for adoption and implementation of appropriate MH policies. These problems are directly associated with the challenges that are categorized under the next theme.

Inappropriate Professionals' Training
Findings of the study indicated that inappropriate or inadequate training of professionals in LMICs is the most frequent knowledge barrier to the provision of high-quality MH services. This problem can be arisen in all professionals from different levels and regarding all necessary skills such as diagnosis and treatment (Andrade et al. 2014;Schierenbeck et al. 2013;McDaid et al. 2008;Wakida et al. 2018Wakida et al. , 2019Caplan et al. 2018).

Imperfect Mental Health Information System
Analysis showed that defective MH information system is a barrier to the provision of appropriate and equitable MH services in many LMICs. This deficiency has an influence almost on all aspects of provision of MH service (Petersen et al. 2017;Sulaberidze et al. 2018;Taghva et al. 2017;Kpobi et al. 2018;Murphy et al. 2018).

Weakness of Evidence-Based Practice
Findings of this study indicated that weakness in evidence-based MH practice is another knowledge barrier to the provision of MH services. Problem of dissemination of researches evidence and lack of appropriate national guidelines are among the main aspects of the barrier in LMICs (Knapp et al. 2006;Saraceno et al. 2007;Sulaberidze et al. 2018;Wakida et al. 2018;Zhang et al. 2019).

Policy and Legislation Barriers
This theme explains challenges that are related to the policy and legislation aspects of health systems stewardship fuction. This theme has an interrelationship with the previous them.

Low Priority of Mental Health in Health Policy
This review revealed that low priority of MH in national health policy is the most frequent policy barrier to the provision of equitable MH services in some LMICs. Limited financial, physical, and human capacities, imperfect information system, as well as restricted participation of stakeholders such as patients and their advocates are highly associated with the problem (Knapp et al. 2006;Petersen et al. 2017;

Weakness of Evidence-Based Policy Making
This study showed that deficient MH information system, restricted infrastructures, as well as limited capacities resulted in weakness of evidence-based policy in many LMICs. Policy weakness has a direct association with decreased quantity and quality of MH services in this countries (Petersen et al. 2017;Sulaberidze et al. 2018;McDaid et al. 2008;Ssebunnya et al. 2011).

Imperfect Legislation on Insurance
We found that one the barriers to the provision of MH services in LMICs is poor legislation on insurance. Providing equitable insurance coverage for mental diseases, as a critical duty of health systems, needs precise legislation in many countries (Martinez et al. 2016;Taghva et al. 2017).

Inappropriate Legislation on Mental Health Services
According to the findings of this study, inappropriate legislation and law enforcement regarding the provision of MH services was a challenge for health systems in LMICs. Accurate legislation for MH is considered as an important stewardship function of health systems (Ssebunnya et al. 2011;Zhang et al. 2019).

Attitudinal Barriers
This theme comprises personal attitudes and beliefs that prevent individuals from seeking MH services. These include cultural beliefs, confidence in the medical system, and sense of shame and stigma.

Concern About Social Stigma
Based on the findings of this review, the main attitudinal obstacle to the utilization of MH services among patients is the concern about being stigmatized by others. A large body of included studies (85%) has reported that fear of being stigmatized hindered people from seeking MH services (Ghanizadeh et al. 2008;Luitel et al. 2017; Taghva  Personal Stigma/Shame According to the findings of current review, self-stigma and embarrassment is the second attitudinal barrier to the utilization of MH services. Selfstigma is a feeling of shame that in many cases leads to reduction in utilization of MH services (Luitel et al. 2017;Taghva et al. 2017; Jack-Ide and Uys 2013; Husain 2020; Baldisserotto et al. 2020;Tirintica et al. 2018;Yu et al. 2018;Tristiana et al. 2018).
Concerns About Effectiveness of Services this study indicates that another frequent barrier to the utilization of MH services in LMICs is concern about effectiveness of services. Patients who suppose that MH service would not help them are less likely to seek and utilize these services (Luitel et al. 2017;Schierenbeck et al. 2013;Borba et al. 2012;Mwansisya et al. 2015;Husain 2020;James et al. 2019).

Concerns About Attitude and Behavior of Professionals
Results of this review showed that negative behaviors and attitudes of MH care providers toward patients is an important underlying factor that affect utilization of available MH services. This problem is pertaining to the past negative experiences with MH professionals (Ghanizadeh et al. 2008;Luitel et al. 2017;Taghva et al. 2017;Schierenbeck et al. 2013;Caplan et al. 2018;Tristiana et al. 2018).

Willingness to Take Alternative Forms of Care
The results demonstrated that patients' preferences for alternative types of treatment is an attitudinal barrier to the utilization of formal MH services. Seeking help from religious and tradi-

Cultural Beliefs Against Treatment
The findings indicated that in many developing countries mental illnesses are attributed to the spirit (Strumpher et al. 2014). Therefore, some cultural beliefs such as fatalism (Tirintica et al. 2018) create a gap between personal beliefs and MH interventions that eventually leads to reduced utilization of MH services (Schierenbeck et al. 2013;Strumpher et al. 2014;Husain 2020;Tirintica et al. 2018).

Patients' Self-reliance
This study showed that because of previous negative experiences or due to the concerns about stigma, patients prefer to handle their problem on own or may decide to wait for the disease to get better by itself (Ghanizadeh et al. 2008;Luitel et al. 2017;James et al. 2019).

Lack of Confidence in Professionals
Results of the review demonstrate that due to the unsuccessful or bad experience with MH care providers, patients may lose their confidence in professionals and may reduce utilization of available services (Ghanizadeh et al. 2008;Husain 2020;Baldisserotto et al. 2020).

Poor Compliance with Treatment
This study showed that the last attitudinal barrier to the utilization MH services is patients' poor compliance with treatment. Patients who think interventions are merely to control their behavior and are not effective for their treatment may have little adherence to the treatments (Sun et al. 2018).

Structural Barriers
This theme explains systemic problems that are associated with availability of MH service. The theme comprises factors that link utilization and provision aspects of MH services. Although these barriers are categorized as utilization challenges, they are also directly dependent on the performance of health systems in providing accessible MH.

Location, Distance and Transportation Barriers
The findings revealed that challenges related to the transportation and location of existing MH services were the second structural barrier to the utilization of services in many LMICs. This problem is more dominant in the remote and rural areas of these countries (

Lack of Family or Social Support
We found that shortage of support from others is a deterrent factor against utilization of MH services in some developing countries. Social support of patients with mental illness has different dimensions including financial, emotional, and physical supports (

Time-Related Barriers
This study showed that challenges pertaining to time are among structural barrier to the utilization of MH services in LMICs. These challenges include waiting time barriers, difficulty taking time off work, and transportation time (Ghanizadeh et al. 2008;Luitel et al. 2017;Sun et al. 2018;Caplan et al. 2018;Jack-Ide and Uys 2013;James et al. 2019).

Inappropriate and Inflexible Services
This review indicated that some MH services in LMICs are not convenient enough for patients. Inappropriateness of services is attributable to inconvenient hours of service provision, inflexible appointments, fragmented service delivery system, as well as undesirable medications and interventions (Ghanizadeh et al. 2008;Luitel et al. 2017;Caplan et al. 2018;Hailemariam et al. 2017;James et al. 2019).

Lack of Adequate Services
Findings of this study demonstrated that due to the shortage of financial, human, and physical resources, provision of equitable and well-distributed MH services is a great problem in many LMICs. Accordingly, lack of adequate MH services has a definite negative effect on equitable access to the services (Taghva et al. 2017;Schierenbeck et al. 2013;Mwansisya et al. 2015;Tirintica et al. 2018;Tristiana et al. 2018).

Limited Insurance Coverage
The results indicated that poor health insurance system in LMICs is a deterrent factor against equitable access to MH services. Imperfect insurance legislation, incomplete basic premium package, low population coverage, and unaffordable premiums are among the most frequent deficits of MH insurance in these countries (Taghva et al. 2017;Schierenbeck et al. 2013;Sun et al. 2018;Murphy et al. 2018;Caplan et al. 2018).

Knowledge Barriers
This theme explains lack of awareness about MH disorders and also lack of knowledge about existing services among individuals or families suffering from ill MH.

Lack of Knowledge About Mental Health Problem
This study showed that the most frequent knowledge barrier to the utilization of MH services in LMICs is lack of adequate knowledge about MH problems among patients and their families. Recognition of MH problems by patients and their families is the first step in utilization of the services (Ghanizadeh et al. 2008;Luitel et al. 2017;Mwansisya et al. 2015;Strumpher et al. 2014;Caplan et al. 2018;Hailemariam et al. 2017;Husain 2020;James et al. 2019;Baldisserotto et al. 2020;Rad et al. 2019;Tirintica et al. 2018).

Lack of Information on Available Services
This study indicated that lack of information about availability of services is another important knowledge barrier to the utilization of MH services. This problem is pertaining to the lack of information about various types of treatment and place of service facilities (Ghanizadeh et al. 2008;Luitel et al. 2017;Mwansisya et al. 2015;Jack-Ide and Uys 2013;James et al. 2019).

Treatment-Related Barriers
This theme involve challenges related to the patients' concern about treatment negative aspects.

Fear of Treatment Side Effects
Results of the study showed that patients' concern about side effects of available treatments has negative impact on utilization of MH services. Treatment side effects are mainly related to medications and technology-based interventions (Luitel et al. 2017;Schierenbeck et al. 2013;Hailemariam et al. 2017;Iseselo and Ambikile 2017;Husain 2020;James et al. 2019).

Long-Term Nature of Treatment
Findings of the study indicated that long-term period of MH treatments is another barrier to the utilization of MH services. Long-dated hospitalizations, repeated out-patient consultations, and delayed treatment outcomes may induce patients to give up treatments (Hailemariam et al. 2017). All the relationships between the main themes and subthemes are clarified in the thematic map (Fig. 2). The thematic map shows that equitable access to MH services is affected by the challenges from supply and demand sides. On the demand side, personal factors, structural determinants, and treatment-related factors influence the use of MH services. On the supply side, LMICs face challenges in legislation and policy, management of services, resource allocation, as well as generating and utilizing appropriate evidence.

Discussion
This review was carried out to determine barriers to the provision and utilization of MH services in LMICs. In this section, we discussed the findings of the study based on each theme and its related sub-themes of provision and utilization separately.

Provision Barriers
This review showed that scarcity of resources for MH services is a major problem for health systems in many LMICs. Limitation of resources in MH is the result of poor economic condition, low priority of MH, and deficient stewardship (Knapp et al. 2006). Insufficiency of resources for providing MH services can be categorized as inadequate financial resources (Saraceno et al. 2007;Murphy et al. 2018), lack of enough professionals (Wakida et al. 2019) particularly at the primary level (Kakuma et al. 2011), shortage of medications (Caplan et al. 2018), and limited service delivery facilities . Countries that are faced with shortage of financial resources in MH have to reallocate resources in order to meet their high priority needs in mental health (Jenkins et al. 2011). Evidence-based resource allocation in LMICs should be done considering the cost-effectiveness of MH services (Saraceno et al. 2007;Chisholm et al. 2019). Furthermore, efficiency and effectiveness of existing financial resources should be assured for provision of sustainable MH services (Jenkins et al. 2011).
Human resources are the core component for provision of MH services. Insufficiency of human resources may occur at both primary and special levels (Kakuma et al. 2011). At the primary level, delivery of MH services is focused mainly on non-specialist workers (Jenkins et al. 2011). Generally, Shortage of MH staff at this level is due to the limited number of educated workforces and unbalanced distribution of existing resources inside the country (Saxena et al. 2007). At the specialty level most challenges regarding the shortage of MH workforces are related to rural-to-urban movement (Kakuma et al. 2011) and migration to the countries with possible higher income (Patel 2003). An appropriate planning and policy on MH human resources is necessary in LMICs for training adequate and qualified workforces, retaining them, and distributing MH care professionals equitably (Kakuma et al. 2011). Shortage of MH medications is considered as a great challenge in some developing countries (McDaid  et al. 2008). Countries that are facing this problem have to improve their pharmaceutical supply chain in order to provide low-cost drugs with the highest possible quality (Petersen et al. 2017;Sulaberidze et al. 2018). Moreover, in countries with severe limitation of resources, redistribution of financial resources is necessary for procurement of essential MH medications (Petersen et al. 2017).
Result of this study indicated that concentration of MH care facilities in urban areas and non-integrated MH services are among the main challenges of providing equitable MH cares in many LMICs. The main challenges of integrating MH services into PHC are lack of adequate infrastructures, insufficient MH human resources, and absence of appropriate initiatives in this regard (Hanlon et al. 2014;Collins et al. 2011). Implementation of multi-dimensional interventions are necessary for integrating MH services into PHC and decentralizing the services (Hanlon et al. 2014). Health systems should adopt appropriate policies for re-distribution of MH resources toward community-based services such as outpatient clinics and community oriented inpatients facilities (Sulaberidze et al. 2018;Ali and Agyapong 2015;Chisholm et al. 2019). Despite the great emphasis on integrating mental health services into PHC, there are also some issues that health systems need to be careful about them (Knapp et al. 2006). The most important challenges in this regard are lack of adequate and well-trained professionals (Saraceno et al. 2007;Wakida et al. 2018Wakida et al. , 2019, imposing overburden on staff at primary care level, failure in efficient supervision (Saraceno et al. 2007), lack of sufficient financial and physical resources, and deficient patient flow and referral processes (Saraceno et al. 2007;Wakida et al. 2019). Therefore, developing a practical and supportive referral system is necessary for integration of MH services into PHC (Saraceno et al. 2007).
Our review showed that provision of appropriate MH services is a concern for health systems in developing countries. In some cases, existing services are not compatible with the community needs (Martinez et al. 2016). Appropriateness of the provided services should be considered from different perspectives such as type of services (preventive or therapeutic) (Wainberg et al. 2017), setting of services (inpatient or outpatient) (Sulaberidze et al. 2018), target population (Adults or children) Knitzer and Cooper 2006), equipment and medications (Knapp et al. 2006;Wakida et al. 2019), as well as location and time of service delivery (Knapp et al. 2006;Martinez et al. 2016). Health systems should reallocate MH resources in accordance with the community needs (Knapp et al. 2006). Some suggestions in this regard include using appropriate technologies and medications based on health technology assessment analysis, improving community-based and integrated services, revision of existing services based on patient's preferences and convenience.
Professionals' competency in relation to the quality of training is a major knowledge barrier to the provision of MH services in the LMICs. Training may be inadequate among professionals at both primary and specialty levels (Schierenbeck et al. 2013;McDaid et al. 2008;Caplan et al. 2018). Also, training may be insufficient regarding various skills necessary for patients' care including, prevention, diagnosis, and treatment (Caplan et al. 2018). Another aspect of this problem is lack of sufficient knowledge on special groups like geriatric psychiatry . Inappropriate training leads to knowledge-practice gap and hinders provision of high quality services (Wakida et al. 2019). Developing in-service training programs would be efficient in filling the gap (Wakida et al. 2018(Wakida et al. , 2019. Therefore, health systems in LMICs have to adopt a holistic approach to the patients' care when developing MH education (Caplan et al. 2018).
Information system was introduced as a key building block of health care systems by World Health Organization (WHO 2007). It is obvious that evidence-based MH policy, planning, education, and practice are dependent upon an efficient information system (Petersen et al. 2017;Sulaberidze et al. 2018;Taghva et al. 2017;Kpobi et al. 2018). Furthermore, a well-developed MH information system has an important role in patients' registration and follow-up, monitoring health plans, and evaluating quality of services (Petersen et al. 2017;Sulaberidze et al. 2018;Murphy et al. 2018). Shortage of logistic resources and lack of skillful staff are the basic challenges for establishment of MH information system in developing countries (Ndetei and Jenkins 2009). Governments have to increase investments in development and maintenance of MH information system. Involvement of all stakeholders such as policy makers, managers, professionals, and researchers is necessary for better development and adoption of the system (Kpobi et al. 2018;Ndetei and Jenkins 2009). A practical MH information system should have the capacity of combining and disseminating evidence in order to develop national guidelines for informed policy, practice and education (Sulaberidze et al. 2018;Wakida et al. 2018;Zhang et al. 2019).
Rigorous MH policy is a neglected part of national health policy in some developing countries. Although high-income countries have had significant achievements in MH policy and practice (McDaid et al. 2008), importance of MH as an integrated part of health policy has not yet been recognized properly in many poorer countries (Jenkins et al.2011). This problem necessitates development of a comprehensive and evidence-informed MH policy in LMICs. Formulation of MH policy should be based on real needs of the community and governments should have adequate commitment to implementation of the policy in all levels (Sulaberidze et al. 2018). National MH policies must be formulated according to the condition of each country and it is necessary to develop compound indicators for assessment of policy at all levels from the adoption of policy to the implementation and practice (Jenkins et al.2011).

Utilization Barriers
This review indicated that, similar to the many other countries, the most important attitudinal barriers to the utilization of MH services in LMICs is fear of social stigma. One useful approach for detracting stigmatization is improving public knowledge about mental disorders (Erickson 2006). Also, it is suggested that inter-personal face to face communication between community individuals and people with mental disorders could be helpful (Penn and Couture 2002). However, these strategies should be used according to the specific intermediaries of each situation . Moreover, it is suggested that developing some anti-stigma campaigns would be effective (Salaheddin and Mason 2016).
Self-stigma as another important attitudinal barrier to the utilization of MH services is related to the negative internalized perceptions and beliefs about MH status. This feeling can result in shame and accordingly reduces willingness to seek MH services (Sharp et al. 2015). Forasmuch as, negative personal attitudes toward mental health problems is the leading cause of this problem, educating patients can alleviate it (Taghva et al. 2017). Support from groups of peer who have controlled the problem successfully (Corrigan and Rao 2012) and self-empowerment (Mittal et al. 2012) are suggested as other approaches for tackling self-stigma.
Patients' concerns about usefulness and quality of services is another challenges of utilization of MH services in developing countries. Undesirable experience of treatment could affect patients to be worried about effectiveness of services (Andrade et al. 2014). Furthermore, patients' tendency towards alternative types of treatment may persuade them to become pessimistic about the specialized services (Luitel et al. 2017;Ali and Agyapong 2015). According to these reasons, it seems that improving the quality of mental health services and increasing public knowledge about these services could remove or modify the barrier.
Concern about negative attitudes and behaviors of MH professionals is another attitudinal barrier to the utilization of MH services in LMICs. An unfavorable experience with care providers may have great impact on the patients' willingness to utilize available services (Ghanizadeh et al. 2008;Tristiana et al. 2018). Lack of adequate training (Luitel et al. 2017;Taghva et al. 2017), failure to align scientific learning with cultural beliefs (Schierenbeck et al. 2013), and fear of working with patients with mental disorders are among the most important causes of professionals' negative attitudes and behaviors toward patients (Caplan et al. 2018). Some researches indicated that implementation of stigma reduction programs for service providers would have positive outcomes (Luitel et al. 2017;Tristiana et al. 2018).
Unaffordable cost of MH services is the most frequent structural barriers to the utilization of available services in LMICs. The highest expenditures are pertaining to the medications and treatment services (Chikovani et al. 2015). A remarkable share of the cost is also attributable to the economic losses due to the reduced productive capacity of patients and their family (Pierce and Brewer 2012). Some of the main reasons for this problem are lack of insurance coverage (Andrade et al. 2014), imperfect coverage (Cadigan et al. 2019), and unaffordable insurance premium (Rugema et al. 2015). In order to reduce direct costs of treatment, it is suggested that countries have to develop initiatives to introduce or improve community-based health insurance schemes (Hailemariam et al. 2017). Providing affordable cost-effective interventions is another approach that would be helpful in alleviating the problem (Wiley-Exley 2007).
Location of MH care facilities and difficulties in transportation are among the most frequent structural barriers to the utilization of services in many developing countries. Geographical distance from MH facilities, especially in rural areas, has a notable adverse effect on equitable access to MH care in LMICs (Jacob et al. 2007). In addition to the limited transportation capacity, cost of transportation as an indirect cost of treatment is also associated with limited access to MH services (Pierce and Brewer 2012). It is suggested that integrating MH services into primary health care and developing more community-based facilities can reduce these barriers in developing countries (Brenes et al. 2015).
In some LMICs lack of social support resulted in reduced access to MH care. Social support is a multi-dimensional issue. From one perspective, patients from poor families usually need financial support for utilization of available MH services (Hailemariam et al. 2017). On the other hand, some patients need support for emotional relief which is known as "implicit support" (Yu et al. 2018). Finally, patients with severe illnesses need someone to help them get professional care (Luitel et al. 2017;James et al. 2019). In order to reduce these problems some strategies such as providing financial grant for poor families (Schierenbeck et al. 2013), improving peer support programs (Yu et al. 2018), as well as expanding adequate and community-based MH services (Hailemariam et al. 2017) are suggested.
Time-related barriers are among the main structural challenges of access to MH services. Long waiting times at outpatient facilities and hospitals may persuade some patients to give up treatments(Jack-Ide and Uys 2013). Another challenge is problem with taking time off work or home responsibilities for employees and housekeepers (Luitel et al. 2017;Caplan et al. 2018;James et al. 2019). Transportation time is another time-related barrier that prevent access to MH services. Health systems in LMICs should give priority to MH and have to support MH services by providing adequate resources in order to promote treatment continuation (Jack-Ide and Uys 2013).
Lack of adequate knowledge about mental problem among patients and their families is a great challenge against utilization of MH services in many developing countries. Recognition of the problem is an essential prerequisite for help-seeking and accordingly utilization of MH services (Whittle et al. 2018). Patients' knowledge about the nature of their mental disorder, symptoms of the disease, and severity of the illness would lead to better recognition of the problem (Stroud et al. 2014). Therefore, more severe cases of disorders are more likely to be identified and treated (Mehta et al. 2009). Therefore, health systems in developing countries have to implement appropriate public education programs in order to improve public knowledge about MH disorders and their symptoms (Luitel et al. 2017).
This study indicated that lack of information about different types of treatment and place of services are important knowledge barriers to the utilization of MH services in some LMICs. In line with our findings, results of a global MH survey conducted by WHO indicated that lack of knowledge about the existing services was a great barrier to the utilization of services (Andrade et al. 2014). Health systems in developing countries should improve public knowledge about available MH services in order to help patients seeking treatment (Jack-Ide and Uys 2013). Also, improving social support could be effective in raising awareness of patients and their families (Luitel et al. 2017).
Past experience of treatment adverse effects, especially in medications and technology-based treatments, plays a deterrent role against utilization of MH services. Lack of adequate knowledge on necessity of continuous treatment and its possible adverse effects is a great challenge which dissuades patients from receiving care and decreases adherence to treatments (Hailemariam et al. 2017;Iseselo and Ambikile 2017). It is suggested that increasing patients' knowledge about different treatment choices and their potential side effects would be beneficial (Schierenbeck et al. 2013). In this regard, studies reported that mass media campaigns could improve community MH literacy (Livingston et al. 2013), increase help seeking behaviors (Demyan and Anderson 2012), and may reduce stigma attitudes (Yamaguchi S 2013).
Studies show that some challenges of equitable access to MH services are more serious in remote and rural areas. In developing countries, the scarcity of MH care resources and, consequently, the geographical imbalance in allocation of these resources have the greatest impact on people living in remote and rural areas (Gamm et al. 2010). Moreover, non-integrated MH services drastically reduce access to the services in these areas (Saraceno et al. 2007;Sulaberidze et al. 2018). Also, it is evident that barriers related to transportation and distance from care facilities are attributable to more deprived locations (Ghanizadeh et al. 2008;Luitel et al. 2017).
Although we developed conceptual map to provide a more comprehensive perspective on the topic, the weight and importance of the barriers must be investigated based on the specific contexts of countries.

Research Gaps
This review indicated that some areas on barriers to the provision and utilization of MH services in LMICs are neglected and require further researches. One of these areas is difficulties in patient-provider relationship in MH services settings. Another field of research is problems of compliance with treatment among mental illness patients. In this review we discussed the results of analysis regarding the frequency of barriers. Therefore, relative importance of these barriers and their related solutions based on the national context of each country remains as an important area of further research.

Study Limitations
In this review we included papers with various types of study and different design methods. This problem sometimes leads to difficulty in the synthesis of data. However, scoping review comprises an approach for appraisal and inclusion of heterogeneous studies. In this regard, a thematic content analysis can greatly alleviate the problem. Although we tried our best to review all studies pertaining to challenges of provision and utilization of MH services in LMICs, access to all relevant studies is dependent on various contributors with the potentiality of missing some evidences. Finally, in this review we focused on barriers to the provision and utilization of MH services among adult population. Therefore, this study did not consider other groups such as children or the elderly.

Conclusion
Equitable access to MH services is under influence of both supply and demand sides. On the supply side, provision of appropriate MH services in LMICs is subjected to some barriers including resource and administrative barriers, information and knowledge obstacles, as well as policy and legislation barriers. On the other side, patients in LMICs are faced with some barriers to the utilization of MH services including attitudinal, structural, knowledge, and treatmentrelated barriers. According to the these evidence, health systems in LMICs cloud adopt various strategies such as 1 3 integration of MH policy into general health policy, reallocation of health resources in favor of high-priority MH services, developing community-based insurance with a special respect to MH services, integration of MH services into all levels of healthcare systems, development of comprehensive MH information system, improvement of public knowledge about MH and its related issues, and developing stigma reduction programs. The weight and importance of these barriers must be determined based on country-specific socio-economic contexts.