Sahibzada Muhammad Hamza

Factors Affecting the Supply of, and Demand for, Mental

Health Care in Qatar (Demand – Side)

1. Literature Review
In recent years, mental health has been highlighted as a priority in Qatar's national health policy, resulting
in improvements in facilities, recruiting, and services. Qatar's mental health sector is still in its early stages
of development, with ambitions to expand inpatient and community mental health care. According to the
World Health Organization (WHO), 25% of the worldwide population will suffer from a mental health
issue at some time in their lives (WHO Atlas, 2014). Evidence-based psychological treatments are critical
to successfully managing many mental health disorders worldwide (WHO, 2016). However, there is a
considerable treatment gap between the number of people needing therapy and those receiving it. In some
areas of the world, up to three-quarters of people who may benefit from therapy do not receive it (Jorm et
al., 2017; Kohn et al., 2004). At the same time, a lack of resources is frequently a factor in this treatment
disparity (Fairburn & Patel, 2014; Lora et al., 2012).

This treatment disparity is not just due to a lack of physicians or services in the middle- and low-income
nations; a relative disparity exists in high-income countries such as the United States (e.g., Kessler et al.,
2005). As a result, other barriers to receiving treatments provided by mental health providers are present.
Stigma (Saxena et al., 2007), poor mental health literacy and a preference for self-reliance (Gulliver,
Griffiths, & Christensen, 2010), a lack of motivation, negative evaluation of therapy, therapy misfit to
needs, time constraints, participation restrictions, and availability of services are among the barriers to
accessing psychological therapy that has been identified (Mohr et al., 2006, 2010).

While there are hurdles to receiving psychiatric therapy worldwide, they are not all the same. Gearing et al.
(2013), for example, identified 78 barriers to successful treatment implementation in Middle East Arab
nations. These were drawn from a systematic review of 22 psychosocial or mental health studies conducted
in Middle Eastern Arab countries. They were divided into three categories: cultural context, community,
systems, and clinical engagement method. Cultural context barriers included attitudes and values, such as
a preference for traditional healers (AlKrenawi et al., 2004; ElIslam, 2005) and the influence of stigma.
This would include sociocultural shame regarding the mental disorder and using services, as well as fear of
showing disrespect to one's family (Shalhoub-Kevorkian, 2005), and fears that women would lose their
marriage potential because of accessing mental health services (AlKrenawi & Graham, 1999; Shalhoub-
Kevorkian, 2005). This possibility of not marrying is crucial in Arabic cultures since marriage is generally
viewed as an obligatory milestone in a woman's life; hence, not marrying might be a source of greater
 Sahibzada Muhammad Hamza

humiliation and disgrace. Access and availability of mental health services were identified as community
and system barriers (AlKrenawi & Graham, 1999; Shalhoub-Kevorkian, 2005), while clinical engagement
process barriers included a lack of understanding of the nature of psychological therapy (AlKrenawi &
Graham, 1999; Murray et al., 2006) and a preference for a medical approach (AlKrenawi et al., 2001).

Gearing and colleagues discuss the need for mental health interventions in the Middle East to consider
culturally specific contexts, such as the overriding value placed on family membership (these countries tend
to be "collectivist" cultures, which refers to valuing the needs of a community over those of an individual),
the role and status of women, stigma associated with mental health symptoms, a preference for indigenous
healing, and a preference for indigenous healing. Despite these potentially beneficial ideas for effective
treatment implementation tactics, there is a scarcity of credible data to support the case for the cultural
adaptation of mental health therapies (Rathod et al., 2018). It is also crucial to emphasize that, while hurdles
to successful treatment implementation are likely comparable to barriers to treatment access, they are not
fundamentally the same.

In the context of Qatar

Qatar is a small Arabian Gulf nation with a land border with Saudi Arabia. Due to its Islamic background,
most people identify as Muslim, and the country is governed by a combination of civil and Sharia law.
Qatar's traditional culture is that of a typical collectivist Arabic community (AlHaj, 1987; Barakat, 1993),
with these societies historically prioritizing communal good above individual benefit and social stability
over social change. There is a propensity to firmly adhere to societal norms and values and gender
segregation rules (AlAttiyah & Nasser, 2016).

Due to its massive natural gas reserves, the country has the world's most extraordinary gross domestic
output per capita. It has witnessed significant economic progress in recent years, capped by being awarded
the privilege to host the FIFA World Cup in 2022. As a result, Qatar's population has shifted dramatically
in recent decades. For example, in the previous 20 years, its population has folded to over 2.4 million, with
87% of the population being foreigners on short-term work contracts (CIA World Factbook, 2019). Indeed,
Qatar boasts the world's highest expatriate-to-citizen ratio. Therefore, this Arab region's demographic
composition is diversified and complicated, yet it is dominated (56%) by immigrants from the Asian
subcontinent working as unskilled labor migrants (Khaled & Gray, 2019).

According to a recent examination of the global burden of illness data set, the burden of mental health issues
is higher in Middle Eastern nations such as Qatar than in other regions of the Western world (Charara et
al., 2017). Furthermore, during the last 20 years, this weight has grown. While potentially a crude measure
of mental wellbeing, particularly in Qatar, where epidemiological data is limited, these statistics highlight
 Sahibzada Muhammad Hamza

the need for substantial resource investment in this area of health care if these countries are to manage the
growing burden that mental illness can place on the country and its population. With the rise in both
population and disease, Qatar's healthcare services urgently need to be expanded. Despite this rise, Sharkey
(2017) found that spending on mental health treatment accounted for only 0.34% of healthcare spending,
which is seven times lower than spending in affluent Western nations. This suboptimal level of spending
on mental health compared to physical health has been consistently observed across the region's low,
middle, and high-income countries (Charara et al., 2017; Okasha, Karam, & Okasha, 2012) and thus appears
to reflect a bias against mental health rather than, say, the persistence of severe health problems affecting
mortality, such as infectious diseases and malnutrition. Sharkey further stated that most of this spending in
Qatar was on inpatient care at the only mental health institution in Doha, Qatar's central city. According to
the most recent WHO Mental Health Atlas, Qatar has 1.66 psychiatrists, 10.94 nurses, and 1.26
psychologists per 100,000 people.

The United Kingdom has an average of 13 psychiatrists, 52 mental health nurses, and four psychologists
per 100,000 people (WHO, 2014). Qatar has a "National Mental Health Strategy" in place (Sharkey, 2017;
Supreme Council of Health, 2013), which outlines plans for modernizing mental health care in the country.
It emphasizes the need for evidence-based practice (including psychological treatment) as a critical stage
in service delivery.

To successfully scale up and enhance mental health services throughout Qatar, the hurdles to treatment,
mainly psychological therapy, must be addressed. Extrapolating obstacles from other Middle Eastern
nations, such as those highlighted by Gearing et al. (2013), is insufficient given the unique nature of each
Middle Eastern country. The current study aimed to understand the hurdles better to receive psychological
therapy in Qatar, as seen by stakeholders with unique perspectives inside the nation.
 Sahibzada Muhammad Hamza

1.1 Conceptual Framework.

Cultural
Implication(s)

Cross -
Cultural Stigma
Theraphy Demand
Barriers For
Seeking Mental
Health

Misunderstandi
Impact of the
ng about
Family
Theraphy

(cited by: Mechammil, Boghosian & Cruz, 2019; Aloud & Rathur, 2009; Nobles & Sciarra, 2000; Keshavarzi &
Haque, 2013; Ali, Milstein & Marzuk, 2005; Chisholm, 2015; Al‐ Krenawi & Graham, 1999; Shalhoub‐Kevorkian,
2005; Rathod et al., 2018; Al‐Krenawi et al., 2004; El‐Islam, 2005).

1.2 Research Instrument

A Likert – Scale Questionnaire will be developed to record respondents' responses. The respondents'
responses will be gauged on a scale of 1 (Strongly Disagree) to 5 (Strongly Agree). A range of control
variable(s), which include Age, Gender; Education; Marital Status, and Income, will be included in the
questionnaire to capture the demographic(s) of the respondents. The questionnaire comprises forty-five (45)
questions that reflect the conceptual framework's five (5) themes. The statement(s) included in the
questionnaire are mentioned in the table below:
 Sahibzada Muhammad Hamza

Statement(s) Theme
1. People hold traditional explanations of mental illness such as “evil eye" or being Cultural Implication(s)
possessed by spirits.
2. People access traditional healers for the treatment of mental illness Cultural Implication(s)
3. A belief that problems should be dealt with within the family Cultural Implication(s)
4. The needs of the family are put before their own needs (a collectivist culture) Cultural Implication(s)
5. A male family member's expected presence in therapy sessions prevents women Cultural Implication(s)
from expressing themselves openly.
6. A person's cultural baggage might unconsciously impact their behavior Cultural Implication(s)
7. Reliance on what is in the Qur'an rather than a newer understanding of how the Cultural Implication(s)
mind works
8. Everything is “God's willing”—Insha’Allah Cultural Implication(s)
9. Issues of anxiety, depression, and trauma are not concepts discussed within the Cultural Implication(s)
culture.
10. Therapy is a Western concept. Cultural Implication(s)
11. The local population feels hostile towards expatriates "taking over their country." Cultural Implication(s)
1. The stigma associated with mental illness Stigma
2. There are no "answers" available yet to tackle the stigma Stigma
3. Fear of being labeled Stigma
4. Preference to self‐medicate Stigma
5. A lack of understanding of mental health problems Stigma
6. Problems are suppressed rather than tackled. Stigma
7. Preference to see mental illness as a physical illness (somatization) Stigma
8. People perceive that if you are mentally unwell, it means you are weak Stigma
9. People perceive that if you need to see a psychologist, then you are mad Stigma
10. Clients would prefer to take medication to "take the problem away" rather than Stigma
talk.
11. Clients are disappointed that therapy does not offer an instant fix Stigma
12. People are only willing to attend therapy sessions when there is a drama/crisis. Stigma
13. Some behaviors that may benefit from therapy are intolerable/illegal in Qatar Stigma
(e.g., suicide)
14. Clients don't want to be a patient who is ill Stigma
15. Society wants to keep mentally ill people away from the rest of Stigma
society
 Sahibzada Muhammad Hamza

16. Fear of discrimination from family, friends & others Stigma

17. Clients don't want to accept a diagnosis Stigma
18. Fear of losing the job because of having therapy Stigma
1. A fear of having your or a family member's chances of getting married affected Impact on the family
2. Therapy is seen as sharing family secrets rather than speaking with someone. Impact on the family
3. The law still criminalizes seeking help for “haram” behaviors (e.g., suicide) Impact on the family
4. Qatar is a small community—fear of being recognized or bumping Impact on the family
into therapist
5. Fear of disgracing family Impact of the family
6. Men do not see therapy as for them Impact of the family
7. Services are only accessed when the family cannot cope any longer Impact of the family
8. Showing need/dependency on others is shameful. Impact of the family
9. Group work is not possible as people do not want to talk in front of others Impact on the family
1. Lack of understanding of confidentiality Local (mis)understanding
of therapy
2. Qatar is not yet in the right place to accept psychological services (new country Local (mis)understanding
of therapy
3. A lack of understanding of what therapy is Local (mis)understanding
of therapy
4. People in Qatar are not used to an appointment-based system instead of turning Local (mis)understanding
up and being seen. of therapy
1. Therapists lack therapeutic abilities to deal with cultural diversity Cross-Cultural Therapy
2. A concern that therapists do not understand traditional/cultural explanations Cross-Cultural Therapy
3. The difficulty in successfully delivering culturally sensitive psychological Cross-Cultural Therapy
therapy