Beliefs, referrals, and mental healthcare pathways in the Eastern Democratic Republic of Congo.

Although the primary healthcare (PHC) system gatekeeps early access to mental healthcare services, little is known about the factors influencing the use of these services by people with mental disorders living in conflict zones of Eastern Democratic Republic of Congo. The current study describes the patterns and factors associated with pathways to mental healthcare, with an emphasis on how religious beliefs and referral patterns are associated with the use of PHC. We surveyed patients (n = 404) attending nine psychiatric hospitals to elucidate the pathway used for those with mental health needs to obtain care. Binary logistic regressions were performed to identify factors associated with first, second, third, and fourth points of contact when seeking care. In total, 47.3% of patients had their first care contact at a psychiatric hospital while 89.3% were self-referred. Roughly one-third of participants' first point of contact was a religious leader. Asked about sources of their compromised mental health, 32.7% of respondents reported witchcraft, 30% supernatural powers, and 12.5% divine punishment. Having a family history of mental disorders and a religious affiliation other than being Pentecostal and non-Pentecostal (aOR=0.17, p = 0.026) were associated with lower odds of non-PHC first contact (aOR=0.06, p = 0.004). Additionally, having multiple psychiatric episodes (aOR=9.86, p = 0.028), self-referral (aOR=6.37, p < 0.001), and attributing challenges to divine punishment (aOR=4.68, p = 0.05) or witchcraft (aOR=2.35, p = 0.04) were associated with higher odds of non-PHC first contact. Findings reveal the significant underutilization of PHC for mental health needs in conflict zones, individuals instead favoring self-referral to psychiatric hospitals or religious leaders. This behavior is driven by cultural and religious beliefs, specifically attributing mental disorders to witchcraft, divine punishment, and lack of integrated mental health services within the PHC system. We conclude with discussion of a collaborative model between religious leaders and medical professionals to improve care pathways in conflict zones.