Table A1.

Community perceptions of barriers to management of chronic psychotic disorders in Dar es Salaam, Tanzania (n = 44)

Themes and categories	Illustrative quotations from respondents
Knowledge barriers: causes/diagnosis; medications; and lack of educational materials Medication barriers	‘We are speaking that the mental illness comes as a result of marriage issues. If you are not married, this illness can take hold of you. This illness will not knock on your doorstep if you are married.’ (Patient respondent 15) ‘My patient knows about the medications but he doesn't believe that they can help him He has already got into despair. He has used the medications for a long time without significant improvements and he has not achieved what he expected. I think these medications are just bringing short term relief. He is just taking the medications but the disease will still be there.’ (FCG1 respondent 6) ‘The level of awareness about mental illness in our community, it is still very low. Therefore, we find that we have a need to focus on provision of sustainable mental illness education. This is why some other patients and family delay to come for treatment and will go for traditional treatment.’ (HCP2 respondent 4)
Attitude and belief barriers	‘You know there are some families that have deep religious beliefs, such that they believe that the patient is to be prayed for, and not to use the medications. Therefore, you find that someone is in prayer services all the time and does not attend the clinics or take the medications.’ (HCP1 respondent 2) ‘Despite the side effects that make the patients not wish to take the medications for a long time, there are false beliefs around the community that, if you start using the medications, you would never stop them because they have an addictive effect. Therefore, such a belief makes some people avoid taking hospital-based medications.’ (HCP2 respondent 6)
Psychological barriers: stigma; stress; loss of self; depression; fear of hospital; admission; and fear of addiction to medications	‘I don't like them [people at work] to stigmatize me at the workplace. I don't like them to know about it [mental illness] otherwise they would find a way to make me feel inferior. You know, being called crazy, hurts in the heart’. (Patient respondent 10) ‘I feel that I am now wasting time. My classmates have made a step forward. I am now 42 years old but I do not have my own home and live a difficult life with my relatives who just want me to go and pick empty cans in the street.’ (Patient respondent 11)
Behavioural barriers: irrational/harmful behaviour; medication non-adherence; substance misuse; and use of traditional healers	‘There are complications. For instance, you can beat someone to death, or become bad tempered. I have beaten a young man recently and some people said that it was part if this illness. I beat him and kicked him as well.’ (Patient respondent 14) ‘I feel that I am no longer sick, why would I have to take these medications, so when I return home from the hospital I usually stop taking the medication, that's why this disease keeps recurring.’ (Patient respondent 3) ‘It is true that if one is on medication and takes alcohol, she/he can forget to take the medications. Most of the patients who take alcohol have this character.’ (HCP2 respondent 3) ‘Among the patients we admit in our wards, it may be only one among ten patients that may not have been to the traditional healers. (HCP1 respondent 5)
Lifestyle barriers: lack of family and community support; access barriers to medications; and access barriers to clinical care	‘The community does not support them. People scorn and despise the patients with mental illness. There are people laughing at them and treating them with contempt.’ (FCG1 respondent 6) ‘The medications are helpful to them, but there are times when you don't have money and these medications are expensive. Therefore, you can sometimes have to get off medications while trying to get money to buy him medications. At this time, it happens that his condition gets worse.’ (FCG2 respondent 7) ‘Some fail to come to the clinics because of stigma. Therefore, if the patient finds that there are negative comments about attending the clinics, she/he feels like there is no need to attend the clinics.’ (HCP2 respondent 3)

FCG1/FCG2, caregiver respondent; HCP1/HCP2, healthcare provider respondent.