‘Since people who have mental illness are stigmatised, their service is also stigmatised. You get a massive hospital building and there is no mental health facility’: exploring perceptions of mental health, stigma of mental illness, care-seeking and

BACKGROUND: There are few mental health services in the Somali Regional State (SRS) of Ethiopia, and many people with mental health conditions turn to traditional healing. Also, little is known about perspectives on mental ill health and care in this sociocultural context. AIMS: The study explores the experiences and manifestations of mental health-related stigma in the SRS, to inform the development of mental healthcare systems. METHOD: We conducted 16 semi-structured interviews with health workers, aspirational leaders, users of mental health services and carers in Jigjiga and Kabridahar, two cities in the SRS, between April and July 2024. Translated transcripts were imported into NVIVO version 14 for coding and were then analysed using the thematic analysis method. We identified three main themes: (a) mental health stigma, (b) societal neglect and (c) misunderstanding of mental ill health. RESULTS: Participants suggested that most people in the SRS view mental health in binary terms, in which a person is either 'mad' or sane; a corollary is that only severe conditions with overt behavioural manifestations were viewed as mental illness. Most people viewed mental health conditions as having spiritual causes. Mental health stigma was reportedly widespread and severe. These barriers contribute to care-seeking that is delayed and initially focused on faith-based providers. CONCLUSIONS: Any intervention to improve the provision of mental health services and the development of mental health systems must take into account the perspectives of service users and carers, and address the widespread stigma and lack of knowledge around mental illness.