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Mental health, Montserrat, Stigma, Primary Care, Healthcare professionals.
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Al-Jabr H, Berners-Lee B, Shepherd T et al. Exploring mental health experiences and support in Montserrat: A healthcare professional’s qualitative study [version 1; peer review: awaiting peer review]. NIHR Open Res 2026, 6:151 (https://doi.org/10.3310/nihropenres.14448.1)
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Research Article
Exploring mental health experiences and support in Montserrat: A healthcare professional’s qualitative study
[version 1; peer review: awaiting peer review]
PUBLISHED 06 Oct 2026
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Abstract
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Corresponding author:
Hiyam Al-Jabr
Competing interests:
No competing interests were disclosed.
Grant information:
This work was supported by a NIHR Senior Investigator Award that was awarded to Prof Christian Mallen. Prof Mallen is also funded as a director of the NIHR SPCR (Award ID: NIHR203020). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:
© 2026 Al-Jabr H et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Al-Jabr H, Berners-Lee B, Shepherd T et al. Exploring mental health experiences and support in Montserrat: A healthcare professional’s qualitative study [version 1; peer review: awaiting peer review]. NIHR Open Res 2026, 6:151 (https://doi.org/10.3310/nihropenres.14448.1)
First published: 06 Oct 2026, 6:151 (https://doi.org/10.3310/nihropenres.14448.1)
Latest published: 06 Oct 2026, 6:151 (https://doi.org/10.3310/nihropenres.14448.1)
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Introduction
Mental health conditions are a significant contributor to morbidity worldwide, accounting for 1 in 6 years lived with disability (World Health Organisation, 2026). Rates of mental health conditions, including anxiety, depression and schizophrenia are growing, particularly in regions such as the Caribbean (Gallimore et al., 2023). The reasons for this are multifactorial and include an aging population, loss of tradition support systems, substance misuse and unemployment (Lacey et al., 2016).
Mental health conditions are often culturally and socially stigmatised in the Caribbean and associated with a feeling of shame and weakness that can result in an underutilisation of mental health services and poor health outcomes (Mascayano et al., 2016).
Montserrat is a British Overseas Territory in the Caribbean that experienced a catastrophic volcanic eruption 30 years ago. The previously dormant Soufriere Hills volcano (SHV) became active in 1995, resulting in two thirds of the country being declared unsafe and the capital, Plymouth being destroyed. Montserratians were forced to either relocate to the north of the island or move completely, often to the United Kingdom, resulting in a loss of traditional family and community support (Avery, 2003; Clay et al., 1999; Kokelaar, 2002).
Awareness of formal mental health services and clinical concepts was reported to be low and stigma towards mental illness high among the general population (Walker et al., 2022). Available mental health services are community based; there is currently no formal mental health inpatient facility and specialist psychiatric services are delivered by a visiting psychiatrist. There are low levels of mental health literacy on the Island, and the long-term consequences of the volcanic eruption are not known, impeding the ability to commission appropriate services to support. This study therefore aimed to investigate mental health and mental health services in Montserrat.
Methods
Patient and public involvement
Patients and members of the public were not involved in the design of this study as the study focused on exploring the views and experiences of HCPs. The study and topic guide were however developed in consultation with academics and clinicians in Montserrat.
Study design
The study was conducted in Montserrat in collaboration with Keele University in England, UK. The study was initially designed to exclusively use focus group discussions, however, to enhance participation and accommodate the needs of participants, individual interviews were also included.
Ethical approval
Prior to commencing the study, ethical approvals were obtained from the Montserrat Ministry of Health (Ref: MHSS/CMO/4/6) and from Keele University Faculty of Medicine and Health Sciences Research Ethics Committee (Ref: 1126). All participants signed a written informed consent form prior to taking part.
Study population
Eligible participants included HCPs employed by the Montserrat Ministry of Health, involved in providing mental health services in Montserrat.
Sampling procedure
HCPs were recruited by emails distributed by the Ministry of Health to current employees. Written information booklets were provided through which participants were aware of the study aim and objectives and what their participation entailed.
Data collection and analysis
Participants were invited to attend either a focus group or individual interview, facilitated by a local researcher (B B-L). The focus group and interviews were conducted face-to-face at the Participant’s workplace or a clinical setting. These were arranged at participants’ convenience and were led by a topic guide that was designed by the research team in consultation with the relevant literature ( Table 1).
Table 1. Interview topic guide.
| Leading question | Probing question(s) |
|---|---|
| 1. What types of mental health problems do you see? |
|
| 2. What types of mental health support are provided in Montserrat? |
|
| 3. What training needs do you have? (if any) |
|
Collected data were audio recorded, transcribed verbatim and anonymised using a professional transcription service. All data were collected by the same local researcher (B B-L) at Montserrat and were analysed by another researcher at Keele University (HAJ).
Data were analysed using reflexive thematic analysis as described by Braun and Clarke (Braun & Clarke, 2006). The data analysis was underpinned by a constructivist perspective. A phenomenological orientation was adopted to prioritise lived experiences and personal interpretations of mental health of participants. An inductive thematic analysis was conducted by following Braun and Clarke six iterative steps: (1) familiarisation with the data through repeated reading of all transcripts; (2) generation of initial codes across the full dataset; (3) construction of candidate themes by identifying patterns of shared meaning across codes; (4) review of candidate themes against both the coded extracts and the full dataset to assess internal coherence and mutual distinctiveness; (5) definition and naming of final themes; and (6) production of the final report.
Transcripts were re-read and initially coded by [HAJ, female research fellow] using NVivo Software. Developed codes were reviewed and discussed with the research team to ensure consistency of the coding process and assist the development of themes. Codes with apparent relationship were grouped together to develop main themes. Final themes were reviewed and agreed upon by other members of the research team.
Informed by the concept of information power, data collection continued until the dataset was judged to contain adequate depth and breadth of information to support a meaningful exploration of the aim and objectives of this study (Malterud et al., 2016).
Reflexivity
Interviews were undertaken by a researcher (B B-L, male epidemiologist), who was resident in Montserrat during the study period and had prior experience conducting qualitative research. His familiarity with the local healthcare landscape, culture, and community context facilitated the development of trust and supported open discussions with participants.
The analysis was led by another researcher (HAJ, female, research fellow) who is based in England and has experience in qualitative methods but limited prior exposure to the Montserratian context. This position as a relative outsider encouraged a more interpretive and reflexive engagement with the data and reduced the likelihood of assumptions arising from local knowledge.
The broader research team brought together expertise in qualitative research and substantial knowledge of Montserrat. Throughout the study, regular discussions were undertaken to consider how researchers’ perspectives, experiences, and positions may have shaped data interpretation. These discussions also supported efforts to ensure that interpretations remained closely aligned with participants’ accounts and to protect participant anonymity within the small-island setting.
Results
Eight HCPs expressed interest in the study and were recruited, of which three chose individual interviews and the remaining were included in a focus group discussion. Most participants were females (n=5, 62.5%) and not born in Montserrat (n=6, 75%). Those who reported their age were mostly between 50-59 years (n=3, 37.5%). Demographic characteristics are summarised in Table 2.
Table 2. Characteristics of recruited participants.
Three main themes were identified. These are described below. Supportive quotes are presented in Table 3.
Table 3. Participants' supportive quotes.
Theme 1: Sources of mental health support in Montserrat
Participants described the mental health illnesses encountered on the island, existing support resources and pathways to accessing mental health support.
A range of mental health illnesses were discussed, ranging from mild to chronic conditions, and affecting almost all age groups. Assessment of mental health conditions during pregnancy was also highlighted to identify early symptoms and manage mental conditions that might develop during pregnancy or after delivery.
Some participants raised alcohol/substance misuse as a problem within the community, seen higher in men. However, the public may not consider this as of concern, until it starts affecting their functioning (see quote 1.1).
Conditions affecting younger age groups were also described, including anxiety, depression, and behavioural and neurodevelopmental disorders. A participant noted that children usually present with multiple conditions rather than one single mental health problem.
Family was reported to be amongst the first sources of support. Participants also highlighted the role of church in providing support including listening to people, praying and fasting, outreach activities on health and wellbeing, and referring people to medical support. However, due to insufficient understanding of mental health, a participant reported that some parents may only seek support for their children from the church and not from professionals. While the church can provide important emotional and social support, some mental health needs may require additional professional care (see quote 1.2).
Charitable organisations offering support were identified by participants. These organisations provide social services (e.g., cloths and food) to people in need on the island, with a lack of an organisation specific to supporting mental health.
Another form of support was related to workplace. One participant mentioned some workplaces contact them to ask them to run a session on mental health. This helped in raising awareness for the whole workplace, and on supporting those who needed support without individually targeting them.
Support from the police was also noted. Unlike in some other countries, policing was described as more community-oriented, with a relaxed, rapport-based approach rather than a primarily criminal approach.
Prison was also considered an important context for the provision of mental health services. Service provision within the prison service provision of psychological rehabilitation services to reintegration into the community. There is no secure inpatient facility for psychiatric patients, only a room at the hospital which can be used to managing acutely mentally ill persons and to care for prisoners needing hospital care.
Support from HCPs was also reported. One participant mentioned several outreach activities they conduct to raise public awareness about mental health issues, their symptoms and tips to getting support. These are diverse training and educational outreach activities, that target people of different age groups and at different places including school pupils, schoolteachers, and workplace. Additionally, a weekly radio programme was mentioned that also increases public awareness on mental health.
Participants mentioned approaches that helps to protect patient’s confidentiality and privacy. This included avoiding open discussions with patients about mental health matters if they happened to encounter one another in public. Moreover, mental health care is provided within a facility that offers a range of healthcare services, helping to preserve patient privacy since others cannot easily determine the reason for an individual’s visit (see quote 1.3).
Some feedback was shared regarding improvements in mental health services on the island. this included increase in number of professionals and in number of people coming forward to seek support, which reflects an increase in their trust in the system.
Theme 2: Barriers to mental health support in Montserrat
Several types of barriers encountered by HCPs were described by participants. These include difficulties with the long-term follow up plan for patients (e.g., lack of follow up referral pathways, lack of long-term follow-up treatments), and lack of sufficient mental health staff. Lack of understanding among the healthcare staff is another barrier, which makes some feel uncomfortable or even refuse caring for people with mental health issues due to lack of sufficient knowledge and skills (see quote 2.1).
Lack of financial and human resources were also reported, and lack of awareness of policy makers of encountered barriers (see quote 2.2).
Theme 3: Strategies to enhance mental health support in Montserrat
Participants suggested a wide range of strategies to support mental health services on the island, including strategies directed to HCPs and associated staff, and those directed to policy makers.
Strategies targeting HCPs
One strategy was focused on addressing mental health differently and softening the terminology used in addressing it. For example, using terms like “welfare” or “wellbeing” would be less off putting than directly using “mental health”. Another strategy talked about working on the environment to make it more productive of the therapeutic intervention for supporting mental health and the use of play therapy, particularly for young people (see quote 3.1).
Another strategy was related to changing the way HCPs act to help normalise mental health within the community and thus reduce associated stigma. It also includes efforts that HCPs can do to influence people change their attitudes and behaviours, by increasing their awareness and highlighting that benefits of seeking help outweigh risks (see quote 3.2).
An additional strategy highlighted meeting the needs of HCPs and staff. This included providing trainings to enhance their knowledge and skills with supporting mental health. To keep up their license, participants mentioned needing to continuously undertake different activities like attending workshops or trainings to gain the necessary credits for their continuous professional development. However, due to financial limitations, no sufficient trainings or courses are being provided, which forces many to enrol and pay for CPD opportunities to help them renew their certificate.
Training other staff and professional groups that interact or provide care/service to people with mental health issues were also noted. This included all other healthcare workers including nurses, receptionists, and prison officers. This would help reduce the fear that some would have when supporting these people and would also provide them with the needed skills to provide optimal support (see quote 3.3).
Addressing mental health needs of HCPs was also suggested. Limited formal mental health and wellbeing support is described, particularly within the constraints of a limited budget. However, participants mentioned using the usual pathways of support from family and friends, debriefing with colleagues where needed, supporting each other, and using remote services which they personally pay for.
Strategies targeting policy makers
The first suggested strategy was related to improving mental health support resources. This included financial resources, human resources to increase capacity (e.g., more mental health support staff and nurses), physical resources (e.g., having an acute care mental health facility or a branch of a hospital rather than one room, designing offices to be conducting of supporting interventions) (see quote 3.4).
Reviewing and updating policy documents was also suggested by many participants. This included updating the language used to describe people with mental health to be non-stigmatising and sharing and raising awareness of these updated policy documents with everyone, including the public (see quote 3.5).
A final suggestion was given by one participant, about having regular inspection by independent people to ensure that that care that people need is being provided at the different facilities (see quote 3.6).
Discussion
This is the first study to explore the views and experiences of HCPs on mental health in Montserrat. Various experiences were shared, with several reported barriers and facilitators to mental health support.
Like other communities, a range of mental health disorders is seen in Montserrat affecting almost all age groups. Besides professional support, several other resources exist, including support from family and the church. These represent key sources of support in the Caribbean (Cabey, 2022; Connect Media, 2023; Montserrat Invest, 2026), where the wellbeing of people is highly dependent on the strength of family relationships, as well as on traditions, spirituality and values (Cabey, 2022). Several denominations exist in Montserrat, providing various types of support (e.g., fasting, praying) to help people in their healing journey (Cabey, 2022). Concerns were raised about relying solely on non-professional support, as some conditions require care from HCPs. While emotional support from family and church represents an important, protective, and supplementary factor in mental health (Fuller-Iglesias et al., 2015; Krause, 2008; Lee & Szinovacz, 2016; Nguyen et al., 2017; Taylor et al., 2004; Taylor et al., 2017), it remains insufficient on its own for treating more chronic, or serious mental health conditions (Skundberg-Kletthagen et al., 2014; Smolak et al., 2013). There is a need to enhancing awareness among the church community as well and to provide them with necessary training. Spiritual support is important as part of the holistic patient care, however, it should not be provided in isolation of more professional and directed care (Raffay et al., 2016).
Police support to people was also mentioned, which is mostly considered as a community service rather than a criminal approach. Despite not being their primary role, in the Caribbean, police can intervene in mental health-related cases and facilitate contact with health services (Wallace, 2020). This form of support is however supplementary to ensure vulnerable people are linked to proper professional care.
Improving awareness and understanding of the healthcare workforce and service delivery personnel (e.g., police) was also noted, to help reduce the barrier that is driven by fear of handling conditions where skills and knowledge are lacking. This aligns with findings of a study where inadequate training caused some HCPs to be fearful of interacting with people with mental health problems (Gunasekaran et al., 2022). Educating and training healthcare workforce was reported to improve their skills and confidence, reduce fear and stigma and improve quality of mental health care (Davidson, 2021; Zhamaliyeva et al., 2025).
Alongside increased awareness, participants suggested that HCPs use more sensitive and acceptable language when discussing mental health. Literature recommended using appropriate, person-centred language to reduce associated stigma and prejudices that would hinder people from seeking and/or receiving services they need (Bouzoubaa et al., 2024; Volkow et al., 2021).
Another suggestion was for HCPs to better use the clinical environment to support mental health interventions, such as incorporating play therapy for young people. Modifying clinical environment to support mental health is well established in approaches referred to as milieu therapy, where the clinical environment is structured to promote patient engagement with treatment interventions, thus enhancing their wellbeing and behaviour change (Kashyap, 2026).
Lack of awareness by policy makers of barriers that HCPs encounter was also highlighted. As suggested by participants, providing this knowledge to policy maker would potentially allow a specific budget to be allocated to mental health services on the island, which would then be used in activities like designing mental health related programmes and overcome many of the encountered barriers. Globally and across the Caribbean, studies report that mental health remains underfunded, limiting service delivery, training, community programs, and access to care (Doshi, 2017; Open Access Government, 2022; Trade Union Congress, 2018).
Another reported barrier was the lack of support for continuous professional development (CPD). The Medical Act (Governement of Montserrat, 2019) governs the registration of medical practitioners to practise in Montserrat. While the Act does not require periodic re-registration or the submission of CPD evidence, ongoing education may be expected by employers as part of maintaining professional competence. However, CPD activities are not always free, and sometimes are expensive, particularly advanced courses/trainings. Participants reported personally covering the fees for some courses to enable them to renew their license. Healthcare organisations have a responsibility to provide the needed financial and structural support to enable professionals to CPD. Leaving HCPs to self-fund these CPD opportunities may create inequalities and barriers to maintaining competence, although this is challenging in resource limited environments.
Addressing mental health and wellbeing of HCPs was raised by participants and that available resources are limited with some seeking remote care from professionals off the island. This is an important point as literature report that poor wellbeing and burnout affects staff retention, quality of delivered care, and may worsen patient satisfaction and outcomes (Hall et al., 2016; Razai et al., 2023). There is limited research on burnout in the Caribbean including Montserrat, however, a study reported that burnout affects both staff wellbeing and workforce retention in Caribbean settings (Lovell et al., 2022). Peer support could be one of the interventions to enhance wellbeing; however, organisations are responsible to provide convenient measures to actively support the wellbeing of its staff.
Participants also reported on strategies that policy makers could consider enhancing mental health support on the island. One strategy was related to improving supportive resources, including financial, physical and human resources. Montserrat relies on external visiting psychiatrists (Walker et al., 2022). Thus, when they are not on the island, remote care delivery is used, however, mental health nurses on the island cannot prescribe medicines, but they can adjust prescriptions with the consent of the psychiatrist/doctor (Cabey, 2022). Regarding inpatient acute facilities, Montserrat has only one side room in a ward, which is rarely used for mental health service users (Walker et al., 2022). There is therefore a need to improve mental health resources on the island, to provide better and continuous care. Financial support has positive impacts on increasing the number of practicing HCPs and also on driving positive patient experiences (Salant et al., 2024).
Reviewing and updating policy documents is another strategy, particularly to use non-stigmatising language and to raise awareness of mental health related policies amongst the public and HCPs. Robust monitoring and reviewing of policies is highlighted by the World Health Organisation (WHO) as means to track progress, inform continuous improvement, and safeguard human rights (WHO, 2025). The Mental Treatment Act that was specifically highlighted by participants was lastly revised in 2013 (Governement of Montserrat, 2013). It contains terminology that is also no longer aligned with modern, person-centred and non-stigmatising approaches (e.g., use of “insane person”, “unsound mind”, “idiot”). Furthermore, old policy documents are usually misaligned with modern multidisciplinary care models (Governement of Montserrat, 2013).
Interestingly, one participant suggested having regular inspections by an independent party to ensure that the needs of people are met. In the UK, there are already existing approaches where external regulatory bodies such as the Care Quality Commission conduct inspects and regulates health and social care services in England across different healthcare settings to ensure services are meeting quality standards, and are safe, effective, and responsive, and when standards are not met, immediate resolution actions are requested. This therefore highlights the importance of independent oversight in maintaining patient-centred care (BMA, 2025).
Strengths and limitations
This study has several strengths. To the best of authors knowledge, this is the first study to explore the experiences of HCPs regarding mental health services in Montserrat. The study therefore addresses this gap and adds to the growing body of mental health literature. The study utilised a qualitative approach to gain further and wide insights on mental health. Data were collected through individual interviews, which allowed for the collection of rich data about the personal experiences of participants. A focus group was also carried out, where group discussions could have stimulated new ideas and encouraged participants to share their experiences. All interviews were conducted by the same researcher, face-to-face, which maintained consistency in data collection, and allowed better engagement, compared to remote data collection. Equally, data were analysed by the same researcher and reviewed by other members of the research team to ensure consistency and reduce the risk of researcher bias. Another strength is the diversity of the sample in terms of age, gender, place of birth, and professional experience, allowing the collection of a wider range of perspectives on mental health.
The study however has some limitations. The recruited sample, although diverse in its characteristics, was small in size, reflected the size of the clinical workforce on the islands. Thus, the views of some non-participating HCPs might not have been represented.
Conclusions
This study highlights several formal and informal resources for mental health support existing in Montserrat. However, significant barriers to mental health support exist, particularly stigma, limited resources, workforce challenges, and outdated policies, all of which hinder effective service delivery. Several strategies were suggested by participants, targeting different components of the Montserratian community, to improve mental health support on the island. These include raising awareness of mental illness, workforce development, improve funding (e.g., staff training), and update policy documents.
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Al-Jabr H, Berners-Lee B, Shepherd T et al. Exploring mental health experiences and support in Montserrat: A healthcare professional’s qualitative study [version 1; peer review: awaiting peer review]. NIHR Open Res 2026, 6:151 (https://doi.org/10.3310/nihropenres.14448.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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