Abstract
IMPORTANCE: A treatment gap reflects the disparity between those with mental health disorders and those receiving care, especially in low- and middle-income countries, where many remain untreated. OBJECTIVE: To assess the mental health treatment gap among individuals seeking holy water healing in Ethiopia and identify associated factors. DESIGN, SETTING, AND PARTICIPANTS: This mixed-methods cross-sectional study was conducted from March 1 to August 31, 2024, in North Wollo, Ethiopia. Individuals with symptoms of mental illness were surveyed using interviewer-administered questionnaires. Data were analyzed from October to December 2024. EXPOSURES: Sociodemographic, behavioral, psychosocial, and clinical factors were assessed using culturally adapted, structured questionnaires based on existing literature. MAIN OUTCOMES AND MEASURES: The General Help-Seeking Questionnaire was used to assess participants' use of professional mental health services. Qualitative data from focus group discussions and key informant interviews were thematically analyzed and triangulated with quantitative findings. RESULTS: A total of 393 participants (mean [SD] age, 30.06 [9.87] years; 201 [51.1%] female) responded to the survey, including 144 (36.6%) younger than 25 years, 375 (95.4%) Orthodox Christians, and 270 (68.7%) residing in rural areas. Traditional healers were consulted by 242 participants (61.6%), whereas only 70 (17.8%) accessed professional mental health care. Fear of being seen as bad parents was cited by 377 (95.9%) as a key barrier. Overall, 323 participants (82.2%; 95% CI, 78.1%-86.0%) experienced a treatment gap. Factors associated with the gap included low perceived need for care (adjusted odds ratio [AOR], 2.49; 95% CI, 1.09-5.71), male gender (AOR, 2.32; 95% CI, 1.20-4.48), higher educational level (AOR, 4.34; 95% CI, 1.79-10.53), low income (AOR, 2.41, 95% CI, 1.72-4.14), not knowing where to go (AOR, 1.97; 95% CI, 1.21-4.53), denial (AOR, 3.21; 95% CI, 1.24-6.43), and internalized stigma (AOR, 2.76; 95% CI, 1.32-5.80). Qualitative results reinforced these and highlighted cultural beliefs, weak social support, and limited institutional focus as additional barriers. CONCLUSIONS AND RELEVANCE: In this cross-sectional study, only 1 in 6 individuals with mental health symptoms sought professional care. The treatment gap was associated with sociocultural, economic, and systemic challenges. Addressing these factors requires culturally sensitive interventions, public education, improved access, and stronger mental health systems.