Accessibility of mental healthcare services to members of the LGBTQIA+ Community in rural South Africa

South Africa, with its diverse population and complex socio-political history, has a high incidence of mental health conditions. The country’s burden of mental health conditions is closely linked to inequality, poverty, and limited access to mental healthcare services. These disparities are particularly pronounced for members of the lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual and other identities (LGBTQIA+) community residing in rural contexts. In response to this issue, this study aimed to explore and describe barriers to and facilitators of access to mental healthcare services as perceived by LGBTQIA+ individuals living in Namaqualand through the lens of the Socio-Ecological Model (SEM). The SEM illustrates how multiple factors across the individual, interpersonal, organisational/community, and societal levels influence an individual’s health behaviour. This study, grounded in the constructivist paradigm, explored the lived experiences of LGBTQIA+ while accessing mental healthcare services. Guided by a relativist ontology and a subjectivist epistemology, the research employed a qualitative case in which semi-structured interviews were conducted with eleven purposively selected participants. The sample size was guided by the principle of data saturation rather than the generalisability of the study’s findings. The data were subsequently analysed thematically using the SEM as an analytical framework. Barriers and facilitators of mental healthcare access were categorised across the SEM’s four levels, with sub-themes emerging inductively from the data. Participants highlighted various mental healthcare needs within their community, including the pressing need for comprehensive mental healthcare services that are LGBTQIA+ affirming and increased community sensitisation on LGBTQIA+ rights, particularly in rural and conservative communities like Namaqualand. Barriers to mental healthcare access were identified across all levels of the SEM. At the individual level, barriers included internalised stigma, identity conflict, substance use, and limited mental health literacy. Interpersonally, a lack of support from family and friends increased isolation and limited help-seeking behaviour. Mental healthcare access was further influenced by systemic and structural inequalities at the organisational level, where limitations in the public health sector, such as shortages of healthcare professionals, inadequate facilities and discrimination against the LGBTQIA+ community, acted as barriers. Finally, stigma and unsupportive cultural norms, especially within Namaqualand’s Coloured communities, emerged as barriers at the societal level. Facilitators of access included individual-level factors, such as mental health literacy and positive health-seeking attitudes. At the interpersonal level, support from family and friends acted as an enabler to mental healthcare access. Organisational facilitators included access to private healthcare for those who could afford it, and unexpected support from faith-based organisations. The data did not show any societal-level factors that acted as enablers for mental healthcare access. The participants recommended establishing integrated healthcare facilities that cater to both mental and physical health, increasing mental health sensitisation, culturally competent training for healthcare workers and establishing LGBTQIA+ support groups in Namaqualand. The study highlights that access to mental healthcare services for LGBTQIA+ individuals in Namaqualand is influenced by complex, multi-level factors. To address the challenges, comprehensive and intersectional strategies are needed that take into account the overlapping influences of gender identity, socioeconomic status, culture, and geography on mental healthcare access. Drawing on the SEM, it is evident that there is a need for culturally competent, LGBTQIA+-affirming services, community education, and systemic reform to improve mental healthcare access in Namaqualand. Lessons learnt from this research could potentially inform strategies to improve access to mental healthcare services in other rural areas of the Northern Cape province in South Africa.