Shadows and Light Examining Community Mental Health Competency in North India
Total Page：16
File Type：pdf, Size：1020Kb
Shadows and light examining community mental health competency in North India Kaaren Mathias Department of Public Health and Clinical Medicine Epidemiology and Global Health Umeå 2016 Shadows and light Examining community mental health competence in North India Kaaren Mathias Department of Public Health and Clinical Medicine Epidemiology and Global Health Umeå University, Sweden 2016 Responsible publisher under Swedish law: the Dean of the Medical Faculty This work is protected by the Swedish Copyright Legislation (Act 1960:729) New Series No. 1856 ISBN: 978-91-7601-588-9 ISSN: 0346-6612 Copyright@2016: Kaaren Mathias Electronic version available at http://umu.diva-portal.org/ Printed by: UmU-tryckservice, Umeå University, Sweden 2016 All the variety, all the charm, all the beauty of life is made up of light and shadow. Leo Tolstoy, Anna Karenina Photo credit – Front cover – Caleb Smallwood iii iv Circling around God – the Ancient Tower Rainer Maria Rilke I live my life in growing orbits which move out over the things of the world. Perhaps I can never achieve the last, but that will be my attempt. I am circling around God, around the ancient tower and have been circling for a thousand years and I still do not know if I am a falcon, a storm or a great song. Translation: Robert Bly, Selected Poems of Rainer Maria Rilke, A Translation from the German and Commentary by Robert Bly This poem by the German poet Rainer Maria Rilke (who himself journeyed through mental distress) encapsulates the deep human urge to engage in the search for meaning, understanding and ultimately truth. It explains why I wanted to start this journey seeking wisdom as I seek to strengthen community mental health competence in North India. v vi Table of Contents Circling around God – the Ancient Tower ............................................................................. v Table of Contents ................................................................................................................. vii Academic abstract - English .................................................................................................. ix Revised conceptual model – community mental health competency ................................... x Plain language summary – English ...................................................................................... xi Plain language summary – Hindi ....................................................................................... xiii Researcher stance................................................................................................................. xv Where did this thesis come from? ....................................................................................... xvi Original papers ................................................................................................................... xvii Glossary ............................................................................................................................. xviii Acronyms used .................................................................................................................... xxi 1.0 Introduction .................................................................................................................... 1 1.1 The importance of global mental health ........................................................................... 1 1.2 Community mental health in India .................................................................................. 7 1.3 Justification of study ...................................................................................................... 10 1.4 Study objectives .............................................................................................................. 10 1.5 Theoretical framework ..................................................................................................... 11 2.0 Context and study design .............................................................................................. 13 2.1 Study setting ................................................................................................................... 13 2.2 Organisation that hosted this research .......................................................................... 15 2.3 Study design ................................................................................................................... 15 3.0 Methods ........................................................................................................................ 17 3.1 Qualitative studies .......................................................................................................... 17 3.2 Quantitative studies ....................................................................................................... 18 3.3 Ethical considerations ....................................................................................................20 4.0 Findings and discussion ............................................................................................... 23 4.1 Knowledge ...................................................................................................................... 26 4.2 Safe social spaces ...................................................................................................... 29 4.3 Access to care ................................................................................................................. 34 4.4 Social determinants of mental health ............................................................................ 37 4.5 Revised conceptual framework of community mental health competency .................. 40 5.0 Methodological considerations ..................................................................................... 42 5.1 Ethical issues – capacity for consent .............................................................................. 42 5.2 Reflexivity on positionality ............................................................................................. 43 5.3 Limitations of PHQ9 and the diagnosis of depression .................................................. 43 5.4 Impact of gender order on data collection ..................................................................... 45 5.5 Strengths and limitations of this research ..................................................................... 45 vii 6.0 Conclusions ................................................................................................................... 48 7.0 Research to practice ...................................................................................................... 51 7.1 Translation ...................................................................................................................... 51 7.2 Policy Implications ......................................................................................................... 52 7.3 Research recommendations ........................................................................................... 54 8.0 Acknowledgements ....................................................................................................... 56 9.0 References ..................................................................................................................... 59 viii Academic abstract - English Background Globally, there is increasing emphasis on the importance of understanding the ways in which social inequality and injustice impact individual and community mental health. Set in the states of Uttar Pradesh and Uttarakhand, India, this thesis examines the complex relationships between individuals, communities and the social environment in relation to mental health. North India is characterised by stark gender and socio-economic inequalities and social exclusion for people with psycho-social disability (PPSD) and mental health services in these study areas were essentially absent. Community mental health competency means people are collectively able to participate in efforts to promote, prevent, treat and advocate for mental health. This thesis reflexively examines the presence and absence of community mental health competence in the upper Ganges region. Methods A mixed methods approach allowed for a multi-level examination of community mental health competence, and generated four sub-studies. In-depth interviews with thirteen PPSD and eighteen caregivers in Bijnor and Saharanpur (Uttar Pradesh state) were carried out in 2013 providing data for qualitative analysis. These data were analysed using qualitative content analysis to examine experiences of exclusion and inclusion of PPSD in sub-study I, and thematic analysis to examine the gendered experiences of caregivers in sub-study II. A community based sample of 960 people in Dehradun district (Uttarakhand) were surveyed in 2014 to examine the prevalence, treatment gap and social determinants of depression in sub- study III, and the attitudes and preferred social distance from people with depression and psychosis were investigated in sub-study IV. Multi-variate regression analysis in both studies was conducted with Stata software Version 13.1. Results Within the domain of knowledge, relatively low community mental health literacy, a diverse range of explanatory models of mental health, and creative and persistent efforts in help- seeking were the themes identified. Within the domain of safe social spaces, social exclusion was harsh and prevalent for PPSD, with contrasting sub-domains