Inverting the deficit model in global mental health: An examination of strengths and assets of community mental health care in Ghana, India, Occupied Palestinian territories, and South Africa.

Global mental health [GMH] scholarship and practice has typically focused on the unmet needs and barriers to mental health in communities, developing biomedical and psychosocial interventions for integration into formal health care platforms in response. In this article, we analyse four diverse settings to disrupt the emphasises on health system weaknesses, treatment gaps and barriers which can perpetuate harmful hierarchies and colonial and medical assumptions, or a 'deficit model'. We draw on the experiential knowledge of community mental health practitioners and researchers working in Ghana, India, the Occupied Palestinian Territory and South Africa to describe key assets existing in 'informal' community mental health care systems and how these are shaped by socio-political contexts. These qualitative case studies emerged from an online mutual learning process convened between 39 academic and community-based collaborators working in 24 countries who interrogated key tenets to inform a social paradigm for global mental health. Bringing together diverse expertise gained from professional practice and research, our sub-group explored the role of Community Mental Health Systems in GMH through comparative country case studies describing the features of community care beyond the health and social care system. We found that the socio-political health determinants of global economic structures in all four countries exert significant influence on local community health systems. We identified that key assets across sites included: family and community care, and support from non-profit organisations and religious and faith-based organisations. Strengthening community assets may promote reciprocal relationships between the formal and informal sectors, providing resources for support and training for communities while communities collaborate in the design and delivery of interventions rooted in localised expertise. This paper highlights the value of informal care, the unique social structures of each local context, and resources within local communities as key existing assets for mental health.

The ambiguities of social inclusion in mental health: learning from lived experience of serious mental illness in Ghana and the occupied Palestinian territory.

PURPOSE: Social inclusion of people living with serious mental illness is widely promoted. However, only limited consideration has been given to the meanings of social inclusion within different settings and the ways in which it is envisioned, negotiated, and practised. In this paper, we explore meanings and practises of social inclusion from the perspectives of people living with serious mental illness and their families in Ghana and Palestine and how this is shaped by differing political and socio-cultural contexts. METHODS: This paper draws on comparative ethnographic research including participant observation and interviews with people living with mental illness and family members in Ghana and the occupied Palestinian territory. Data were triangulated and analysed using thematic analysis. RESULTS: Participants described experiences of social inclusion and participation within communities, home and family life, friendships and social life, and work and livelihoods. This revealed how such experiences were variously shaped by differing political contexts and socio-cultural norms and expectations within the two settings. These in turn intersected with aspects such as gender roles, age, and socio-economic status. Aspirations for inclusion included greater awareness and understanding within society, accompanied by opportunities and support for meaningful inclusion at the political as well as community level. CONCLUSION: Findings point to the value of a contextual understanding of social inclusion, taking account of the impact of the wider socio-cultural, political, and economic environment. They also point to the need for an intersectoral approach, beyond communities and mental health services, to provide meaningful opportunities and support for social inclusion.

Access to advanced cancer care services in the West Bank-occupied Palestinian territory.

Introduction: Universal Health Coverage (UHC) identifies the provision of palliative care for people with advanced disease as an essential health service. Palliative care is also stipulated as a human right under existing covenants. Oncology services provided by the Palestinian Authority under Israeli military occupation are limited to surgery and chemotherapy treatment. Our study aimed to describe the experiences of patients with advanced-stage cancer in the West Bank in accessing oncology services and meeting their health care needs. Methodology: We conducted a qualitative study among adult patients diagnosed with advanced lung, colon, or breast cancer in three Palestinian governmental hospitals, and with oncologists. Thematic analysis was conducted on the verbatim interview transcripts. Results: The sample consisted of 22 Palestinian patients (10 men and 12 women) and 3 practicing oncologists. The findings reveal that cancer care is fragmented, with limited access to the services needed. Patients face referral delays in accessing treatment which worsen their health condition in some cases. Some patients reported difficulties in getting Israeli permits to access radiotherapy treatment in East-Jerusalem, and others experienced interruptions of their chemotherapy treatment sessions due to the unavailability of chemotherapy medications caused by Israeli-side delays. Other reported problems were related to the Palestinian health system and service delivery and quality, including fragmentation of services, infrastructure issues, and unavailability of medications. Advanced diagnostic services and palliative care are almost absent at Palestinian governmental hospitals, and patients need to seek these services in the private sector. Conclusion: The data demonstrate specific access restrictions to cancer care in the West Bank due to Israeli military occupation of Palestinian land. This affects all stages of the care pathway, from restricted diagnosis services, to limited treatment and then poor availability of palliative care. Cancer patients will continue to suffer if the root causes of these structural constraints are not addressed.

The association between uncertainty and mental health: a scoping review of the quantitative literature.

BACKGROUND: The current moment is characterised by deep-rooted uncertainties, such as climate change and COVID-19. Uncertainty has been reported to be associated with negative mental health outcomes, such as stress and anxiety. However, no comprehensive review on the association between uncertainty and mental health exists. AIM: The aim of the current scoping review was to systematically explore and describe the literature on the link between uncertainty and mental health. METHODS: A scoping review was undertaken following guidelines by Arksey and O'Malley (2005). RESULTS: One hundred and one papers addressing the association between uncertainty and mental health were identified. Most were cross-sectional studies (67%) conducted in the fields of medicine or nursing (59%), in high-income countries, among adult populations (74%), and in medical settings. Substantial heterogeneity was identified in the measurements of uncertainty and mental health. Most studies (79%) reported a positive association between uncertainty and mental health problems. CONCLUSIONS: Research is needed in more diverse contexts and populations. More robust designs are required to provide insight into the directionality and strength of the association between uncertainty and mental health. Few studies reported how individuals coped with uncertainty. Future studies should address the identified gaps and investigate interventions to address uncertainty and its determinants.

Life and Health Under Israeli Military Occupation During COVID-19: Report from the West Bank, Occupied Palestinian Territory.

This qualitative study explores lived experiences of Palestinians in the West Bank during the COVID-19 pandemic intersecting with life under Israeli military occupation, structural violence, and racism. Insight is provided into the pandemic's effect on daily life and health and into coping and support mechanisms employed under apartheid conditions. Forty-three semi-structured interviews were conducted among a stratified sample of Palestinian adults. Interviews were digitally recorded, transcribed, and analyzed using thematic analysis. During the pandemic, Palestinian social lives were interrupted, jobs were lost, and incomes declined. Families fell into social and financial crises, with strife, insecurity, uncertainty, and fear negatively affecting physical and mental health. Pandemic effects were compounded by the Palestinian Authority's shortcomings and policies not taking into account citizens' rights and social protection and by Israel's continued colonization of Palestinian land and violation of Palestinian human rights. Social solidarity was instrumental for coping during the pandemic just as it was during intensified political violence. One key feature that helped Palestinians survive promoting their cause for freedom, sovereignty, and self-determination is their social solidarity in times of strife. This has proven to be a crucial component in overcoming threats to the survival of a people during the twentieth century and into the twenty-first century.

The double burden of COVID-19 and Israeli military rule on persons with disabilities in the West Bank of the occupied Palestinian territory.

Background: The COVID-19 pandemic has enormous negative effects on people's lives. People with disabilities (PWDs) who have been made vulnerable and who tend to face significant barriers in accessing public services are likely to be affected even more. This study aims to shed light on the impact of the COVID-19 pandemic on PWDs with special attention to their ability to access public services in the West Bank region of the occupied Palestinian territory. Methods: This qualitative study was conducted between March 2021 and October 2021. The study was divided into two phases. The first phase consisted of interviews with people with different disabilities, while the second phase targeted policymakers and stakeholders in discussion of the results of the first phase. A total of 16 interviews with people with different types of disabilities (7 males, 9 females) were conducted via telephone. For the second phase, a total of 6 interviews were conducted with stakeholders most responsible for addressing the issue of disability and the needs of PWDs in the West Bank. Analytical memos were prepared for all interviews. Main themes and subthemes were identified by reading and re-reading memos and transcripts until themes and subthemes emerged. Results: All participants agreed that the COVID-19 pandemic had affected all aspects of life for all groups of people, including PWDs. The effects of the pandemic exacerbated the overall living conditions and access to basic services for PWDs. The results show that access to public transportation, public services, and to health services was all interrupted during the pandemic. This was compounded by deterioration of the financial situation for PWDs which further worsened their access. The stakeholders' interviews confirmed and explained the findings as mainly due to lack of prioritization of PWD's rights and needs. Conclusion: The study emphasized that most of the reported barriers to accessing essential services were intensified during the pandemic. Furthermore, the results show that PWDs and their needs are not considered a priority by the Palestinian Authority, exacerbated by the Israeli occupation. Our findings underline the importance of including PWDs in any future crisis planning.

Pathways to food insecurity in the context of conflict: the case of the occupied Palestinian territory.

BACKGROUND: Conflict reduces availability of production input and income, increases the number of days households had to rely on less preferred foods, and limits the variety of foods eaten and the portion size of meals consumed. While existing studies examine the impact of conflict on different food security measures (e.g., Food Consumption Score, Food Insecurity Experience Scale), the relationship between these measures as well as their relationship with political, economic, and agricultural factors remain under explored. Food insecurity may not only be an externality of conflict but also food deprivation may be utilized as a weapon to discourage residency in contested territories or to incentivize rebellions. METHODOLOGY: This paper examines the association between political factors (e.g., violence, policies that require permit for passage in one's own hometown), economic factors (e.g., loss of assets, unemployment), agricultural factors (e.g., shortage of water, poor weather conditions), and food insecurity experience and dietary diversity in a conflict setting-that of the occupied Palestinian territory (oPt). The study employs generalized structural equation models to analyze the 'Survey on socio-economic conditions for Palestinian households 2014' dataset compiled by the Palestinian Central Bureau of Statistics-which contains a representative sample of the population in the oPt at governorate and locality levels. RESULTS: We find that in the West Bank, residence in Area C-administered by Israel in both civil and security issues and contains illegal Israeli settlements and outposts-is associated with a higher level of agricultural hardship (p < 0.01) but lower economic hardship (p < 0.01) and a higher dietary diversity (p < 0.001), as compared to those living outside of Area C. In the Gaza Strip, living within one kilometer to a buffer zone is associated with lower dietary diversity (p < 0.01), higher level of political hardship (p < 0.01), and higher level food insecurity experience (p < 0.01) compared to not living in close proximity to a buffer zone. Concomitantly, in the Gaza Strip, food insecurity experience is associated with approximately a one-point reduction in dietary diversity as measured by the food consumption score (p < 0.01). CONCLUSIONS: The results suggest that broader socio-political conditions in the oPt impact different aspects of food security through augmenting the economic and agricultural hardships that are experienced by the residents. As such, it is important to address these broader political and economic structures in order to have more sustainable interventions in reducing food insecurity.

The experience of people with psychosocial disabilities of living independently and being included in the community in war-affected settings: A review of the literature.

This article explores the experience of people with psychosocial disabilities with independent living and community inclusion in war-affected settings. While the UN CRPD obliges states to protect the rights of persons with psychosocial disabilities to community living (Article 19) in contexts of war (Article 11), information is lacking about people's lived experience. We reviewed studies published between 1980 and 2020, exploring concepts central to the CRPD's Article 19. Sixteen articles met the inclusion criteria. Findings indicate that support for persons with psychosocial disabilities is lacking while also being insufficiently described; little information is available about types of mental health and psychosocial support services; and data are almost absent about access to community services available for the general population. To ensure independent living and community integration in contexts of war, we emphasize the need for comprehensive and intersectional approaches that are locally relevant, participatory, and based on human rights.

The mental health impact of multiple deprivations under protracted conflict: A multi-level study in the occupied Palestinian territory.

Building on the literatures examining the impacts of deprivation and war and conflict on mental health, in this study, we investigate the impact of different forms of deprivation on mental health within a context of prolonged conflict in the occupied Palestinian territory(oPt). We expand the operationalization go deprivation while accounting for more acute exposures to conflict and political violence and spatial variations. We use multilevel modelling of data from the Socio-Economic & Food Security Survey 2014 conducted by the Palestinian Central Bureau of Statistics, which included a sample size of 7827 households in the West Bank(WB) and Gaza Strip(GS). We conduct the analysis for the combined sample, as for the WB and GS separately. We use a General Health Questionnaire-12 (GHQ12) score as our main outcome measure of poor health. We used various measures of deprivation including subjective deprivation, material deprivation, food deprivation, and political deprivation. In addition to the different measures of deprivation, we included acute political, health, and economic shocks in our analysis along with background socio-demographic characteristics. The results indicate significant variance at the locality level. We find a significant association between poor mental health and subjective, economic, political, and food deprivation; health, economic, and political stressors; age, and being a woman. Post-secondary education and wealth have a significant inverse association with poor mental health. Subjective deprivation is the strongest predictor of GHQ12 score in the models whereby people who feel very deprived have GHQ12 scores that are almost 4-points higher than people who do not feel deprived. Economic conditions, particularly subjective measures, are significant predictors of mental health status. Our findings confirm that political and social factors are determinants of health. Feeling deprived is an important determinant of mental health. The community effect suggests that spatial characteristics are influencing mental health, and warrant further investigation.

The psychological impact of deprivation in regions affected by conflict: a multilevel analysis of a cross-sectional survey in the occupied Palestinian territory.

BACKGROUND: Deprivation is an important determinant of poor health. Locality can be key in understanding variation in deprivation across a population. This study aimed to analyse how different forms of deprivation affect mental health among Palestinians, and how they account for locality effects in the occupied Palestinian territory. METHODS: We used multilevel modelling to analyse data from the Socio-Economic & Food Security Survey 2014 conducted by the Palestinian Central Bureau of Statistics, which had a sample size of 7827 adults representing the same number of households. The main outcome is a General Health Questionnaire (GHQ) score, in which a higher score signifies worse mental health. Deprivation variables include subjective deprivation, material deprivation, food deprivation, and political deprivation (which was measured by use of the human insecurity scale). For the analysis, we included data on experience of different stressors (economic, political, health-related, and weather-related stress) reported at the household level in the 6 months preceding the survey, and we controlled for demographic characteristics, including age, gender, education, wealth, and region. We also conducted a two-level random effects multilevel regression, with locality as a proxy for neighbourhood. FINDINGS: The model indicates significant variance at the locality (neighbourhood) level. There is a significant association between poor mental health and subjective, economic, political, and food deprivation; health, economic, and political stressors; age, and being a woman. Education beyond secondary school level and wealth have a significant inverse association with poor mental health. Individuals who indicated that they felt somewhat or very deprived have significantly higher GHQ scores than individuals who indicated that they did not feel deprived (ß=1·73 and 4·33 for those who felt deprived and who did not feel deprived, respectively, p<0·0001). Food consumption was inversely associated with GHQ score (ß=-0·01, p<0·0001) and food insecurity was positively associated with GHQ score (ß=0·19, p<0·0001). Political deprivation, and health-related, political, and economic stressors were significantly positively associated with GHQ scores (ß=0·043, 0·23, 0·35, and 0·19 respectively, p<0·0001). Age (ß=0·079, p<0·0001) and being a woman were positively associated with GHQ score (ß=0·26, p=0·0040), whereas education beyond secondary school level was inversely associated with GHQ score (ß=-0·54, p<0·0001). INTERPRETATION: The findings that the mental health of Palestinians is associated with various forms of deprivation and stressors, provide further evidence that political and social factors are determinants of health. Correlated factors include both subjective and objective measures, and suggest that although material conditions are important, people's subjective experiences are also important. Feeling deprived is an important correlate of mental health. The community effect suggests that services (or lack thereof), checkpoints and blockades, political situations, and other factors that vary across localities, may influence mental health issues at the neighbourhood level. FUNDING: This project is part of the study "Re-conceptualising health in wars and conflicts: a new focus on deprivation and suffering" funded by the Middle East Centre at the London School of Economics and Political Science.

Food insecurity in the context of conflict: analysis of survey data in the occupied Palestinian territory.

BACKGROUND: Conflict impacts food security and decreases household dietary diversity. However, few studies have explored the routes by which prolonged conflict and social stressors affect food insecurity experience and food diversity. This study examines the influence of political, economic, and agricultural stressors on food insecurity and food diversity, and evaluates variations in food insecurity and food diversity with location of residence for households in the occupied Palestinian territory. METHODS: A secondary data analysis with structural equation modelling was carried out on data from the Socio-Economic & Food Security Survey 2014 of the Palestinian Central Bureau of Statistics. The survey was completed by a representative sample of the Palestinian population in the occupied Palestinian territory at governorate and locality levels, and consisted of 4215 households in the West Bank and 2916 households in the Gaza Strip. The primary outcomes were food diversity (measured with a food consumption score) and food insecurity (assessed with a composite experience-based measure of food security). We used structural equation models to examine the relationships between location of residence (in the West Bank, living in Area C versus not Area C; in the Gaza Strip, proximity of residence to the buffer zone), the number of political stressors, economic stressors, and agricultural stressors (eg, restricted access to land), and the primary outcomes. We controlled for demographic characteristics, including education, governorate, and wealth. FINDINGS: In the West Bank, there was no statistically significant direct association between living in Area C and food insecurity. Living in Area C is associated with a higher number of agricultural stressors than not Area C (p=0·032), and a higher number of agricultural stressors is in turn associated with lower food diversity (p=0·0080) and higher food insecurity (p=0·040). In the Gaza Strip, proximity to the buffer zone is directly associated with higher food insecurity (p=0.041) and lower food diversity (p=0·019) and a higher number of political stressors (p=0·057). A higher number of political stressors is associated with a higher number of economic stressors (p=0·026) and higher food insecurity (p=0·034). INTERPRETATION: The findings suggest that political, economic, and agricultural factors contribute to food insecurity and food diversity, and that their interactions are complex. Conflict and occupation affect food availability through both direct and indirect channels. In the Gaza Strip, living in close proximity to the buffer zone is associated with lower food diversity and higher food insecurity. In the West Bank, although residing in Area C may not directly increase food insecurity, the hardship generated by the conditions in Area C contributes to higher food insecurity. FUNDING: The Emirates Foundation.

Support groups for mothers of children with a handicap: a quantitative and qualitative study.

BACKGROUND: Since 2013, the community-based rehabilitation programme in the north of the West Bank has established nineteen support groups for mothers following a Multi-Family Approach (MFA), with technical support from the Institute of Community and Public Health (Birzeit University) and the War Trauma Foundation (Netherlands). The main aims of the programme are to improve the wellbeing of mothers who have children with a handicap, to build support networks between vulnerable families, and to counter problems associated with social isolation and stigma. The MFA intervention is monitored and evaluated through an approach called outcome mapping. METHODS: We used both quantitative and qualitative methods to evaluate mothers support groups in relation to outcomes and changes in behaviours, as reported by the mothers. We used a survey to investigate support group members' satisfaction with the intervention and changes in self-reported behaviour. Group interviews were done with mothers. We obtained approval from the University Research Ethics Committee and verbal informed consent from the mothers. FINDINGS: 51 members from seven support groups completed the survey. Four group interviews were done, including 12 mothers in total. 33 (64%) mothers reported that their participation in MFA groups leads to stress relief and having fun. 18 (36%) mothers reported that they exchanged experiences during the group sessions. Mothers attended the groups due to their desire to solve pressing practical problems that they experienced when caring for their children, to receive more community support, and to be able to leave the house to attend meetings deemed useful by their families. INTERPRETATION: The evaluation highlights the psychosocial value of support groups for mothers of children with a handicap. Having fun is an important factor ensuring regular group attendance and an indicator of improved wellbeing. Importantly, mothers were also able to experience stress relief by exchanging experiences and suggesting possible solutions in a caring and trusting environment. FUNDING: The British Academy.

The Multi-Family Approach to facilitate a family support network for Palestinian parents of children with a disability: a descriptive study.

BACKGROUND: Families with a child who has a disability have extra difficulties, particularly when services are hard to reach or less available. In a collaborative project, the Institute of Community and Public Health, the Palestinian community-based rehabilitation programme, and international non-governmental organisations cooperated to share and develop expertise and knowledge on increasing families' resilience through establishing family groups. This contribution focuses on the use of the Multi-Family Approach (MFA) in a Palestinian context. MFA is a family-oriented method provided in a group setting. The aim of this study was to investigate the feasibility of implementing the intervention and the experiences gained by introducing the MFA in the West Bank. METHODS: Parents taking the MFA approach learn from other parents by sharing experiences. Allowing parents to examine communalities and contrasts increases social support and parenting skills and decrease stress reactions. A high turnover of exercises and activities facilitate pleasant interactions. The basic principles of MFA are derived from both group and family interventions. Adjusting MFA entailed training of community-based rehabilitation teams (supervisors, field workers, and volunteers) through a learning-by-doing principle and employed a comparable strategy and structure to MFA. MFA was introduced and practiced, and early experiences were used to rehearse and elaborate. Training experiences were monitored and reflected upon within the team. A manual was written as a collaborative activity. No additional ethical approval was necessary. This project did not encompass the involvement, assessment, or monitoring of families or family members. The trainees participated on a voluntary base. FINDINGS: Qualitative analyses of the monitoring reports from the training sessions show that MFA is feasible for families with a child with a disability in the West Bank but that organisational, translational, and cultural adjustments are needed for MFA to be suitable within a Palestinian context. INTERPRETATION: MFA proved appropriate for the Palestinian setting. Most of the workers in the community-based rehabilitation programme and group participants were comfortable with the approach and adopted it within communities. FUNDING: Stichting Boo and Gieskes Strijbis Fonds.

Women's health in the occupied Palestinian territories: Contextual influences on subjective and objective health measures.

The links between two commonly used measures of health-self-rated health (SRH) and self-reported illness (SRI)-and socio-economic and contextual factors are poorly understood in Low and Middle Income Countries (LMICs) and more specifically among women in conflict areas. This study assesses the socioeconomic determinants of three self-reported measures of health among women in the occupied Palestinian territories; self-reported self-rated health (SRH) and two self-reported illness indicators (acute and chronic diseases). Data were obtained from the 2010 Palestinian Family Health Survey (PFHS), providing a sample of 14,819 women aged 15-54. Data were used to construct three binary dependent variable-SRH (poor or otherwise), and reporting two SRI indicators-general illness and chronic illness (yes or otherwise). Multilevel logistic regression models for each dependent variable were estimated, with individual level socioeconomic and sociodemographic predictors and random intercepts at the governorate and community level included, to explore the determinants of inequalities in health. Consistent socioeconomic inequalities in women's reports of both SRH and SRI are found. Better educated, wealthier women are significantly less likely to report an SRI and poor SRH. However, intra-oPt regional disparities are not consistent across SRH and SRI. Women from the Gaza Strip are less likely to report poor SRH compared to women from all other regions in the West Bank. Geographic and residential factors, together with socioeconomic status, are key to understanding differences between women's reports of SRI and SRH in the oPt. More evidence is needed on the health of women in the oPt beyond the ages currently included in surveys. The results for SRH show discrepancies which can often occur in conflict affected settings where a combination of ill-health and poor access to health services impact on women's health. These results indicate that future policies should be developed in a holistic manner by targeting physical and mental health and well-being in programmes addressing the health needs of women, especially those in conflict affected zones.