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.

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.

SymptomSpeak: Women's Struggle for History and Health in Kosovo.

What are the linguistic dimensions of pain, and what kind of articulations arise from these painful experiences? How does the language of pain circulate, connect, and reach across histories, gendered realities, and social politics? In what ways might the language of pain act on and transform the world by shaping and changing socio-political agendas? I explored these questions among women in Kosovo and discovered a unique symptomatic language which I call SymptomSpeak. SymptomSpeak is a powerful language evoked, shared, and exchanged by women to articulate political, social, and economic grievances, to challenge societal norms, and to demand justice. The language itself consists of a detailed symptom vocabulary which is variously assembled into meaning complexes. Such assemblages shift depending on the social context in which they are conveyed and are referred to as nervoz (nervousness), mërzitna (worried, sad), mzysh (evil eye), and t'bone (spell). I describe in detail how women variously combine and exchange components of SymptomSpeak and, thereby, question dominant framings of reality. Thereby, my intention is to contribute to a new understanding of pain as language which straddles the fine line between socio-political commentary and illness; produces gendered political realities; and challenges the status quo through its communicative power.

"Making Patients" in Postwar and Resource-scarce Settings. Diagnosing and Treating Mental Illness in Postwar Kosovo.

Postwar development contexts are increasingly sites of mental health and psychosocial interventions in which local health providers are trained by foreign experts in evidence-based diagnostic and treatment strategies. Underlying this course of action is a well-accepted biomedical logic that assumes symptoms can be identified and translated into mental disorders, and disorders into forms of treatment. I question this logic by investigating how patients are actually "made" in postwar and resource-scarce settings. Specifically, I focus on the tensions and ethical dilemmas with which practitioners in Kosovo grapple as they navigate requirements of international standards, their own perception of good care, and the limited resources at their disposal. The resultant practice of "making patients" to fit diagnostic repertoires is a product of health practitioners' structural power, but also an ethical response to the materially untenable conditions that practitioners and their patients are confronting.

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.

Mental Health System Reform in Contexts of Humanitarian Emergencies: Toward a Theory of "Practice-Based Evidence".

Humanitarian emergencies such as armed conflicts are increasingly perceived as opportunities to improve mental health systems in fragile states. Research has been conducted into what building blocks are required to reform mental health systems in states emerging from wars and into the barriers to reform. What is less well known is what work and activities are actually performed when mental health systems in war-affected resource-poor countries are reformed. Questions that remain unanswered are: What is it that international humanitarian aid workers and local experts do on the ground? What are the actual activities they perform in order to enable and sustain system reform? This article begins to answer these questions through ethnographic case studies of mental health system reform in Kosovo and Palestine. Based on the findings, a theory of "practice-based evidence" is developed. Practice-based evidence assumes that knowledge is derived from practice, rather than the other way around where practice is believed to be informed by systematic evidence. It is argued that a focus on practice rather than evidence can improving system reform processes as well as the provision of mental health care in a way that is sensitive to local contexts, structural realities, culture, and history.

A village possessed by "witches": a mixed-methods case-control study of possession and common mental disorders in rural Nepal.

In Nepal, spirit possession is a common phenomenon occurring both in individuals and in groups. To identify the cultural contexts and psychosocial correlates of spirit possession, we conducted a mixed-method study in a village in central Nepal experiencing a cluster of spirit possession events. The study was carried out in three stages: (1) a pilot study consisting of informal interviews with possessed individuals, observations of the possession spells, and video recording of possession events; (2) a case-control study comparing the prevalence of symptoms of common mental disorders in women who had and had not experienced possession; and (3) a follow-up study with focus group discussions and in-depth interviews with possessed and non-possessed men and women, and key informants. Quantitative results indicated that possessed women reported higher rates of traumatic events and higher levels of symptoms of mental disorder compared to non-possessed women (Anxiety 68 vs. 18 %, Depression 41 vs. 19 %, and PTSD 27 vs. 0 %). However, qualitative interviews with possessed individuals, family members, and traditional healers indicated that they did not associate possession states with mental illness. Spirit possession was viewed as an affliction that provided a unique mode of communication between humans and spirits. As such, it functioned as an idiom of distress that allowed individuals to express suffering related to mental illness, socio-political violence, traumatic events, and the oppression of women. The study results clearly indicate that spirit possession is a multi-dimensional phenomenon that cannot be mapped onto any single psychiatric or psychological diagnostic category or construct. Clinical and public health efforts to address spirit possession must take the socio-cultural context and systemic dynamics into account to avoid creating iatrogenic illness, undermining coping strategies, and exacerbating underlying social problems.

Community integration, quality of life, thriving, and mental health among refugees and asylum seekers. A London service provider perspective.

Introduction: This article explores how systemic injustices and social inequalities affect refugee and asylum seeker integration, thriving, and mental health in London. This is pertinent as the United Kingdom currently operates a 'broken' asylum system with unfair policies and a 'tough' immigration rhetoric which makes it extraordinarily difficult for asylum seekers and refugees to achieve community integration, have a good quality of life, be able to thrive, and have good health including mental health. Paradoxically, the United Kingdom Home Office also features an Indicators for Integration Framework to provide practical ways to design more effective strategies, monitor services and evaluated integration interventions. Methods: This study employed a qualitative research design including semi-structured interviews with 19 mental health and psychosocial support service providers working in third-sector organizations in London. Results: The study results show that the current asylum system severely undermines efforts to support asylum seekers and refugees with their integration. All participants highlighted that asylum seekers and refugees lacked experienced poor quality of life and faced structural challenges to build meaningful social connections; to have access education, fair employment and good work; to achieve good mental health and wellbeing; and to be able to thrive. Discussion: To improve community integration, quality of life, thriving, and mental health for asylum seekers and refugees in London and, beyond, the United Kingdom, four recommendations are made on structural and service-levels: (1) reform of the current asylum system by centering human rights; (2) implement and carry out needs assessments among asylum seekers and refugees focussing on key social determinants; (3) ensure asylum seekers and refugees benefit from the NHS Inclusion Health framework; and (4) extend the NHS Patient and Carer Race Equality framework beyond England. To be effective, all four initiatives need to be grounded in a participatory approach that meaningfully involves diverse groups of stakeholders including asylum seekers and refugees.

Somali refugees in urban neighborhoods: an eco-social study of mental health and wellbeing.

Background: Impact of pre-migration trauma and post-migration settlement on refugee mental health and wellbeing is well-documented. However, little research has focused on the specific places where refugees settle and spend their daily lives within the post-migration context. This study adopts an eco-social perspective to explore the relationship between urban neighborhoods and refugee mental health and wellbeing. Methods: We conducted twenty-six qualitative interviews with Somali refugees in London and Bristol in the UK. The transcripts were coded using an inductive approach and analyzed through thematic analysis. Results: Somali refugees navigate a complex urban environment comprising various neighborhood features which include important places near home, interactions with neighbors, and community spaces. While these features afford them resources to improve mental health and wellbeing, they also present challenges such as high urban density, exposure to violence or discrimination, and neighborhood disorder. Conclusion: The societal and physical features of urban neighborhoods intersect with refugee experiences of adversity, trauma and stress over time. As eco-social niches, urban neighborhoods are both accommodating, safe and familiar, as well as alien, threatening and unwelcoming. To support mental health and wellbeing and ensure successful settlement, it is essential to recognize the agency of refugees and provide continuous support throughout the entire asylum process and after, ensuring stable and safe living conditions.

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.

Refugee mental health and the role of place in the Global North countries: A scoping review.

Post-migration factors significantly influence refugee mental health. This scoping review looks at the role of place in refugee mental health. We included 34 studies in Global North high-income countries that elaborated on the place characteristics of facilities, neighbourhoods, urban and rural areas, and countries. While the role of place remains under-theorised, all studies reveal common characteristics that support a strong relationship between place of residence, refugee mental health and wellbeing outcomes in post-migration context. Given that refugees often have little or no choice of where they ultimately live, we suggest future research should focus on how characteristics of place co-constitute post-migration refugee mental health risks, protections, and outcomes.

The challenges of international collaboration in conflict and health research: experience from the Research for Health in Conflict-Middle East and North Africa (R4HC-MENA) partnership.

BACKGROUND: Healthcare is a basic human right extending across all humanitarian contexts, including conflict. Globally, two billion people are living under conditions of insecurity and violent armed conflict with a consequent impact on public health. Health research in conflict-affected regions has been recognised as important to gain more understanding of the actual needs of such populations, to optimise healthcare delivery, as well as to inform advocacy and policy change. International collaborative research maximises the resources and skills available for dealing with global health issues, builds capacity and endeavours to ensure the research reflects real needs of the populations. Under the UK's Global Challenge Research Fund in 2017 a number of such international programs were created including the Research for Health in Conflict-Middle East and North Africa (R4HC-MENA) partnership to build capacity in conflict and health research as well as study specific areas, namely noncommunicable diseases in conflict (cancer & mental health) and the political economy of health in conflict. METHODS: A qualitative study using semi-structured online interviews was conducted to explore researchers' and stakeholders' perspectives on the R4HC-MENA programme over its lifetime from 2017 to 2021. It aimed to understand the factors that influenced and accelerated international collaboration within the R4HC-MENA programme on conflict and health research, and to provide deeper insights into the implementation of the programme. Data collection was conducted from March 2022 to June 2022. Purposive and snowball sampling techniques were used for participant recruitment. Thematic analysis was applied for data analysis. RESULTS: Twelve researchers/stakeholders participated in this study: four men and eight women. Four main themes were generated: Theme 1: Network building (personal and institutional levels); Theme 2: Hierarchies and power dynamics (power imbalance between different academic status, genders and institutions); Theme 3: Communication challenges; Theme 4: Career development (management, leadership, research, and teaching skills). CONCLUSIONS: This study provided preliminary insights into perspectives on international collaboration in a major international programme of research on conflict and health. Several key challenges and outputs were generated by the researchers in this study. The findings are important for further developing effective strategies to tackle the challenge of power imbalance and ineffective communication in international research collaborations.

A mixed methods PAR study investigating social capital as a resource for Black and other racially minoritised communities in the UK: A study protocol.

Understanding how different Black and other racially minoritised communities thrive is an emerging priority area in mental health promotion. Literature demonstrates health benefits of social capital (social resources embedded within social networks). However, its effects are not always positive, particularly for certain subpopulations who are already disadvantaged.The CONtributions of social NEtworks to Community Thriving (CONNECT) study will use Participatory Action Research (PAR) to investigate social capital as a resource that benefits (or hinders) racially minoritised communities and their mental health. The CONNECT study was designed within a partnership with community organisations and responds to local policy in two South-East London Boroughs, thereby providing potential channels for the action component of PAR. Taking an anti-racism lens, we acknowledge the underpinning role of racism in creating health inequities. We apply an intersectional framework to be considerate of overlapping forms of oppression such as age, gender, socioeconomic status, and sexual orientation as an essential part of developing effective strategies to tackle health inequities. Key components of this mixed methods PAR study include (1) involving racialised minority community members as peer researchers in the team (2) collecting and analysing primary qualitative data via interviews, photovoice, and community mapping workshops, (3) developing relevant research questions guided by peer researchers and collaborating organisations and analysing secondary quantitative data accordingly, (4) integrating qualitative and quantitative phases, and (5) working closely with community and policy partners to act on our findings and use our research for social change.The PAR approach will allow us to engage community (voluntary sector and government) and academic partners in decision making and help address imbalances in power and resource allocation. Knowledge generated through this collaborative approach will contribute to existing community initiatives, policies, and council strategies. This will ensure the views and experiences of racially minoritised communities drive the changes we are collaboratively committed to achieving.

Ageism, an invisible social determinant of health for older Syrian refugees in Lebanon: a service providers' perspective.

BACKGROUND: Older refugees face particular challenges because their health and social needs are largely overlooked in humanitarian programmes, policies and research. The few studies available have shown that older refugees suffer from a high prevalence of non-communicable diseases, including mental health problems, increased social isolation and poverty, and difficulty accessing health and social services. This article aims to provide further in-depth understanding of how service providers perceive health and social challenges of older Syrian refugees living in Lebanon by focusing on (1) their health and social challenges; (2) the available and lacking services; (3) participation; and (4) policy recommendations to improve services. METHODS: This study is based on a qualitative research approach. Fifteen semi-structured interviews were conducted with health and social workers providing services to older Syrian refugees living in Lebanon. All interviews were digitally recorded, transcribed, coded and analysed using thematic analysis. RESULTS: Study results clearly show that older refugees face increased marginalisation and neglect, mainly because of ageism. Ageism experienced at aid agency, family and individual levels, impacts negatively on older refugees. They have a sense of social isolation, neglect and feel they are a burden, consequently their social participation decreases, impacting negatively on their physical and mental health as well as their access to social and health care. Linked to experiences of ageism, study participants noted: (1) high prevalence rates of non-communicable diseases and mental health problems; (2) difficulties accessing care, with inadequate services to support the needs of older refugees; and (3) policy recommendations calling for an holistic approach to aid which takes into consideration the specific needs of older refugees as well as their capabilities. CONCLUDING REMARKS: Ageism is a key determinant of health which negatively impacts the physical, mental and social health, and wellbeing of older Syrian refugees. It pushes them to the margins of society where they are left behind by the humanitarian response, policy makers and researchers, as well as their communities and families. To mitigate this situation, this article calls for directly addressing ageism on social, service and policy levels.

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.

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.

Erratum: Towards decolonising research methods training: The development of a locally responsive online learning course on research methods for mental health in war and conflict for researchers and practitioners in the Gaza Strip - ERRATUM.

[This corrects the article DOI: 10.1017/gmh.2021.40.].

Llaki and ñakary: idioms of distress and suffering among the highland Quechua in the Peruvian Andes.

This article examines some of the long-term health outcomes of extreme adversities and the ways in which social inequalities and idioms of distress are historically and socially produced in the Peruvian context. We describe how the highland Quechua of northern Ayacucho construct and experience expressions of distress and suffering such as pinsamientuwan (worrying thoughts, worries), ñakary (suffering) and llaki (sorrow, sadness), in a context of persistent social inequalities, social exclusion and a recent history of political violence. It is concluded that the multiple expressions of distress and suffering are closely related to past and current events, shaped by beliefs, core values and cultural norms and, in this process, transformed, recreated and invested with new meanings and attributions.

The Long-Term Mental Health Consequences of Torture, Loss, and Insecurity: A Qualitative Study Among Survivors of Armed Conflict in the Dang District of Nepal.

Background and Objectives: Nepal has witnessed several periods of organized violence since its beginnings as a sovereign nation. Most recently, during the decade-long Maoist Conflict (1996-2006), armed forces used excessive violence, including torture, resulting in deaths and disappearances. Moreover, there is widespread gender-, ethnic- and caste-based discrimination, and grossly unequal distribution of wealth in the country. While the immediate mental health effects of the conflict are well studied, less is known about the long-term effects of the conflict. This article sets out to explain how Nepalese survivors of violence perceive their wellbeing and mental health, search for help and construct their health care pathways and therapeutic itineraries. The aim is to provide a better understanding of local explanatory models and healthcare behaviors. Methods: Semi-structured interviews were carried out with 25 people (14 men, 11 women) aged 30 to 65 in Dang district in 2013. To elicit illness narratives, a translated and culturally adapted version of the McGill Illness Narrative Interview (MINI) was used. Additionally, participants were interviewed about their war experiences and present-day economic and social situations. The transcripts were coded using deductive and inductive approaches and analyzed through thematic analysis. Results: The study provides insight into temporal narratives of illness experience and explanatory modules. Symptoms were found to be widespread and varied, and were not solely attributed to violent experiences and memories, but also to everyday stressors related to survivors' economic, social, and familial situations. In terms of help- and health-seeking behavior it was found that participants resorted to various coping strategies such as social activities, avoidance, withdrawal, and substance use. Many participants had received biomedical treatment for their psychosocial problems from doctors and specialists working in public and private sector clinics and hospitals as well as different forms of traditional healing. Conclusions: These results shed light on the long-term impact of the Nepalese conflict on survivors of extreme violence, highlighting local explanatory models and help- and health-seeking behaviors. These findings inspire recommendations for the development of context specific and holistic psychosocial interventions focusing on well-being, social determinants of health, and human rights.