Opening up the 'black-box': what strategies do community mental health workers use to address the social dimensions of mental health?

PURPOSE: Community-based workers promote mental health in communities. Recent literature has called for more attention to the ways they operate and the strategies used. For example, how do they translate biomedical concepts into frameworks that are acceptable and accessible to communities? How do micro-innovations lead to positive mental health outcomes, including social inclusion and recovery? The aim of this study was to examine the types of skills and strategies to address social dimensions of mental health used by community health workers (CHWs) working together with people with psychosocial disability (PPSD) in urban north India. METHODS: We interviewed CHWs (n = 46) about their registered PPSD who were randomly selected from 1000 people registered with a local non-profit community mental health provider. Notes taken during interviews were cross-checked with audio recordings and coded and analyzed thematically. RESULTS: CHWs displayed social, cultural, and psychological skills in forming trusting relationships and in-depth knowledge of the context of their client's lives and family dynamics. They used this information to analyze political, social, and economic factors influencing mental health for the client and their family members. The diverse range of analysis and intervention skills of community health workers built on contextual knowledge to implement micro-innovations in a be-spoke way, applying these to the local ecology of people with psychosocial disabilities (PPSD). These approaches contributed to addressing the social and structural determinants that shaped the mental health of PPSD. CONCLUSION: Community health workers (CHWs) in this study addressed social aspects of mental health, individually, and by engaging with wider structural factors. The micro-innovations of CHWs are dependent on non-linear elements, including local knowledge, time, and relationships. Global mental health requires further attentive qualitative research to consider how these, and other factors shape the work of CHWs in different locales to inform locally appropriate mental health care.

Mutuality as a method: advancing a social paradigm for global mental health through mutual learning.

PURPOSE: Calls for "mutuality" in global mental health (GMH) aim to produce knowledge more equitably across epistemic and power differences. With funding, convening, and publishing power still concentrated in institutions in the global North, efforts to decolonize GMH emphasize the need for mutual learning instead of unidirectional knowledge transfers. This article reflects on mutuality as a concept and practice that engenders sustainable relations, conceptual innovation, and queries how epistemic power can be shared. METHODS: We draw on insights from an online mutual learning process over 8 months between 39 community-based and academic collaborators working in 24 countries. They came together to advance the shift towards a social paradigm in GMH. RESULTS: Our theorization of mutuality emphasizes that the processes and outcomes of knowledge production are inextricable. Mutual learning required an open-ended, iterative, and slower paced process that prioritized trust and remained responsive to all collaborators' needs and critiques. This resulted in a social paradigm that calls for GMH to (1) move from a deficit to a strength-based view of community mental health, (2) include local and experiential knowledge in scaling processes, (3) direct funding to community organizations, and (4) challenge concepts, such as trauma and resilience, through the lens of lived experience of communities in the global South. CONCLUSION: Under the current institutional arrangements in GMH, mutuality can only be imperfectly achieved. We present key ingredients of our partial success at mutual learning and conclude that challenging existing structural constraints is crucial to prevent a tokenistic use of the concept.

Conducting research with young people at the margins - lessons learnt and shared through case studies in Cambodia, India, Sweden and Zambia.

Building on the value of engaging with and enabling the participation of marginalised young people in research, the aim of this article was to profile practical and procedural issues faced when conducting studies with young people who experience some form of marginalisation. Drawing on observations and research experiences from four diverse case studies involving young people who were either imprisoned in Cambodia, living in informal urban communities in North India, residing in rural northern Sweden or attending school in rural Zambia, learnings were identified under three thematic areas. Firstly, a need exists to develop trusting relationships with stakeholders, and especially the participating young people, through multiple interactions. Secondly, the value of research methods that are creative and context sensitive are required to make the process equitable and meaningful for young people. Thirdly, it is important to flatten power relations between adults and young people, researchers and the researched, to maximise participation. These findings can inform future youth research in the field of global public health by detailing opportunities and challenges of engaging in research with young people on the margins to promote their participation.

Improving Social Inclusion for Young People Affected by Mental Illness in Uttarakhand, India.

Young people experiencing mental ill-health are often excluded from peer networks, family events, education, marriage and employment. We evaluated a community-based, peer-led intervention guided by the Nae Disha (new pathways) program, targeting young people affected by mental ill-health in Uttarakhand, India. A total of 11 groups involving 142 young people (30 male, 112 female) and 8 peer facilitators participated, most of whom were enrolled in a community mental health program. The impact of the intervention on participation, mental health, and social strengths and difficulties was measured at baseline and endline using validated instruments. The proportion experiencing significant social isolation reduced from 20.6 to 5.9% (p < 0.001), and those classified in the 'abnormal' range of the social difficulties measure halved from 42.6 to 21.3% (p < 0.001). These findings clearly demonstrate that perceptions of social inclusion and mental health of young people affected by mental illness can be significantly strengthened through participation in this low-resource intervention.

"We've got through hard times before: acute mental distress and coping among disadvantaged groups during COVID-19 lockdown in North India - a qualitative study".

BACKGROUND: The COVID-19 crisis in India negatively impacted mental health due to both the disease and the harsh lockdown, yet there are almost no qualitative studies describing mental health impacts or the strategies of resilience used, and in particular, no reports from the most vulnerable groups. This study aimed to examine the acute mental health impacts of the COVID-19 crisis as well as coping strategies employed by disadvantaged community members in North India. METHODS: We used an intersectional lens for this qualitative study set in rural Tehri Garwhal and urban Dehradun districts of Uttarakhand, India. In-depth interviews were conducted in May 2020 during lockdown, by phone and in person using purposive selection, with people with disabilities, people living in slums with psychosocial disabilities and widows (total n = 24). We used the framework method for analysis following steps of transcription and translation, familiarisation, coding, developing and then applying a framework, charting and then interpreting data. FINDINGS: The participants with compounded disadvantage had almost no access to mobile phones, health messaging or health care and experienced extreme mental distress and despair, alongside hunger and loss of income. Under the realms of intrapersonal, interpersonal and social, six themes related to mental distress emerged: feeling overwhelmed and bewildered, feeling distressed and despairing, feeling socially isolated, increased events of othering and discrimination, and experiencing intersectional disadvantage. The six themes summarising coping strategies in the COVID-19 crisis were: finding sense and meaning, connecting with others, looking for positive ways forward, innovating with new practices, supporting others individually and collectively, and engaging with the natural world. CONCLUSIONS: People intersectionally disadvantaged by their social identity experienced high levels of mental distress during the COVID-19 crisis, yet did not collapse, and instead described diverse and innovative strategies which enabled them to cope through the COVID-19 lockdown. This study illustrates that research using an intersectional lens is valuable to design equitable policy such as the need for access to digital resources, and that disaggregated data is needed to address social inequities at the intersection of poverty, disability, caste, religious discrimination and gender inherent in the COVID-19 pandemic in India.

Co-production of a pictorial recovery tool for people with psycho-social disability informed by a participatory action research approach-a qualitative study set in India.

Mental health problems are recognized as a leading cause of disability and have seen increased allocations of resources and services globally. There is a growing call for solutions supporting global mental health and recovery to be locally relevant and built on the knowledge and skills of people with mental health problems, particularly in low-income countries. Set in Dehradun district, North India, this study aimed to describe first, the process of co-production of a visual tool to support recovery for people affected by psycho-social disability; second, the key outputs developed and third, critical reflection on the process and outputs. The developmental process consisted of participatory action research and qualitative methods conducted by a team of action researchers and an experts by experience (EBE) group of community members. The team generated eight domains for recovery under three meta-domains of normalcy, belonging and contributing and the ensuing recovery tool developed pictures of activities for each domain. Challenges to using a participatory and emancipatory process were addressed by working with a mentor experienced in participatory methods, and by allocating time to concurrent critical reflection on power relationships. Findings underline the important contribution of an EBE group demonstrating their sophisticated and locally valid constructions of recovery and the need for an honest and critically reflective process in all co-productive initiatives. This study generated local conversations around recovery that helped knowledge flow from bottom-to-top and proposes that the grass-root experiences of participants in a disadvantaged environment are needed for meaningful social and health policy responses.

Women's freedom of movement and participation in psychosocial support groups: qualitative study in northern India.

BACKGROUND: Depression, the world's leading cause of disability, disproportionately affects women. Women in India, one of the most gender unequal countries worldwide, face systemic gender disadvantage that significantly increases the risk of common mental disorders. This study's objective was to examine the factors influencing women's participation in psychosocial support groups, within an approach where community members work together to collectively strengthen their community's mental health. METHODS: This community-based qualitative study was conducted from May to July 2016, across three peri-urban sites in Dehradun district, Uttarakhand, Northern India. Set within an NGO-run mental health project, data were collected through focus group discussions with individuals involved in psychosocial support groups including women with psychosocial disabilities as well as caregivers (N = 10, representing 59 women), and key informant interviews (N = 8) with community members and mental health professionals. Data were analyzed using a thematic analysis approach. RESULTS: The principal barrier to participating in psychosocial support groups was restrictions on women's freedom of movement. Women in the community are not normally permitted to leave home, unless going to market or work, making it difficult for women to leave their home to participate in the groups. The restrictions emanated from the overall community's attitude toward gender relations, the women's own internalized gender expectations, and most significantly, the decision-making power of husbands and mothers-in-law. Other factors including employment and education shaped women's ability to participate in psychosocial support groups; however, the role of these additional factors must be understood in connection to a gender order limiting women's freedom of movement. CONCLUSIONS: Mental health access and gender inequality are inseparable in the context of Northern India, and women's mental health cannot be addressed without first addressing underlying gender relations. Community-based mental health programs are an effective tool and can be used to strengthen communities collectively; however, attention towards the gender constraints that restrict women's freedom of movement and their ability to access care is required. To our knowledge, this is the first study to clearly document and analyze the connection between access to community mental health services in South Asia and women's freedom of movement.

Under the banyan tree--exclusion and inclusion of people with mental disorders in rural North India.

BACKGROUND: Social exclusion is both cause and consequence of mental disorders. People with mental disorders (PWMD) are among the most socially excluded in all societies yet little is known about their experiences in North India. This qualitative study aims to describe experiences of exclusion and inclusion of PWMD in two rural communities in Uttar Pradesh, India. METHODS: In-depth interviews with 20 PWMD and eight caregivers were carried out in May 2013. Interviews probed experiences of help-seeking, stigma, discrimination, exclusion, participation, agency and inclusion in their households and communities. Qualitative content analysis was used to generate codes, categories and finally 12 key themes. RESULTS: A continuum of exclusion was the dominant experience for participants, ranging from nuanced distancing, negative judgements and social isolation, and self-stigma to overt acts of exclusion such as ridicule, disinheritance and physical violence. Mixed in with this however, some participants described a sense of belonging, opportunity for participation and support from both family and community members. CONCLUSIONS: These findings underline the urgent need for initiatives that increase mental health literacy, access to services and social inclusion of PWMD in North India, and highlight the possibilities of using human rights frameworks in situations of physical and economic violence. The findings also highlight the urgent need to reduce stigma and take actions in policy and at all levels in society to increase inclusion of people with mental distress and disorders.

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.

Does the Nae Umeed group intervention improve mental health and social participation? A pre-post study in Uttarakhand, India.

There are few evidence-based interventions to support caregiver mental health developed for low- and middle-income countries. Nae Umeed is a community-based group intervention developed with collaboratively with local community health workers in Uttarakhand, India primarily to promote mental wellbeing for caregivers and others. This pre-post study aimed to evaluate whether Nae Umeed improved mental health and social participation for people with mental distress, including caregivers. The intervention consisted of 14 structured group sessions facilitated by community health workers. Among 115 adult participants, 20% were caregivers and 80% were people with disability and other vulnerable community members; 62% had no formal education and 92% were female. Substantial and statistically significant improvements occurred in validated psychometric measures for mental health (12-Item General Health Questionnaire, Patient Health Questionnaire-9) and social participation (Participation Scale). Improvements occurred regardless of caregiver status. This intervention addressed mental health and social participation for marginalised groups that are typically without access to formal mental health care and findings suggest Nae Umeed improved mental health and social participation; however, a controlled community trial would be required to prove causation. Community-based group interventions are a promising approach to improving the mental health of vulnerable groups in South Asia.

Developing relevant community mental health programmes in North India: five questions we ask when co-producing knowledge with experts by experience.

Knowledge co-production can improve the quality and accessibility of health, and also benefit service users, allowing them to be recognised as skilled and capable. Yet despite these clear benefits, there are inherent challenges in the power relations of co-production, particularly when experts by experience (EBE) are structurally disadvantaged in communication skills or literacy. The processes of how knowledge is co-produced and negotiated are seldom described. This paper aims to describe processes of co-production building on the experiences of EBE (people with lived experience of psychosocial or physical disability), practitioners and researchers working together with a non-profit community mental health programme in North India. We describe processes of group formation, relationship building, reflexive discussion and negotiation over a 7-year period with six diverse EBE groups. Through a process of discussion and review, we propose these five questions which may optimise co-production processes in communities: (1) Who is included in co-production? (2) How can we optimise participation by people with diverse sociodemographic identities? (3) How do we build relationships of trust within EBE groups? (4) How can we combine psychosocial support and knowledge co-production agendas in groups? and (5) How is the expertise of experts by experience acknowledged?

Scaling a group intervention to promote caregiver mental health in Uttarakhand, India: A mixed-methods implementation study.

Caregivers are integral to health and social care systems in South Asian countries yet are themselves at higher risk of mental illness. Interventions to support caregiver mental health developed in high-income contexts may be contextually inappropriate in the Global South. In this mixed-methods study, we evaluated the implementation and scaling of a locally developed mental health group intervention for caregivers and others in Uttarakhand, India. We describe factors influencing implementation using the updated Consolidated Framework for Implementation Research, and selected implementation outcomes. Key influencing factors we found in common with other programs included: an intervention that was relevant and adaptable; family support and stigma operating in the outer setting; training and support for lay health worker providers, shared goals, and relationships with the community and the process of engaging with organisational leaders and service users within the inner setting. We identified further factors including the group delivery format, competing responsibilities for caregivers and opportunities associated with the partnership delivery model as influencing outcomes. Implementation successfully reached target communities however attrition of 20% of participants highlights the potential for improving outcomes by harnessing enablers and addressing barriers. Findings will inform others implementing group mental health and caregiver interventions in South Asia.

Improving mental ill-health with psycho-social group interventions in South Asia-A scoping review using a realist lens.

This scoping review aimed to synthesise current evidence related to psycho-social groups as part of community-based mental health interventions in South Asia. We used a realist lens to pay attention to the contexts and mechanisms supporting positive outcomes. We included studies published from January 2007 to February 2022 that: were based in communities in South Asia, included a group component, reported on interventions with a clear psychosocial component, targeted adults and were implemented by lay community health workers. Two reviewers extracted data on intervention components, groups and facilitators, participant demographics and enabling contexts, mechanisms and outcomes. Expert reference panels including people with lived experience of psycho-social disability, mental health professionals and policy makers confirmed the validity and relevance of initial review findings. The review examined 15 interventions represented by 42 papers. Only four interventions were solely psycho-social and nearly all included psychoeducation and economic support. Only 8 of the 46 quantitative outcome measures used were developed in South Asia. In a context of social exclusion and limited autonomy for people with psychosocial disability, psychosocial support groups triggered five key mechanisms. Trusted relationships undergirded all mechanisms, and provided a sense of inclusion, social support and of being able to manage mental distress due to improved skills and knowledge. Over time group members felt a sense of belonging and collective strength meaning they were better able to advocate for their own well-being and address upstream social health determinants. This led to outcomes of improved mental health and social participation across the realms of intrapersonal, interpersonal and community. Psychosocial groups merit greater attention as an active ingredient in community interventions and also as an effective, relevant, acceptable and scalable platform that can promote and increase mental health in communities, through facilitation by lay community health workers.

Is the Parwarish parenting intervention feasible and relevant for young people and parents in diverse settings in India? A mixed methods process evaluation.

OBJECTIVE: To assess the feasibility, acceptability and relevance of the Parwarish, a positive parenting intervention (adapted from PLH-Teens) in three diverse settings in India. DESIGN: This mixed methods study used the Medical Research Council framework for process evaluations of complex interventions. SETTING: This study was set in disadvantaged communities in urban Agra, rural Uttar Pradesh and tribal Jharkhand in India. PARTICIPANTS: Data were collected from 86 facilitators, implementers, parents and teens who participated in the Parwarish intervention among 239 families. INTERVENTION: Couples from target communities facilitated groups of parents and teens over the 14-module structured, interactive Parwarish intervention which focused on building communication, reducing harsh parenting and building family budgeting skills. OUTCOME MEASURES: We assessed relevance, acceptability and feasibility of the intervention using mixed methods. Qualitative data collected included semistructured interviews and focus group discussions with implementers, facilitators, parents and young people who were transcribed, translated and thematically analysed to develop themes inherent in the data. Quantitative data which assessed attendance, fidelity to the intervention and facilitator training and coaching were analysed descriptively. RESULTS: Findings were grouped under the three domains of facilitation, community engagement and programme support with the following seven themes: (1) community-based facilitators increased contextual validity of the intervention; (2) gender relations were not only influenced by Parwarish implementation but were also influenced and transformed by Parwarish; (3) facilitator responsiveness to group concerns increased participation; (4) participation gathered momentum; (5) Parwarish's strong core and porous periphery allowed adaptations to local contexts; (6) technology that included Skype and WhatsApp enhanced implementation and (7) critical reflection with community trained coaches strengthened facilitation quality and programme fidelity. CONCLUSION: This study found Parwarish engaging, feasible and acceptable in three diverse, low-income communities, although constrained by patriarchal gender relations. It paves the way for larger-scale implementation in other South Asian settings.

Exploring Community Mental Health Systems - A Participatory Health Needs and Assets Assessment in the Yamuna Valley, North India.

BACKGROUND: In India and global mental health, a key component of the care gap for people with mental health problems is poor system engagement with the contexts and priorities of community members. This study aimed to explore the nature of community mental health systems by conducting a participatory community assessment of the assets and needs for mental health in Uttarkashi, a remote district in North India. METHODS: The data collection and analysis process were emergent, iterative, dialogic and participatory. Transcripts of 28 in-depth interviews (IDIs) with key informants such as traditional healers, people with lived experience and doctors at the government health centres (CHCs), as well as 10 participatory rural appraisal (PRA) meetings with 120 people in community and public health systems, were thematically analysed. The 753 codes were grouped into 93 categories and ultimately nine themes and three meta-themes (place, people, practices), paying attention to equity. RESULTS: Yamuna valley was described as both 'blessed' and limited by geography, with bountiful natural resources enhancing mental health, yet remoteness limiting access to care. The people described strong norms of social support, yet hierarchical with entrenched exclusions related to caste and gender, and social conformity that limited social accountability of services. Care practices were porous, pluralist and fragmented, with operational primary care services that acknowledged traditional care providers, and trusted resources for mental health such as traditional healers (malis) and government health workers (accredited social health activists. ASHAs). Yet care was often absent or limited by being experienced as disrespectful or of low quality. CONCLUSION: Findings support the value of participatory methods, and policy actions that address power relations as well as social determinants within community and public health systems. To improve mental health in this remote setting and other South Asian rural locations, community and public health systems must dialogue with the local context, assets and priorities and be socially accountable.

Participatory mental health interventions in low-income and middle-income countries: a realist review protocol.

INTRODUCTION: The launch of the Movement for Global Mental Health brought long-standing calls for improved mental health interventions in low-and middle-income countries (LMICs) to centre stage. Within the movement, the participation of communities and people with lived experience of mental health problems is argued as essential to successful interventions. However, there remains a lack of conceptual clarity around 'participation' in mental health interventions with the specific elements of participation rarely articulated. Our review responds to this gap by exploring how 'participation' is applied, what it means and what key mechanisms contribute to change in participatory interventions for mental health in LMICs. METHODS AND ANALYSIS: A realist review methodology will be used to identify the different contexts that trigger mechanisms of change, and the resulting outcomes related to the development and implementation of participatory mental health interventions, that is: what makes participation work in mental health interventions in LMICs and why? We augment our search with primary data collection in communities who are the targets of global mental health initiatives to inform the production of a programme theory on participation for mental health in LMICs. ETHICS AND DISSEMINATION: Ethical approval for focus group discussions (FGDs) was obtained in each country involved. FGDs will be conducted in line with WHO safety guidance during the COVID-19 crisis. The full review will be published in an academic journal, with further papers providing an in-depth analysis on community perspectives on participation in mental health. The project findings will also be shared on a website, in webinars and an online workshop.

The Effectiveness of a Multi-Pronged Psycho-Social Intervention Among People With Mental Health and Epilepsy Problems - A Pre-Post Prospective Cohort Study Set in North India.

BACKGROUND: In low- and middle-income settings, many people with mental health problems cannot or do not access psychiatric services. Few studies of people with epilepsy and mental problems have evaluated the effectiveness of a predominantly psycho-social intervention, delivered by lay community workers. The aim of this study was to assess the effectiveness of a community-based complex mental health intervention within informal urban communities while simultaneously addressing social determinants of mental health among disadvantaged people with severe and common mental disorders (CMDs), and epilepsy. METHODS: In this observational, prospective cohort study set in Uttarakhand, India, the lay-worker led intervention included psychoeducation, behavioural activation, facilitation of access to care, and facilitated psycho-social support groups. Participants were categorised as having a severe or CMD or epilepsy and assessed 5 times over 24 months using primary outcome measures, including the Patient Health Questionnaire (PHQ9) (severity of depression), the World Health Organization Disability Assessment Schedule (WHODAS 2.0), the Recovery Star, and scoring of a bespoke Engagement Index. Analysis included descriptive statistics as well as hierarchical linear regression models to report fixed effects as regression coefficients. RESULTS: Among the 297 (baseline) participants only 96 people (31%) regularly used psychotropic medication (at least 4 weeks) and over 60% could not or did not consult a psychiatrist at all in the study period. Nonetheless, people with CMDs showed a significant reduction in their depression severity (PHQ9: B=-6.94, 95% CI -7.37 to -6.51), while people with severe mental disorders (SMDs) showed a significant reduction in their disability score (WHODAS 2.0: B=-4.86, 95% CI - 7.14 to- 2.57). People with epilepsy also reduced their disability score (WHODAS 2.0: B=-5.22, 95% CI -7.29 to -3.15). CONCLUSION: This study shows significant improvements in mental health, depression, recovery, disability and social engagement for people with common and SMDs, and epilepsy, through a community-based intervention that was nonpharmaceutical. It provides preliminary evidence of the value of predominantly psycho-social interventions implemented by lay health workers among people with limited or no access to psychiatric services.

Process and impact evaluation of the Greater Christchurch Urban Development Strategy Health Impact Assessment.

BACKGROUND: despite health impact assessment (HIA) being increasingly widely used internationally, fundamental questions about its impact on decision-making, implementation and practices remain. In 2005 a collaboration between public health and local government authorities performed an HIA on the Christchurch Urban Development Strategy Options paper in New Zealand. The findings of this were incorporated into the Greater Christchurch Urban Development Strategy. METHODS: using multiple qualitative methodologies including key informant interviews, focus groups and questionnaires, this study performs process and impact evaluations of the Christchurch HIA including evaluation of costs and resource use. RESULTS: the evaluation found that the HIA had demonstrable direct impacts on planning and implementation of the final Urban Development Strategy as well as indirect impacts on understandings and ways of working within and between organisations. It also points out future directions and ways of working in this successful collaboration between public health and local government authorities. It summarises the modest resource use and discusses the important role HIA can play in urban planning with intersectoral collaboration and enhanced relationships as both catalysts and outcomes of the HIA process. CONCLUSION: as one of the few evaluations of HIA that have been published to date, this paper makes a substantial contribution to the literature on the impact, utility and effectiveness of HIA.

"We sold the buffalo to pay for a brain scan" - a qualitative study of rural experiences with private mental healthcare providers in Uttar Pradesh, India.

The majority of persons with mental distress (PWMD) in India do not have access to care, and even those who seek care are pushed to attend private providers, given the weak and largely absent public mental health services framework. The aim of this study was to examine the experiences in help-seeking and with unethical health service provision among persons with mental distress in the Saharanpur and Bijnor districts of Uttar Pradesh. In-depth interviews were conducted with twenty persons with mental distress and their caregivers. Thematic analysis yielded four key findings about help-seeking: first, that it was syncretic and persistent; second, that expenditure for private care was high and often catastrophic; third, that investigations and care provided were pharmacological and predominantly irrational and excessive; and lastly, that help-seeking was abandoned. This study demonstrates that PWMD are particularly vulnerable to exploitation by private providers with illnesses that are stigmatising, poorly understood, chronic, relapsing, and disabling and that often require complex management. Responding to mental distress requires multiple empowering and interacting policy and programme initiatives that must include regulation of private and public providers, resources, and actions to strengthen public and primary mental healthcare and promotion of mental health competence in communities.

An asymmetric burden: Experiences of men and women as caregivers of people with psycho-social disabilities in rural North India.

Caring for a family member with a psycho-social disability can be both rewarding and burdensome. This study analyses the experiences of caregivers of people with psychosocial disabilities (PPSDs) in rural communities in North India using relational gender theory. In-depth interviews with 18 female and male caregivers of PPSDs probed the social, emotional and health impacts of their caregiving role. Nine themes were identified that were grouped under three meta-themes: intra-personal, inter-personal and institutional impacts. Under the intra-personal meta-theme, all caregivers experienced high tension, with women describing almost overwhelming stress. Women minimised their role as caregivers, and felt negative and hopeless about their futures, while men had a more positive view of the future and themselves. Embodied experiences of psychological and social distress were consistently described by women, but not by men. Within the interpersonal meta-theme, men experienced opportunity for social connection and social support that was seldom available to women. Interpersonal violence with other household members was described by both men and women. Within the institutional meta-theme, both men and women described strength in unity, and gestures leading to the reordering of gender relations. These findings underline the significant and diffuse impacts of a gender order that values males and disadvantages females as caregivers of PPSDs, with the asymmetry of a greater burden for women. The findings point to the urgent need for global mental health policies that support and empower caregivers and that strengthen gender equality.