RESUMO
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.
Assuntos
Agentes Comunitários de Saúde , Saúde Mental , Humanos , Pesquisa Qualitativa , Índia , Agentes Comunitários de Saúde/psicologiaRESUMO
SUMMARY: In this analysis, we argue that the 'treatment gap' for common mental disorders often reflects lack of demand, arising because services fail to address the needs of disadvantaged communities. We propose a route forward for global mental health, with explicit focus on action on the socioeconomic determinants of psychological suffering.
Assuntos
Transtornos Mentais , Serviços de Saúde Mental , Saúde Global , Necessidades e Demandas de Serviços de Saúde , Humanos , Transtornos Mentais/terapia , Saúde MentalRESUMO
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.
Assuntos
Pesquisa Participativa Baseada na Comunidade/métodos , Transtornos Mentais/reabilitação , Obras Pictóricas como Assunto/psicologia , Adulto , Pessoas com Deficiência/psicologia , Pessoas com Deficiência/reabilitação , Feminino , Humanos , Índia , Masculino , Transtornos Mentais/psicologia , Pessoa de Meia-Idade , Pesquisa Qualitativa , Recuperação de Função FisiológicaRESUMO
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.
Assuntos
Serviços Comunitários de Saúde Mental/estatística & dados numéricos , Liberdade , Relações Interpessoais , Participação do Paciente/psicologia , Participação Social/psicologia , Adulto , Ásia , Atitude , Tomada de Decisões , Depressão/psicologia , Emprego/psicologia , Família , Feminino , Grupos Focais , Identidade de Gênero , Humanos , Índia , Transtornos Mentais/psicologia , Saúde Mental , Pesquisa Qualitativa , Grupos de Autoajuda , Cônjuges , Saúde da MulherRESUMO
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.
RESUMO
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.
RESUMO
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?
Assuntos
Saúde Mental , Confiança , Humanos , Índia , Populações VulneráveisRESUMO
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.
RESUMO
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.
Assuntos
Poder Familiar , Pais , Adolescente , Comunicação , Humanos , Índia , Pais/educação , PobrezaRESUMO
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.
Assuntos
Países em Desenvolvimento , Saúde Mental , COVID-19 , Humanos , Renda , PobrezaRESUMO
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.