Towards the Development of an Intervention to Address Social Determinants of Non-Communicable Disease in Kerala, India: A Mixed Methods Study.

In India, cardiovascular disease (CVD), with hypertension as its foremost risk factor, has the highest prevalence rate of non-communicable diseases (NCDs) and a rising mortality. Previous research has found a clustering of behavioural and social risks pertaining to NCDs, though the latter are infrequently addressed in public health interventions in India. This paper reaches toward the development of a social intervention to address social determinants of NCD relating to hypertension and diabetes. We used Theory of Change (ToC) as a theoretical approach to programme design. Mixed methods were used, including qualitative interviews with community members (n = 20), Accredited Social Health Activists (n = 6) and health professionals (n = 8), and a stakeholder workshop (n = 5 participants). The recruitment of participants from one local area in Kerala enabled us to map service provision and gain a holistic understanding of how to utilise the existing workforce to target social risk factors. The findings suggest that social interventions need to focus on ensuring health behaviour information reaches all parts of the community, and that those with more social risk factors are identified and supported to engage with treatment. Further research is required to test the resulting intervention model.

Social and behavioural risk factors in the prevention and management of cardiovascular disease in Kerala, India: a catchment area population survey.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of mortality in India. Social and behavioural factors are strongly interrelated in the prevention and control of CVD. The ability to make lifestyle changes to control hypertension and diabetes (major risk factors for CVD) is determined by factors such as education, gender, caste, poverty, and urbanicity. This study aimed to improve our understanding of the inter-relationship of social and behavioural factors in the management of elevated serum glucose and high blood pressure and co-morbid mental health conditions. METHODS: A population-based catchment area cross sectional survey was conducted in Kerala, India. Data were collected from residents aged over 30 years (n = 997) using standardized tools and clinical measures. We performed latent class analysis incrementally to extract homogeneous latent classes of individuals based on their responses to social and behavioural risk factors in the survey. Using structural equation models, we assessed the mediating effect of depression and anxiety, and social or behavioural risk factors, on management of high blood pressure and raised serum glucose levels. RESULTS: The prevalence of high blood pressure and blood glucose in the sample was 33 and 26% respectively. Latent class analysis found three clusters of risk factors. One had a predominance of behavioural characteristics, another of social risk factors and the third was a low risk group. Age, female sex, and marital status had an effect on high blood pressure and high glucose, though were mediated by mental health, social and behavioural risk factors. CONCLUSIONS: Interventions to improve the management of risk factors for CVD need to address social risk factors and be sensitive to the needs of population sub-groups that may require additional support to access health services. An integration of social and health services may be required to achieve this.

Social factors associated with chronic non-communicable disease and comorbidity with mental health problems in India: a scoping review.

OBJECTIVES: The purpose of this study is to examine the existing literature of the major social risk factors which are associated with diabetes, hypertension and the comorbid conditions of depression and anxiety in India. DESIGN: Scoping review. DATA SOURCES: Scopus, Embase, CINAHL Plus, PsycINFO, Web of Science and MEDLINE were searched for through September 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies reporting data on social risk factors for diabetes or hypertension and depression or anxiety in community-based samples of adults from India, published in English in the 10 years to 2019, were included. Studies that did not disaggregate pooled data from other countries were excluded. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted study aims; methods; sample size and description; demographic, social and behavioural risk factors and a summary of findings from each paper. Risk factors were synthesised into six emergent themes. RESULTS: Ten studies were considered eligible and included in this review. Nine presented cross-sectional data and one was a qualitative case study. Six themes emerged, that is, demographic factors, economic aspects, social networks, life events, health barriers and health risk behaviours. CONCLUSIONS: Literature relating to the major social risk factors associated with diabetes, hypertension and comorbid depression and anxiety in India is sparse. More research is required to better understand the interactions of social context and social risk factors with non-communicable diseases and comorbid mental health problems so as to better inform management of these in the Indian subcontinent.

Cultural adaptation framework of social interventions in mental health: Evidence-based case studies from low- and middle-income countries.

BACKGROUND: Evidence-based strategies for treating mental health conditions need to be scaled up to address the mental health treatment gap in low- and middle-income countries. Most medical and psychological interventions for the treatment of mental health conditions have been developed and evaluated in high-income countries. However, the imperative of scaling up such interventions potentially ignores local realities, and may also discredit or replace local frameworks for responding to distress. AIMS: This article aims to develop a framework for the cultural adaptation of social interventions which are developed within, and draw upon, local contexts, to ensure they are acceptable, feasible and effective. METHOD: A case study approach is used to discuss the feasibility of developing and adapting psychosocial interventions which are embedded in local knowledge, values and practices. RESULTS: The first case study introduces yoga as an alternative and/or complementary, and culturally relevant, approach for people experiencing mental health conditions in India. The second case study is a cross-cultural adaptation of a psychosocial intervention from the United Kingdom to fit the local idioms of distress and service context in Sierra Leone, as the country battled with the Ebola outbreak. We use these case studies to develop a Cultural Adaptation Framework, which recognises that people and their mental health are products of their culture and society, to inform the future development, adaptation and evaluation of sociocultural interventions for people experiencing mental health conditions in low- and middle-income countries. CONCLUSION: The Cultural Adaptation Framework can be used to ensure interventions are culturally relevant and responsive to local conditions prior to evaluating in experimental studies.

A review of social participation interventions for people with mental health problems.

PURPOSE: The association between social networks and improved mental and physical health is well documented in the literature, but mental health services rarely routinely intervene to improve an individual's social network. This review summarises social participation intervention models to illustrate different approaches which practitioners use, highlight gaps in the evidence base and suggest future directions for research. METHODS: A systematic search of electronic databases was conducted, and social participation interventions were grouped into six categories using a modified narrative synthesis approach. RESULTS: Nineteen interventions from 14 countries were identified, six of which were evaluated using a randomised controlled trial. They were grouped together as: individual social skills training; group skills training; supported community engagement; group-based community activities; employment interventions; and peer support interventions. Social network gains appear strongest for supported community engagement interventions, but overall, evidence was limited. CONCLUSIONS: The small number of heterogeneous studies included in this review, which were not quality appraised, tentatively suggests that social participation interventions may increase individuals' social networks. Future research needs to use experimental designs with sufficient samples and follow-up periods longer than 12 months to enable us to make firm recommendations for mental health policy or practice.