Strengthening community mental health competence-A realist informed case study from Dehradun, North India

Abstract

Few accounts exist of programmes in low-and middle-income countries seeking to strengthen community knowledge and skills in mental health. This case study uses a realist lens to explore how a mental health project in a context with few mental health services, strengthened community mental health competence by increasing community knowledge, creating safer social spaces and engaging partnerships for action. We used predominantly qualitative methods to explore relationships between context, interventions, mechanisms and outcomes in the "natural setting" of a communitybased mental health project in Dehradun district, Uttarakhand, North India. Qualitative data came from focus group discussions, participant observation and document reviews of community teams' monthly reports on changes in behaviour, attitudes and relationships among stakeholder groups. Data analysis initially involved thematic analysis of three domains: knowledge, safe social spaces and partnerships for action. By exploring patterns within the identified themes for each domain, we were able to infer the mechanisms and contextual elements contributing to observed outcomes.Community knowledge was effectively increased by allowing communities to absorb new understanding into pre-existing social and cultural constructs. Non-hierarchical informal community conversations allowed "organic" integration of unfamiliar biomedical knowledge into local explanatory frameworks. People with psycho-social disability and caregivers found increased social support and inclusion by participating in groups. Building skills in respectful communication through role plays and reflexive discussion increased the receptivity of social environments to people with psychosocial disabilities participation, thereby creating safe social spaces. Facilitating social networks through groups increases women's capacity for collective action to promote mental health. In summary, locally appropriate methods contribute most to learning, stigma reduction and help-seeking. The complex social change progress was patchy and often slow. This study demonstrates a participatory, iterative, reflexive project design which is generating evidence indicating substantial improvements in community mental health competence.

Service user involvement in global mental health

“…Our rapid review returned 10 studies from nine countries across Asia (China, 5 India, [6][7][8] Malaysia, 9 Nepal 6, 10, 11 ), Africa (Ethiopia, 6,[11][12][13] Nigeria, 6,11 South Africa, 6 Uganda 6 ) and Europe (Lithuania 14 ). The majority of included studies were qualitative and conducted as part of a situation analysis, pilot study or other formative research.…”

“…The majority of included studies were qualitative and conducted as part of a situation analysis, pilot study or other formative research. Three reported on user involvement in mental health policy and planning, 6,11,12 three on user involvement in mental health services or capacity-building of service providers, 5,7,10 and three on user involvement in treatment decisions. 9,13,14 Upon further consultation with the corresponding author, an additional study was identified as having involved users in data collection.…”

“…In keeping with Hanlon, Eshetu, Alemayehu et al's (2017) observations, 12 our review identified more examples of user involvement in mental health services than in policy or planning. Two studies evaluate mental health programmes involving self-help groups (India) 7 and formal peer support (China). 5 Researchers are also piloting a training module on mental health stigma co-facilitated by service users and delivered to primary care workers (Nepal).…”

“…10 Mathias, Mathias, Goicolea and Kermode (2017) present a case study of the Burans mental health project in India, which aims to improve community mental health competence through a variety of community-level interventions, including self-help groups for users and caregivers. 7 Participants report benefits of self-help groups, such as improved social inclusion, though outcomes are not assessed quantitatively. However, self-help groups are widely used in LMICs and their effectiveness has already been investigated in previous studies, including in India.…”

Lived Experience of Psychosocial Disability and Social Inclusion: A Participatory Photovoice Study in Rural India and Nepal

“…These data highlight the central role of relationships in recovery and the imperative of building mutual understanding and supportive environments for families and households (Wyder & Bland, 2014;Foster et al, 2016;Price-Roberts et al, 2016). The evidence suggests that this support could be offered through individual and family-based counselling, peer support groups, self-help groups and advocacy group membership (Tew et al, 2012;Price-Robertson et al, 2016;Mathias et al, 2017).…”