Abstract
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.
Highlights
Describing the resources communities draw on to respond to mental ill-health acknowledges communities as experts in their own right, and as active agents promoting ‘community mental health competence.’[4]. Ongoing contact with and use of trusted local providers can increase accessibility and acceptability of healthcare facilities.[7,8]
Ten themes related to assets and needs within community and public health systems in the Yamuna valley were identified and grouped under 3 meta-themes related to place, people and practices
The participatory dialogue during and after data collection moved beyond consultation to dialogue and preliminary partnerships between community participants and the health system
Summary
In India mental illness accounts for the largest portion of the disease burden, yet more than 80% of those affected do not access care.[1,2] With 1.3 billion people, 630 districts and 22 official languages, there are diverse contexts and systems, and a key component of this ‘mental healthcare gap’ is poor system responsiveness to the contexts and needs of community members.[1,3,4] Identifying and describing community mental health needs and assets can increase partnerships, responsiveness and community agency to allow excluded citizens to shape systems and policies.[5,6,7] Describing the resources communities draw on to respond to mental ill-health acknowledges communities as experts in their own right, and as active agents promoting ‘community mental health competence.’[4]. Set in India, the ‘community mental health system’ is considered as the collective of the social and political determinants of health and relationships at the community level along with Indian state health systems players including ASHAs (accredited social health activists).[6,11,12] The key public mental ill-health response, the National Mental Health programme (NMHP) focuses primarily on access to psychiatric care and medicines, facets which have seen significant progress and roll-out in the past 5 years.[13,14] Government, academia and civil society have called for strengthening the NMHP by integrating mental health with community health systems and platforms such as non-
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