Abstract
BackgroundThere is a large burden of psychological distress in low and middle-income countries, and culturally relevant interventions must be developed to address it. This requires an understanding of how distress is experienced. We conducted a qualitative grounded theory study to understand how mothers experience and manage distress in Dhanusha, a low-resource setting in rural Nepal. We also explored how distressed mothers interact with their families and the wider community.MethodsParticipants were identified during a cluster-randomised controlled trial in which mothers were screened for psychological distress using the 12-item General Health Questionnaire (GHQ-12). We conducted 22 semi-structured interviews with distressed mothers (GHQ-12 score ≥5) and one with a traditional healer (dhami), as well as 12 focus group discussions with community members. Data were analysed using grounded theory methods and a model was developed to explain psychological distress in this setting.ResultsWe found that distress was termed tension by participants and mainly described in terms of physical symptoms. Key perceived causes of distress were poor health, lack of sons, and fertility problems. Tension developed in a context of limited autonomy for women and perceived duty towards the family. Distressed mothers discussed several strategies to alleviate tension, including seeking treatment for perceived physical health problems and tension from doctors or dhamis, having repeated pregnancies until a son was delivered, manipulating social circumstances in the household, and deciding to accept their fate. Their ability to implement these strategies depended on whether they were able to negotiate with their in-laws or husbands for resources.ConclusionsVulnerability, as a consequence of gender and social disadvantage, manifests as psychological distress among mothers in Dhanusha. Screening tools incorporating physical symptoms of tension should be envisaged, along with interventions to address gender inequity, support marital relationships, and improve access to perinatal healthcare.
Highlights
There is a large burden of psychological distress in low and middle-income countries, and culturally relevant interventions must be developed to address it
The trial evaluated the impact of participatory women’s groups on neonatal mortality and several secondary outcomes [12]. One of these outcomes was postnatal psychological distress, measured using the 12-item General Health Questionnaire (GHQ-12), which has been validated in Nepal [13]
We purposively identified participants from a total of 1272 mothers who had participated in the Dhanusha cluster-randomised controlled trial (cRCT) and completed the GHQ-12 in the previous two months
Summary
There is a large burden of psychological distress in low and middle-income countries, and culturally relevant interventions must be developed to address it. This requires an understanding of how distress is experienced. Psychological distress, which includes depressive, anxiety, panic and somatic disorders, is a major cause of disability among pregnant and postnatal women. Qualitative studies in South Asia have shown that, while distressed pregnant and postnatal women experience symptoms of depressive biomedical disorders, they interpret their symptoms as social constructs related to economic difficulties, poor marital relations, and having too many daughters [3,4]. There have been no qualitative studies of perinatal distress in Nepal to contextualise findings from these quantitative studies and to guide intervention development
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