Exploring Community Mental Health Systems – A Participatory Health Needs and Assets Assessment in the Yamuna Valley, North India

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.

Inverting the deficit model in global mental health: An examination of strengths and assets of community mental health care in Ghana, India, Occupied Palestinian territories, and South Africa

“…Our findings underscore that programmes and policies need to engage with local historical and socio-political contexts as well as informal care practices to ensure mental healthcare is relevant and acceptable [ 104 , 105 ]. The design and delivery of mental health care in these four countries and elsewhere should be co-designed with communities and build on and strengthen local assets and address locally-identified needs to ensure policies, services and interventions are more acceptable, relevant and equitable [ 92 , 104 , 106 ]. Co-production of policies or services with people with mental health conditions are not well represented in any of these four community mental health case studies.…”

A scoping review of community health needs and assets assessment: concepts, rationale, tools and uses

“…1) Community demographic characteristics: Literacy rates [13], youth population [58,68], and elderly population [68]; 2) Natural capitals: Geographical location and natural resources [21,81,85]; 3) Economic and financial capitals: Community business [12,81] community members' income [21], and housing land ownership [13]; 4) Community infrastructure: Level of technology/ mobile phone coverage [13,21], transportation [86], parks and sidewalks [12], sport and recreational facilities [31,87,88], public libraries and community centres [88]; 5) Community social and educational facilities: Nonprofit and non-governmental organizations [59,87], media [89], educational institutions [12,31,81,90], faith communities [58,81,90], and community associations [31]; 6) Community health and social facilities: Health and social facilities and providers [72,81,85,86,89], traditional medicine providers [72], and ongoing health programmes [13,87]; 7) Community's social and cultural values and resources:…”

“…Tribal and community culture [58,68,74,91], cultural diversity [81], spirituality and religion [58,74], strong family bonds and values [59,74], strong community connections, teamwork and willingness to volunteer [21,81,86,91], mutual support, social support and networks [45,58,81,85], unity, community cohesion and collectivity [21,59,74], community capacity [58], community-led activities [86,91], and community values and traditions [68,74,86], resiliency [58], unifying power of communities [13], community administration units e.g. women's committees [13], an existing group of dedicated healthcare providers [39], a group of concerned citizens [39], community safety [12], the knowledge base of the community members themselves [39] and members' desire to be healthy [58].…”

“…Various qualitative methods such as individual interviews (one-on-one structured conversations) or focus groups (guided, structured, small group discussions) with community members, or key informants' interviews (formal and informal conversations with leaders and stakeholder groups) or a combination of these methods were reported as the main methods to collect information on community's assets among reviewed studies. Of these, focus group was the widely used method in community assets assessment [8,21,31,45,58,59,67,81,82,85,87,90,92,93].…”

Working Towards Inclusive, Socially Accountable and Resilient Community Health Systems: An Introduction to a Special Issue

“…Two explicitly foreground the role of trust in shaping performance -Zulu and colleagues 9 explore how prioritising trust relations unlocked access to care for the stigmatized condition of hydrocoele in Zambia, while Assegaai and Schneider 10 conversely describe how wider institutional mistrust generated low interpersonal trust between frontline actors in a community health worker programme. Mathias et al 11 conducted participatory action research which surfaced unique local knowledge for the design of mental health care in Uttarakhand State, India. Finally, Sirili et al 12 offer novel insights into rural health worker retention in Tanzania by locating the problem as one of relationships with the community -either accommodation or rejection -rather than the usual focus on health system (supply side) incentives.…”