Inclusion of people with psychosocial disability in low and middle income contexts: a practice review

Abstract

Much of the literature about mental illness in low and middle income countries (LMICs) focuses on prevalence rates, the treatment gap, and scaling up access to medical expertise and treatment. As a cause and consequence of this, global mental health programs have focused heavily on service delivery without due exploration of how programs fit into a broader picture of culture and community. There is a need for research which highlights approaches to broader inclusion, considering historical, cultural, social, and economic life contexts and recognises the community as a determinant of mental health-in prevention, recovery, resilience, and support of holistic wellness. The purpose of this practice review is to explore the experiences of three local organisations working with people with psychosocial disability living in LMICs: Afghanistan, India, and Nepal. All three organisations have a wealth of experience in implementing mental health programs, and the review brings together evidence of this experience from interviews, reports, and evaluations. Learnings from these organisations highlight both successful approaches to strengthening inclusion, and the challenges faced by people with psychosocial disability, their families and communities. The findings can largely be summarised in two categories, although both are very much intertwined: first, a broad advocacy, public health, and policy approach to inclusion; and second, more local, community-based initiatives. The evidence draws attention to the need to acknowledge the complexities surrounding mental health and inclusion, such as additional stigmatisation due to multidimensional poverty, gender inequality, security issues, natural disasters, and additional stressors associated with access. Organisational experiences also highlight the need to work with communities' strengths to increase capacity around inclusion and to apply community development approaches where space is created for communities to generate holistic solutions. Most significantly, approaches at all levels require efforts to ensure that people with psychosocial disability are given a voice and are included in shaping programs, policies, and appropriate responses.

Social inclusion and exclusion of people with mental illness in Timor-Leste: a qualitative investigation with multiple stakeholders

“…The stigmatising beliefs that Timorese people with mental illness are dangerous, lack capacity and have an incurable illness are consistent with stereotypes that have been reported in both HICs and LMICs [12,46]. Sometimes these beliefs were related to the sociocultural conceptualisation of mental illness as a sign of intractable ancestral punishment, as has been reported in other parts of Asia [30]. Mental illness may appear intractable to people in Timor-Leste due to the lack of effective mental health care, which means that people may not witness the possibility of recovery [32,44].…”

“…The communitarian orientation of many LMICs locates responsibility for the individual, their illness and stigma with the family [24][25][26]. There is an emerging body of evidence related to social inclusion and exclusion of people with mental illness in Asia, but only a few studies have examined the perspectives of people with mental illness and their families, and even fewer have explored positive effects of inclusion [27][28][29][30].…”

Challenges of inclusion: a qualitative study exploring barriers and pathways to inclusion of persons with mental disabilities in technical and vocational education and training programmes in East Africa

“…The culture includes all thoughts, norms, values that actors in the context attribute to persons with mental disability. Beliefs and practices relating to mental illness can lead to discrimination and hinder access to development programmes [26]. Finally, the structure entails the laws and policies regarding people with mental disability, e.g., the admission requirements to TVET programmes or the training of teachers.…”

“…These three concepts are not independent of one another, but, as depicted by the arrows in Figure 1, dynamically influence one another. Actors' thoughts about people with mental disabilities are shaped by and shape the policies and laws in place [27], and at the same time define the practices of actors [26,28]. The interactions with persons with mental disabilities, i.e., the practices, also shape both the beliefs (i.e., the culture) and the regulations (i.e., the admission criteria and policies defining who benefits and who does not).…”

“…Moreover, whereas theoretical paradigms have explicitly offered a multifaceted notion of disability, the societal perceptions of disability have not accommodated persons with mental illness [26,42,43]. At the same time, although mental illness is included as a disability in the UNCRPD, many, including persons with mental disabilities themselves, do not recognise it as such and do not necessarily support it as it adds another layer of stigma [18].…”