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Social distance and community attitudes towards people with psycho-social disabilities in  Uttarakhand, India
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Emmanuel Hospital Association, New Delhi, India; Landour community hospital, Mussoorie, Uttarakhand 248 179, India.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.ORCID iD: 0000-0002-8114-4705
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2018 (English)In: Community mental health journal, ISSN 0010-3853, E-ISSN 1573-2789, Vol. 54, no 3, p. 343-353Article in journal (Refereed) Published
Abstract [en]

Stigma is an important contributor to the large treatment gap for people with mental and psycho-social disabilities (PPSD) in India. Social distance as assessed by willingness to engage in relationships with PPSD is a proxy measure of stigma and potential discrimination. In North India, investigations of community attitudes towards PPSD have been limited. To describe attitudes towards people with depression and psychosis, a community sample of 960 adults in Dehradun district, India from 30 randomised clusters, was surveyed using a validated tool to assess social distance, beliefs and attitudes related to mental illness. Participants preferred greater social distance from a person with psychosis than a person with depression. Beliefs and attitudes around mental illness were diverse reflecting a wide spread of belief frameworks. After controlling for confounding, there was increased social distance among people who believed PPSD were dangerous. Factors that reduced social distance included familiarity with PPSD, and belief that PPSD can recover. Attitudes to PPSD, stigma and social distance are complex and likely to require complex responses that include promoting awareness of mental health and illness, direct contact with PPSD and increasing access to care for PPSD.

Place, publisher, year, edition, pages
Springer, 2018. Vol. 54, no 3, p. 343-353
Keywords [en]
Stigma, Mental disorders, India, Social distance, Quantitative
National Category
Public Health, Global Health, Social Medicine and Epidemiology Psychiatry
Identifiers
URN: urn:nbn:se:umu:diva-127176DOI: 10.1007/s10597-017-0211-yISI: 000427078200011PubMedID: 29143156OAI: oai:DiVA.org:umu-127176DiVA, id: diva2:1043983
Note

Originally included in thesis in manuscript form.

Available from: 2016-11-01 Created: 2016-11-01 Last updated: 2018-06-09Bibliographically approved
In thesis
1. Shadows and light: examining community mental health competence in North India
Open this publication in new window or tab >>Shadows and light: examining community mental health competence in North India
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[sv]
Studier av psykisk ohälsa i norra Indien ur ett folkhälsoperspektiv
Abstract [en]

Background

Globally, there is increasing emphasis on the importance of understanding the ways in which social inequality and injustice impact individual and community mental health. Set in the states of Uttar Pradesh and Uttarakhand, India, this thesis examines the complex relationships between individuals, communities and the social environment in relation to mental health. North India is characterised by stark gender and socio-economic inequalities and social exclusion for people with psycho-social disability (PPSD) and mental health services in these study areas were essentially absent. Community mental health competency means people are collectively able to participate in efforts to promote, prevent, treat and advocate for mental health. This thesis reflexively examines the presence and absence of community mental health competence in the upper Ganges region.

Methods

A mixed methods approach allowed for a multi-level examination of community mental health competence, and generated four sub-studies. In-depth interviews with thirteen PPSD and eighteen caregivers in Bijnor and Saharanpur (Uttar Pradesh state) were carried out in 2013 providing data for qualitative analysis. These data were analysed using qualitative content analysis to examine experiences of exclusion and inclusion of PPSD in sub-study I, and thematic analysis to examine the gendered experiences of caregivers in sub-study II. A community based sample of 960 people in Dehradun district (Uttarakhand) were surveyed in 2014 to examine the prevalence, treatment gap and social determinants of depression in substudy III, and the attitudes and preferred social distance from people with depression and psychosis were investigated in sub-study IV. Multi-variate regression analysis in both studies was conducted with Stata software Version 13.1.

Results

Within the domain of knowledge, relatively low community mental health literacy, a diverse range of explanatory models of mental health, and creative and persistent efforts in helpseeking were the themes identified. Within the domain of safe social spaces, social exclusion was harsh and prevalent for PPSD, with contrasting sub-domains of belonging, social support, social participation and ahimsa (non-violence). Women were disadvantaged more than men in most spheres of caregiving.

Social determinants of depression with an adjusted odds ratio of more than 2.0 included being a member of the most oppressed caste or tribal group, having taken a recent loan, and not completing primary schooling. The prevalence of depression was 6.0% in the community sample, and there was a 100% treatment gap for counselling, and a 96% treatment gap for anti-depressant therapy, even though 79% of those with depression had visited a primary care provider in the previous three months. Social determinants of health and access to care are proposed as additional domains of community mental health competency. The prevailing gender regime that values males and disadvantages women influenced every domain of community mental health competency, particularly increasing caregiver burden, social exclusion and experiences of physical violence for women. 

Conclusions

In this thesis I have refined and strengthened a conceptual framework that portrays community mental health competence as a tree, where foundational roots of social determinants of mental health support four branches depicting access to care, knowledge, safe social spaces and partnerships for action. This tree model proposes that all five domains must operate in unison to support action for community mental health involving: development of community knowledge; promoting social inclusion, gender equality and participation; addressing upstream health determinants; and increasing access to mental health care. 

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2016. p. 72
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1856
Keywords
Global mental health, Gender, Health determinants, India, Mental health competence, Social distance, Social exclusion, Caregiver, Depression
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-127219 (URN)978-91-7601-588-9 (ISBN)
Public defence
2016-12-02, Sal 135, by 9A, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2016-11-11 Created: 2016-11-03 Last updated: 2018-06-09Bibliographically approved

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Mathias, KaarenGoicolea, IsabelSan Sebastian, Miguel

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