Human resources and models of mental healthcare integration into primary and community care in India: Case studies of 72 programmes

Background: Given the scarcity of specialist mental healthcare in India, diverse community mental healthcare models have evolved. This study explores and compares Indian models of mental healthcare delivered by primary-level workers (PHW), and health workers’ roles within these. We aim to describe current service delivery to identify feasible and acceptable models with potential for scaling up. Methods: Seventy two programmes (governmental and non-governmental) across 12 states were visited. 246 PHWs, coordinators, leaders, specialists and other staff were interviewed to understand the programme structure, the model of mental health delivery and health workers’ roles. Data were analysed using framework analysis. Results: Programmes were categorised using an existing framework of collaborative and non-collaborative models of primary mental healthcare. A new model was identified: the specialist community model, whereby PHWs are trained within specialist programmes to provide community support and treatment for those with severe mental disorders. Most collaborative and specialist community models used lay health workers rather than doctors. Both these models used care managers. PHWs and care managers received support often through multiple specialist and non-specialist organisations from voluntary and government sectors. Many projects still use a simple yet ineffective model of training without supervision (training and identification/referral models). Discussion and conclusion Indian models differ significantly to those in high-income countries—there are less professional PHWs used across all models. There is also intensive specialist involvement particularly in the community outreach and collaborative care models. Excessive reliance on specialists inhibits their scalability, though they may be useful in targeted interventions for severe mental disorders. We propose a revised framework of models based on our findings. The current priorities are to evaluate the comparative effectiveness, cost-effectiveness and scalability of these models in resource-limited settings both in India and in other low- and middle- income countries

Blame, Symbolic Stigma and HIV Misconceptions are Associated with Support for Coercive Measures in Urban India

This study was designed to examine the prevalence of stigma and its underlying factors in two large Indian cities. Cross-sectional interview data were collected from 1,076 non-HIV patients in multiple healthcare settings in Mumbai and Bengaluru, India. The vast majority of participants supported mandatory testing for marginalized groups and coercive family policies for PLHA, stating that they “deserved” their infections and “didn’t care” about infecting others. Most participants did not want to be treated at the same clinic or use the same utensils as PLHA and transmission misconceptions were common. Multiple linear regression showed that blame, transmission misconceptions, symbolic stigma and negative feelings toward PLHA were significantly associated with both stigma and discrimination. The results indicate an urgent need for continued stigma reduction efforts to reduce the suffering of PLHA and barriers to prevention and treatment. Given the high levels of blame and endorsement of coercive policies, it is crucial that such programs are shaped within a human rights framework

Prevalence and drivers of HIV stigma among health providers in urban India: implications for interventions

IntroductionHIV stigma inflicts hardship and suffering on people living with HIV (PLHIV) and interferes with both prevention and treatment efforts. Health professionals are often named by PLHIV as an important source of stigma. This study was designed to examine rates and drivers of stigma and discrimination among doctors, nurses and ward staff in different urban healthcare settings in high HIV prevalence states in India.MethodsThis cross-sectional study enrolled 305 doctors, 369 nurses and 346 ward staff in both governmental and non-governmental healthcare settings in Mumbai and Bengaluru, India. The approximately one-hour long interviews focused on knowledge related to HIV transmission, personal and professional experiences with PLHIV, instrumental and symbolic stigma, endorsement of coercive policies, and intent to discriminate in professional and personal situations that involve high and low risk of fluid exposure.ResultsHigh levels of stigma were reported by all groups. This included a willingness to prohibit female PLHIV from having children (55 to 80%), endorsement of mandatory testing for female sex workers (94 to 97%) and surgery patients (90 to 99%), and stating that people who acquired HIV through sex or drugs "got what they deserved" (50 to 83%). In addition, 89% of doctors, 88% of nurses and 73% of ward staff stated that they would discriminate against PLHIV in professional situations that involved high likelihood of fluid exposure, and 57% doctors, 40% nurses and 71% ward staff stated that they would do so in low-risk situations as well. Significant and modifiable drivers of stigma and discrimination included having less frequent contact with PLHIV, and a greater number of transmission misconceptions, blame, instrumental and symbolic stigma. Participants in all three groups reported high rates of endorsement of coercive measures and intent to discriminate against PLHIV. Stigma and discrimination were associated with multiple modifiable drivers, which are consistent with previous research, and which need to be targeted in future interventions.ConclusionsStigma reduction intervention programmes targeting healthcare providers in urban India need to address fear of transmission, improve universal precaution skills, and involve PLHIV at all stages of the intervention to reduce symbolic stigma and ensure that relevant patient interaction skills are taught

Traditional community resources for mental health: a report of temple healing from India

In addition to herbal and other traditional medicines, healers and healing temples are seen as providing curative and restorative benefits. In India many people troubled by emotional distress or more serious mental illnesses go to Hindu, Muslim, Christian, and other religious centres. The healing power identified with these institutions may reside in the site itself, rather than in the religious leader or any medicines provided at the site. Studies of these healing sites have focused primarily on ethnographic accounts.5 Research has not systematically examined the psychiatric status of the people coming for help at these religious centres or the clinical impact of healing. It has focused primarily on possession and non­psychotic disorders, rather than serious psychotic illnesses. Yet people with serious psychotic illnesses do visit such healing temples in India,6 and understanding the role of these institutions may help with planning for community mental health services in underserved rural areas.We describe here the work of a Hindu heal­ing temple in South India known as a source of help for people with serious mental disorders.We also tried to measure the clinical effectiveness of religious healing at this site

Birth rights and rituals in rural South India: Care seeking in the intrapartum period

Maternal morbidity and mortality are high in the Indian context, but the majority of maternal deaths could be avoided by prompt and effective access to intrapartum care (WHO, 1999). Understanding the care seeking responses to intrapartum morbidities is crucial if maternal health is to be effectively improved, and maternal mortality reduced. This paper presents the results of a prospective study of 388 women followed through delivery and traditional postpartum in rural Karnataka in southern India. In this setting, few women use the existing health facilities and most deliveries occur at home. The analysis uses quantitative data, collected via questionnaires administered to women both during pregnancy and immediately after delivery. By virtue of its prospective design, the study gives a unique insight into intentions for intrapartum care during pregnancy as well as events following morbidities during labour. Routine care in the intrapartum period, both within institutions and at home, and impediments to appropriate care are also examined. The study was designed to collect information about health seeking decisions made by women and their families as pregnancies unfolded, rather than trying to capture women's experience from a retrospective instrument. The data set is therefore a rich source of quantitative information, which incorporates details of event sequences and health service utilization not previously collected in a Safe Motherhood study. Additional qualitative information was also available from concurrent in-depth interviews with pregnant women, their families, health care providers and other key informants in the area. The level of unplanned institutional care seeking during the intrapartum period within the study area was very high, increasing from 11% planning deliveries at a facility to an eventual 35% actually delivering in hospitals. In addition there was a significant move away from planned deliveries with the auxiliary nurse midwife (ANM), to births with a lay attendant or dai. The proportion of women who planned for an ANM to assist was 49%, as compared with the actual occurrence, which was less than half of this proportion. Perceived quality of care was found to be an important factor in health seeking behaviour, as was wealth, caste, education and experience of previous problems in pregnancy. Actual care given by a range of practitioners was found to contain both beneficial and undesirable elements. As a response to serious morbidities experienced within the study period, many women were able to seek care although sometimes after a long delay. Those women who experienced inadequate progression of labour pains were most likely to proceed unexpectedly to a hospital delivery

Alternative Approaches To Locating The Food Insecure: Qualitative and Quantitative Evidence From South India

This paper reports on two methods used for identifying alternative indicators of chronic and acute food insecurity. A need for alternative indicators exists since many of the "benchmark" or "gold standard" indicators (such as household income or dietary intake) are too cumbersome to be of practical use in food aid targeting. The ideal alternative indicator should be statistically reliable, yet straightforward to collect and analyze. The study uses data collected in four villages in the Indian Semi-Arid Tropics to illustrate two methods for identifying the alternative indicators. A qualitative methodology included ethnographic case studies of at-risk households, participatory mapping of vulnerable households within a community, food charts, and seasonality charts. The quantitative methods included both economic and nutrition surveys. The data were collected over three rounds in 1992-93 from 324 households in south-central India. For the qualitative work, we used both the villagers' perceptions of food insecurity as well as the ethnographers' observations to generate a list of indicators for these areas. Triangulation among the various qualitative methods was used to validate the indicators suggested. For the quantitative study, we used statistical methods to test the strength of association between each indicator and six benchmark measurements of food security. The benchmark measurements were derived from dietary recall, anthropometric, and blood data. The dietary data were used to generate a benchmark for chronic and acute households' food insecurity. The anthropometric data were used to construct benchmarks of chronic and acute preschooler food insecurity. Finally, serum measures of vitamin A and iron adequacy were used to generate benchmarks of household micronutrient insecurity. We tested a core set of alternative indicators against each of these benchmarks. The majority of the alternative indicators were drawn from a review of the food security literature as well our own qualitative work in the study sites. Other indicators were included as they represent information that is typically available in secondary data sets collected by governments and research institutions

Cultural context and impact of alcohol use in the Sundarban Delta, West Bengal, India

Hazardous alcohol consumption is a worldwide problem with many locally distinctive features across cultures, but studies to guide policy in developing countries are notably lacking. This community study aimed to clarify local patterns of alcohol use in six villages of West Bengal, India. It considered the variety of local alcoholic preparations, who consumed them, when, and where. It sought to determine how social changes in the region influence changing patterns of acceptable and problem use of alcohol. Ethnographic methods included participant observation and focus group discussions. The qualitative data analysis of field notes and transcripts included a review of full texts and a computer-assisted analysis of thematically coded segments with reference to a structured agenda. We found that drinking is an integral feature of the cultural landscape. Locally brewed rice beer (handia), palm wine (tadi), distilled country liquor (chullu), and so-called Indian-made foreign liquor (IMFL) are consumed in these villages. Each is identified with particular segments of society and settings in these communities. Reported effects of problem drinking included social disturbances, family discord, and domestic violence. Increasing problem alcohol use was attributed by villagers to social changes resulting from development, which were otherwise valued, such as improved transportation and communications. In a field dominated by Western and urban studies, this research clarifies features of alcohol availability, use, and acceptance in a neglected rural area of India. It illustrates the limitations of western clinical models of dependence and the importance of clarifying sociocultural conditions that define locally acceptable and problem use