Impact Of Discrimination On Accessing Mental Healthcare Services In Rural India

Literature Review

Discuss about the Impact Of Discrimination On Access To Mental Health Services.

Search strategy

The database used for searching the relevant materials was Google Scholar, Scopus, Proquest, PubMed, MEDLINE, Web of Science and Psychinfo. These are advanced search engines comprise of high-quality peer-reviewed journals, and enabled me to look for the relevant articles using the appropriate keywords.

Some of the keywords that were used to search the literature were discrimination, mental health and rural India. I have consulted my friends who have studied on health sociology and teachers who specialize on the area of stratification. Discrimination refers to exclusion and subjugation in relation to access of resources, mobility and so on. Mental health refers to the condition of the person about their emotional and psychological state. Rural India refers to village or countryside regions of India. The timeframe of the search persisted for a period of one week as I found this period enough to find the relevant documents for the research. The inclusion criterion for the search was literature on mental health concerning rural India. The exclusion criterion was keeping away articles that were not concerned with rural India or articles that did not discuss about discrimination. I have obtained around 15 literatures for the purpose of the study that discusses about the context of discrimination regarding mental health in rural India.

The process that I used to identify the themes emerged from the research questions and objectives of the research. These themes are impact in accessing healthcare service, role and degree of social location and role of government bodies in disseminating healthcare services in India.

Mental health illness is a serious issue that has plagued countries across the world. India features in the list of countries have a bad reputation of dealing with mental health disorder. Kumar (2012) have found that the delivery of mental healthcare services in rural India is quite poor. This is due to the lack of a robust approach by the government, civil society institutions and the policymakers. The National Mental Health Programme had attempted to usher in transformation in the rural areas but this without much result. There is an overall absence of community based interventions in minimizing the effects of stress in the rural areas (Thornicroft et al. 2016). At the village level, the non-trained service providers mostly provide mental health services in rural India. According to Das et l. (2012), the service delivery in mental health has become low for the rural India, thus creating a gap in access to health. Studies have demonstrated that stigma precludes people in the hinterlands of rural India from the pursuit of healthcare service.

Mental health illness has become an issue of great concern for the India. It has been reported that around 14 per cent of the global burden of illness in the world is related to neuropsychiatric disorders (Firstpost 2018). Mental health awareness have yielded positive impact, however that is insufficient considering the persistence and stigma that continue circumscribe around discussions on mental health services in India. This leads to the silencing of people with mental health disorder and posits further obstacles in their access to mental health care service in rural India. This has motivated me to intervene into the issue of discrimination that impacts on the access to healthcare service in India.

Theme Identification

In the context of increasing incidents of mental health disorder, there is no corresponding initiatives to espouse and implement mental health literacy (Patel et al. 2016). The term mental health literacy alludes to the ability of a community or an individual to understand their plight, access healthcare service and tap the information in the promotion of good health. The WHO have recognized that the rate of suicide in India as a consequence of severe mental health disorder is higher than the global average (Semrau et al 2015). There is a gap in the treatment of mental health disorder. In the light of existing research on mental health, I purport to conduct a study to understand the impact of discrimination in accessing healthcare service in rural India.. I feel that the large wealth of literature have not addressed the issue of social location of the person that may exacerbate their plight in reaching out to the adequate service providers, professionals and institutions in access to healthcare.

The aim of this research is to study the impact of discrimination on people with mental healthcare service in accessing healthcare. The objective of the research would be to

To examine the role and degree to which the social location of an individual or the position of a community determines their chance in accessing healthcare in rural India.

To investigate whether there is presence of any community-based intervention to address the issue.

To examine the role of government bodies in disseminating healthcare service in rural India and the attitude of the service providers.

RQ1. What is the role and degree to which the social location of an individual or the position of a community determines their chance in accessing healthcare in rural India?

RQ2. Is there is presence of any community-based intervention to address the issue and what have been their contributions so far?

RQ3. What is the role of government bodies in disseminating healthcare service in rural India and the attitude of the service providers?

The research hypothesis is that there is a strong impact of discrimination in accessing mental healthcare service in rural India.

An elaborate discussion on literature review have been done in the second part of the assignment.

Theme Identification

Based on the critical review of literature I found that the key themes that emerged in the study were that there is stigmatization of mental health patients are common in the rural hinterlands of India. Secondly, it was found that this fesr being labelled and stigmatization pushes prevents the mental health patients in India in accessing healthcare services. Thirdly, it was found that mental health patients are subjected to discrimination and this discrimination is exacerbated by their gender identity. However, there is a silence on the caste identity and mental health discrimination in context of modern India that I found quite startling considering caste violence an important aspect of the Indian society. Fourthly, it has been found that there has been interventions from the government at the grassroot level. However, those interventions fail to grasp the complexity of the multiple dimensions that subject mental health patient to greater discrimination. There has been no discussion on the training of health care service providers operating at the grassroot level to alleviate the ordeals of the mental health patients and help them to come out of the closet of stigma.  This review of the literature enabled me to identify the themes based on the keywords of each of the articles and also enabled me to identify the lacuna in literature and scope of further research in this domain.

Research Questions

According to Neuman, (2014), research philosophy or epistemology can be defined as the foundational premise of knowledge that would influence the methodological framework. Keeping in consideration the temperament of the research, I feel critical social research theory would be appropriate. The aim of critical social research is to generate knowledge that would catalyse a social transformation through praxis. Through my research, I intend to explore the range, ramifications and nuances of discriminatory practises that impedes patients with mental health in accessing mental healthcare service.

Since the research aims to generate awareness and contribute to the existing wealth of knowledge about the discrimination associated with mental health, I feel the action research design would serve the purpose (McKenney 2014).

My universe of study will be two villages in India (Andhra Pradesh and Tamil Nadu). I would employ the purpose sampling technique and approach my respondents through the snowball sampling technique. The sample size would be 30 people in each of these villages.

I would employ mixed methods to collect data. These methods would include ethnography, participant observation, focussed group discussion and in-depth qualitative interviewing. I would also conduct archival research through the analysis of the government documents to examine the timeline of initiatives of the government

Some of the ethical considerations for the research will be marinating the confidentiality of the patients and respect their privacy. The second ethical consideration would be not to interfere with daily activities of the people in the village through my research. I would take special care not to lacerate the sentiments of the people in village especially the ones suffering from mental health disorder.

Limitations are common in any research despite the accurate planning involved in research. One major limitation of the study would be the timeline for the study. The second limitation of the study would be the lack of availability of resources. The third limitation of the study may be that since it is concerned with one village each in the states of Andhra Pradesh and Tamil Nadu it will be difficult to generalize the data for the rest part of the country.

Mental health is believed to be an integral part of the health system. It refers to a wide array of activities that are associated with mental health and the welfare of an individual. It concerns with the prevention of disorders and the treatment of people who are affected by mental health condition (India is facing a possible mental health epidemic, says President, 2017). In the context of India, it has been identified that there is an urgency of mobilization of endeavours to espouse the principles of mental health.

According to a report published in the Times of India, it was found that mental health has become an epidemic in India. The NHMS (National Health and Mental Sciences) in India, have provided insightful data regarding the mental health disorder in the country. In ‘Evaluation of an anti-stigma campaign related to common mental disorders in rural India: a mixed methods approach’, Maulik et al (2016), found that stigma associated with mental health poses impediment in seeking succour of mental health services. The method used in this study is multi-media interventions as part of the SMART Mental Health Project in rural Andhra Pradesh. There was the conduction of mixed-methods in two villages of Andhra Pradesh through a pre-post design. There were pre- and post interview phases of interview. It was identified that drama and social contract are the most beneficial interventions recognized during the qualitative interviews. The authors argued that the campaign has been beneficial and steered to the amelioration of the behavior and attitude of mental health. Social contract has been found to be the most effective intervention.   

Research Hypothesis

In Promoting wellbeing and improving access to mental health care, Shields-Zeeman et al, (2017), have argued that mental health is substantial in India. They reported that 70 million people in the Indian nation have experienced some kind of mental health problem or the other. More than 20 per cent of the population is exacerbated by common health disorders (CMDs) that includes depression and anxiety. These kind of disorders are underreported and naturally remains untreated due a variety of other factors. They discuss about the Atmityata programme that has been implemented in Maharashtra from 2013 to 2015. Frequent consultations with the psychiatrist facilitates in securing the consultations of people who have been affected by mental health disorders.  The authors have emphasized on the importance of funding in the supervision and the mentoring mechanism for the training of new groups.

In Under the Banyan Tree-exclusion and inclusion Mathias, et al (2015), it was found that social inclusion contributes to both the cause and consequence of mental disorders. It has been found that people with mental health disorders are among the ones who are marginalized in the society. This qualitative study conducted by the authors found that there is a spectrum of exclusion that has been a pre-dominant experience for the participants that range from the nuanced distancing, negative perceptions and isolation from the social circles. Stigma acts to overt situations of exclusion. This exclusion is manifested in the form of ridiculing, physical violence and disinheritance. Some of the participants of the interview found a sense of belonging with the community, there were opportunities for participation and there were support from both the family members. In-depth interviews were conducted with 20 PWMD and 8 caregivers. Some of the questions that were addressed in the interview were exclusion and agency, participation and discrimination. A qualitative content analysis was implemented to bring attention to 12 key themes. The authors have identified that the various social and non-social actors need to collaborate and work together in expanding the knowledge base and enhancing the participation of the people who belong to the disadvantageous sections of the society.

Knaak, Mantler & Szeto (2017), found that mental health related stigma is quite common the healthcare system in India. This posits a serious barrier for the providers of healthcare and practitioners in catering to the needs of people who are suffering from mental healthcare issues. Stigma has been understood as a complex process of labeling, devaluation, othering and associated discrimination. It has been reported that stigmatization and discriminatory behavior is meted out to people and is ubiquitous all across the health sector. The authors have identified that lack of awareness and unconscious biases that acknowledges the power dimensions that influence stigmatized behavior. Another interesting finding of the study is that healthcare providers are quite pessimistic about the reality and likelihood of recovery.

Similar arguments have emerged from Shidaye and Kermonde (2013) (in Stigma and discrimination as a barrier to mental health service utilization in India) who are of the view that stigma contributes in the discrimination of people in rural India. Another argument put forth by the authors is that this experience of stigma poses constraint in seeking mental healthcare services and rehabilitation therefore limiting the opportunities for fuller participation. In the context of India, it has been found that there is a general negative attitude towards people who have mental disorder. The author exhorts for collaboration between the professional care-givers, mental health service providers and community health workers.

According to Srivastava, Chatterjee and Bhat,(2016), mental health has been identified as an issue that demands urgent attention. Indians are quite slow when it comes to the acceptance of people with mental health disorder. The barriers in the dissemination of effective healthcare system is low and middle income countries. The problems in the delivery of mental healthcare service can be attributed to the lack of a robust approach by the government.

References

Das, J., Holla, A., Das, V., Mohanan, M., Tabak, D. and Chan, B. 2012. In urban and rural India, a standardized patient study showed low levels of provider training and huge quality gaps. Health affairs, 31(12), 2774-2784.

India is facing a possible mental health epidemic, says President. 2018. The Hindu. Retrieved 18 April 2018, from https://www.thehindu.com/news/national/karnataka/india-is-facing-a-possible-mental-health-epidemic-says-president/article22335971.ece.

Knaak, S., Mantler, E. and Szeto, A. 2017, March. Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions. In Healthcare management forum (Vol. 30, No. 2, pp. 111-116). Sage CA: Los Angeles, CA: SAGE Publications.

Kumar, A. 2012. Mental health services in rural India: challenges and prospects.

Mathias, K., Kermode, M., San Sebastian, M., Koschorke, M and Goicolea, I. 2015. Under the banyan tree-exclusion and inclusion of people with mental disorders in rural North India. BMC public health, 15(1), 446.

McKenney, S. 2014. Methods, goals and educational design research.

Murthy, R. S. 2017. National mental health survey of India 2015–2016. Indian journal of psychiatry, 59(1), 21.

Neuman, L. W. 2014. Social research methods. Pearson Education Limited.

Our silent relationship with mental health: Stigma is still strong in India – Firstpost. 2018. Firstpost. Retrieved 19 April 2018, from https://www.firstpost.com/living/our-silent-relationship-with-mental-health-stigma-is-still-strong-in-india-2739554.html

Patel, V., Xiao, S., Chen, H., Hanna, F., Jotheeswaran, A. T., Luo, D and Druss, B. G. 2016. The magnitude of and health system responses to the mental health treatment gap in adults in India and China. The Lancet, 388(10063), 3074-3084.

Semrau, M., Evans-Lacko, S., Koschorke, M., Ashenafi, L and Thornicroft, G. 2015. Stigma and discrimination related to mental illness in low-and middle-income countries. Epidemiology and psychiatric sciences, 24(5), 382-394.

Shidhaye, R and Kermode, M. 2013. Stigma and discrimination as a barrier to mental health service utilization in India. International health, 5(1), 6-8.

Shields-Zeeman, L., Pathare, S., Walters, B. H., Kapadia-Kundu, N and Joag, K. 2017. Promoting wellbeing and improving access to mental health care through community champions in rural India: the Atmiyata intervention approach. International journal of mental health systems, 11(1), 6.

Srivastava, K., Chatterjee, K and Bhat, P. S. 2016. Mental health awareness: The Indian scenario. Industrial psychiatry journal, 25(2), 131.

Thornicroft, G., Mehta, N., Clement, S., Evans-Lacko, S., Doherty, M., Rose, D and Henderson, C. 2016. Evidence for effective interventions to reduce mental-health-related stigma and discrimination. The Lancet, 387(10023), 1123-1132.

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