Soma Saha& Kumkum Bhattacharya2

1Associate Professor in Psychiatric Social Work, Institute of Psychiatry – A Centre of Excellence, Kolkata, West Bengal. 2Professor and Head of The Department, Department of Social Work, Palli Samgathana Vibhaga, Visva Bharati University, Sriniketan, Birbhum, West Bengal.

Correspondence: Soma Saha, e-mail:


Aim: This focused group discussion was conducted to see the local knowledge and perceptions of service delivery system to treat symptoms of mental illness among the caregivers of persons suffering from mental illness.  Process: The data were collected in a district hospital of urban area of West Bengal. Researcher conducted six focus group discussions within a span of 6 months, with each group comprised of 8–13 eligible caregivers visiting the outdoor who were coming for follow up and not engaged in any healthcare services.  Outcome: Regarding analysis, the researcher first reviewed group theme in detail to begin initial coding and analysis of the narratives. Researcher mapped out individual findings built upon and tested consensus on the emerging themes. Researcher followed an interview guide that systematically and one by one touched on key areas of knowledge of mental illness, services available nearby, help-seeking patterns (conventional and alternative) and overall information needs and preferences regarding  accessing mental health services.

Key Words: Focus Group Discussion, Mental Health Care Delivery System, Knowledge about Mental Illness.


Slow progress in mental health service delivery has been observed in most low- and middle-income countries. Problems in the existing public-health priorities and its influence on funding; challenges to delivery of mental health care in primary-care settings; the low manpowers of those trained in mental health care(Saraceno et al., 2007). There have been several calls for ongoing political will, for enhancing advocacy and for enhancing community participation; all with less improvement in outcomes. About 14% of the global burden of disease is attributed to neuropsychiatric disorders. The burden of mental disorders is likely to have been underrated because of less appreciation of the inter-connection between mental illness and other health disorders (Prince et al., 2007). There come many issues of priority-setting based on the burden of health problems and of addressing inequalities in relation to determinants and solutions for health problems. So it is very important now opportune to explore the paradigm of mental health awareness as a means of stigma, enhancing prevention, early recognition, and also stimulating simple and practical interventions within the community. 

Over the several years, services for the mentally ill in India have moved to centre stage and there has been a concerted effort to provide more comprehensive, modern and advanced services which is also steadily improving. From a predominantly mental hospital based service, provision has now moved to general hospitals and primary health centres. A variety of factors have contributed to changes in the quality of services. Provisions such as District Mental Health Programme and National Mental Health Programme now working closely to deliver services for mentally ill persons.

 As per understanding of exploration of knowledge, attitude change, information, awareness and behaviour tendency are very important components. This Focused Group Discussion technique has a few characteristic features: a) opinions can be expressed, b) debates are possible; c) opinions can be transformed, d) information can be shared; e) cohesions can be built up among the members. Effective service delivery system depends on utilization of available resources based on knowledge. The objectives of the focus group study were:

1. To gain the understanding of the caregiver’s needs and their perception of the main challenges in service delivery system to treat mental illness. 

2. To see the local knowledge and perceptions of symptoms of mental illness.

In depth analysis from FGDs are presented in this section to provide preliminary insights into community knowledge and perceptions of mental health services and access to care. 

Process of Focused Group Discussions

Universe of these group are caregivers of person suffering from mental disorders and behavioural problems are the main group participants. Caregivers are family members in these groups. Researcher first taken up the follow up patients with their caregivers from outpatient department of Suri District Hospital. This hospital doesn’t have District Mental Health Programmes, but do have psychiatric care services on out-patient department basis. Caregivers who were taken for participation, first screened through adult population (Age range 18-60) and GHQ-12 administered. Score obtained less than 3 which is cut off for this scale were taken for group with their consent. Researcher conducted six focus group discussions within a span of 6 months, with each group comprised of 8–13 eligible caregivers visiting the outdoor who were coming for follow up and not engaged in any healthcare services. Led by the researcher, each group sessions conducted for approximately two hours. Group discussions were recorded with consent of the participants. The moderator or researcher followed an interview guide that systematically and one by one touched on key areas of knowledge of mental illness, services available nearby, help-seeking patterns (conventional and alternative) and overall information needs and preferences regarding  accessing mental health services.

The focus group process uses a method that encourages discussion in a non-threatening environment (Krueger, 1994, 1998), with the researcher often using appropriate probes to draw out the breadth of the discussion. The discussion began with questions about what all the participants had in common to highlight and then launched into a group discussion of what ‘mental health’ meant to them. This was followed by discussion of participants’ views about types of professionals and services, and other beliefs, values, and opinions about mental illness, mental health care and the barriers related with it.


Regarding analysis, the researcher first reviewed group theme in detail to begin initial coding and analysis of the narratives. Additionally, decisions were made regarding which part of the discussion provided the most density to answer our focal question about help-seeking. The FGDs proceeded in the following manner: 1. The themes were categorized as per consensus; 2. To help in focusing attention to a visual representation (chalk – board) was made again by consensus; 3. The participants drew from a bowl (in lottery system) numbered steps in the total process of care of mental illness that were put in the correct order by the participants and then discussed one-by-one. Due to the small number of focus groups, no qualitative software was used in the analysis.

As the analysis proceeded data were additionally managed and reduced through the use of comparing and contrasting the narratives of six focus groups and the categories which emerged. The practical model used is one developed by Krueger (Krueger, 1994; Rabiee, 2004). The researcher reached consensus on the conceptual framework by reviewing the concordance, elaboration, and intensity of some of the responses to the matter while consistently being mindful of the context and make-up of groups, that is, patient and caregiver population in an urban setting who were not directly in contact with the mental health services system. to the matter while consistently being mindful of the context and make-up of groups, that is, patient and caregiver population in an urban setting who were not directly in contact with the mental health services system. 

It was found that the members after participating in at least one or two sessions of FGD were better equipped to deal with their individual patients and follow the prescribed protocols. 

In all, 68 men and women participated in the six focus groups. One group comprised only women of 13 members; whereas other 5 groups are mixed. The majority of participants were male, married, had either some primary level education or secondary passed and earning member.

Participants for the first FGD discussed the theme of information about mental health/ illnesses and information about accessing mental health services that they considered as one and the same. This was because, as some participants indicated, they hadn’t considered need for mental health information till someone in their family was not diagnosed with mental or emotional problems. At the beginning, they did not differentiate between the two regarding information about mental illness and delivery preferences for treatment care. Therefore, discussions about mental health and information about accessing services are addressed together.
In the focused group discussions, while discussing with participants as caregivers, the issue which researcher understood that only physiological changes of being mentally ill, such as muttering to self or violent behaviour etc. So this can be said that in Birbhum, the language of distress is largely somatic. Whereas cognitive symptoms may not be considered worthy of concern, somatic symptoms are viewed as benchmark for consultation. Individuals with mental distress will most often present with somatic symptoms, and this means that frequently a considerable time elapses between the first presentation and meeting a mental health professional. However, FGDs show that participants finally recognised social, cognitive and behavioural presentations of mental distress/illness, also and not just physiological. 
 The community’s knowledge of services available for the treatment and management of mental illness is largely limited to a biomedical understanding of doctors and medicine. This biomedical understanding is combined with traditional approaches, such as seeking the guidance of a pir (spiritual healer). Table 1.2 summarises the themes related to the knowledge and perceptions of mental health services.

Treatment seeking behaviours: FGDs revealed that there was a common model of treatment-seeking behaviour among rural people. Participants reported taking the affected individual to a pir or ojha (spiritual healer), or less commonly a hakeem (traditional healer). The pir [spiritual healer] uses chants of Mantra, verses from nowhere, and instructs the individual to perform niyam and wear tabeez (ritual acts and supplies that will cure them). If treatment is unsuccessful with the traditional healers, the family may seek out another alternative traditional healer or go to a hospital to see a doctor. Respondents reported that doctors give medicine and that they adhere to the treatment of both the doctor and the pir or ojha or hakeem. While many reported visiting the traditional healer first and then the doctor, the reverse was also true; when their symptoms were not relieved after visiting the doctor they would go to the traditional healer. 
Awareness services: While the majority of participants referred to the spiritual or traditional healers and the doctor when asked about the services that were available for people with mental illness, in all focus groups someone referred to the ‘mental hospital’ and it is only available in Ranchi city, which is placed in different state. Little was known about other mental health services on offer.

Even though the ‘mental hospital’ was mentioned in all focus groups, it was largely a place people had just heard about rather than considered as an accessible service. It was often referred to as a last resort: when all other treatments and efforts had been exhausted the person would need to go to the ‘mental hospital’.

Barriers to accessing services: Respondents identified a number of barriers to accessing care, including inadequate infrastructure such as poor roads and transport, the cost of travelling long distances to obtain specialised care.

Identified service needs:

Participants identified a number of services as necessary for the management of mental health in their communities. The most commonly cited needs included: employment, roads, transport, hospitals and doctors. Although many did not know the terms for mental health professionals, they described the service need in terms of roles and functions specifically performed by different professionals.
Despite being unaware of mental health service availability in the district, beyond the psychiatric wing of district hospital in Suri, many participants recognised the potential benefit of having access to a service that understood the needs of individuals suffering from mental illness.
A predominant theme throughout all FGDs was the understanding of mental illness. Medicine was repeatedly mentioned by participants in response to questions on the management of mental illness and in terms of service needs. However, all groups also identified a need for access to individuals with an understanding of mental illness and how to treat and manage it. Participants did not recognise the term ’counsellor’; they had either not heard of it or had heard it but had no understanding of a counsellor’s role in mental healthcare.
The stakeholders i.e. caregivers as family members involved in this study have provided important insights into the issues that facilitate access and demand for mental health services. This is a crucial aspect of the strategy to integrate mental health care into primary care, above and beyond the actual provision of services. The main findings were that mental health stigma underlies many of the problems regarding demand and access to services at the community level, and those barriers to demand and access at the health facility level are composed mainly of more pragmatic problems. 

Although the data demonstrate the expected high level of tangible barriers to care for marginalized social groups (such as the lack of money and time to travel to health centres, they also indicate low demand from all sectors of society, including the more privileged. This appears in contrast to past research on general medical help seeking in Birbhum, where higher castes seek more modern medical care. This was surprising as we expected that more educated groups would have greater mental health awareness. This was not the case: stigma related barriers to care affected these groups in the absence of poverty related ones, indicating that our initial focus on people living in poverty could be broadened in order to address this issue.

The families and close friends of mentally ill people were considered to be primary detectors and identifiers of problems, and therefore the first step in their relative’s pathway to appropriate care. However, when this is considered in the light of findings about patients hiding mental illness from people close to them (for example, family-in-law), a core problem regarding detection and identification is illuminated: family members and close friends are given responsibility for improving detection and identification of mental health problems, but are also recognized as key barriers to this process. This reflects the findings of another qualitative research into access for hard- to-reach groups in the UK, which revealed a phenomenon they label the “paradox of demand”, where a close social network facilitates access to services, whilst simultaneously disapproving of outside help, creating stigma or providing incomplete information about services (Kovandžiæ M et al., 2011).

Overall, respondents suggest that these improvements alone are not to increase service use. Cultural norms and deeply engrained habits of seeking alternative help (i.e. from traditional healers) were portrayed as fundamentally important. This highlights existing influences that interact with those anchored in the health facility to determine the extent to which people will use the care package. This corroborates the findings of James (James S et al, 2002): that the use and effectiveness of mental health care (supply side factors) is influenced by the attitudes and help-seeking behaviours of the local population (demand side factors). Moreover, the finding that mental health stigma also operates in health facilities- through the mistreatment of mental health patients- reminds us that the health facility is embedded in, and inextricably linked to the wider community.

This research was done for the need to understand how information needs to spread so that general population will get benefited from the service delivery system. The findings from these FGDs suggested that stigma and access to care are major barriers faced by them seeking mental health/ illness information and/or services. Moreover, they may lead some denial of mental illness to oneself and/or others and to avoid actively seeking help. In addition, some rural concept especially culturally- and traditionally-based belief systems regarding mental health/ illness are the biggest barrier. Our results corroborated findings by others (National Mental Health Survey, 2015-16) that people’s fear of stigma regarding mental illnesses leads them to sometimes hide or deny their distress, frame it (and other’s distress) in alternative ways, and/or avoid help modalities that might imply mental illness (Alvidrez, 1999; Hines-Martin et al., 2003). This FGDs extend such knowledge by adding participants’ articulation of secondary needs that stigma creates, which then shape preferences for how to receive mental health information and/or access services. These preferences thereby become the beginning of strategies that may help close the gap between mental health needs and information and services received among patients and families.

Limitations and Future Directions 
In these groups, it was not efficient in covering maximum depth on a particular issue. A particular problem might be there as disadvantage that members may not express their honest and personal opinions about the topic. They may be hesitant to express their thoughts, especially when their thoughts oppose the view of another participant. The more engagements and research may strengthen the research essentially in longer period of time. The further periodical intervention is needed for better outcome of these groups. The fact that service users reported doubts about both traditional healers and health workers, after consulting both sources, suggest that this medical pluralism may be more problematic than has previously been reported in this context. Further research into the specific patterns and effects of receiving both traditional and Western mental health care would shed more light on this matter.
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Conflict of interest: None
Role of funding source: None 

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