LOCAL KNOWLEDGE AND PERCEPTIONS ABOUT MENTAL HEALTH CARE SERVICE DELIVERY SYSTEM: FOCUSED GROUP DISCUSSIONS IN SURI DISTRICT HOSPITAL OF WEST BENGAL

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.

 

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:

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.

Conflict of interest: None
Role of funding source: None