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i
Evaluation of a Community Mental Health
programme in a tribal area – South India
Dr. Mahantu Yalsangi
Dissertation submitted in partial fulfillment of the
requirements for the award of the degree of
Master of Public Health
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and
Technology
Thiruvananthapuram, Kerala.
October 2011
ii
Acknowledgement
I would begin with thanking my beloved father, mother and sister, who have always
supported and encouraged me throughout my life, especially when I decided to work in a
rural setup after my graduation.
I would like to express my sincere gratitude to Dr. P.G. Premila, Mr. Manoharan, Dr.
Nandakumar, Dr. Shyla, and Dr. Sunil, who have been a source of inspiration to a lot of
people like me.
This piece of work would not have taken shape without the help of my mentor and guide
Dr. V. Raman Kutty. I thank him for his unconditional support all through the study.
I thank Dr. Jithesh who has supported, guided and taught me throughout this course and
has been very humble in repeatedly explaining various aspects of this study.
I express heartfelt thanks to my Gudalur family and ASHWINI team, who have
immensely supported me to pursue this course and also to conduct this study.
I thank Dr. K. R. Thankappan, Dr. Sundari Ravindran, Dr. Sankara Sarma, Dr. Ravi
Verma, Dr. Biju Soman, Dr. Manju Nair, Dr. Mala Ramanathan, and Mrs. Sheena for
their valuable suggestions and guidance during this course and Mrs. Archana who spent
time and guided me in doing my qualitative analysis.
I thank Dr. Sherab Tsheringla, Dr. Arun, Mr. Tarsh, and Dr. Mrudulla, have helped me in
designing my study and Dr. Aneena, Mr. Sathiseelan, Mr. Krishnamurthy, Ms. Jiji, Mr.
Ramesh, Mrs. Janaki, Mr. Eshwaran, Dr. Mahesh, Dr. Prasan and Mrs. Malathi, who have
helped me in various aspects of my study.
It was wonderful time that I spent in Trivandrum with my classmates, seniors, and
juniors, especially Dr. Palash, Dr. Abhijeet, Dr. Siddhartha, Dr. Brajesh, Dr. Anoop, and
Dr. Lipika, Thank you all.
Finally I thank all those who have helped me directly or indirectly in these two years.
iii
Certificate
I hereby certify that the work embodied in this dissertation entitled
“Evaluation of a Community Mental Health programme in a tribal area –
South India.” is a bona fide record of original research work undertaken by
Dr. Mahantu Yalsangi, in partial fulfillment of the requirements for the
award of the degree of „Master of Public Health‟ under my guidance and
supervision.
Prof (Dr.) Raman Kutty, MD, MPH, MPhil;
Achutha Menon Centre for Health Science Studies,
Sree Chitra Tirunal Institute for Medical Sciences and Technology,
Thiruvananthapuram, Kerala.
October 2011.
iv
Declaration
I hereby declare that the work embodied in this dissertation entitled
“Evaluation of a Community Mental Health programme in a tribal area –
South India.” Is the result of original research and has not been submitted for
any other university or institution.
Dr. Mahantu Yalsangi, MPH-2010,
Achutha Menon Centre for Health Science Studies,
Sree Chitra Tirunal Institute for Medical Sciences and Technology,
Thiruvananthapuram, Kerala.
October 2011.
TABLE OF CONTENTS
LIST OF TABLES
v
LIST OF FIGURES
ABBREVIATIONS
ABSTRACT
CHAPTERS
Chapter 1 Introduction and review of literature Page No.
1.1 Introduction……………………………………………………………. 1
1.2 Global burden of mental illness………………………………………. 1
1.2.1 Depressive disorders………………………………………. 2
1.2.2 Substance use disorder……………………………………. 3
1.2.3 Schizophrenia……………………………………………… 4
1.2.4 Epilepsy…………………………………………………….. 5
1.2.5 Alzheimer’s disease………………………………………... 5
1.2.6 Mental retardation………………………………………… 5
1.2.7 Disorders of childhood and adolescence…………………. 5
1.2.8 Co morbidity………………………………………………. 6
1.2.9 Suicide……………………………………………………… 6
1.3 Spending on mental health……………………………………………. 6
1.4 Mental illness – Burden in India……………………………………... 7
1.4.1 Schizophrenia……………………………………………… 7
1.4.2 Mood disorders……………………………………………. 7
1.4.3 Substance abuse…………………………………………… 7
1.4.4 Mental retardation………………………………………… 7
1.4.5 Dementia…………………………………………………… 8
1.4.6 Epilepsy……………………….…………………………… 8
1.4.7 Suicides…………………………………………………….. 8
1.5 Resources in mental health sector……………………………………. 8
1.5.1 Psychiatric beds……………………………………………. 9
1.6 Mental health care in India…………………………………………… 9
1.7 Mental health care a paradigm shift…………………………………. 10
1.8 Community based mental health care……………………………….. 11
1.9 Examples of community based mental health care………………….. 11
1.10 Community Based Care versus Hospital Based Care………………. 14
vi
1.11 Programme evaluation………………………………………………... 14
1.11.1 Process evaluations………………………………………... 14
1.11.2 Outcome evaluations………………………………………. 15
1.12 Rationale of the study…………………………………………………. 15
1.13 Objectives of the study……………………………………………… 16
1.13.1 Major objectives…………………………………………… 16
1.13.2 Minor objectives…………………………………………… 16
Chapter 2 Methodology……………………………………………….. 17
2.1 Study Design…………………………………………………………… 17
2.2 Cross sectional survey………………………………………………… 17
2.2.1 Study setting……………………………………………….. 17
2.2.2 Sample size…………………………………………………. 17
2.2.3 Sample selection…………………………………………… 17
2.2.3.1 Intervention area………………………………… 17
2.2.3.2 Control area……………………………………… 19
2.2.4 Data collection……………………………………………... 20
2.2.5 Data storage………………………………………………... 20
2.2.6 Data Analysis and Statistical Measures………………….. 20
2.3 Secondary data………………………………………………………… 21
2.3.1 Data collection……………………………………………... 21
2.3.2 Sample selection…………………………………………… 21
2.3.3 Data storage………………………………………………... 21
2.3.4 Data Analysis and Statistical Measures………………….. 21
2.4 In-depth interviews……………………………………………………. 21
2.4.1 Sample selection…………………………………………… 21
2.4.2 Sample size…………………………………………………. 22
2.4.3 Data collection and storage……………………………….. 22
2.4.4 Data analysis……………………………………………….. 22
2.5 Triangulation…………………………………………………………... 22
2.6 Ethical considerations…………………………………………………. 22
2.6.1 Risks to the participants…………………………………... 22
2.6.2 Privacy and confidentiality……………………………….. 23
vii
2.6.3 Benefits……………………………………………………... 23
2.6.4 Informed consent process…………………………………. 23
Chapter 3 Programme description…………………………………… 24
3.1 History and context of the programme………………………………. 24
3.2 Organogram………………………………………………………….... 27
3.3 Present status…………………………………………………………... 28
3.4 Program management………………………………………………… 28
3.5 Medication supplies…………………………………………………… 28
3.6 Accessibility of services and transportation………………………… 29
3.7 Case-finding methods…………………………………………………. 29
3.8 Monitoring……………………………………………………………... 30
3.9 Referral systems……………………………………………………….. 30
3.10 Information systems…………………………………………………... 30
3.11 Livelihood Programs………………………………………………….. 31
Chapter 4 Results……………………………………………………… 32
4.1 Cross sectional survey………………………………………………… 32
4.1.1 Sample characteristics……………………………………. 33
4.1.2 Distribution of scores……………………………………… 34
4.1.3 Two-way anova……………………………………………. 36
4.1.4 Multivariate analysis……………………………………… 39
4.2 Secondary data………………………………………………………… 41
4.2.1 Early detection / Duration of untreated illness………….. 41
4.2.2 Continuity of care / follow-up…………………………….. 41
4.3 Qualitative analysis……………………………………………………. 42
4.3.1 Help community take responsibility for mentally ill patients... 42
4.3.2 Provide treatment close to home…………………………. 43
4.3.3 Give economic support during hospitalization………….. 43
4.3.4 Rehabilitation where applicable………………………….. 44
4.3.5 Other findings……………………………………………... 45
4.3.6 Strengths and bottlenecks in the programme…………… 46
4.3.6.1 Strengths…………………………………………. 46
viii
4.3.6.2 Bottlenecks……………………………………….. 46
4.4 Triangulation………………………………………………………….. 47
4.4.1 Awareness………………………………………………….. 47
4.4.2 Early detection…………………………………………….. 47
4.4.3 Continuity of care…………………………………………. 47
Chapter 5 Discussion and conclusion………………………………… 48
5.1 Discussion……………………………………………………………… 48
5.1.1 Cross sectional survey…………………………………….. 48
5.1.1.1 Sample characteristics…………………………... 48
5.1.1.2 Distribution of scores by other variables………. 48
5.1.1.3 Two way anova…………………………………... 48
5.1.1.4 Multivariate analysis……………………………. 49
5.1.2 Secondary data analysis…………………………………... 49
5.1.2.1 Early detection…………………………………... 49
5.1.2.2 Continuity of care / follow-up………………….. 49
5.1.3 Qualitative analysis……………………………………….. 50
5.1.3.1 Help community take responsibility for
mentally ill patients……………………………… 50
5.1.3.2 Provide treatment close to home……………….. 50
5.1.3.3 Give economic support during hospitalization... 50
5.1.3.4 Rehabilitation where applicable………………... 51
5.1.4 Triangulation………………………………………………. 51
5.2 Strengths and limitations of the study……………………………….. 51
5.2.1 Strengths…………………………………………………… 51
5.2.2 Limitations of the study…………………………………… 51
5.3 Recommendations……………………………………………………... 52
5.4 Conclusions…………………………………………………………….. 52
REFERENCES
APPENDICES
ix
Appendix I: Informed consent – community members
Appendix II: Informed consent – In-depth interview
Appendix III: Interview schedule
Appendix IV: Interview guidelines - Beneficiary
Appendix V: Interview guidelines – Health Guide
Appendix VI: Interview guidelines – Health Animator
Appendix VII: Interview guidelines – Programme implementers
LIST OF TABLES:
Table 1.1 Human resources in mental health sector………………………... 8
Table 2.1 Distribution of clusters in intervention area……………………... 18
Table 2.2 Distribution of clusters in control area…………………………... 19
Table 4.1 Sample characteristics…………………………………………… 33
Table 4.2 Distribution of scores by other characteristics…………………... 34
Table 4.3 Factorial anova…………………………………………………... 36
Table 4.4 Model summary………………………………………………….. 39
Table 4.5 ANOVA table for the final model……………………………….. 40
Table 4.6 Coefficients of the final model…………………………………... 40
Table 4.7 Duration of untreated illness before detection…………………... 41
Table 4.8 Follow-up of patients……………………………………………. 41
LIST OF FIGURES:
Figure 3.1 Organogram of three tier system of ASHWINI…………………. 27
Figure 3.2 Organogram of Gudalur team…………………………………… 27
Figure 4.1 Mean awareness scores with standard deviation in intervention
and control areas…………………………………………………. 35
Abbreviations
x
AC: Area center
ACCORD: Action for Community Organization Rehabilitation and Development
ACT: Area Center Team
ASHWINI: Association for Health Welfare in the Nilgiris
CBR: Community Based Rehabilitation
CDC: Centre for Disease Control and Prevention
CMC: Christian Medical College
CMH: Community Mental Health
DALY: Disability Adjusted Life Years
GAH: Gudalur Adivasi Hospital
GBD: Global Burden of Disease
HA: Health Animator
HG: Health Guide
LOCOST: Low Cost Standard Therapeutics
NIMHANS: National Institute of Mental Health and Neuro Sciences
OPC: Out Patient Care
PPS: Population Proportional to Size
SCARF: Schizophrenia Research Foundation
SRTT: Sir Ratan Tata Trust
THC: Tribal Health Counselors
TNHSP: Tamil Nadu Health Systems Project
WHO: World Health Organization
YLD: Years Lived with Disability
Abstract
xi
“Evaluation of a Community Mental Health programme in a tribal area – South India.”
Introduction: Mental illness is a burden on the family and the society. Social stigma,
difficulty in accessing mental health care facilities, poor adherence to treatment, irregular
follow up, and poverty aggravate the disease thus even a person with the potential to
recover suffers due to these reasons. If these problems could be addressed, then de-
institutionalization of care through a paradigm shift to community based care would be
the ideal situation for domiciliary treatment. Evaluation of community based mental
health programmes in resource poor settings can give information on the strengths,
drawbacks and effectiveness of such models, providing a platform for starting similar
initiatives in comparable settings.
Methodology: It is a mixed method study consisting of three components to assess the
programme objectives. The first is a cross sectional survey of 240 members of the
community to assess the awareness about mental illness in the intervention and control
areas of the Nilgiris district. The second component is secondary data analysis to study
the early detection of cases and providing continuity of care/follow-up of patients. The
third component is in-depth interview of the stakeholders to assess all the programme
objectives.
Results: The awareness score in the intervention area was found to be much higher than
the control area. The mean scores were 5.13 + 2.27 and 1.57 + 2.82 and median of 5 and
2 in the intervention and control areas respectively.
From the secondary data it was found that the mean (1497.91 to 474.33 days) and median
(730 to 30 days) duration of untreated illness has been decreasing.
Analysis of the in-depth interview indicated that programme has progressed to the desired extent
on all the objectives.
Conclusion: The programme has been successful in integrating the community mental
health programme with the primary health care and has progressed to a desired level in
achieving most of the objectives set forth. This model is viable and can be replicated
successfully in comparable settings.
1
CHAPTER 1: Introduction and review of literature
1.1 Introduction
The World Health Organization defines health as "a state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity". It also
defined Mental health as “a state of well-being in which every individual realizes his or
her own potential, can cope with the normal stresses of life, can work productively and
fruitfully, and is able to make a contribution to her or his community”.1
Mental health in itself forms an integral and a very important aspect of health.2
Mental and behavioural disorders not only affect the individual but also the family and
the community. The individual not only suffers from the illness but in most instances will
not be able to participate fully in work and leisure activities. The patients suffer stigma
and discrimination. In many instances the families not only have to provide support but
also share the stigma and discrimination. A mental and behavioural disorder decreases the
quality of life of people affected by the disorder in a big way. The quality of life of the
affected individuals often is poor even after recovery.
Global burden of mental illness
In the world health report 2001 it is stated that there are about 450 million people who
suffer from some form of mental or behavioural disorder. Unfortunately only a very small
proportion of them receive the most basic treatment. Most of them suffer the illness
silently and bear all the consequences.3 Mental illnesses include unipolar depressive
disorders, bipolar affective disorder, schizophrenia, epilepsy, alcohol and selected drug
use disorders, Alzheimer‟s and other dementias, post traumatic stress disorder, obsessive
and compulsive disorder, panic disorder, and primary insomnia.
2
It is estimated that one member out of every four families is currently suffering from
mental or a behavioural disorder. More than 25% of people during their entire life time
will suffer from some form of mental and behavioural disorder. 3
Mental illness is
universal and can affect any individual irrespective of any group they belong to. It can
affect the men and women, rich and the poor, the urban and rural.
In 1990 about 10% of DALY‟s were attributed to mental and neurological disorders,
increasing to 12% in 2000. It is estimated that by the year 2020 neuropsychiatric
disorders will contribute 15% of the global burden of disease. 3
Approximately 31.7% of all the years lived with disability (YLD) can be attributed to
neuropsychiatric disorders. The major contributors are unipolar depression (11∙8%),
alcohol-use disorder (3∙3%), schizophrenia (2∙8%), bipolar depression (2∙4%), and
dementia (1∙6%).2
Overall prevalence of mental disorders is found to be same among men and women; the
differences that are present are due to the differential distribution of disorders, such as
Depression is found to be more prevalent among women and substance abuse is more
common among men. 3
1.2.1 Depressive disorders:
Unipolar depressive disorders rank third among the ten leading causes of global burden of
diseases. It contributes to 4.3% of the total DALY‟s lost and it is expected that by the
year 2030 unipolar depression will stand at rank one by contributing to 6.2% of the total
DALY‟s lost.4
Depression is more common in women than men.3 The global burden of disease 2000
estimated that the point prevalence of unipolar depression is 1.9% for men and 3.2% for
3
women. About 5.8% of men and 9.5% of women will experience some sort of depressive
disorder over a period of 12 months. However this may vary across different
populations.5
Adherence to treatment is very important factor in the prognosis of depression; it
is found that non adherence to treatment is up to three times higher among the depressed
people than the non-depressed people.6
One of the adverse outcomes of depression is
suicide; it remains one of the common and avoidable outcomes of depression. Around 15
% to 20 % of the depressed patients end their lives by committing suicide.7
Bipolar affective disorder refers to patients with depressive illness along with
episodes of mania characterized by elated mood, increased activity, over-confidence and
impaired concentration. According to GBD 2000, the point prevalence of bipolar disorder
is around 0.4%.5
1.2.2 Substance use disorder:
Abuse of some of the psychoactive substances results in the mental and
behavioural disorders. Some of the the harmful substances are alcohol, opioids such as
opium or heroin, cannabinoids such as marijuana, sedatives and hypnotics, cocaine, other
stimulants, hallucinogens, tobacco and volatile solvents. Most times the harmful use is
identified when damage has been done to the physical or mental health.
Tobacco and alcohol are the two major substances consumed in the world and
give rise to very serious public health problems.3 Globally there are approximately 1.2
billion people who smoke; by the year 2025 the number is expected to rise to more than
1.6 billion. Over 3 million deaths were attributed to tobacco in 1990 which would be
about 4 million deaths in the year 1998. It is estimated that tobacco attributed deaths will
rise to 8.4 million in 2020 and 10 million annual deaths by the year 2030. 8
4
Alcohol is also a commonly used substance in most regions of the world. The
point prevalence of alcohol use disorders (harmful use and dependence) in adults has
been estimated to be around 1.7% globally according to GBD 2000 analysis. The rates are
2.8% for men and 0.5% for women. The period prevalence of drug abuse and dependence
range from 0.4% to 4%, but the type of drugs used varies greatly from region to region.
GBD 2000 analysis suggests that the point prevalence of heroin and cocaine use disorders
is 0.25%.5
1.2.3 Schizophrenia:
Schizophrenia is a severe disorder that typically begins in late adolescence or
early adult-hood. It is characterized by fundamental distortions in thinking and
perception, and by inappropriate emotions. Schizophrenia is found approximately equally
in men and women, though the onset tends to be later in women, who also tend to have a
better course and outcome of this disorder.3
The GBD 2000 reports a point prevalence of 0.4% for schizophrenia; in the global burden
of disease study, schizophrenia accounted for 1.1% of the total DALYs and 2.8% of
YLDs.5
Quite a few individuals suffering from schizophrenia attempt suicide some time during
the course of their illness. A study showed that 30% of patients suffering from this illness
had attempted suicide at least once during their life time,9 and about 10% of people
suffering from schizophrenia end life by suicide. On an average this illness reduces 10
years of an affected person‟s life.10
5
1.2.4 Epilepsy:
It is estimated that there are about 37 million people globally are suffering from
primary epilepsy and when epilepsy caused by other diseases of injury is also included
the total number increases to 50 million and more than 80% of these individuals live in
the developing countries and epilepsy contributes to 0.5% of the total disease burden, 5
there is this increased burden as epilepsy goes untreated in many cases especially in the
developing countries. Significant stigma and discrimination is attached to epilepsy which
prevents them from participating fully in normal and leisure activities.3
1.2.5 Alzheimer’s disease:
Alzheimer‟s and other dementia‟s have an overall point prevalence of 0.06% and
prevalence among people above 60 years of 5% for men and 6% for women. There is no
sex difference in the incidence of the disease; prevalence is more in women due to the
increased life expectancy of the women. Alzheimer‟s disease contributes to 0.84% of
DALY‟s and 2% of YLD‟s.5
1.2.6 Mental retardation:
The overall prevalence of mental retardation is about 1% to 3%. It is more
common in the developing countries due to higher incidence of injuries and anoxia during
birth and early childhood brain infections. Mental retardation causes a huge burden to the
individual and the family. In some cases it becomes difficult for the individual even to
carry out the daily routine activities, thus depending on others for help.3
1.2.7 Disorders of childhood and adolescence:
Mental and behavioural disorders are very common among children and
adolescents. However not much of effort is made in understanding this aspect of mental
6
health. The overall prevalence of mental and behavioural disorder among children is
found to be about 10% to 20%.3
1.2.8 Co morbidity:
Co-morbidity is a situation when two or more mental and behavioural disorders occur
together in an individual.3 A study in the United States showed that 79% of all mentally
ill people were co-morbid and only in 21% of patients a mental disorder presented
singly.11
A 12 month prevalence of co-morbid mood-anxiety disorder in United Stated was
found to be 3%.12
1.2.9 Suicide:
Suicide is turning out to be a major public health problem. In the year 1996 the
age adjusted suicide rates were calculated for 53 countries for which the complete data
were available. The suicide rates were 15.1 per 100000. However the differential suicide
rates for men and women were very different; the male suicide rate was 24 per 100000
and for females it was 6.8 per 100000. The attempt to suicide may be around 20 times
higher than the completed suicides.3 Suicides contribute to 1.3% of all the DALY‟s.
5
1.3 Spending on Mental health:
Out of 101 countries from which the data were available 20.9% covering a population of
more than 1 billion, spend less than 1% of the total health budget on mental health. In the
Regions of Africa and South-East Asia, 70.0% and 50.0% of countries respectively spend
less than 1% of their health budget on mental health care. At the same time more than
61.5% of countries in the European Region spend more than 5% of their health budget on
mental health care.13
7
1.4 Mental illness – Burden in India
Several studies in India have reported a wide a range of prevalence of mental and
behavioural disorders. However the prevalence of mental and behavioural disorders in
India is derived as a median value of 65 per 1000 population from two studies conducted
in India. The prevalence rates among females are found to be higher by 20% to 25 %. The
prevalence of mental and behavioural disorders is higher in the urban areas.14, 15
1.4.1 Schizophrenia:
Prevalence of schizophrenia ranges from 1.1 to 14.2 per 1000 population.14, 15
All
India prevalence of schizophrenia is taken as 2-3 per 1000 population.
1.4.2 Mood disorders:
Studies have showed that prevalence of mood disorders to be about 11 to 34 per
1000 in rural, 18 to 37 per thousand in urban areas.14, 15
Mood disorders were more in the
urban areas and in women.
1.4.3 Substance abuse:
The overall prevalence of substance abuse in India is 6.9 per 1000 with prevalence
of 5.8 and 7.3 per thousand in the urban and rural areas respectively. The prevalence
among men and women were 11.9 and 1.7 per 1000 respectively.15
1.4.4 Mental retardation:
The prevalence of mental retardation was found to be 6.9 per 1000 population
with a higher prevalence in males. The prevalence in the urban and rural areas were 8.9
and 6.4 per 1000 respectively.15
8
1.4.5 Dementia:
The prevalence of dementia is about 31 per 1000 in those who are 60 years or
above or 2.48 per 1000 population of all ages.15
1.4.6 Epilepsy:
A study conducted in Vellore, south India showed the prevalence of epilepsy to be
3.83 per 1000 population. The prevalence in the urban area was 6.23 per thousand and in
the rural area were 3.04 per thousand. 16
1.4.7 Suicides:
It is estimated that approximately 1.2 lakh people in India commit suicide every
year; more than four lakh people attempt it. Suicides in India vary from region to region.
Studies have reported incidence of suicides from 2.36 to 44.7 per 100000 populations.17,
18, 19
1.5 Resources in mental health sector:
A huge gap exists between the high, and low income countries in mental health
care resources, with most of the resources concentrated in the high income countries. The
following table shows us the gap present between high, low-middle and low income
countries among different professionals.20
Table 1.1: Human resources in mental health sector.
Median Professionals per
100,000 population
High income
countries
Low-Middle
income
countries
Low income
countries
Psychiatrists 8.59 0.54 0.05
Nurses 29.15 2.93 0.42
Psychologists 3.79 0.14 0.02
Social Workers 2.16 0.13 0.01
9
A world health organization report pointed out that the density of psychiatrists in or
around the largest city of a state in low and middle income country was 2.5 times greater
than the density of psychiatrists in the entire state. The density of nurses is 4.13 times
greater in the largest city than the entire State.21
1.5.1 Psychiatric beds:
The mean and median psychiatric beds per 10,000 populations in low income
countries are 0.68 and 0.24 respectively and that of the high income countries are 8.94
and 7.5 respectively. There are approximately 1.84 million psychiatric beds in the world
and 68.6% of them are in the mental hospitals.13
1.6 Mental health care in India:
Mental health has been long neglected as a public health problem in developing
countries. In India, like in many other developing countries, the reasons for this neglect
are complex; they include cultural beliefs of the population, lack of technical and
financial resources and inadequate political commitment.22
India being one of the pioneers in primary health care, initiated its National Mental
Health Program in 1982 with the objective of providing basic mental health care to all by
integrating it with primary health care at four levels, primary care at the village level,
primary health centers, district hospitals, and psychiatric units at medical colleges.
However, the program maintained a low profile due to financial constraints.23, 24
Integration of mental health care into the primary care was piloted in Bellary,
Karnataka.25
This model was adopted by the government of India and the District Mental
Health Programme was launched as part of the national mental health programme in
1995.24
This has been planned to spread to 100 districts in the country. Currently, the
10
District Mental Health Programme is under implementation in 123 Districts throughout
the country. Grants have also been released for upgradation of Psychiatric wings of 75
Government Medical Colleges/General Hospitals and modernization of 26 Mental
Hospitals.26
1.7 Mental health care a paradigm shift.
Over a few centuries people with mental and behavioural disorders have been
treated in various ways. They were given the status of god and were worshiped, compared
to the evils, burnt to death3 and put in institutions which were called lunatic asylums and
some places as madhouse. 27, 28
However in almost all the developing countries mental institutions never existed in a
scale to be replaced by the community care. In India there are several holy places such as
temples, dargas where the mentally ill are treated. In one of many such mental asylums an
incidence occurred in Erwadi, south India where 27 patients were burnt in a fire accident
where they were chained to a pillar. This brought out the unjust and inhumane treatment
towards the mentally ill.28
In the second half of the 20th
century there was a shift in the mental health care paradigm
owing mainly to the introduction of new drugs, human rights movements, failure of the
asylums and the social and mental components were firmly incorporated into the
definition of health.3 and in the past few decades this has resulted in a slow shift from
institutional care towards community-based treatment and rehabilitation in the
management of mental disorders.27
11
1.8 Community based mental health care:
Community-based care is the care that the client can access nearest to home,
which encourages participation by people, responds to the needs of people, encourages
traditional community life and creates responsibilities. Community mental health services
include a range of services that provide care to people with mental disorders in the
communities where they live and work.29, 30
Community mental health (CMH) refers primarily to treatment and intervention
programmes initiated and implemented outside institutions such as mental hospitals.
Basically CMH deals with the care of mentally ill persons in the community where the
communities itself participate in the process. Over a few years, CMH has broadened its
concern to address all mental health problems of the population.
CMH not only deals with different levels of mental morbidity in a population but it is also
concerned with the perceived psychological welfare and wellbeing of society. CMH
attempts to use methods and techniques of behavioural sciences and public health to
prevent mental disorders, promote mental health and improve the general quality of life.
CMH also includes service delivery strategies for identification, management as well as
rehabilitation of persons with various mental disorders. The practice of CMH requires
coordinated and multi-sectored action involving a number of government sectors as well
as nongovernmental and community-based organizations.31
1.9 Examples of community based mental health care:
A prospective study was conducted in a resource poor setting in India to compare
community based rehabilitation (CBR) and outpatient care (OPC), the outcomes
measured using Positive and Negative Symptom Scale and the modified WHO Disability
12
Assessment Schedule at the end of 12 months. Among the fully compliant patients CBR
had better outcomes than OPC among the men. Within the CBR fully compliant patients
had better outcome than partially or non compliant patients. Compliance was also better
in the CBR compared to OPC. This model has three tiers, first the outpatient care, second
the community health workers and third the rehabilitation involving the family and
community members. Community based rehabilitation is a feasible model in the resource
poor settings which involves active participation by the community and requires low
levels of technical expertise to deliver the services.32
A qualitative study was conducted in Jamaica with the objective to find out whether de-
institutionalization and integration of community mental health into the primary health
care reduces the stigma associated towards the mentally ill people. With 20 focus group
discussions it was found that there was reduction in the stigma associated with mental
illness over a period of time and this could be possibly due to the de-institutionalization.33
Another prospective cohort study was conducted on the outcomes of people with
psychotic disorders in community based rehabilitation in rural India. There were marked
improvements in the patients and poor outcomes were found in the patients who dropped
out. Being in a self help group, involvement of the family in the programme and medicine
adherence had better outcomes while lack of formal education, diagnosis of schizophrenia
and dropping out of the programme had poor outcomes. This study concluded that
community based rehabilitation is acceptable and feasible intervention for people with
psychosis in a resource poor setting.34
A meta analysis done on effective clinical interventions that community psychiatry can
implement to reduce non-adherence in psychosis patients concluded that community
13
psychiatric services can use effective clinical interventions backed by scientific evidence
for reducing patient non-adherence.35
Schizophrenia Research Foundation (SCARF), an NGO in Chennai had established a
community clinic in 1989 in Thiruporur, which was functional till 1999. In 2005 a follow-
up was done to know the status of the people enrolled in the programme. Out of the 185
patients followed up, 15% had continued treatment, 35% had stopped treatment, 21% had
died, 12% had wandered away from home and 17% were untraceable. Of the patients who
had discontinued treatment 25% were asymptomatic while 75% were acutely psychotic.
The study concluded that community based initiatives in the management of mental
disorders however well intentioned will not be sustainable unless the family and the
community are involved in the intervention program with support being provided
regularly by mental health professionals.36
Another study was conducted in rural Tasmania to evaluate the effectiveness of a primary
care mental health service to usual mental health service and no treatment over a period
of 12 months. Changes in the symptomatology were assessed using the SCL-90R
summary scales, and changes in quality of life were assessed using the EuroQOL. It was
found that the participants who were treated by the primary mental health care worker
showed significant improvements in symptoms and quality of life compared to the other
groups.37
A study conducted on suicides in Finland found that well developed community mental
health services are associated with lower suicide rates than the services oriented towards
inpatient care.38
14
A follow-up study on the community outreach programme conducted in rural Karnataka,
India found that the participants experienced better clinical, functional and economic
outcomes.39
1.10 Community Based Care versus Hospital Based Care:
There are no scientific evidences to say that hospital based mental health care
model is better than the community based care nor is there evidence to say that
community based care and services alone can provide a comprehensive and better care
than the hospital care model. A balanced care that has the components of both the hospital
care model and the community based care and integrating mental health services into
primary health care is the most viable way of closing the gap and ensuring that people get
the mental health services.40, 41
1.11 Programme evaluation:
Program evaluation is a systematic method for collecting, analyzing, and using
information to answer basic questions about a program.42
There are different types of evaluation and different types of terms used such as formative
evaluation, summative evaluation, process evaluation, outcome evaluation, cost-
effectiveness evaluation, and cost-benefit evaluation.42
They are broadly classified as
process evaluation and outcome evaluation.
1.11.1 Process evaluations assess whether an intervention or program model was
implemented as planned, whether the intended target population was reached, and what
are the major challenges and successful strategies associated with program
implementation.
15
1.11.2 Outcome evaluations determine whether, and to what extent, the expected
changes in child or youth outcomes occur and whether these changes can be attributed to
the program or program activities.42
Centre for Disease Control and Prevention (CDC) recommended a framework for
programme evaluation in public health.43
The framework explains the steps in programme
evaluation and the standards need to be met in a programme evaluation.
1.12 Rationale of the study
Mental illness is a burden on the family and to the society. Social stigma,
difficulty in accessing mental health care facilities, poor adherence, irregular follow up,
and poverty aggravate the disease; thus even a person with the potential to recover suffers
due to these reasons. If these problems could be addressed, then de-institutionalization of
care through a paradigm shift to community based care would be the ideal situation for
domiciliary treatment. Evaluation of community based mental health programmes in
resource poor settings can give information on the strengths, drawbacks and effectiveness
of such models, providing a platform for starting similar initiatives in comparable
settings.
16
1.13 Objectives of the study:
1.13.1 Major objectives
To assess the Community Mental Health Programme run by ASHWINI in a
tribal area in the Nilgiris at the end of 5 years, vis a vis the programme
objectives.
The programme objectives are:
Create awareness in the community about mental illness
Ensure early detection and treatment.
Provide continuity of care.
Help the community take responsibility for its mentally ill patients.
Provide treatment close to home.
Give economic support during hospitalization.
Rehabilitation where applicable.
1.13.2 Minor objectives
To identify the strengths and bottlenecks of the programme.
17
Chapter 2: Methodology
2.1 Study Design: Both “Quantitative” and “Qualitative” research methods were used.
The study had three components as follows:
Component 1: Cross sectional survey of the community members in the intervention and
control area to assess the awareness about mental illness.
Component 2: Secondary data to study the second and third programme (Early detection
and continuity of care) objectives.
Component 3: In-depth interviews with the stake holders of the community mental health
programme to assess programme objectives 4 to 7 and minor objective of the study.
2.2 Cross sectional survey:
2.2.1 Study setting: The study was conducted in the Gudalur, Pandalur, and Masinagudi
areas of the Nilgiris district, Tamil Nadu, India.
2.2.2 Sample size: Assuming a 20% difference in awareness levels between control and
intervention areas, to get a study result with 80% power and a maximum alpha error of
5%, the sample size calculated using epi-info version 3.5.2 statcalc was 122. Accounting
for design effect of 1.5 and non response rate of 20% the sample size was 236, rounded to
240.
2.2.3 Sample selection:
2.2.3.1 Intervention area
Total number of blocks = 8
Total number of hamlets = 203
18
Cluster sampling with population proportional to size (PPS) was adopted. Number of
hamlets selected in each area was proportional to the size of the stratum. The hamlets
from each area were selected by the lottery method. From each cluster, 5 individuals were
chosen randomly.
Total no of clusters = 24
No of samples per cluster = 5
Total sample = 120
Distribution of clusters:
Table 2.1: Distribution of clusters in intervention area
Block/Area No of hamlets % of total population No of clusters
Ayyankoly 29 14.28 3
Devala 17 8.37 2
Devarshola 32 15.76 4
Erumad 28 13.79 4
Gudalur 24 11.82 3
Pattavayal 29 14.28 3
Ponnani 18 8.86 2
Srimadurai 26 12.8 3
Total 203 100 24
19
2.2.3.2 Control area:
Total number of villages = 6
Cluster sampling with population proportional to size (PPS) was adopted. Number of
clusters selected in each village was proportional to the size of the stratum. The hamlets
from each area were selected by the lottery method. From each cluster, 5 individuals were
chosen randomly.
Total no of clusters = 24
No of samples per cluster = 5
Total sample = 120
Distribution of clusters:
Table 2.2: Distribution of clusters in control area
Villages Population % of total population No of clusters
Annaikatti 883 34.2 8
Bokkapuram 1023 39.7 9
Chokkanalli 213 8.2 2
Masinagudi 350 13.6 3
Siriyur 53 2.0 1
Vazhathottam 58 2.2 1
Total 2578 100 24
20
2.2.4 Data collection: The data were collected by the principal investigator and two
others who were trained prior to the data collection.
2.2.5 Data storage: All data were kept safely with the principal investigator, who bears
the sole responsibility for safe keeping and any breach of confidentiality. Data shall be
kept with the principal investigator for any future reference.
2.2.6 Data Analysis and Statistical Measures: A pre tested structured interview
schedule was used which had positive and negative scoring. The interview schedule
contained nine questions. During the study it was noted that respondents either did not
respond or gave inappropriate responses consistently for two questions. Hence, these two
questions were excluded from the final analysis.
Each question had three options, agree, unsure and disagree. There is a pre-set correct
answer for each question. If the answer was correct a score of + 1 was given, scored - 1 if
the answer was wrong and 0 if the answer was unsure. The total score of each individual
for all the 7 questions, ranging between – 7 and + 7, was calculated and used for the
analysis.
Descriptive analysis was done to look at the sample characteristics. Relation between the
predictor and outcome variables were explored using standard statistical methods. Further
multivariate analysis was done using multiple linear regression which yielded the final
model for the first programme objective. All these data were entered in Epidata version
3.1 and analysed in SPSS version 17.
21
2.3 Secondary data
2.3.1 Data collection: Secondary data were collected from the unlinked anonymous
patient records to assess the second and third programme objectives that are the early
detection and continuity of care.
2.3.2 Sample selection: For the second programme objective that is the early detection
all the patient records were reviewed.
For the third programme objective that is the continuity of care a sample of the patient
records were used. The inclusion criteria was that all the patient records who were on
treatment during the year 2010 who‟s treatment was started on or before January 2010
and the treatment was not stopped before December 2010.
2.3.3 Data storage: All data are kept safely with the principal investigator, who shall
bear the sole responsibility for safe keeping and any breach of confidentiality. Data shall
be kept with the principal investigator for any future reference.
2.3.4 Data Analysis and Statistical Measures: All the data were entered in open office
spreadsheet and analyzed in SPSS version 17.
2.4 In-depth interviews:
2.4.1 Sample selection: The study population consisted of beneficiaries of programme,
health volunteers, health animators and the programme implementers. Whoever agreed to
be interviewed were included. Everyone approached agreed to participate in the study.
The researcher was not able to approach one of the programmed implementer.
22
2.4.2 Sample size:
Beneficiaries: 5
Health Volunteers: 5
Health Animators: 5
Programme implementers: 2
2.4.3 Data collection and storage: Data were collected after receiving consent, using a
pre designed guideline. The respondent was interviewed in Malayalam or Tamil or
Kannada or English according to his/her choice. Twelve interviews were conducted in
Malayalam, two in Tamil, one in Kannada and two in English. All the participants agreed
for the interviews to be digitally recorded. These records were later transcribed and
translated by the researcher. All the digital recordings and transcripts are kept safely with
the principal investigator. It shall be completely destroyed within one year of submission
of the study.
Field notes were prepared after the village visits and were used in the analysis.
2.4.4 Data analysis: Deductive method was used to analyze the data, using the guideline
as template.
2.5 Triangulation: I have tried to triangulate the findings from various components in
this study.
2.6 Ethical considerations:
2.6.1 Risks to the participants: There were no risks involved in participating in the
study. A person trained on counseling was present all the time in case of any breakdown.
23
2.6.2 Privacy and confidentiality: Identity of the participants was only known to the
principal investigator. Once the consent was taken, further analysis was done only on the
basis of the characteristics of the participants.
2.6.3 Benefits: This study did not have any direct benefit to the participant. However the
study results may bring forth policy changes which may prove beneficial to the
community at large.
2.6.4: Informed consent process: Witnessed consent was taken. After all the information
was provided to the participant a witness signed the form after the participant was willing
to take part in the study. Informed consent was taken from the Health Animators and
understood consent for the programme implementers. Clearance was obtained from the
institutional ethics committee before commencement of the study.
24
Chapter 3: Programme Description
3.1 History and context of the programme:
The Community Mental Health Programme here reviewed, was instituted by Association
for Health Welfare in the Nilgiris (ASHWINI) in Gudalur, a town in the Nilgiris District
of Tamil Nadu, in 2005.
ASHWINI itself is a part of the voluntary organization ACCORD (Action for Community
Organization Rehabilitation and Development), was set up in 1987, to address the health
needs of about 13000 adivasis spread over 200 villages, in the Gudalur and Pandalur
taluks of the Nilgiris.
A 20 bedded hospital Gudalur Adivasi Hospital (GAH) was started by ASHWINI 1990 in
response to the high incidence of preventable mortality and morbidity among adivasis
which the local Government hospital was not equipped to handle
ASHWINI has a three-tier health system:
The first tier consists of trained Village Health Guides (HG) in the village.
The second tier consists of eight „Area Centers‟ (AC), one in each of the eight
zones, (each Area Centre covers between 20 to 40 adivasi villages.)
The third tier is the Gudalur Adivasi Hospital in the Gudalur town (run by
ASHWINI).
The Village Health Guides are unpaid volunteers who are trained in the basic health
issues. They form the link between the village and the larger community.
Area Centers: The whole project area is divided into eight zones for easy logistical
accessibility, each consisting of Area center Team (ACT) comprising of health, education
25
and development personnel. Health delivery is managed by trained adivasi nurses called
„Health Animators‟ (HA) from the community. They undergo a three to four years of
training at the GAH before being placed in the AC. The community members from the
surrounding villages have access to these centers for the treatment of common illnesses
and follow-up. Seriously ill patients are referred to Gudalur Adivasi Hospital (GAH) in
the Gudalur town.
Gudalur Adivasi Hospital: With a team of five full-time doctors, (a surgeon, gynecologist,
an internal medicine specialist, two physicians), and some visiting specialists, it provides
secondary level health care to the adivasi population in the region.
ASHWINI was providing only curative care at the GAH, both in-patient and out-patient
care was provided. The follow-up of these patients was not systematic and adequate due
to various reasons but primarily due to lack of awareness about mental illness and the
need for care among the community members, HG and the HA.
Over a period of time it was learnt that suicides were one of the main causes of death
among the community and most of the people who committed suicide had some form of
mental illness. The need for a systematic programme was felt at this juncture.
Therefore ASHWINI with the help of SRTT (Sir Ratan Tata Trust) initiated a community
mental health programme to address the issues of ineffective care due to limited follow-
up, high suicide rate and a general lack of awareness. The programme was funded by the
SRTT for a period of three years.
26
With community participation as the main thrust of the programme, the programme was
started with the following objectives:
Create awareness about mental illness in the community
Ensure early detection and treatment.
Provide continuity of care.
Help the community take responsibility for its mentally ill patients.
Provide treatment close to home.
Give economic support during hospitalization.
Rehabilitation where applicable.
To achieve these objectives the programme started off with the following activities.
Workshops were conducted by psychiatrists from National Institute of Mental
Health and Neuro Sciences (NIMHANS), Bangalore, St John‟s medical college,
Bangalore and Christian Medical College (CMC), Vellore. Doctors, Hospital staff
and HA were trained in basic psychiatry.
Regular training sessions were conducted for the HA by the doctors from GAH.
Five HG from each project area were selected and trained specifically in mental
health to identify people with symptoms of mental illness. The training was spread
over a period of one year and the trainings for the HG were conducted by the
doctors, HA and programme coordinator from GAH.
27
3.2 Organogram: The following two figures show the three tier system of ASHWINI
and how GAH fits in a larger organization.
Figure 3.1: Organogram of three tier system of ASHWINI.
Figure 3.2: Organogram of Gudalur team.
28
3.3 Present status:
The programme coverage has spread over a period of time and currently the programme
caters to a population of about 20000 adivasis spread over 250 villages. More than 230
HG from various villages have been trained by the implementers and the HA; ongoing
training sessions for the HG are being conducted.
Tribal Health Counselor‟s (THC) has been appointed at the Primary Health Center and
the Taluk hospital by the Tamil Nadu Health Systems Project (TNHSP). The THC forms
the link between the community and the Government health centers. Training for the
THC are being done by ASHWINI.
The mental health programme is integrated into the routine community health activities of
ASHWINI. The programme also provides clinical care to the non tribal patients attending
the hospital with mental health problems; this however is hospital based only.
3.4 Program management:
The programme is managed by five doctors none of whom is a specialist in psychiatry.
Three of the doctors were trained in basic psychiatry by the visiting psychiatrists. There
are 14 HA in the eight area centers and more than 230 HG from various villages who are
actively involved in the programme.
3.5 Medication supplies:
Some of the required medicines are purchased from the LOCOST (Low Cost Standard
Therapeutics-- a public, non-profit charitable trust, registered in Baroda, India). One of
the medicines is supplied by the Government of Tamilnadu. In case of a patient requiring
a medication that is not available in the low cost sector then it is purchased from a
pharmaceutical dealer directly.
29
3.6 Accessibility of services and transportation:
The programme provides inpatient and outpatient care at the hospital, and community
clinics are conducted at the area centers. Four of the eight area centers have been
provided with a mobile van by the TNHSP (Tamilnadu Health Systems Project) for the
health care providers to visit the villages every month. Follow-up of patients and the
community clinics are conducted in the village. The respective area Health Animator/s
and a doctor would be present during the visit; frequently the HG is also present.
In the other four areas, clinics are conducted every month at the area center by a doctor
from the hospital, the HA concerned and occasionally the HG. A Jeep is hired for the visit
to the area center, and the community members are informed about the clinic beforehand.
In case of difficulties in transportation of patients to the area center or hospital, the doctor
visits the patients at the doorstep.
The programme does not have its own transport facility. In case of emergencies the
transportation costs are reimbursed to the beneficiaries and also the 108 emergency
services started recently in the area are utilized to transports acutely ill patients to the
hospital.
3.7 Case-finding methods:
When the programme was started, a door to door survey was conducted with the help of
HG and the HA, to identify new cases. Currently many suspected cases are brought to the
attention of the health staff by HG in the village, the HA are now well trained in
diagnosing mental health cases which are confirmed by the doctors at the area center or
the hospital.
30
3.8 Monitoring
The entire three tiers are involved with the monitoring of the beneficiaries. The HG at the
village level monitors all the beneficiaries at their village. The HA monitors the
beneficiaries during their regular village visit and also keep in touch with the HG. The
GAH monitors all the areas through the HA and the HG.
3.9 Referral systems:
Supervised mental health care is available only at the Gudalur Adivasi Hospital; therefore
in case of an acute illness, the patients are referred to the GAH. If the condition does not
need immediate care, then the patient is referred to the area center on the day of doctors‟
visit. If transportation or referral to area center or Gudalur Adivasi Hospital is not
possible, then the doctor visits the patient at his or her house. In case a patient needs
immediate specialist care, then the patient is referred to a tertiary center which would be
about four to nine hours journey by road. The costs towards referrals are met by the
hospital.
3.10 Information systems:
Each patient‟s details when enrolled in the programme will be entered in a patient record.
Two sets of records are maintained, one set of records at the hospital and the other in the
area centers. These records are updated on a monthly basis.
Each family has a book in which all the health related details of the family are entered at
the time of consultation with the doctor or the HA and they are advised to bring the
family record on every visit.
31
3.11 Livelihood Programs:
There are several livelihood programmes initiated by ACCORD and ASHWINI such as
cattle distribution program, tea planting programmes, land redemption schemes, crop
loans, adivasi tea leaf marketing, adivasi credit funds, community fund, etc. These
programmes are for the community people in general and special attention is provided
particularly to the beneficiaries of the community mental health programme.
32
Chapter 4: Results
This chapter describes the outcomes of data analysis in concordance with the objectives.
Quantitative part of the study is presented first.
After scrutinizing and cleaning the entered data, they were analyzed using SPSS version
17. The data were analyzed for identifying the characteristics of the population and the
association between the independent and the outcome variables (awareness, early
detection and continuity of care). The results are organized first with description of
sample characteristics, distribution of awareness scores. Bivariate analysis and
multivariate model predicting better awareness regarding mental illness has been done.
Chapter also includes qualitative in-depth interviews with the stakeholders of the
community mental health programme, which were analyzed using qualitative methods.
4.1 Cross sectional survey:
Interview -schedule based cross sectional survey of the community members was
conducted in the intervention and control areas. Total of 240 participants were
approached. The non response rate in the intervention and control areas were 6.66% and
11.66% respectively.
33
4.1.1 Sample characteristics:
Table 4.1: Sample characteristics
Variable name Intervention N (%) Control N (%) Overall N (%)
No of participants 112 106 218
Age group
<=25
26-35
36-45
46-55
>55
22(19.6)
40(35.8)
25(22.3)
10(8.9)
15(13.4)
29(27.4)
33(31.0)
18(17.0)
15(14.2)
11(10.4)
51(23.4)
73(33.5)
43(19.7)
25(11.5)
26(11.9)
Mean age (SD) 37.88(13.8) 35.76(13.2) 36.5(13.6)
Sex
Male
Female
46(41.1)
66(58.9)
46(43.4)
60(56.6)
92(42.2)
126(57.8)
Marital status
Never married
Currently married
Separated
Widow/widower
2(1.8)
101(90.2)
1(0.9)
8(7.1)
16(15.1)
87(82.1)
0(0)
3(2.8)
18(8.3)
188(86.2)
1(0.5)
11(5.0)
Education
Never attended school
Up to 5th
Up to 10th
More than 10th
64(57.1)
28(25.0)
17(15.2)
3(2.7)
27(25.5)
40(37.8)
31(29.2)
8(7.5)
91(41.9)
68(31.1)
48(22.0)
11(5.0)
Tribes
Paniya
Kattunaicken
Bettakurumba
Mullukurumba
Irula
64(57.2)
14(12.5)
25(22.3)
9(8.0)
0(0)
0(0)
0(0)
5(4.7)
0(0)
101(95.3)
64(29.4)
14(6.4)
30(13.8)
9(4.1)
101(46.3)
34
4.1.2 Distribution of scores:
Table 4.2 Distribution of scores by other characteristics
Variable Mean SD Median Range P value
Area
Intervention
Control
5.13
1.57
2.27
2.82
5
2
10
13
<0.001
Age group
<=25
26-35
36-45
46-55
>55
3.04
3.56
3.98
2.80
3.23
3.02
3.22
3.05
3.30
3.07
4
4
5
4
4
12
12
13
10
10
0.50
Sex
Males
Females
3.12
3.60
3.26
3.02
4
4
13
12
0.27
Marital status
Never married
Currently married
Separated
Widowed/r
1.33
3.61
4
3
2.7
3.06
0
3.95
1
4.5
4
5
9
13
0
10
0.02
Education
Never attended school
Up to 5th
Up to 10th
More than 10th
4.02
3.09
2.73
3.00
2.90
3.08
3.44
3.28
5
3.5
3.5
4
10
12
13
9
0.08
Tribes
Paniya
Kattunaicken
Bettakurumba
Mullukurumba
Irula
4.98
5.50
4.40
6.00
1.56
2.53
1.99
2.43
1.22
2.88
5
6
5
7
2
10
7
9
3
13
<0.001
35
Figure 4.1: Bar plot – Mean awareness scores with standard deviation in
intervention and control areas.
36
4.1.3 Two-way ANOVA
Factorial (2-way) anova was done with awareness score as the outcome variable and
different combinations of predictor variables. The variable “intervention/ control” was
kept on one axis, with other predictors on the other axis, mainly to see if the effect of
intervention persisted even after adjusting for other variables.
Table 4.3 Factorial anova
Variable name Intervention Control P value
Mean SD Mean SD
Age group
<=25
26-35
36-45
46-55
>55
4.68
5.50
5.60
4.3
4.53
2.53
2.13
1.32
3.36
2.56
1.79
1.21
1.72
1.8
1.45
2.78
2.72
3.35
2.95
2.91
0.82
P value for intervention < 0.001
Variable name Intervention Control P value
Mean SD Mean SD
Sex
Males
Females
5.20
5.08
1.78
2.58
1.04
1.97
3.09
2.62
0.27
P value for intervention < 0.001
37
Variable name Intervention Control P value
Mean SD Mean SD
Marital status
Never married
Currently married
Separated
Widowed/r
4.91
5.29
5.47
6.33
2.49
1.99
1.97
1.15
1.93
1.55
1.23
1.75
2.74
2.77
3.14
2.91
0.26
P value for intervention <0.001
Variable name Intervention Control P value
Mean SD Mean SD
Education
Never attended school
Up to 5th
Up to 10th
More than 10th
4.91
5.29
5.47
6.33
2.49
1.99
1.97
1.15
1.93
1.55
1.23
1.75
2.74
2.77
3.14
2.91
0.92
P value for intervention <0.001
38
Variable name Intervention Control P value
Mean SD Mean SD
Tribes
Paniya
Kattunaicken
Bettakurumba
Mullukurumba
Irula
4.98
5.50
4.96
6.00
2.53
1.99
2.01
1.22
1.60
1.56
2.60
2.88
0.80
P value for intervention 0.009
39
4.1.4 Multivariate analysis:
Multiple linear regressions were done to build a predictor model for awareness using the
continuous and binary variables from the data using backward method. The predictor
variable tribe was not included in multivariate analysis as it cannot be clubbed into a
binary variable, and also because the control area constituted predominantly of Irula tribe
and a very small proportion of Bettakurumba tribe.
Table 4.4 Model summary
Model Variables R R2 Adjusted R
2 Std. error of
estimate
1 Age, sex, currently
married/currently unmarried,
not educated/educated,
intervention/control areas
0.584 0.341 0.326 2.570
2 Sex, currently
married/currently unmarried,
not educated/educated,
intervention/control areas
0.584 0.341 0.329 2.564
3 Sex, currently
married/currently unmarried,
intervention/control areas
0.584 0.341 0.331* 2.560
4 Currently married/currently
unmarried,
intervention/control areas
0.580 0.336 0.330 2.562
„* Selected as the final model.
40
Table 4.5 ANOVA table for the final model
Model Sum of Squares Df Mean Square F Sig
Regression 724.105 3 241.368 36.843 <0.001
Residual 1401.968 214 6.551
Total 2126.073 217
Table 4.6 Coefficients of the final model
Model Un standardized Coefficients t Sig
B Std. Error
(Constant) .493 .532 .927 .355
sex .425 .352 1.209 .228
Currently married / currently not
married 1.014 .507 1.999 .047
Intervention/Control 3.467 .349 9.922 <0.001
41
4.2 Secondary data
Secondary data were analyzed to answer some of the research questions
4.2.1 Early detection / Duration of untreated illness:
Table 4.7 Duration of untreated illness before detection in days.
Year N Mean SD Median Range P-value
2000-04 11 1497.91 1616.52 730 5415
<0.001
2005-06 51 1465.77 1446.82 730 6008
2007-08 29 506.93 850.73 120 2913
2009-10 31 148.87 220.09 45 728
2011 9 474.33 695.66 30 1823
All 131 876.46 11240.88 365 6020
4.2.2 Continuity of care / follow-up
Table 4.8 Follow-up of patients
Follow-up N(%)
Good (10-12 times a year) 69(77.5)
Satisfactory (7-9 times a year) 6(6.7)
Poor (0-6 times a year) 14(15.8) Irregular – 2(2.25)
Dropout – 9(10.15)
Migrated – 3(3.40)
Total 89(100)
42
4.3 Qualitative analysis
The in-depth interviews were conducted to assess some of the programme objectives.
Deductive method was used to analyze the qualitative data. All the data were coded
against the programme objectives and the coded data under each programme objective
were summarized.
4.3.1 Help community take responsibility for mentally ill patients:
Tribal people have always been taking care of the ill people in their community, taking
them to a temple or a mantravadi or other places and also support them at home. Hopes of
recovery from the illness tend to fade after several visits to different places and they begin
to accept that this illness or wrath cannot be cured which leads to neglecting the person
with mental illness but not to the extent of ill treating the person.
The fact that many people with similar illness have been cured and are back to their
regular activities, better awareness in the community has brought back the lost hope of
recovery from the illness. This has led to increased participation and responsibility by the
community in the recovery process of the mentally ill people.
“Even within family since they have seen people being cured, responsibility from their
side has increased as they know if medicines are given the person will become fine, so
they come to hospital or come to the area center so definitely there is an increase in the
participation of the family, but it’s not with all the families” [Health Animator]
43
4.3.2 Provide treatment close to home:
People were referred to a higher center such as medical colleges which were far off. Most
of the tribal people were not exposed to the outside world and would most often end up
not accessing health care. On several occasions health animators have accompanied the
beneficiaries to access health care at a referral center.
The geographical area, environmental conditions and little awareness about mental illness
were a hindrance at times to access health care.
The programme has ensured availability of treatment at doorstep by the presence of
health volunteers in the hamlet, health animator‟s regular visits to the hamlet, the doctor‟s
visit to the area centers and hamlets and the community owned hospital at Gudalur in case
of hospital admissions.
“Now we don’t refer people to Calicut or other place for treatment. And even if it’s still a
problem for people to collect medicines we go to their village every month and we give
the medicines. It’s our rule that even if a person with mental illness or TB don’t come to
us for medicines we have to go to them and give their medicines” [Health Animator]
4.3.3 Give economic support during hospitalization:
During the initial phases of the programme economic support such as transportation costs
and food at the hospital were provided to the beneficiaries and the bystanders as people
were not willing to come for the treatment. Over a period of time people have started
accessing the hospital for treatment and no extra support is provided for the beneficiaries.
Currently all the medicines provided at the village are free, a charge of Rs 10 is collected
at the area center and the hospital for whatever the medicines are prescribed to the
beneficiaries, all the hospital admissions are free, transportation costs in case of
44
emergency are reimbursed and in case of referral needing specialists care the costs are
borne by the hospital.
“They pay just Rs 10 for their medicines when they come to the hospital, any admission is
completely taken care of and they can stay as long as they want to, we don’t force them to
go back home. And even regarding the food we don’t force them to pay, it’s just how
much they can pay” [Programme implementer]
“When I was sent to Bangalore for a scan, our hospital took care of all the expenses”
[Beneficiary]
4.3.4 Rehabilitation where applicable:
During the preparatory phase for the community mental health programme it was decided
to plan for the rehabilitation after three years of implementing the programme, however it
was decided to start rehabilitation on an experimental basis by providing some of the
beneficiaries with some small activities of jobs. Thus no specific budget was included for
the rehabilitation.
Over few years of managing the programme some of the stakeholders have felt that the
best way of rehabilitation is to get the people back to what they were doing before which
is mostly manual labour for men and household work for women. Few of the
beneficiaries have been rehabilitated but mostly it is counseling the relatives and the
community members to take the beneficiaries for work. The programme implementers
feel that there is question of sustainability with a rehabilitation center and currently there
are no plans to start a center.
45
Of the patients enrolled in the programme about 74 % of the beneficiaries are functional,
going to work and earning a living, 20% are partially functional and 6% are not yet
functional.44
“There was a patient in Elumaram suffering from psychosis, he had stopped going to
work, after medication and he became a little better he dint find work then our Animators
went to the village and spoke to a person and told that this person in fine now and can
work and it will be very helpful for him, then he started working, after some time the
animators helped him to get a loan from government and now he has a small shop. Many
people who suffered from illness are going to estate work and some people are doing
house work.” [Health Animator]
“There was a carpenter whom we tried getting him back to work and we give him some
work to do, there was a guy who was literate and we have made him the village
librarian” [Programme implementer]
“They have given me a cow so I have a lot of work to do” [Beneficiary]
4.3.5 Other findings
The following findings are from the observations during the village visits and in-depth
interviews.
A person was identified during the village visit, with symptoms suggestive of psychiatric
illness for about a year, but was not referred or reviewed by a doctor. The THC had seen
this person wandering on the road several times but did not recognize these symptoms as
an illness thus did not inform the HA. Later on speaking to the THC, the awareness about
mental illness was found to be inadequate.
46
Some of the stakeholders said that not all the members of ACT had good awareness about
mental illness. If they are trained this would lead to early diagnosis of cases and better
functioning of the programme.
Less than half of the stakeholders said that they want to improve their counseling skills.
It was opined that some of the beneficiaries who are old, with severe mental illness are
not getting adequate nutrition due to various reasons. If programme can provide some
nutrition supplements, it would help such beneficiaries.
Majority of the stakeholders said that alcoholism is creating lot of problems among the
community members and this has adverse effects on the beneficiaries.
4.3.6 Strengths and bottlenecks in the programme
4.3.6.1 Strengths
● Community health programme is functioning for more than 20 years, making it
easy for implementation and functioning of the programme.
● Community is directly involved in all the stages of the programme, thus making it
acceptable and sustainable.
● Presence of health volunteers in the villages forming a link between the village
and the larger community.
● Programme coverage is extensive, covering almost all the villages.
4.3.6.2 Bottlenecks
● There is no systematic rehabilitation, thus the programme is not able to
rehabilitate all the needy people.
● Alcoholism is playing a spoilsport and the programme at the moment is not able to
address this issue.
47
4.4 Triangulation
Triangulation was done with quantitative data (crosse sectional survey and secondary
data) qualitative data (in-depth interview and field notes) for the first three programme
objectives (awareness, early detection and continuity of care).
4.4.1Awareness:
Both quantitative and qualitative components indicated good awareness in the community
about mental illness. Though the personal beliefs about the causes of mental illness has
not changed much, people are aware about the symptoms of mental illness and the need to
access health care for the same.
The awareness among the youth and people who have migrated was felt to be inadequate.
4.4.2 Early detection:
The stakeholders said that presence of health volunteers in the villages made a huge
difference in the early detection of cases; patients are being diagnosed much faster. Most
of the cases are being referred by the health animators and health volunteers and there is
an increase in relatives of the beneficiaries and the beneficiaries accessing the health care
directly.
4.4.3 Continuity of care:
All the beneficiaries interviewed said that the health animators visit them regularly and
they have not faced a situation where they needed the medicine and were not able to get
them.
48
Chapter 5 Discussion and conclusion
5.1 Discussion
5.1.1 Cross sectional survey
5.1.1.1 Sample characteristics:
We find that all the sample characteristics were comparable between the intervention and
control area except the education status and tribal groups, which were different from each
other. The education status was found to be higher in the control area. There were four
different tribal groups in the intervention area and two tribal groups in the control area.
5.1.1.2 Distribution of scores by other variables
The awareness score in the intervention area was found to be much higher than the
control area. The mean scores were 5.13 and 1.57and median of 5 and 2 in the
intervention and control areas respectively and it was statistically significant with p value
of <0.001.
The other variables which were found to have significant difference were marital status
and composition of tribal groups with a p value of 0.02 and <0.001 respectively. The
awareness scores were not significantly different from each other with respect to the
variables, age group, sex and education status.
5.1.1.3 Two way anova:
Analysis done using the factorial (2 way) anova showed that the awareness in the
intervention area was significantly higher than the control area when adjusted for age,
sex, marital status, education status and tribal groups. None of the predictor variables
were found to affect the scores, after adjusting for intervention. This indicates that only
49
the intervention by the Community Mental Health programme is the likely cause for
better awareness in the intervention area.
5.1.1.4 Multivariate analysis:
Multivariate analysis showed that the best model could explain 33.1 % of better
awareness in the intervention area when adjusted for variables, sex and marital status. The
variable “intervention / control” was found to be highly significant with a p value of
<0.001and currently married / currently not married was also found to be significant with
a p value of 0.047.
5.1.2 Secondary data analysis:
5.1.2.1 Early detection:
Studies have shown that there are better outcomes with early intervention on psychiatric
illness. 45, 46, 47
From the study we found that the mean and median duration of untreated
illness has been decreasing since the programme has started. This indicates that the cases
are diagnosed and the intervention starts early.
5.1.2.2 Continuity of care / follow-up
The programme has very good follow-up of beneficiaries, about 77.5 % of patients were
followed up for ten or more times in a year. Only 6.7 % of beneficiaries had satisfactory
follow-up of seven to nine times and 15.8% of the beneficiaries had poor follow-up of
zero to six times in a year. Out of the 15.8% poor follow-up beneficiaries, 2.25% were
irregular, 10.15% had dropped out of treatment due to various reasons and 3.4% of the
beneficiaries had migrated. Over all the follow-up of patients is very good in this
programme.
50
5.1.3 Qualitative analysis:
5.1.3.1 Help community take responsibility for mentally ill patients:
A definite change in attitude towards mental illness is seen since the programme has
started. People are having better awareness and have seen the improvements with
mentally ill people after medication; this has resulted in increased community
participation and responsibility in the care of the mentally ill people. Though this is not
the same with all the families, but community participation is slowly increasing in the
positive way.
5.1.3.2 Provide treatment close to home:
Even with the difficult terrain and natural conditions the programme has covered almost
all the tribal villages in the area. The three tier system and the dedicated members of the
programme with the help of the community have ensured availability of treatment at the
grass root level. Extra efforts are taken for people with mental illness and tuberculosis in
delivering services at the village level.
5.1.3.3 Give economic support during hospitalization:
The programme supported the beneficiaries and their bystanders to reduce the expenses
during any adverse events making it convenient for the beneficiaries and their families to
access health care. Currently the programme with the support of TNHSP and other
funding organizations is able to subsidize the costs of medicine, provide free hospital
admissions and referrals to the beneficiaries of the programme.
51
5.1.3.4 Rehabilitation where applicable:
On the rehabilitation front the programme has achieved what was planned for. Though
rehabilitation has not been done for all the beneficiaries, in situations where rehabilitation
was feasible the programme has addressed the issue. There is a question of acceptability
and sustainability of a rehabilitation center which needs to be studied further.
5.1.4 Triangulation
Through triangulation we found that the data from the quantitative and qualitative aspects
of the study are consistent with each other. It was also learnt from the qualitative data that
the youth in the community seen not to have good awareness about mental illness.
5.2 Strengths and limitations of the study
5.2.1 Strengths
● This is the first systematic study done at the end of six years of programme
implementation.
● Control area is being targeted for expansion of the programme and the findings
from this study will be utilized in the expansion phase.
5.2.2 Limitations of the study
● Secondary data has been used in the evaluation of the programme thus there is a
question of reliability of the data.
● Economic costing of the programme was not done.
● The study did not look at the outcomes of the beneficiaries.
52
5.3 Recommendations
This study was done to find whether the programme has been able to achieve its
objectives, to see if this model is feasible for replication and to give some suggestions.
The recommendations this study would like to make are as follows:
● Refresher training for HA, HG and doctors to improve the counseling skills.
● Train the THC and ACT about mental illness.
● Conduct more awareness programmes and specifically targeting the youth of the
community.
● Provide nutritional supplements to the needy beneficiaries.
● Expand the programme in control area.
5.4 Conclusions
The programme has been successful in integrating the community mental health
programme with the primary health care and has progressed to a desired level in
achieving the objectives set forth. This model is viable and can be replicated successfully
in comparable settings.
I
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III
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IV
44. Report - Association for Health Welfare In the Nilgiris. Addressing the hidden
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46. Saravanan B, Jacob KS, Johnson S, Prince M, Bhugra D, David AS. Outcome of
first-episode schizophrenia in India: longitudinal study of effect of insight and
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V
Appendix-I
Informed consent –Community members
I am Dr. Mahantu Yalsangi, a post graduate student in Public Health from Achutha Menon Centre
for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology,
Thiruvananthapuram. As part of my course, I am conducting a study titled “Evaluation of a
community mental health programme in a Tribal area – south India”, under the guidance of
Prof (Dr.) V.Raman Kutty. I want to study how the programme is running and specifically to
look whether the programme has been able to achieve what was planned before beginning of the
programme and to get your opinion about the mental illness and functioning of the programme. I
would like to ask you some questions related to this study which will take about 20 minutes.
There is no direct benefit for you from the study but your cooperation will help us assess and also
to improve the programme.
The information given by you will be used for research purposes only. It will not be disclosed to
anyone under any circumstances, anywhere, at any time and will be kept confidential. You are
free to withdraw from the interview at any point of time. Also you can refuse to answer any
question that you are not comfortable with. If you choose not to take part or to stop at any time, it
will not affect any of the services you are receiving.
If you have any queries or doubt please feel free to clarify those. I will answer your queries right
now or in future to the best of my abilities. My contact number is 9037137759/9626748741. In
case you need any clarifications about my credentials or the study you can contact Dr.
Ramankutty, Professor, AMCHSS (0471-2524240), SCTIMST, Thiruvananthapuram-695011. or
Dr. Anoop Kumar Thekkuveettil, Member-Secretary of the Institutional Ethical Committee at
SCTIMST, Thiruvananthapuram (0471-2348394).
Are you willing to take part in the study?
Yes No
If you are not willing to take part thank you for your time.
VI
Witness:
Dr Mahantu Yalsangi has explained all the details of the study and
Mr./Ms./Mrs._________________________________has expressed willingness to take part in
the study in my presence.
Signature of the witness: ______________________
Signature of the investigator: ________________________
Time: Date: Place:
VII
Appendix-II
Informed consent-In-depth interview
I am Dr. Mahantu Yalsangi, a post graduate student in Public Health from Achutha Menon Centre
for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology,
Thiruvananthapuram. As part of my course, I am conducting a study titled “Evaluation of a
community mental health programme in a Tribal area – south India”, under the guidance of
Prof (Dr.) V.Raman Kutty. I want to study the functioning of the programme and specifically to
look whether the programme has been able to achieve what was planned before beginning of the
programme and to get your ideas and suggestions towards the programme. I would like to ask you
some questions related to this study which will take about 1 hour.
There is no direct benefit for you from the study but your cooperation will help us assess and also
to improve the programme.
The information given by you will be used for research purposes only. It will not be disclosed to
anyone under any circumstances, anywhere, at any time and will be kept confidential. You are
free to withdraw from the interview at any point of time. Also you can refuse to answer any
question that you are not comfortable with. If you choose not to take part or to stop at any time, it
will not affect any of the services you are receiving.
If you have any queries or doubt please feel free to clarify those. I will answer your queries right
now or in future to the best of my abilities. My contact number is 9037137759/9626748741. In
case you need any clarifications about my credentials or the study you can contact Dr.
Ramankutty, Professor, AMCHSS (0471-2524240), SCTIMST, Thiruvananthapuram-695011. or
Dr. Anoop Kumar Thekkuveettil, Member-Secretary of the Institutional Ethical Committee at
SCTIMST, Thiruvananthapuram (0471-2348394).
Are you willing to take part in the study?
Yes No
If you are not willing to take part thank you for your time.
VIII
Informed Consent
I, ..................................................................................................... have been explained the
details of the study and I understand the purpose of the study. By signing/giving thumb
impression on this form I give my free and informed consent to participate in this study.
.............................................
......
..............................................
.......
.............................................
......
Signature/thumb
impression of the
participant
Name Date
IX
Appendix-III
Interview schedule
1. Id No: 2. Date:
3. Name: 4. Age:
5. Sex: 6. Tribe: 7. Village:
8. Marital status:
Never married Married Separated Widowed/r
9. Education:
Never attended school Up to 5th
standard
Up to 10th
standard More than 10th
standard
10. A person is talking to himself very often and simply runs away into the forest.
a. This person is suffering from mental illness.
Agree Unsure/Don‟t know Disagree
11. A person is not going to work from past two months, sitting at home, is very sad, and is
not talking to anyone.
a. This person is suffering from mental illness.
Agree Unsure/Don‟t know Disagree
12. A person is excessively suspicious of people around him, even with his family members.
a. This person is suffering from mental illness.
Agree Unsure/Don‟t know Disagree
13. A person has told people that she wants to die and she is having suicidal thoughts from
past two months.
a. This person is suffering from mental illness
Agree Unsure/Don‟t know Disagree
14. Going only to a mantravadi is sufficient to treat mental illness.
Agree Unsure/Don‟t know Disagree
2 3 4 1
1 2
3 4
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
X
15. A person who is treated for mental illness can lead a normal life.
Agree Unsure/Don‟t know Disagree
16. Mental illness can be cured with English medicines.
Agree Unsure/Don‟t know Disagree
17. Mental illness is a punishment by god for doing some bad things.
Agree Unsure/Don‟t know Disagree
18. Performing black magic on a person can cause mental illness.
Agree Unsure/Don‟t know Disagree
1 2 3
1 2 3
1 2 3
1 2 3
XI
Appendix-IV
Interview guidelines – Beneficiary
1. Id No: ____________ Date of Interview:________________
2. Name of the Informant:____________________ Age of the informant:_______
3. Sex: ______ Tribe:______ Village:________________________________
4. Marital status:
a. Never married b. Married c. Separated d. Widowed/r
5. Education:
a. Never attended school b. Up to 5th
standard
c. Up to 10th
standard d. More than 10th
standard
Detailed description of events from the beginning of illness till now.
Can you briefly tell me about how your illness started? What treatment did you take? What
treatment are you taking now? How are you feeling now?
What sort of work were you doing before you fell ill? Are you going to work now? If yes what
sort of work? Did anyone support or help you to get back to your work/find employment.
During the course of treatment did you take medicines regularly? Did people remind you about
taking medication? Who helped you when you were ill? Did anybody other than your family help
you in any way during your illness? If yes how?
What did you do when your medicines were over? Do you go to the area centre or hospital or any
other place to get a check up or did health staff come to your village to see you? Were there any
period when you wanted to take medication but could not? If so what are the reasons?
Are there any concession or benefits you received from the organization? If yes can you give
details?
Are you happy with the treatment and services that you are receiving or received?
I am specifically looking at ways to improve the programme. If you can discuss certain problems
in the programme that you may or may not have faced and how we can improve it, we can make
the programme better.
XII
Appendix-V
Interview guidelines – Health Guide
1. Id No: ____________ Date of Interview:________________
2. Name of the Informant:_____________________Age of the informant:_______
3. Sex: ______ Tribe:______ Village:________________________________
4. Education:
a. Never attended school b. Up to 5th
standard
c. Up to 10th
standard d. More than 10th
standard
How long have you been a health volunteer and involved in the community mental health
programme?
Please tell me briefly about your activities in community mental health programme.
Are there any differences that you have seen among the people‟s attitude towards mental illness
and mentally ill people since you have started work here till now? If so what are the differences?
What does the community think are the causes of mental illness? Do you see any change in
people‟s ideas about these causes over the past few years? What are the changes that you see?
Are the community / relatives taking up responsibility of caring for the mentally ill patients? Was
the situation any different few years ago?
What are the kinds of problems that you think the mentally ill or the community people face?
One of the major problems in treatment of mental illness is drop out /discontinuation of treatment.
Has the programme addressed this issue? If yes how? Do you see any change now? If yes what
are the changes?
Another major issue is non availability of treatment at a nearby place or people have to travel a
long distance to access treatment. Do you see any problems as these in your community? What do
you think the programme has been able to do on this front?
Do you get any support in your activities? Who all support you?
Has the beneficiary or family of the beneficiary received any sort of benefit? Has the programme
helped them reduce their expenses in any way?
It may be difficult for mentally ill patients to earn a living or become part of society. Has there
been any attempt to rehabilitate them? If yes who initiated the rehabilitation? Can you give some
examples?
I am specifically looking at ways to improve the programme. Based on your experience of the
programme, have you attempted to resolve some of the problems faced? If so, how did you do
this? Are there any suggestions or ideas that you would like to bring out to improve the
programme? If yes what are they?
XIII
Appendix-VI
Interview guidelines – Health Animator 1. Id No: ____________ Date of Interview:________________
2. Name of the Informant:________________Age of the informant:_______
3. Sex: ______Tribe:______ Village/Area:________________________________
4. Education:
a. Never attended school b. Up to 5th
standard
c. Up to 10th
standard d. More than 10th
standard
How long have you been working as a Health worker.
Please tell me briefly about your activities in community mental health programme.
Are there any differences that you have seen among the people‟s attitude towards mental illness
and mentally ill people since you have started work here till now? If so what are the differences?
What does the community think are the causes of mental illness? Do you see any change over the
past few years? What are the changes that you see?
Are the community / relatives taking up responsibility of caring for the mentally ill patients? Was
the situation any different few years ago?
What are the kinds of problems that you think the mentally ill are facing?
One of the major problems in treatment of mental illness is drop out /discontinuation of treatment.
Has the programme addressed this issue? If yes how? Do you see any change now? If yes what
are the changes?
Another major issue is non availability of treatment at a nearby place or people have to travel a
long distance to access treatment. Do you see any problems as these in your community? What do
you think the programme has been able to do on this front?
Do you get any support in your activities? Who all support you?
Has the beneficiary or family of the beneficiary received any sort of benefit? Has the programme
helped them reduce their expenses in any way?
It may be difficult for mentally ill patients to earn a living or become part of society. Has there
been any attempt to rehabilitate them? If yes who initiated the rehabilitation? Can you give some
examples?
I am specifically looking at ways to improve the programme. Based on your experience of the
programme, have you attempted to resolve some of the problems faced? If so, how did you do
this? Are here any suggestions or ideas that you would like to bring out to improve the
programme? If yes what are they?
XIV
Appendix-VI
Interview guidelines – Programme implementers
1. Id No: ____________ Date of Interview:________________
2. Name of the Informant:_____________________Age of the informant:_______
3. Sex: ______
When was the community mental health programme started? What were the reasons to start the
programme?
What were the difficulties that you faced during the Implementation of the programme? How did
you overcome them?
What were the strengths or advantages for the implementation of the programme?
What is your opinion on the awareness level of mental illness in the community? Is there a change
since the programme has started? What are the changes that you see?
Do you see an increase in people accessing mental health care?
Is there an increase in the referrals? Are these referrals being made by the health volunteers and
the health workers? Are people accessing the hospital without any referral?
Are there any concession or benefits that are being provided to the beneficiaries? What are they?
How does the programme address rehabilitation of the beneficiaries?
If you had to start the community mental health programme all over again. What would you do
differently?
Are there any specific factors that have helped in the implementation of the programme? Will the
same factors work anywhere else? If not what is different?
Are there any specific future plans regarding the community mental health programme? If yes
what are they?
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