Non-disclosure of widowhood in Nepal: Implications for women and their children

Guardians Looking From Outside: Gendered Experiences of Labor Migration and Psychosocial Health Among Nepalese Migrant Fathers and Left-Behind Mothers

Nepalese migrant workers are at heightened risk of adverse mental health problems. However, the social mechanisms by which experiences of labor migration create such vulnerabilities are not well understood. Moreover, limited attention has been paid to the experiences of left-behind spouses. This study explores how migrant fathers and left-behind mothers experience labor migration and how migration affects mental health across migrant household members, paying special attention to the role of gender. We conducted 29 in-depth interviews with Nepalese migrant fathers (N = 18) in South Korea and left-behind mothers (N = 11) in Nepal. Labor migration imposes substantial stress on the entire family. Migrant fathers discussed their feelings of guilt and worry regarding their relationships with their children due to physical and emotional distance. Left-behind mothers indicated loneliness and caregiver stress due to additional responsibilities as a single parent. Migrant fathers reported that they felt respected by their communities for their work, while left-behind mothers felt heavily scrutinized. Our findings highlight how labor migration reinforces gender inequalities in domestic responsibilities and norms regarding the expected roles of migrating men and left-behind women. These findings suggest that psychosocial services must be tailored to the unique needs of migrant workers and left-behind families.

Understanding Nepali widows' experiences for the adaptation of an instrument to assess Prolonged Grief Disorder

The experience of grief varies across different cultures and contexts. Women in Nepal who lose their husbands confront discrimination, social isolation, and abuse that influence their experience of grief. Through eight focus group discussions with Nepali widows, we elicited socially sanctioned grief reactions and local idioms used to describe common cognitive, behavioral, and emotional symptoms of grief. Accordingly, modifications to an existing instrument for Prolonged Grief Disorder, the PG-13, are suggested to capture grief symptoms as experienced by Nepali widows. Items in the PG-13 were translated to colloquial Nepali and adapted to maintain comprehensibility, acceptability, relevance, and completeness. Based on the grief-related issues reported in the focus group discussions, the addition of five new items and a new criterion to capture symptoms related to social discrimination are proposed. Widows perceived elevated symptoms one year after the loss to be problematic. It is thus recommended that the duration criterion in the original PG-13 be adjusted from at least six months to at least one year after the loss. These proposed modifications to the instrument should be validated through future psychometric testing.

Social determinants of impaired functioning among Nepali widows: A mixed methods study

Despite considerable stigmatisation of widows in Nepal, little is known about factors affecting their ability to function in society. Using mixed methods, we studied psychosocial factors associated with impaired functioning among Nepali widows. For the qualitative analysis, we analysed 3 focus groups, 25 in-depth interviews, and 12 key-informant interviews. The quantitative analysis was based on data from 204 widows. Odds ratios were calculated linking psychosocial exposures to impaired functioning using adjusted logistic regression models. Low social support (aOR = 2.35, 95% CI: 1.2, 4.6, generally; aOR = 3.3, 95% CI: 1.7, 6.42, specifically from family members), experiences of discrimination (aOR = 2.97, 95% CI: 1.43, 6.14), and low life control (aOR = 4.3, 95% CI: 1.86, 10.1) were risk factors for impaired functioning. Qualitative findings suggested how discrimination and lack of control contribute to impaired functioning. Support from the husband's family appeared to be more important to a widow's functioning, compared to from her own parents. Knowledge about risk factors for impaired functioning can help inform interventions for Nepali widows.

Young Single Widow, Dynamics of In-Laws Interference and Coping Mechanisms: Simplicity-Parsimony Approach

The incidence of short marital duration due to the demise of a husband that often exposes young widows to in-laws' exploitation of the asset of the deceased spouses, without regard for negative health consequences and potential vulnerability to poverty has not been exhaustively investigated, especially in sub-Saharan Africa where 16% of adult women are widows. The study examined the coping mechanisms among the young widow (aged ≤ 40) who have experienced short conjugal relationships (≤5 years) and burdensome from in-laws. The research design followed a qualitative approach with the aid of semi-structured in-depth interviews among 13 young widows selected through snowballing and informant-led approaches in the purposively selected communities. Data collected were analysed using descriptive statistics and a thematic approach. The findings, among others, shows the median age of young widow as 29 years. All participants, except one, have faced exploitation from their in-laws over their husbands' assets. All the participants desired to re-marry in order to: have a father figure for their children, have their own children or have more children. There is an absence of government support, but a few have received support from religious organisations. The author proposed attitudinal-change campaigns targeting the in-laws through accessible media and legislature that could challenge the exploitation of widows and unhealthy widowhood rites.

Feasibility of implementing a culturally adapted Prolonged Grief Disorder scale in the mental healthcare system in Nepal

BACKGROUND

Nepali widows have a high prevalence of mental disorders, including prolonged grief disorder (PGD). Despite the considerable needs that Nepali widows have for mental health services, resources for mental health in Nepal are limited, amplifying the importance of accurate screening and diagnosis. The objective of this study was to explore the feasibility of implementing a culturally adapted Prolonged Grief Scale (PG-12/17-N) and provide actionable recommendations for its implementation.

METHODS

Twenty-five mental health service providers in Kathmandu and Chitwan, Nepal were interviewed using a semi-structured guide based on selected constructs from the Consolidated Framework for Implementation Research. Qualitative data were inductively and deductively coded and analyzed to identify prominent themes.

RESULTS

Providers reported that the main advantages of the scale were the need to identify widows at risk, cultural relevance, easy language, and inclusion of detailed and specific symptoms. Perceived weaknesses included the complexity in response options and scoring, length, item redundancy, overlap with depression symptoms, and lack of somatic symptoms. Providers discussed the need for training, supervision, and a referral and detection system required to implement the scale in Nepal. Further development of a brief version of the scale as a routine screener may facilitate detection and referral to care.

CONCLUSION

Based on the results showing need to address PGD in Nepali widows, further efforts are needed to increase awareness about PGD and develop evidence-supported treatments for PGD, after which screening could be made routine for widows.

Suicidal ideation among Nepali widows: an exploratory study of risk factors and comorbid psychosocial problems

PURPOSE

Suicide is a leading cause of death among Nepali women of reproductive age. Suicidal ideation has known associations with stressful life events, which Nepali widows disproportionately experience. We aimed to identify risk and protective factors that could lead to effective interventions for this population.

METHODS

To study suicidal ideation in Nepali widows, we collected data from 204 women in urban, semi-urban, and rural areas whose husbands died at least one year prior. The questionnaire included sociodemographic information, the Hopkins Symptom Checklist-25, PTSD Checklist-Civilian Version, Somatic Symptom Scale-8, and the Multidimensional Scale of Perceived Social Support. Overall severity of prolonged grief was assessed by a counselor after completing a structured clinical interview. Using multivariate regression models, we assessed associations of sociodemographic and psychosocial indicators with past-year suicidal ideation. Latent profile analysis was also performed to estimate profiles of comorbidities.

RESULTS

Past-year suicidality was high, with 16.2% (N = 33). Each year increase since husband's death was protective and reduced odds of ideation 8% (95% CI 0.85-0.98) and being educated and of older age also reduced the odds of ideation by 0.21 (95% CI 0.06-0.70), and 0.09 (95% CI 0.01-0.64), respectively. Depression (OR = 6.37, 95% CI 2.78-14.59), PTSD (OR = 3.84, 95% CI 2.15-6.86), prolonged grief (OR = 6.04, 95% CI 3.04-12.00) and anxiety (OR = 6.52, 95% CI 2.96-14.38) were highly associated with suicidality, and mapped onto the three profiles of increasing mental distress severity.

CONCLUSION

Suicide remains a major issue among Nepali widows, showing high comorbidity with other mental disorders. Screening for depression, anxiety, and prolonged grief, may aid in identifying widows at increased risk of suicidal ideation.

Resilience Among Nepali Widows After the Death of a Spouse: "That Was My Past and Now I Have to See My Present"

Responses to the death of a spouse vary; although some are at increased risk of poorer physical and mental health outcomes, others have more resilient responses. In light of the limited scope of research on widows' experiences in Nepal, a setting where widows are often marginalized, we explore themes of resilience in Nepali widows' lives. Drawing from a larger qualitative study of grief and widowhood, a thematic narrative analysis was performed on narratives from four widows that reflected resilient outcomes. Individual assets and social resources contributed to these widows' resilient outcomes. Forgetting, acceptance, and moving forward were complemented by confidence and strength. Social support and social participation were key to widows' resilient outcomes. These four narratives reflect the sociocultural context that shape widows' resilient outcomes in Nepal. Future studies on the emergent themes from this exploratory study will help identify how best to encourage resilient outcomes among widows.

Persistent Complex Bereavement Disorder and Culture: Early and Prolonged Grief in Nepali Widows

OBJECTIVE

Persistent complex bereavement disorder (PCBD) in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), has not been well studied in socioculturally diverse populations. Thus, this qualitative study examined (a) how widows in Nepal understand grief, (b) whether a local construct of PCBD exists, and (c) its comparability with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), terminology.

METHODS

Using an adapted Explanatory Model Interview Catalogue (EMIC) framework, semistructured interviews with 25 widows and 12 key informants, as well as three focus-group discussions (n = 20), were conducted between October 2014 and April 2015. Through an inductive grounded theory-based approach, we used the constant comparative method, iteratively coding transcripts to identify themes and patterns in the data. Also, we created two lists of grief responses, one of early reactions and another all reactions to grief, based on the frequency of mention.

RESULTS

No single term for grief was reported. Widows reported a local construct of PCBD, which was broadly compatible with DSM-5 terminology but with important variation reflecting societal influence. Surviving torture during conflict, economic and family stressors, and discrimination were mentioned as important determinants that prolong and complicate grief. Suicidal ideation was common, with about 31% and 62% of widows reporting past-year and lifetime suicidality, respectively. Findings may not be generalizable to all Nepali widows; participants were recruited from a non-governmental organization, from Kathmandu and its neighboring districts, and were primarily of reproductive age.

CONCLUSIONS

While PCBD symptoms proposed in DSM-5 were mentioned as relevant by study participants, some components may need adaptation for use in non-Western settings, such as Nepal.