In search of 'community': a critical review of community mental health services for women in African settings

Psychiatric Experiments with "Community" Under Dictatorship and Authoritarianism: The Case of the Protected Commune Experience, 1980-1989

In Chile, a long and oppressive military regime (1973-1990) dismantled emergent initiatives for the deinstitutionalisation of psychiatric care, imposing a neoliberal constitution that opened public services to market forces and limited the state's role in health and social care. After being associated with communism and socialism, community-based mental health work was banned, and socialist psychiatrists were silenced through torture or exile. However, some therapeutic initiatives persisted, such as the "Protected Commune" (PC) initiative within the El Peral psychiatric asylum. The PC attempted to mimic a real town inside the asylum's gated perimeter. It featured an ecumenical chapel, a school, and various "council" departments like recreation, education, waste, economy, and health. Paths received names, wards became districts, and patients and workers were assigned new, democratic roles, all while the authoritarian regime entirely controlled the "outside" world. The initiative ceased with the return of democracy in 1990. Deemed an eccentric and negligible episode, the PC is often seen as an interruption to the radical community-based experiences of the pre-dictatorial era. Drawing on archival research and oral history interviews with participants, this paper examines how the PC harnessed the notion of community to navigate the complex socio-political landscape of the dictatorship. Differing from established accounts of the political uses of psychiatry under authoritarianism, the study positions the PC as a prism for understanding the contradictory ways in which the idea of 'community' has been able to transcend radically opposed social and political regimes, becoming a core feature in the vocabulary of mental health reform, despite its ambiguities.

Misunderstood and underappreciated: a critical review of mental health advocacy and activism in low- and middle-income countries

Mental health advocacy and activism have been highlighted as important in the effort towards creating environments for better mental health. However, relevant research in low- and middle-income country settings remains limited and lacks critical exploration. We seek to contribute to filling this gap by exploring driving factors behind mental health advocacy and activism efforts in low- and middle-income country settings. This review uses a critically informed thematic analysis employing conceptual frameworks of productive power to analyse peer-reviewed articles on mental health advocacy or activism over the last 20 years. We suggest that the current body of research is marred by superficial explorations of activism and advocacy, partly due to a lack of cohesion around definitions. Based on our findings, we suggest a conceptual framework to guide deeper explorations of mental health advocacy and activism. This framework identifies 'legitimacy', 'context' and 'timing' as the main dimensions to consider in understanding activism and advocacy efforts. The fact that they remain misunderstood and underappreciated creates missed opportunities for meaningful inclusion of lived experience in policy decisions and limits our understanding of how communities envision and enact change.

Inverting the deficit model in global mental health: An examination of strengths and assets of community mental health care in Ghana, India, Occupied Palestinian territories, and South Africa

Global mental health [GMH] scholarship and practice has typically focused on the unmet needs and barriers to mental health in communities, developing biomedical and psychosocial interventions for integration into formal health care platforms in response. In this article, we analyse four diverse settings to disrupt the emphasises on health system weaknesses, treatment gaps and barriers which can perpetuate harmful hierarchies and colonial and medical assumptions, or a 'deficit model'. We draw on the experiential knowledge of community mental health practitioners and researchers working in Ghana, India, the Occupied Palestinian Territory and South Africa to describe key assets existing in 'informal' community mental health care systems and how these are shaped by socio-political contexts. These qualitative case studies emerged from an online mutual learning process convened between 39 academic and community-based collaborators working in 24 countries who interrogated key tenets to inform a social paradigm for global mental health. Bringing together diverse expertise gained from professional practice and research, our sub-group explored the role of Community Mental Health Systems in GMH through comparative country case studies describing the features of community care beyond the health and social care system. We found that the socio-political health determinants of global economic structures in all four countries exert significant influence on local community health systems. We identified that key assets across sites included: family and community care, and support from non-profit organisations and religious and faith-based organisations. Strengthening community assets may promote reciprocal relationships between the formal and informal sectors, providing resources for support and training for communities while communities collaborate in the design and delivery of interventions rooted in localised expertise. This paper highlights the value of informal care, the unique social structures of each local context, and resources within local communities as key existing assets for mental health.

The impact of community engagement as a public health intervention to support the mental well-being of single mothers and children living under housing insecure conditions - a rapid literature review

BACKGROUND

In the UK, the population of homelessness and housing insecurity is increasing among families headed by mothers. The unique stressors of housing insecurity and living in accommodations ill-suited to long-term dwellings increase mental distress for mothers and children. Community engagement interventions present a public health opportunity to alleviate adverse outcomes for vulnerable families.

AIM

To synthesise and evaluate evidence of the impact of community engagement interventions in supporting the mental well-being of mothers and children living under housing insecure conditions. To synthesise the components of community engagement interventions as a public health intervention in alleviating mental well-being and non-health outcomes of mothers and children living under housing insecurity.

METHODS

A systematic search of five online bibliographic databases (MEDLINE, EMBASE, PsychINFO, Global Health and Child Development & Adolescent Studies) and grey literature (Carrot2) was conducted in May 2022. Primary studies with community engagement components and housing-insecure single-mother families were included. Intervention data was extracted using the TIDieR checklist and a community engagement keywording tool. The studies' quality was critically appraised using the MetaQAT framework.

RESULTS

Ten studies meeting inclusion criteria were identified, across two countries (USA & UK). Data from the studies reported positive significant effects for health and personal maternal outcomes in addition to higher positive effects for child health outcomes (e.g., decrease in depression symptoms). Interventions targeting social support and self-efficacy demonstrated potential to improve maternal and child outcomes via the maternal-child relationship. Community engagement at the design, delivery and evaluation intervention stages increased the level of community engagement, however there were tentative links to directly improving mental well-being outcomes.

CONCLUSION

There is evidence to suggest that community engagement may be applied as an effective intervention in supporting the mental well-being of mothers and children living under housing insecurity. Proposed intervention effectiveness may be achieved via psychosocial pathways such as improved maternal self-efficacy and social support. However, more embedded long-term process evaluations of these interventions are needed to establish maintenance of these observed benefits and to understand to what extent the findings apply to the UK context.

The double-edged sword of 'community' in community-based psychosocial care: reflections on task-shifting in rural Nepal

Research in the field of Global Mental Health has stoked hopes that 'task-shifting' to community workers can help fill treatment gaps in low-resource settings. The fact that community workers inhabit the same local moral worlds as their clients is widely framed as a boon, with little consideration of the social and ethical dilemmas this might create in the care of chronic, stigmatized conditions. Drawing on 14 months of ethnographic research focused on psychosocial interventions in Nepal, this paper traces how the multiple roles community workers occupied with respect to their clients - clinician, neighbour, and at times kin - came to bear on the care they provided. In-depth case studies are used to explore two divergent logics of care informing Nepali community workers' practice. While formal psychosocial care guidelines emphasized clients' autonomy, calling for non-judgmental and non-directive forms of emotional support, everyday efforts to 'convince' neighbours and relatives in distress often involved directive guidance oriented toward the restoration of moral personhood and social relations. These approaches could be mutually supportive, but tensions arose when community workers invoked moral standards linked with mental health stigma. This analysis highlights the challenge of mobilizing communities' strengths and resources without inadvertently reproducing their exclusions. It suggests the deployment of community workers to address psychosocial care gaps may entail not only leveraging existing relationships within communities, but also reconfiguring the very terms of relatedness.

Whose knowledge counts? Involving communities in intervention and trial design using community conversations

BACKGROUND

Current debates in Global Health call for expanding methodologies to allow typically silenced voices to contribute to processes of knowledge production and intervention design. Within trial research, this has typically involved small-scale qualitative work, with limited opportunities for citizens to contribute to the structure and nature of the trial. This paper reports on efforts to move past typical formative trial work, through adaptation of community conversations (CCs) methodology, an action-oriented approach that engages large numbers of community members in dialogue. We applied the CC method to explore community perspectives about pneumonia and managing the health of children under-5 in Northern Nigeria to inform our pragmatic cluster randomised controlled trial evaluating a complex intervention to reduce under-5 mortality in Nigeria.

METHODS

We conducted 12 rounds of community conversations with a total of 320 participants, in six administrative wards in Kiyawa Local Government Area, Jigawa state, our intervention site. Participants were male and female caregivers of children under five. Conversations were structured around participatory learning and action activities, using drawings and discussion to reduce barriers to entry. During activities participants were placed in subgroups: younger women (18-30 years of age), older women (31-49 years) and men (18 years above). Discussions were conducted over three 2-h sessions, facilitated by community researchers. Following an initial analysis to extract priority issues and perspectives on intervention structure, smaller focus group discussions were completed with participants in five new sites to ensure all 11 administrative wards in our study site contributed to the design.

RESULTS

We identified enabling and limiting factors which could shape the future trial implementation, including complex power relationships within households and wider communities shaping women's health decision-making, and the gendered use of space. We also noted the positive engagement of participants during the CC process, with many participants valuing the opportunity to express themselves in ways they have not been able to in the past.

CONCLUSIONS

CCs provide a structured approach to deep meaningful engagement of everyday citizens in intervention and trial designs, but require appropriate resources, and commitment to qualitative research in trials.

TRIAL REGISTRATION

ISRCTN39213655. Registered on 11 December 2019.

Gender, mental health and resilience in armed conflict: listening to life stories of internally displaced women in Colombia

For over 60 years, Colombia has endured violent civil conflict forcibly displacing more than 8 million people. Recent efforts have begun to explore mental health consequences of these contexts, with an emphasis on national surveys. To date few Colombian studies explore mental health and well-being from a lived experience perspective. Those that do, overlook processes that enable survival. In response to this gap, we conducted a life history study of seven internally displaced Colombian women in the Cundinamarca department, analysing 18 interview sessions and 36 hours of transcripts. A thematic network analysis, informed by Latin-American perspectives on gender and critical resilience frameworks, explored women’s coping strategies in response to conflict-driven hardships related to mental well-being. Analysis illuminated that: (1) the gendered impacts of the armed conflict on women’s emotional well-being work through exacerbating historical gendered violence and inequality, intensifying existing emotional health challenges, and (2) coping strategies reflect women’s ability to mobilise cognitive, bodied, social, material and symbolic power and resources. Our findings highlight that the sociopolitical contexts of women’s lives are inseparable from their efforts to achieve mental well-being, and the value of deep narrative and historical work to capturing the complexity of women’s experiences within conflict settings. We suggest the importance of social interventions to support the mental health of women in conflict settings, in order to centre the social and political contexts faced by such marginalised groups within efforts to improve mental health.