An asymmetric burden: Experiences of men and women as caregivers of people with psycho-social disabilities in rural North India

Separate and combined associations of cognitive impairment and body pain with functional and mobility disabilities among older women and men in India

This study examined the separate and combined associations of cognitive impairment and body pain with functional and mobility disabilities (FMDs) among older women and men in India. Multivariable linear regression models were applied using data from the Longitudinal Aging Study in India (2017-18) comprising 31,464 adults aged 60+. Older adults with cognitive impairment and pain reported higher levels of FMDs than peers without any pain and cognitive impairment. The likelihood of FMDs was significantly greater among older Indians enduring both cognitive impairment and pain (p < 0.05). Moreover, the association between cognitive impairment and functional disability was noticeably stronger in older women, particularly those with frequent pain, while the link between cognitive impairment and mobility disability was more pronounced in men with pain. Integrated cognitive rehabilitation and pain management programs, along with guided physical therapy, gender-specific support groups, and community-based health promotion activities, should be considered to reduce FMDs in older Indians.

The Burden and Psychological Distress of Family Caregivers of Individuals with Autism Spectrum Disorder: A Gender Approach

Background/Objectives: Relatives play the main role as caregivers of autism spectrum disorder (ASD) individuals. Women, specifically mothers, are the majority of caregivers of ASD relatives. In addition, the literature on caregivers has shown that women have worse mental health and higher perceived burdens than men. Therefore, the aim of this work was to evaluate the relationships between psychological distress and burden using a gender approach in caregivers of ASD relatives. Methods: A cross-sectional design was applied in this study with a convenience sample of 250 caregivers of ASD relatives. Most of them were mothers caring for a child who ranged in age from 1 to 31 years. Sociodemographic variables considered were age, education level, marital status, and relation to the care recipient. Additionally, psychological distress and objective burden, in the form of hours/day caring, and subjective burden, in the form of perceived burden, were analyzed. Results: Significant gender differences were found in psychological distress and objective and subjective burden, with women showing higher scores than men. Both types of burden played a serial mediating role between gender and psychological distress. Conclusions: The results highlight the important role of gender, with women bearing the high cost of caring for their children with ASD in the form of high objective burden, caring for more hours, and subjective burden, perceiving more burden and showing poorer mental health than men. These results show the need for specific support and intervention programs targeted to women caregivers to reduce burden and improve their mental health.

Positive Emotions in Family Caregivers of Alzheimer's Disease Patients: Factors Associated with Gain in Caregiving from a Gender Perspective

Background/Objectives: Gender differences in the variables of burden, anxiety, depression, and others associated with psychological distress have been found in studies on caregivers caring for a dependent relative, but a gender perspective is seldom used when analysing the positive aspects of caregiving. This study contributes to filling this gap by analysing gender differences in caregivers in a specific positive variable: gain. Methods: A cross-sectional design was used in a sample of 44 male and 96 female caregivers from Family Alzheimer Associations. Gender differences were analysed in demographic and psychological variables associated with the caregiving situation. Results: Female caregivers showed higher psychological distress than male caregivers, but gender differences in gain were only obvious when a deeper analysis of the GAIN scale responses was performed. The mediational role of psychological distress and other predictive variables showed a different pattern in male and female caregivers. The important predictive and mediating role that psychological distress plays in the greater perception of gains in caregiving and the result showing that female caregivers are the ones with poorer mental health support the need for preventive and therapeutic programs specifically targeting the positive aspects of caregiving in female caregivers. Conclusions: Three aspects could be highlighted in this study: family caregivers of AD patients perceived gain in the caregiving situation; gender plays a differential role in the perception of gain; and, finally, psychological distress should be the target when interventions are planned, not only to alleviate negative aspects but also to increase the positive aspects of caregiving.

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.

Opening up the 'black-box': what strategies do community mental health workers use to address the social dimensions of mental health?

PURPOSE

Community-based workers promote mental health in communities. Recent literature has called for more attention to the ways they operate and the strategies used. For example, how do they translate biomedical concepts into frameworks that are acceptable and accessible to communities? How do micro-innovations lead to positive mental health outcomes, including social inclusion and recovery? The aim of this study was to examine the types of skills and strategies to address social dimensions of mental health used by community health workers (CHWs) working together with people with psychosocial disability (PPSD) in urban north India.

METHODS

We interviewed CHWs (n = 46) about their registered PPSD who were randomly selected from 1000 people registered with a local non-profit community mental health provider. Notes taken during interviews were cross-checked with audio recordings and coded and analyzed thematically.

RESULTS

CHWs displayed social, cultural, and psychological skills in forming trusting relationships and in-depth knowledge of the context of their client's lives and family dynamics. They used this information to analyze political, social, and economic factors influencing mental health for the client and their family members. The diverse range of analysis and intervention skills of community health workers built on contextual knowledge to implement micro-innovations in a be-spoke way, applying these to the local ecology of people with psychosocial disabilities (PPSD). These approaches contributed to addressing the social and structural determinants that shaped the mental health of PPSD.

CONCLUSION

Community health workers (CHWs) in this study addressed social aspects of mental health, individually, and by engaging with wider structural factors. The micro-innovations of CHWs are dependent on non-linear elements, including local knowledge, time, and relationships. Global mental health requires further attentive qualitative research to consider how these, and other factors shape the work of CHWs in different locales to inform locally appropriate mental health care.

Vulnerabilities, care, and exposure to illness risks among people with intellectual disabilities in Brazil during the COVID-19 pandemic (2020-2021)

People with intellectual disabilities, especially those who require care, are among the most affected by severe forms of COVID-19 and COVID-19- related deaths. In this study we investigated how care needs and other vulnerabilities influence the possibility COVID-19 infection among people with intellectual disabilities in Brazil. Method: Descriptive quantitative study using an online questionnaire answered by 2,800 respondents with intellectual disabilities over the age of sixteen. Results: Individuals with a greater need for care had higher frequencies of positive COVID-19 diagnoses (6.5%-8%) and were approximately six times more likely to be infected by family members than those who did not have COVID-19 in the family. Conclusions: There is a need for specific government measures to protect people with intellectual disabilities and their caregivers, because those with greater care needs are the most exposed to risks of contagion and sickness and have potential vectors of infection among family members and caregivers.

Caregiving and all-cause mortality in postmenopausal women: Findings from the Women's Health Initiative

BACKGROUND

Caregiving is commonly undertaken by older women. Research is mixed, however, about the impact of prolonged caregiving on their health, well-being, and mortality risk. Using a prospective study design, we examined the association of caregiving with mortality in a cohort of older women.

METHODS

Participants were 158,987 postmenopausal women aged 50-79 years at enrollment into the Women's Health Initiative (WHI) who provided information on current caregiving status and caregiving frequency at baseline (1993-1998) and follow-up (2004-2005). Mortality was ascertained from baseline through March of 2019. Cox regression with caregiving status defined as a time-varying exposure was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for mortality, adjusting for sociodemographic factors, smoking, and history of diabetes, hypertension, cardiovascular disease (CVD), and cancer. Stratified analyses explored whether age, race-ethnicity, depressive symptoms, frequency of caregiving, optimism, and living status modified the association between caregiver status and mortality.

RESULTS

At baseline, 40.7% of women (mean age 63.3 years) self-identified as caregivers. During a mean 17.5-year follow-up, all-cause mortality (50,526 deaths) was 9% lower (multivariable-adjusted HR = 0.91, 95% CI: 0.89-0.93) in caregivers compared to non-caregivers. The inverse association between caregiving and all-cause mortality did not differ according to caregiving frequency or when stratified by age, race-ethnicity, depressive symptoms, optimism, or living status (interaction p > 0.05, all). Caregiving was inversely associated with CVD and cancer mortality.

CONCLUSION

Among postmenopausal women residing across the United States, caregiving was associated with lower mortality. Studies detailing the type and amount of caregiving are needed to further determine its impact on older women.

People with mental illness stigmatize mental illness less: A comparison study between a hospital-based sample of people with mental illness and a non-clinical general population sample in urban India

Evidence shows that stigma negatively influences the quality of life of persons with severe mental illness. Nonetheless, stigma towards mental illness is lower among persons with a lived experience of mental illness compared to the rest of the population. Understanding the association between stigma of mental illness and the mental status of individuals living in urban India and whether this association is moderated by demographic factors opens a new avenue for prevention of social exclusion. Persons diagnosed with schizophrenia, bipolar disorder, or severe unipolar depression (cases, n  =  647) were recruited from among hospital patients in New Delhi between November 2011 and June 2012 and matched with non-psychiatric urban dwellers by age, sex, and location of residence (controls, n  =  649). Propensity score matching with multivariable linear regression was used to test whether stigma towards mental illness, measured by a 13-item Stigma Questionnaire, differed between cases and controls. Cases reported significantly lower stigma scores than controls (b  =  -0.50, p < 0.0001). The strength of the association between mental illness and stigma was not affected after controlling for age, caste, sex, education, and employment status, while wealth marginally reduced the strength of the association. These findings suggest individuals with a lived experience of mental illness, in New Delhi, India, may be more tolerant towards mental illness and support the need to involve persons with lived experience in the development and implementation of health promotional campaigns and programs aimed at reducing stigma towards mental illness.

Scaling a group intervention to promote caregiver mental health in Uttarakhand, India: A mixed-methods implementation study

Caregivers are integral to health and social care systems in South Asian countries yet are themselves at higher risk of mental illness. Interventions to support caregiver mental health developed in high-income contexts may be contextually inappropriate in the Global South. In this mixed-methods study, we evaluated the implementation and scaling of a locally developed mental health group intervention for caregivers and others in Uttarakhand, India. We describe factors influencing implementation using the updated Consolidated Framework for Implementation Research, and selected implementation outcomes. Key influencing factors we found in common with other programs included: an intervention that was relevant and adaptable; family support and stigma operating in the outer setting; training and support for lay health worker providers, shared goals, and relationships with the community and the process of engaging with organisational leaders and service users within the inner setting. We identified further factors including the group delivery format, competing responsibilities for caregivers and opportunities associated with the partnership delivery model as influencing outcomes. Implementation successfully reached target communities however attrition of 20% of participants highlights the potential for improving outcomes by harnessing enablers and addressing barriers. Findings will inform others implementing group mental health and caregiver interventions in South Asia.

Quality of life, social support, and pathways of care among persons with psychiatric disorders-A cross-sectional study

Background

Patients with psychiatric disorders have varied psychosocial realities embedded in the community context. Help-seeking behavior is extremely crucial in determining the prognosis and outcome of interventions.

Objectives

(1) To assess the levels of quality of life, perceived social support, and decision to first seek help. (2) To assess the association of socio-demographic variables with these domains.

Materials and Methods

A cross-sectional descriptive survey with 100 psychiatric patients in a tertiary care setting employed three scales, namely WHOQOL-BREF, PSSS, and WHO Pathways Encounter form.

Results

Patients had higher levels of quality of life and perceived social support. The majority of patients chose health professionals over faith healers at the onset of symptoms, had higher reliance on family members, and continued with hospital visits till the third follow-up. Sex, occupation, and marital status were associated with perceived social support, and duration of illness was associated with help-seeking behavior.

Conclusions

Community-based interventions must include holistic services and reduce the gap between onset and first contact, leading to higher quality of life and perceived social support.

Does the Nae Umeed group intervention improve mental health and social participation? A pre-post study in Uttarakhand, India

There are few evidence-based interventions to support caregiver mental health developed for low- and middle-income countries. Nae Umeed is a community-based group intervention developed with collaboratively with local community health workers in Uttarakhand, India primarily to promote mental wellbeing for caregivers and others. This pre-post study aimed to evaluate whether Nae Umeed improved mental health and social participation for people with mental distress, including caregivers. The intervention consisted of 14 structured group sessions facilitated by community health workers. Among 115 adult participants, 20% were caregivers and 80% were people with disability and other vulnerable community members; 62% had no formal education and 92% were female. Substantial and statistically significant improvements occurred in validated psychometric measures for mental health (12-Item General Health Questionnaire, Patient Health Questionnaire-9) and social participation (Participation Scale). Improvements occurred regardless of caregiver status. This intervention addressed mental health and social participation for marginalised groups that are typically without access to formal mental health care and findings suggest Nae Umeed improved mental health and social participation; however, a controlled community trial would be required to prove causation. Community-based group interventions are a promising approach to improving the mental health of vulnerable groups in South Asia.

Prevalence and associated factors of insomnia symptoms during the COVID-19 pandemic lockdown among Mettu town residents

BACKGROUND

Insomnia is a prevalent sleep disorder that affects people all over the world. Creating suitable interventions will require a better understanding of the magnitude and determinants of insomnia. This study aimed to assess the prevalence and associated factors of insomnia symptoms among residents of Mettu town during the pandemic lockdown.

METHODOLOGY

A community-based cross-sectional study was conducted among residents of Mettu town from October 1st to October 15th, 2020. Residents who lived in Mettu town at least for six months were included. To determine the prevalence and determinants of insomnia symptoms, both descriptive and inferential analyses were used. The chi-squared test of association and logistic regression was used to identify predictors of insomnia symptoms among residents of Mettu town. We used SPSS version 25 for all statistical analyses.

PRINCIPAL FINDINGS

The prevalence of depressive symptoms among residents of Mettu town was 52.6%. According to results of multivariable binary logistic regression, being female [AOR = 3.677, 95%CI: 2.124-6.365], being aged between 19 and 40 [AOR = 13.261, 95%CI: 6.953-25.291], being aged above 41 [AOR = 2.627, 95%CI: 1.120-6.159], smoking [AOR = 15.539, 95%CI: 7.961-30.329], satisfaction with information available [AOR = 0.310, 95%CI: 0.168-0.570], fear Corona Virus Disease 2019 (COVID-19), [AOR = 2.171, 95%CI: 1.262-3.733], feeling alienated from others [AOR = 3.288, 95%CI: 1.897-5.699], having somatic symptoms [AOR = 2.298, 95% CI: 1.360-3.884], having depressive symptoms [AOR = 1.841, 95% CI: 1.073-3.160], and experiencing psychological distress [AOR = 1.962, 95% CI: 1.173-3.281] were significantly associated with insomnia symptoms.

CONCLUSION

In this study, the prevalence of insomnia symptoms was found to be high among residents of Mettu town. Being female, being aged between 19 and 40, being aged above 41 years, smoking, fear of Corona Virus Disease 2019, feeling alienated from others, having somatic symptoms, having depressive symptoms, and experiencing psychological distress were all associated with an increased risk of developing insomnia symptoms while being satisfied with the information available decreased the risk of insomnia symptoms among residents of Mettu town. Interventions should be put in place to promote healthy sleep among residents of Mettu town.

Spousal support and working woman’s career progression: a qualitative study of woman academicians in the University of Kashmir

Purpose

The purpose of this paper is to explore the importance of spousal support toward a working woman’s career progression. As women continue to bear the brunt of shouldering more domestic responsibilities than men, this research focuses on their extensive need for spousal support. The work attempts to examine how working women perceive the roles their spouses play in sharing home and childcare responsibilities vis-à-vis supporting them in pursuing a career. The compartmentalization of gender roles and how it influences division of labor between husband and wife have also been explored.

Design/methodology/approach

The study used a qualitative approach based on analysis of multiple cases regarding women academicians. In-depth narratives based on rich interview data presented an inquiry into spousal support working women received. The impact of spousal support on the career trajectories of women was also explored.

Findings

Results show that spousal support is an important dimension toward the success of a woman’s career. Findings also suggest that gender role is an essential dynamic that determines the pattern of dominance between couples. Gender role ideology between the husband and wife was a key determinant of husbands’ support toward his working wife.

Originality/value

The present research, unlike previous studies, explores how women perceive the presence/absence of a husband’s support in a little studied group of female workers.

Improving Social Inclusion for Young People Affected by Mental Illness in Uttarakhand, India

Young people experiencing mental ill-health are often excluded from peer networks, family events, education, marriage and employment. We evaluated a community-based, peer-led intervention guided by the Nae Disha (new pathways) program, targeting young people affected by mental ill-health in Uttarakhand, India. A total of 11 groups involving 142 young people (30 male, 112 female) and 8 peer facilitators participated, most of whom were enrolled in a community mental health program. The impact of the intervention on participation, mental health, and social strengths and difficulties was measured at baseline and endline using validated instruments. The proportion experiencing significant social isolation reduced from 20.6 to 5.9% (p < 0.001), and those classified in the 'abnormal' range of the social difficulties measure halved from 42.6 to 21.3% (p < 0.001). These findings clearly demonstrate that perceptions of social inclusion and mental health of young people affected by mental illness can be significantly strengthened through participation in this low-resource intervention.

Accessibility to people with motor, visual, or hearing disabilities during delivery and childbirth: the structure of SUS facilities linked to Rede Cegonha

There are no nationwide studies characterizing accessibility for people with disabilities during delivery. This study aimed to describe the physical structure of hospital units regarding accessibility for pregnant and puerperae with motor (MD), visual (VD), or hearing (HD) disabilities in Brazil. This is an ecological, descriptive study conducted in all 606 health facilities linked to the "Rede Cegonha" where deliveries occurred, according to 2015 databases. We performed the descriptive and geospatial analysis and considered the presence of motor accessibility when the establishment had a handrail or elevator ramp, wheelchair-sized doors, and accessible bathroom with bars. We assumed visual accessibility when there was tactile signage on the floor (Braille system or embossed figures) and hearing accessibility when there was signage by texts, pictures, signs, posters, or symbols in the environments. In Brazil, only 26 (4.3%) of the facilities had accessibility for people with MD, 20 (3.3%) for people with VD, and none for HD. Motor accessibility was worse in the North and Northeast of Brazil, and hearing accessibility in the North region. Despite advances in the implementation of the "Rede Cegonha" in Brazil, the facilities' structure is not adapted for women with MD, VD, or HD.

Caregivers of people with disorders of consciousness: which burden predictors?

OBJECTIVES

Caregivers of patients diagnosed with disorders of consciousness (DoCs) play a pivotal role in the care pathway of these patients. Due to the high costs of care, among other symptoms and disorders previously described in the literature, they can manifest also mood and stress-related disorders which greatly impact their life and increase their burden. It is noteworthy to identify which factors are better related to the manifestation of mood and stress-related disorders to care for the caregivers in time. However, no studies have explored which factors are related to the manifestation of these disorders within this population yet.

MATERIALS AND METHODS

We explored with different questionnaires whether patient-, caregiver-, and caregiving environment-related factors are associated with mood and stress-related disorders on 114 caregivers of patients with DoCs.

RESULTS

Our results showed that female caregivers manifested higher levels of both depression and prolonged grief disorder; furthermore, the presence of economic problems increased the levels of depression. Moreover, different levels of caregivers' depression, anxiety, anger expression, and prolonged grief disorder were closely linked to the degree of behavioural responsiveness of the patients.

CONCLUSIONS

Our results highlighted the need to consider also caregivers' mood and stress-related disorders when defining the care pathway of patients with DoCs; indeed, caregivers constitute the main environment of DoC patients and they need tailored interventions aimed at reducing their burden due to caregiving.

The Problem of Psychological Rehabilitation of Persons with Disorders of the Musculoskeletal System Acquired in Adulthood

The problem of improving the quality of life of people with lesions of the musculoskeletal system is relevant to modern society. However, the circumstances of disabled people in modern Russia are characterized by the presence of many problems, including psychological ones. The aim of this study was to study the psychological characteristics of persons with acquired disorders of the musculoskeletal system and to determine the direction and content of psychological rehabilitation. In this study, we studied the characteristics of the emotional-volitional sphere of persons with musculoskeletal disorders (n = 30) acquired in adulthood, as well as scientific approaches to the study of rehabilitation and the main directions of rehabilitation of persons with musculoskeletal disorders. Clinical, psychological, and psychodiagnostic methods, alongside statistical methods of empirical data analysis, were used. It was found that persons with acquired disorders of the musculoskeletal system have a low adaptive capacity, a high level of neuropsychic stress, a low level of self-actualization and self-regulation and are not capable of the conscious planning of activities. The personal factors that intensify the manifestation of maladjustment are isolation and emotional stress when interacting with others. The article presents the main directions for rehabilitation.

Disabled Families: The Impacts of Disability and Care on Family Labour and Poverty in Rural Guatemala

An increasing body of literature has started to look at how disability impacts and shifts poverty in the global South in and through a range of areas, including health, education, and livelihoods. However, much of this research is limited to disabled individuals, while qualitative research focusing on and articulating the circumstances, needs and demands of rural families remains scarce, especially research focusing on Latin America. This paper reports on a qualitative study looking at how disability affects family labouring patterns in rural Guatemala, with a special focus on women carers of people with acquired physical impairments, in the bid to contribute to a more inclusive understanding of the disability and poverty relationship and its gendered dimensions. Findings highlight how in rural communities already living in dire poverty, the fragmentation of labour input of the disabled person, costs (notably health care) and intensified collective poverty, push fragile families with no safety nets into a set of dynamic responses in the bid to ensure survival of the family unit. These include harder and longer work patterns, interruption of paid labour, and/or induction into exploitative and perilous labour, not only for women, but also children. These responses are erosive and have severe personal, social, cultural and economic consequences, strengthening a deep, multidimensional, chronic and intergenerational impoverishment, transforming these families into ‘disabled families’, among the poorest of the poor. This paper concludes that research, policy and services need to move beyond the disabled individual to understand and address the needs and demands of whole families, notably women, and safeguard their livelihoods, because ultimately, these are the units that singlehandedly care for and ensure the well-being and survival of disabled people. It is also within these units that disability is constructed, shaped, and can ultimately be understood.

Gender-specific experiences of serious mental illness in rural Ethiopia: A qualitative study

Considerable variation in the gender-specific prevalence of serious mental illness (SMI) has been reported in low- and middle-income countries (LMICs). In the rural setting of Butajira, Ethiopia, the male-to-female prevalence ratio of schizophrenia was reported to be 5:1. This qualitative study explores gender-specific experiences of SMI and the extent to which sociocultural factors may explain the observed difference in prevalence estimates. Using purposive sampling, 39 in-depth interviews were conducted with community members from Butajira, a rural district in South Central Ethiopia. Transcripts were analysed using thematic analysis to elicit community perspectives on cultural explanatory models of SMI and experiences in this region. Gender-specific experiences were reported to differ due to visibility of symptoms, community responses, and varying levels of family support towards individuals with SMI. Overall, respondents described how various sociocultural factors subject women with SMI to higher levels of physical and social isolation compared to men, greatly affecting community health workers' ability to identify and provide care to women with mental illness. Future case detection methods should involve family members as they interact with women with SMI early on in the development of their symptoms and play an essential role in their path to mental health care.

Women's freedom of movement and participation in psychosocial support groups: qualitative study in northern India

BACKGROUND

Depression, the world's leading cause of disability, disproportionately affects women. Women in India, one of the most gender unequal countries worldwide, face systemic gender disadvantage that significantly increases the risk of common mental disorders. This study's objective was to examine the factors influencing women's participation in psychosocial support groups, within an approach where community members work together to collectively strengthen their community's mental health.

METHODS

This community-based qualitative study was conducted from May to July 2016, across three peri-urban sites in Dehradun district, Uttarakhand, Northern India. Set within an NGO-run mental health project, data were collected through focus group discussions with individuals involved in psychosocial support groups including women with psychosocial disabilities as well as caregivers (N = 10, representing 59 women), and key informant interviews (N = 8) with community members and mental health professionals. Data were analyzed using a thematic analysis approach.

RESULTS

The principal barrier to participating in psychosocial support groups was restrictions on women's freedom of movement. Women in the community are not normally permitted to leave home, unless going to market or work, making it difficult for women to leave their home to participate in the groups. The restrictions emanated from the overall community's attitude toward gender relations, the women's own internalized gender expectations, and most significantly, the decision-making power of husbands and mothers-in-law. Other factors including employment and education shaped women's ability to participate in psychosocial support groups; however, the role of these additional factors must be understood in connection to a gender order limiting women's freedom of movement.

CONCLUSIONS

Mental health access and gender inequality are inseparable in the context of Northern India, and women's mental health cannot be addressed without first addressing underlying gender relations. Community-based mental health programs are an effective tool and can be used to strengthen communities collectively; however, attention towards the gender constraints that restrict women's freedom of movement and their ability to access care is required. To our knowledge, this is the first study to clearly document and analyze the connection between access to community mental health services in South Asia and women's freedom of movement.

Promoting social inclusion for young people affected by psycho-social disability in India - a realist evaluation of a pilot intervention

India has 600 million young people, more than any other country in the world. Mental illness is the leading burden of disease for young people, and those affected experience restrictions in social participation that compromise recovery. The aim of this study was to assess the impact of a peer-led, community-based, participatory group intervention on social inclusion and mental health among 142 young people affected by psycho-social disability (PSD) in Dehradun district, Uttarakhand. Qualitative data were obtained via in-depth interviews and focus-group discussions. A realist evaluation identified contextual factors, mechanisms and outcomes to develop the programme theory. Group participants described intermediate outcomes including establishment of new peer friendship networks, increased community participation, greater self-efficacy (for young women particularly), and improved public image (for young men) that are likely to have contributed to the primary outcomes of greater (self-perceived) social inclusion and improved mental health (as assessed quantitatively). Mechanisms were identified that explain the link between intervention and outcomes. These findings demonstrate the effectiveness of a brief intervention to improve mental health and social inclusion for young people with PSD and are potentially relevant to programme implementers and policy-makers working with young people and promoting social inclusion, in other low- and middle-income settings.