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Fellmeth G, Kanwar P, Sharma D, Chawla K, DasGupta N, Chhajed S, Chandrakant, Jose EC, Thakur A, Gupta V, Bharti OK, Singh S, Desai G, Thippeswamy H, Kurinczuk JJ, Chandra P, Nair M, Verma A, Kishore MT, Alderdice F. Women's awareness of perinatal mental health conditions and the acceptability of being asked about mental health in two regions in India: a qualitative study. BMC Psychiatry 2023; 23:829. [PMID: 37957589 PMCID: PMC10644637 DOI: 10.1186/s12888-023-05323-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 10/29/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Mental health conditions are common during pregnancy and the first year after childbirth. Early detection allows timely support and treatment to be offered, but identifying perinatal mental health conditions may be challenging due to stigma and under-recognition of symptoms. Asking about symptoms of mental health conditions during routine antenatal and postnatal appointments can help to identify women at risk. This study explores women's awareness of perinatal mental health conditions, their views on the acceptability of being asked about mental health and any preference for specific assessment tools in two regions in India. METHODS Focus group discussions (FGDs) were conducted with pregnant, post-partum and non-perinatal women in Kangra, Himachal Pradesh (northern India) and Bengaluru, Karnataka (southern India). Settings included a hospital antenatal clinic and obstetric ward, Anganwadi Centres and Primary Health Centres. FGDs were facilitated, audio-recorded and transcribed. Narratives were coded for emerging themes and analysed using thematic analysis. RESULTS Seven FGDs including 36 participants were conducted. Emerging themes were: manifestations of and contributors to mental health conditions; challenges in talking about mental health; and the acceptability of being asked about mental health. Difficult familial relationships, prioritising the needs of others and pressure to have a male infant were cited as key stressors. Being asked about mental health was generally reported to be acceptable, though some women felt uncomfortable with questions about suicidality. No preference for any specific assessment tool was reported. CONCLUSIONS Women face many stressors during the perinatal period including difficult familial relationships and societal pressure to bear a male infant. Being asked about mental health was generally considered to be acceptable, but questions relating to suicidality may be challenging in a community setting, requiring sensitivity by the interviewer. Future studies should assess the acceptability of mental health assessments in 'real world' antenatal and postnatal clinics and explore ways of overcoming the associated challenges in resource-constrained settings.
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Affiliation(s)
- Gracia Fellmeth
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Pankaj Kanwar
- Department of Psychiatry, Dr Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
| | - Diksha Sharma
- Department of Obstetrics and Gynaecology, Dr Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
| | | | - Neha DasGupta
- Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences, Bengaluru, India
| | - Shreyash Chhajed
- Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences, Bengaluru, India
| | - Chandrakant
- Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences, Bengaluru, India
| | - Emily C Jose
- Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences, Bengaluru, India
| | - Anita Thakur
- Department of Psychiatry, Dr Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
| | - Vikesh Gupta
- Department of Psychiatry, Dr Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
| | - Omesh Kumar Bharti
- State Institute of Health and Family Welfare, Department of Health and Family Welfare, Government of Himachal Pradesh, Shimla, India
| | - Sukhjit Singh
- Department of Psychiatry, Dr Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
| | - Geetha Desai
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, India
| | - Harish Thippeswamy
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, India
| | - Jennifer J Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Prabha Chandra
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bengaluru, India
| | - Manisha Nair
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ashok Verma
- Department of Obstetrics and Gynaecology, Dr Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
| | - M Thomas Kishore
- Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences, Bengaluru, India
| | - Fiona Alderdice
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland
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Lavy C, Mkandawire N. Starting a spine surgery service in a low-resource setting: a look back over twenty five years of spine surgery in Malawi. Int Orthop 2022. [PMID: 35229178 DOI: 10.1007/s00264-022-05339-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/04/2022] [Indexed: 10/28/2022]
Abstract
PURPOSE This is a short historical narrative of the development of spine surgery in Malawi. METHODS The authors communicated and both drew on memories and anecdotes over the last 25 years. RESULTS This is not a scientific paper, so there are no results. CONCLUSION The short paper outlines the development of spine surgery in Malawi over the last 25 years. This develops in association with the overall increase in the number of surgeons in the country.
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Vaitheswaran S, Currie G, Dhandapani VR, Mohan G, Rangaswamy T, Preet Singh S. Implementation of first episode psychosis intervention in India - A case study in a low-and middle-income country. SSM Ment Health 2021; 1:None. [PMID: 34957426 PMCID: PMC8654684 DOI: 10.1016/j.ssmmh.2021.100018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/11/2021] [Accepted: 09/01/2021] [Indexed: 11/28/2022] Open
Abstract
First Episode Psychosis (FEP) is a serious mental illness affecting adolescents and young persons. While many effective interventions are available, there has not been much research to understand the implementation of such interventions in India and other low- and middle-income countries (LMIC). We studied the implementation of an FEP intervention program in a specialist mental health facility in Chennai, India, using a well-established framework for doing so, the Consolidated Framework for Implementation Research (CFIR). We conducted 27 in-depth interviews with the service users (15 persons with FEP and 12 family caregivers of persons with FEP). We also conducted a focus group discussion with 8 service providers and in-depth interviews with 7 other service providers including those in the service management. A thematic analysis approach was used to identify emerging themes. First, we found CFIR effectively accommodated implementation challenges evident in LMICs; that is, it is transferable to LMIC settings. Second, we highlight barriers to implementation that include cost, limited human resources, cultural and professional hierarchy, divergence from evidence-based guidelines, and lack of awareness and stigma in the wider community. Third, we highlight facilitators for implementation such as, leadership engagement, the need for change that was recognized within the service, cosmopolitan perspectives derived from clinicians’ local and international collaborative experiences and expertise, compatibility of the intervention with the existing systems within the organization, accommodating the needs of the service users, and rapport developed by the service with the service users. Fourth, we propose a model of service delivery incorporating a task-sharing approach for first episode psychosis in resource restricted settings based on the feedback from the stakeholders. Implementation of interventions for First Episode Psychosis in India is explored systematically. Resource constraints, cultural factors, lack of awareness, and stigma are the main barriers to the implementation. Buy-in from the service providers, accommodating the needs and developing rapport with the service users are the facilitators.
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Affiliation(s)
- Sridhar Vaitheswaran
- Schizophrenia Research Foundation (SCARF), R/7A, North Main Road, Anna Nagar West Extension, Chennai, 600101, Tamil Nadu, India
| | - Graeme Currie
- Warwick Business School, University of Warwick, Coventry, UK
| | - Vijaya Raghavan Dhandapani
- Schizophrenia Research Foundation (SCARF), R/7A, North Main Road, Anna Nagar West Extension, Chennai, 600101, Tamil Nadu, India
| | - Greeshma Mohan
- Schizophrenia Research Foundation (SCARF), R/7A, North Main Road, Anna Nagar West Extension, Chennai, 600101, Tamil Nadu, India
| | - Thara Rangaswamy
- Schizophrenia Research Foundation (SCARF), R/7A, North Main Road, Anna Nagar West Extension, Chennai, 600101, Tamil Nadu, India
| | - Swaran Preet Singh
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
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Fellmeth G, Harrison S, Opondo C, Nair M, Kurinczuk JJ, Alderdice F. Validated screening tools to identify common mental disorders in perinatal and postpartum women in India: a systematic review and meta-analysis. BMC Psychiatry 2021; 21:200. [PMID: 33879130 PMCID: PMC8056564 DOI: 10.1186/s12888-021-03190-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 03/30/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Perinatal common mental disorders are associated with significant adverse outcomes for women and their families, particularly in low- and middle-income settings. Early detection through screening with locally-validated tools can improve outcomes. METHODS We searched MEDLINE, Embase, PsycINFO, Global Health, Cochrane Library, Web of Science and Google Scholar for articles on the validation of screening tools for common mental disorders in perinatal women in India, with no language or date restrictions. Quality was assessed using the QUADAS-2 tool. We used bivariate and hierarchical summary receiver operating characteristic models to calculate pooled summary estimates of sensitivity and specificity. Heterogeneity was assessed by visualising the distance of individual studies from the summary curve. RESULTS Seven studies involving 1003 women were analysed. All studies assessed the validity of the Edinburgh Postnatal Depression Scale (EPDS) in identifying perinatal depression. No validation studies of any other screening tools were identified. Using a common threshold of ≥13 the EPDS had a pooled sensitivity and specificity of 88·9% (95%CI 77·4-94·9) and 93·4 (95%CI 81·5-97·8), respectively. Using optimal thresholds (range ≥ 9 to ≥13) the EPDS had a pooled sensitivity and specificity of 94·4% (95%CI 81·7-98·4) and 90·8 (95%CI 83·7-95·0), respectively. CONCLUSION The EPDS is psychometrically valid in diverse Indian settings and its use in routine maternity care could improve detection of perinatal depression. Further research is required to validate screening tools for other perinatal common mental disorders in India.
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Affiliation(s)
- Gracia Fellmeth
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK.
| | - Siân Harrison
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK
| | - Charles Opondo
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK
| | - Manisha Nair
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK
| | - Jennifer J Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK
| | - Fiona Alderdice
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, BT9 7BL, Northern Ireland
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Rook JM, Wood E, Boeck MA, Blair KJ, Monroy A, Ludi E, Keller EJ, Victorson D, Foíanini E, Swaroop M. The Bolivian trauma patient's experience: A qualitative needs assessment. Injury 2021; 52:167-174. [PMID: 33386153 DOI: 10.1016/j.injury.2020.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/16/2020] [Accepted: 12/02/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite a significant burden of injury-related deaths, the Plurinational State of Bolivia (Bolivia), a lower- middle-income country in South America, lacks a formalized trauma system. This study sought to examine Bolivian trauma care from the patient perspective in order to determine barriers to care and targets for improvement. METHODS Investigators conducted 15 semi-structured interviews with trauma patients admitted at four hospitals in Santa Cruz de la Sierra, Bolivia in June and July of 2016. Interviews were transcribed, translated, and analyzed through content and discourse analysis to identify key themes and perceptions of trauma care. RESULTS Participants primarily presented with orthopedic injuries due to road traffic incidents and falls. Only one participant reported receiving first aid from a layperson at the scene of injury. Of the 15 participants, 12 did not know any number to contact emergency medical services (EMS). Participants expressed negative views of EMS as well as concerns for slow response times and inadequate personnel and training. Two thirds of participants were initially brought to a hospital without adequate resources to care for their injuries. Participants generally expressed positive views regarding healthcare workers involved in their hospital-based medical care. CONCLUSIONS This region of Bolivia has a disorganized, underutilized, and distrusted trauma system. In order to increase survival, interventions should focus on improving prehospital trauma care. Potential interventions include the implementation of layperson trauma first responder courses, the establishment of a medical emergency hotline, the unification of EMS, the implementation of basic training requirements for EMS personnel, and public education campaigns to increase trust in EMS.
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Affiliation(s)
- Jordan M Rook
- Northwestern University Feinberg School of Medicine, Department of Surgery, Division of Trauma and Critical Care, Chicago, IL, USA; David Geffen School of Medicine at the University of California Los Angeles, Department of Surgery, Los Angeles, CA, USA.
| | - Ethan Wood
- Northwestern University Feinberg School of Medicine, Department of Surgery, Division of Trauma and Critical Care, Chicago, IL, USA; Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Marissa A Boeck
- Northwestern University Feinberg School of Medicine, Department of Surgery, Division of Trauma and Critical Care, Chicago, IL, USA; Brigham and Women's Hospital, Center for Surgery and Public Health, Boston, MA, USA; New York Presbyterian Hospital/Columbia University, Department of Surgery, New York City, NY, USA; University of California San Francisco School of Medicine, Department of Surgery, San Francisco, CA, USA
| | - Kevin J Blair
- Northwestern University Feinberg School of Medicine, Department of Surgery, Division of Trauma and Critical Care, Chicago, IL, USA; David Geffen School of Medicine at the University of California Los Angeles, Department of Surgery, Los Angeles, CA, USA
| | - Alexa Monroy
- Northwestern University Feinberg School of Medicine, Department of Surgery, Division of Trauma and Critical Care, Chicago, IL, USA; Children's Hospital Los Angeles, Department of Pediatrics, Los Angeles, CA, USA
| | - Erica Ludi
- Emory University School of Medicine, Department of Surgery, Atlanta, GA, USA
| | - Eric J Keller
- Stanford University School of Medicine, Department of Interventional Radiology, Palo Alto, CA, USA
| | - David Victorson
- Northwestern University Feinberg School of Medicine, Department of Medical Social Sciences, Chicago, IL, USA
| | - Esteban Foíanini
- Clínica Foíanini, Department of Surgery, Santa Cruz de la Sierra, Bolivia
| | - Mamta Swaroop
- Northwestern University Feinberg School of Medicine, Department of Surgery, Division of Trauma and Critical Care, Chicago, IL, USA
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Maldonado LY, Songok JJ, Snelgrove JW, Ochieng CB, Chelagat S, Ikemeri JE, Okwanyi MA, Cole DC, Ruhl LJ, Christoffersen-Deb A. Promoting positive maternal, newborn, and child health behaviors through a group-based health education and microfinance program: a prospective matched cohort study in western Kenya. BMC Pregnancy Childbirth 2020; 20:288. [PMID: 32398156 PMCID: PMC7216653 DOI: 10.1186/s12884-020-02978-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 04/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chamas for Change (Chamas) is a group-based health education and microfinance program for pregnant and postpartum women that aims to address inequities contributing to high rates of maternal and infant mortality in rural western Kenya. In this prospective matched cohort study, we evaluated the association between Chamas participation and facility-based delivery. We additionally explored the effect of participation on promoting other positive maternal, newborn and child health (MNCH) behaviors. METHODS We prospectively compared outcomes between a cohort of Chamas participants and controls matched for age, parity, and prenatal care location. Between October-December 2012, government-sponsored community health volunteers (CHV) recruited pregnant women attending their first antenatal care (ANC) visits at rural health facilities in Busia County to participate in Chamas. Women enrolled in Chamas agreed to attend group-based health education and microfinance sessions for one year; controls received the standard of care. We used descriptive analyses, multivariable logistic regression models, and random effect models to compare outcomes across cohorts 12 months following enrollment, with α set to 0.05. RESULTS Compared to controls (n = 115), a significantly higher proportion of Chamas participants (n = 211) delivered in a health facility (84.4% vs. 50.4%, p < 0.001), attended at least four ANC visits (64.0% vs. 37.4%, p < 0·001), exclusively breastfed to six months (82.0% vs. 47.0%, p < 0·001), and received a CHV home visit within 48 h postpartum (75.8% vs. 38.3%, p < 0·001). In multivariable models, Chamas participants were over five times as likely as controls to deliver in a health facility (OR 5.49, 95% CI 3.12-9.64, p < 0.001). Though not significant, Chamas participants experienced a lower proportion of stillbirths (0.9% vs. 5.2%), miscarriages (5.2% vs. 7.8%), infant deaths (2.8% vs. 3.4%), and maternal deaths (0.9% vs. 1.7%) compared to controls. CONCLUSIONS Chamas participation was associated with increased odds of facility-based delivery compared to the standard of care in rural western Kenya. Larger proportions of program participants also practiced other positive MNCH behaviors. Our findings demonstrate Chamas' potential to achieve population-level MNCH benefits; however, a larger study is needed to validate this observed effect. TRIAL REGISTRATION ClinicalTrials.gov, NCT03188250 (retrospectively registered 31 May 2017).
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Affiliation(s)
- Lauren Y Maldonado
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, Eldoret, 30100, Kenya. .,Department of Medicine, Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA.
| | - Julia J Songok
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, Eldoret, 30100, Kenya.,Moi University School of Medicine, College of Health Sciences, Eldoret, Kenya
| | - John W Snelgrove
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Sheilah Chelagat
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, Eldoret, 30100, Kenya
| | - Justus E Ikemeri
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, Eldoret, 30100, Kenya
| | | | - Donald C Cole
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Laura J Ruhl
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, Eldoret, 30100, Kenya.,Moi University School of Medicine, College of Health Sciences, Eldoret, Kenya.,Department of Medicine, Indiana University, Indianapolis, IN, USA
| | - Astrid Christoffersen-Deb
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, Eldoret, 30100, Kenya.,Moi University School of Medicine, College of Health Sciences, Eldoret, Kenya.,Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
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Bourey C, Stephenson R, Bautista-Arredondo S. Syndemic Vulnerability and Condomless Sex Among Incarcerated Men in Mexico City: A Latent Class Analysis. AIDS Behav 2018; 22:4019-4033. [PMID: 29968142 DOI: 10.1007/s10461-018-2216-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In order to address common statistical and population-based limitations in epidemiological literature applying syndemic theory, this study uses latent class analysis (LCA) to explore how health and social problems coalesce and shape sexual risk behaviors linked to HIV transmission in three Mexico City prisons. Among the studied male inmates, LCA identified four classes, defined by low syndemic risk (61.4%); marijuana (14.3%); depression, substances, and trauma (19.7%); and depression, substances, and marijuana (4.7%). In multinomial regression models, classes with a greater number of syndemic exposures were associated with increased odds of condomless anal sex during incarceration. In analyses stratified by pre-incarceration sexual risk behaviors, however, high syndemic burden classes were associated with condomless anal sex during incarceration differently. Overall, the study findings suggest that LCA has potential utility for syndemic analyses and highlight the need to attend to health and social adversities when addressing sexual risk behaviors and HIV transmission during incarceration.
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Abstract
PURPOSE OF THE REVIEW The vast majority of research on the social determinants of mental health has been generated from high-income country (HIC) populations, even as the greatest health disparities, and greatest disease burden, is observed in lower- and middle-income countries (LMICs). The goal of this review is to examine the evidence base on how key social epidemiology constructs relate to mental health in LMIC contexts. A special focus is on points of departure from the HIC knowledge base, gaps in overall understanding, and opportunities for social epidemiology to make a significant contribution. RECENT FINDINGS A growing body of literature suggests that there is significant heterogeneity, both in the direction and magnitude, of association between factors such as socioeconomic status, income inequality, gender, and social networks/supports and mental health in LMIC. For example, higher levels of education and being married can be risk factors for worse mental health among women in certain contexts. However, many studies have methodological limitations that make causal inference difficult. Poverty alleviation interventions offer a unique opportunity to examine the impact of improving economic resources and mental health. SUMMARY Much remains unknown about the impact of key social factors on mental health in LMIC. Findings from HICs may not apply to LMIC populations, since the meaning and distribution of a given social variable may differ significantly from what is commonly observed in HICs. These points of departure point to opportunities for social epidemiology to make a contribution to the field of global mental health.
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Affiliation(s)
- Joanna Maselko
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 2105e McGavran-Greenberg Hall, Campus Box 7435, Chapel Hill, NC 27599-7435 USA
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