Kaaren Mathias - Herbertpur Christian Hospital, Dehradun, India
Meenal Rawat - Herbertpur Christian Hospital, Dehradun, India
Anna Thompson - Sir Edmund Hillary Marg, New Delhi, India
Rakhal Gaitonde - Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
Sumeet Jain - Department of Social and Political Science, University of Edinburgh, Edinburgh, UK

BackgroundIn India and global mental health, a key component of the care gap for people with mental health problems is poor system engagement with the contexts and priorities of community members. This study aimed to explore the nature of community mental health systems by conducting a participatory community assessment of the assets and needs for mental health in Uttarkashi, a remote district in North India. MethodsThe data collection and analysis process were emergent, iterative, dialogic and participatory. Transcripts of ۲۸ in-depth interviews (IDIs) with key informants such as traditional healers, people with lived experience and doctors at the government health centres (CHCs), as well as ۱۰ participatory rural appraisal (PRA) meetings with ۱۲۰ people in community and public health systems, were thematically analysed. The ۷۵۳ codes were grouped into ۹۳ categories and ultimately nine themes and three meta-themes (place, people, practices), paying attention to equity. ResultsYamuna valley was described as both ‘blessed’ and limited by geography, with bountiful natural resources enhancing mental health, yet remoteness limiting access to care. The people described strong norms of social support, yet hierarchical with entrenched exclusions related to caste and gender, and social conformity that limited social accountability of services. Care practices were porous, pluralist and fragmented, with operational primary care services that acknowledged traditional care providers, and trusted resources for mental health such as traditional healers (malis) and government health workers (accredited social health activists. ASHAs). Yet care was often absent or limited by being experienced as disrespectful or of low quality. ConclusionFindings support the value of participatory methods, and policy actions that address power relations as well as social determinants within community and public health systems. To improve mental health in this remote setting and other South Asian rural locations, community and public health systems must dialogue with the local context, assets and priorities and be socially accountable.

Participatory, Needs Assessment, India, Mental Health, Community, Health Systems