Mental Health Issues in Rural Community of Nepal

Introduction

I am originally from the country of hills Nepal. Nepal is a developing country with a low socio-economic condition where people are suffering from multiple Health care challenges in today’s world. Few programs are running through Government and Non-Government organizations for health promotion however lack of attention on Mental Health Promotion has been identified as the biggest issue. (Rijal, 2017)

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Globally, one out of four people is facing Mental health issues. Likewise, three out of four people refuse to be treated for mental health disorders (Jenkins, 2011). There is a higher number of suffering among developing counties because of Mental health disorders. This is the negative outcome of inefficient health care services, especially within the mental health department. Suicide has been identified as the second leading factors of death among the young population in the world. Unfortunately, Nepal ranks seventh in the world for the incidence of suicide. Additionally, people are diagnosed with PTSD (Post-traumatic stress disorder) after the disastrous event of the earthquake. (Rijal, 2017)

Furthermore, an article represented some challenges in Psychiatric services in Nepal. Firstly, the policy regarding Mental health developed in 1997 has not been implemented yet. And they have allocated insufficient Budget to cover most of the mental health issues. Similarly, other issues like insufficient psychotropic drugs, overburdened health caregivers, lack of Mental health supervision & lack of coordinating department in MOHP (Ministry of Health & Population) were determined. To solve these issues few strategies were developed like; supply of enough medicines, coordinating with senior-level officers, involving MOHP in the process & collaborating with National health training centers for training programs. (Luitel, 2015)

The vulnerability of Population and Health Disparity:

Nepal is a country with multiple cultures and languages. The interesting thing about the Nepalese community is that although they are from different cultural background while talking about Mental Health most of them have similar views, especially in remote areas. They perceive mental health issues as a state of Madness that is not acceptable for the community. Similarly, their view on the causes of mental health problem is more interesting, they believe the suffering of Mental problems occurs because of spirits, black magic or peoples sin on previous life. People deny accepting an individual with a mental disorder, even the family member they neglect. On the other hand, individual themselves who are suffering from these disorders refuse to visit doctors because of social stigma. That’s why it is surprising to identify mental health being neglected from Health care department of Nepal. There is a piece of evidence that, Nepalese government formulated separate policies targeting towards mental Health, however, they haven’t implemented yet. This justifies that, there is a lack of attention on Mental health department from Individual, Family, Society and even Government of Nepal. (Simkhada, 2015)

Furthermore, WHO in 2006 identified that there are overall thirty-two Psychiatric Specialist, six Psychologists, Sixteen Doctors without specialization in Mental health and sixty-eight nurses. However, there were no occupational therapists and Social workers available. This data reflects that there is a lack of Mental Health manpower to address Mental health issues. (Devkota, 2011)

This evidence determines that there is an inefficient mental health service in Nepal. So, I choose the Nepalese Community as a Vulnerable Population for this study because knowledge is lacking in individual level, insufficient support from family and community and system and policy is not effective in the government level.

Now I would like to discuss regarding Determinants of Mental health in the context of Nepal:

• Education and Literacy: A research represented that only 56.5% (71.5% male and 44.5% female) of adolescents are literate. Most of the illiterate population tend to have a problem of unemployment which directly or indirectly is resulting in Mental Health Issues. (Subedi & Dahal, 2015)
• Social Status, Ethnicity & Religion: Traditional values, hospital expenses, religious belief, cultural value, views of disease are directly affecting an individual’s perception of psychiatric disorders. (New Comer Health Matters, 2016)
•  Availability of Health care service and readiness to receive treatment: Mostly in rural areas, there is a lack of health resources and availability of health care workers. Additionally, people over there only trust in traditional healers in case of Mental issues. And the stigma attached to mental problems is another reason for refusing to visit the hospital for treatment. (Subedi & Dahal, 2015)

These are the few significant factors directly or indirectly impacting on Mental Health of Nepalese Community.

Health Promotion Need Assessment:

1. Mental health Services:

In this article, I would like to assess the Health Promotion Need through the effectiveness of previous and existing Health Promotion Programs. There is 1 Mental Health Hospital available in a ratio of 0.2 beds per 100,000 people. They have got outpatient facilities and no beds organized for children and adolescents. They provide treatment for 3.43 people among 100,000. Most of the patients admitted to hospitals are diagnosed with Schizophrenia (34%) and Mood affective Disorders (21%). The good point is that each hospital has at least one class of psychotropic medicine however they don't have enough in numbers. And they are lacking inpatient services. Beside of Hospitals, there are 145 beds in other facilities like residence for mentally retarded, Detoxification facilities, etc. Unfortunately, there is no data available in community based mental health services. (WHO, 2006)

2. Mental Health in Primary Health Care:

According to WHO (2006), only 2% of health-related training is directed towards Mental Health training for Health care workers. There is the availability of both physician & non-physician based Primary Health care clinics however in terms of adopting Mental health care protocols Physician based PHC is better. They refer patients to a higher health care centre. Additionally, it is found that some of the primary doctors consult with mental health professionals once in 12 months. Likewise, psychotropic medicines are mostly available in physician-based PHC than in non-physician based PHC. This proves that at least there is some initiation towards Mental health services in PHC however, still, barriers are relying on in the whole system. (Subedi & Dahal, 2015 & WHO, 2006)

3. Human Resources:

Human resources within urban and rural areas are allocated disproportionately. It is determined that maximum psychiatrists and nurses aim to work in bigger cities where they get more facilities. And almost 21-50 percentage of health graduates transfer to abroad within five years of their training. This is a negative point in the context of our country. However, there are 5 Non-governmental Organizations in Nepal providing services like counselling, housing, or support groups. (Rijal, 2017 & WHO, 2006))

4. Public Education & Research:

In a country like Nepal, there is a lack of mental health literacy and awareness of mental health issues. Few of the Governmental agencies, NGOs, Professional organizations like KOSHIS Nepal are promoting education and awareness programs by targeting general people & some of the professional groups. Additionally, there is not a formal system of data collection and research in mental health department as till now Government receives data from Mental Hospitals and only 3% of health research is done on Mental Health issues. (WHO, 2006)

Strength & Weakness of Previous and Existing Mental health Services:

Strength:

• Established National Mental Health Policy
• Positive inclination in Mental health awareness and health-seeking behavior among people
• Increased availability of Psychotropic drugs
• NGO & private medical colleges are providing Mental Health services
• Effective Community Mental health services by NGO

Weakness:

• Low Socioeconomic condition of a majority of the population
• Only 1 Mental hospital
• Lack of Health services in rural/remote areas
• Stigma related to Mental disorders
• Lack of human resources, infrastructures in mental health services
• Mental health legislation not developed yet
• Insufficient Budget Allocation
• Lack of health Education & Mental health information system

Health Promotion Programs and its Importance:

Health Promotion is defined as action and intervention to resolve potentially modifiable health determinants. World Health organization have a focus on strategies for Mental health promotion i.e. Building effective health policy, develop personal skills, creating support environment and empower the community interventions. The health promotion framework is oriented towards reducing health inequalities. To be successful, the model is supposed to be focused on economic & social determinants of Mental health. (Nutbeam, 2000)

The issue in setting up mental health promotion is poorly allocated infrastructures and limited resources (Human & material). Additionally, there are many more social changes necessary for Mental Health Promotion. WHO is focused on 3 important areas: Advocacy, Empowerment & Social Support to Promote Mental Health in Poor Socio-economical country like Nepal. (WHO, 2004)

Furthermore, I would like to discuss some Mental health promotion intervention carried out by WHO. The WHO guide attracts attention to the individual, social & environmental factors influencing health. There is an

 effective framework for this approach with current public health philosophy, health policy, supporting environments & addressing health problems by people in their daily life. The main strategies are: Developing better public policy, promoting a supportive environment, empowering community actions, advancing personal skills & re-establishing health care services. (WHO, 2001)

• Development of Better Policy: Mental health promotion is viewed as a model having a supportive role that enhances the value of mental health within individual & societies. So, it is important to develop a healthy policy regarding Mental health and implement the policy to address Mental health issues.  
• Promoting supportive environment: Environmental health is an essential component of health. Therefore, more attention should be given towards the social environment which influences the health of the community. The relationship between individual & environment is regulated by their skills, experience, culture and social factors. So, it is important to identify the influence of these factors on the environment, formulate interventions to modify and finally evaluate the result.
• Empowering Community Actions: The actions of people struggling to gain mutual objective develops a sense of empowerment and finally develops the capability of the whole community. So, to empower a community should be organized empowerment programs regarding Mental health from National or community levels.
• Advancing Personal Skills: To make people understand and aware regarding Mental health and its importance, Governmental & Non-Governmental Organizations can organize regular awareness program especially for the people in rural areas where they are unable to access communication technologies. Because Mental Health Literacy is the root of Mental Health Promotion.
• Re-establishing Health Services: Health service sector re-establishment should be done with the provision of enough mental health manpower and resources. The manpower of specialists in mental health, i.e., psychiatrists, psychiatric nurses, clinical psychologists, psychiatric social workers, etc., must be further developed. Additionally, provision of required training for health care staffs should be done. Motivation and Positive Incentives to convince health care workers to agree to work in remote areas as well.

These are the importance of the above-discussed health promotion intervention according to the World Health Organization. (WHO, 2001, 2004 & 2006)

Recommendations

To resolve the issue on Mental Health I have formulated some recommendations. First and foremost, the action is to promote Mental health literacy among people through advertisement, media, school, colleges, etc. School, Colleges are the best areas to apply to this educational program. Similarly, programs related to speaking up regarding stress, anxiety, failure, etc among student is one of the best ways to address mental health problem from the root level. Likewise, awareness programs can be conducted based on drug addiction, bullying, identification of sign and symptoms of psychiatric problems, etc. (Barry et al. 2013) In addition to these approaches stress management and prevention strategies can be implemented in workplace in order to prevent staffs from work-related stress which may further lead to mental problems. Similarly, to provide support and gain empowerment among a group, a support group can be formed so that they can determine the risk of mental issues and refer them for treatment or counselling accordingly.

On the other hand, to address the challenge of stigma related to the mental issue, we can conduct programs like ‘Let’s take the initiative of the World Health Organization’, which helps in sharing their problems in a group and reducing social stigma among people to some extent. (Rijal, 2017)

Besides, we can promote organizations like KOSHISH, which aim is to help people with psychiatric disorders to live a respectful life through the formulation and application of new health policies, an extension of community mental health services and creation of supportive groups. (Koshish, 2018)

Conclusion:

At the end of this article, I would like to sum up that, there are various Health promotional Needs identified as per the previous articles. Firstly, Nepal is a poor socio-economical country that is the main problem leading towards Mental health disparity. Some social determinants of mental health were identified: Education & Literacy, Social Status/Ethnicity/Religion, Access to Health Services and health Seeking behaviours. These are the determinants that directly impacts on the mental health of the common population. Likewise, there is a lack of Mental hospital (especially in rural areas), Insufficient health resources & Budget and another important need identified is lack of mental health education within the Nepalese community. According to the WHO Health Promotion Model and Principle, there are few aspects to be focused on and various interventions to be done to promote Mental Health Services. Governmental organizations & NGOs are supposed to focus on Developing healthy Mental health policy, promoting a supportive environment, Empowering community actions, Advancing personal skills and reorienting health services. With the better implementation of these Mental Health Promotion strategies, we can reduce Mental Health Issues and eventually increases Mental health literacy among Nepalese people to some extent.

References:

• Barry, MM., Clarke, AM., Jenkins, R., Patel, V. (2013). A systematic review of the effectiveness of mental health promotion interventions for young people in low- and middle-income countries. NCBI, Pub-med. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/24025155
• Devkota. M, (2011). Mental health in Nepal: The voices of Koshish. American Psychological Association. Retrieved from: https://www.apa.org/international/pi/2011/07/nepal.aspx
• Jenkins, R., Baingana, F., Ahmad, R., McDaid, D., Atun, R. (2011). Mental health and the global agenda: core conceptual issues. Mental health in family medicine. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3178188/
• KOSHISH. Retrieved Oct 29, 2018, from http://koshishnepal.org/about
• Luitel, N. P., Jordans, M. J., Adhikari, A., Upadhaya, N., Hanlon, C., Lund, C., & Komproe, I. H. (2015). Mental health care in Nepal: current situation and challenges for development of a district mental health care plan. Conflict and health, 9, 3. doi:10.1186/s13031-014-0030-5
• New Comer Health Matters (2016). The effects of stigma on accessing mental health care. Retrieved from: https://newcomerhealthmatters.com/2016/03/23/the-effects-of-stigma-on-accessing-mental-health-care/
• Nutbeam. D. (2000). Health promotion effectiveness – the questions to be answered. In: A report for the European Commission by the International Union for Health Promotion and Education. The evidence of health promotion effectiveness: shaping public health in a new Europe. Brussels Luxembourg, European Commission, 1–11.
• Rijal. A, (2017). Mental Health situation in Nepal and priorities for interventions. Health Prospect: Journal of Public Health. Retrieved from: file:///C:/Users/goics/Downloads/19662-62835-1-PB.pdf
• Simkhada. P., Teijlingen. E. R. & Marahatta. S. B. (2015). Mental health services in Nepal: Is it too late? Research gate. Retrieved from: https://www.researchgate.net/publication/282519919_Mental_health_services_in_Nepal_Is_it_too_late
• Subedi. M & Dahal. GP, (2015). Social Determinants of Health in Nepal: A Neglected Paradigm. Research Gate. Retrieved from: https://www.researchgate.net/publication/289540976
• WHO (2001). Strengthening mental health promotion. Geneva, World Health Organization (Fact sheet, No. 220).
• WHO (2004). Promoting Mental Health. Geneva, World Health Organization, 27-50, Retrieved from: https://www.who.int/mental_health/evidence/en/promoting_mhh.pdf
• World Health Organization. (2006). WHO-AIMS report on mental health system in Nepal. Retrieved from: http://www.who.int/mental_health/evidence/nepal_who_aims_report.pdf