MANISHA SHASTRI, NIYOSHI SHAH, JASMINE KALHA | 19 AUGUST, 2020
The strength of this model lies in its use of social capital
It is often thought that mental health conditions are more prevalent in urban areas because people in the villages lead relatively stress free lives. The reality, however, is far from this.
The National Mental Health Survey of 2016 recorded that about four out of 100 people in rural areas were likely to face depression in the course of their lives. This distress is caused by an interplay of poverty, social discrimination, partner violence, and loneliness amongst other factors. Alcohol and tobacco use, which can be classified as substance use disorders, is also high. These challenges are compounded by a marked lack of mental health care services.
Approximately 150 million people in India suffer from some form of mental illness but there are gaping disparities in the distribution of trained professionals. Currently the country has about four psychiatrists per million people, most of whom practice in urban settings that are difficult to access due to basic deficits such as lack of transport.
Inadequate infrastructure and lack of mental health professionals aren’t the only barriers though. The decision to seek support is also shaped by far subtler aspects.
Lack of awareness, appropriateness, stigma, and affordability also contribute to what is called the ‘mental health care gap’. In India according to the same 2016 survey, between 70 and 92% of persons in need of mental health care were unable to access quality services.
There is a need for innovative, evidence-based and community-led solutions and resources that complement the public health system. Recognising this, in 2013 the Centre for Mental Health Law and Policy in Pune started the Atmiyata program, which now operates across 615 villages in the Mehsana district of Gujarat.
Atmiyata, which means ‘shared compassion’ in Marathi and Gujarati, is a core tenet of this intervention, based in part on the Sadharanikaran theory of communication which also centres on the idea of shared compassion.
Atmiyata uses community-based volunteers, ‘Champions’ who are local village residents and are trained to provide low-intensity, evidence-based counselling techniques to those in mental health distress in their villages. A referral pathway is also created to connect those with severe mental health conditions to specialised services at the nearest facility such as the district hospital, the primary or community health centres.
In addition the volunteers narrow-cast films about social determinants of distress, which helps begin conversations about people’s daily struggles that impact their mental health.
The Atmiyata model is designed on the premise that well being isn’t merely the absence of illness, it is about leading full lives; well being is based on the ability to participate in society as equal members.
Therefore the programme links people in distress from vulnerable and marginalised groups to social care benefits such as disability certificates, housing and pension schemes, and so on.
Since 2018 some 16,580 individuals with common mental disorders have been reached out to; 2,535 individuals with severe mental health conditions have been provided with referrals and linked to the public health system, access to social benefit schemes has been facilitated for 5,964 individuals and 62,042 individuals have viewed the films being narrowcast.
The strength of this model lies in its use of social capital. There are various types of mental health services that can be organised into a pyramid. On the top are specialised care services that often are more expensive (say, a mental health hospital), while at the base of the pyramid are self-care and informal care, which indicate higher need for and lower cost interventions.
Atmiyata fills in the care gap through improving informal care at the community level, to provide more people with psychosocial support. It is therefore an evidence-based and scalable solution to the mental health care gap that other populous and low-income countries too can adopt.
The need for such programmes is emphasised by the ongoing pandemic, which has laid bare the inadequacies and inequities of our health and mental health infrastructure.
Since March 2020 when the first lockdown was imposed, more than 500 Atmiyata champions have been working on the ground to raise awareness about Covid-19, its impact on mental health, and provide psychosocial support in their villages.
To address distress during the lockdown, Atmiyata’s champions circulated specially designed videos among their networks. These videos gave practical tips for ensuring the wellbeing of different groups of people during the pandemic—children, the elderly, persons with disabilities, and caregivers. Visuals with narration were used to overcome barriers of illiteracy and were shared over commonly used platforms such as WhatsApp.
However the role of the volunteers was not limited to disseminating supportive content. Over a phone call one afternoon, Varshaben Vaghela, a champion from Sendrana, told us how people were initially unconcerned.
“They weren’t ready to implement the lockdown. They thought it only pertains to the cities.” She and some others then approached the Sarpanch and conducted meetings across the village to explain the need for protective measures - though the problem wasn’t limited to these.
Most understand the importance of being cautious but the current situation is bewildering. People often feel robbed of their agency with the restrictions on mobility. This has sometimes led to clashes, where champions like Varshaben had to step in.
“When a person visits the village they are asked to stay indoors, they are quarantined, but they don’t always cooperate,” explains Shailesh Solanki, Atmiyata’s project manager.
“The government can be coercive, but we take a different approach. We don’t say ‘I am here to help.’ Instead, we apply our learnings from the programme, and first introduce ourselves before asking, ‘May I help?’”
The manner Atmiyata engages with stakeholders has fostered a strong sense of ownership within the community, examples of which range from champions voluntarily stitching masks and distributing them for free, to discussing how the lockdown will lead to an increase in domestic violence which must be addressed.
Chetanbhai Bharvad, who teaches at a school in the small village of Della and has been volunteering with Atmiyata for four years now, expresses concern about how the children will continue their studies.
He is worried that a simplistic shift to digital platforms may not work. In his village, most children use mobile phones to play games — they are viewed as a recreational device, not an educational one.
Also, parents may not have the time or ability to provide mentorship – Della has just a handful of graduates and is largely deprived of the capital to support a child’s learning and growth.
Thus the role of the champions is not limited to lay counselling support; rather it is about ensuring the overall well being of the communities they are part of.
In the absence of a robust public health system and other support infrastructure, models such as Atmiyata enable communities to define ‘wellbeing’ for themselves, and actively pursue it through problem solving, contextualised support, and simple acts of empathy.
Or in the words of Shailesh, by asking, ‘May I help?’
Jasmine Kalha is a Programme Manager and Research Fellow, and Niyoshi Shah and Manisha Shastri are Research Associates, at the Centre for Mental Health Law and Policy, ILS, Pune
Cover Photo: This photograph was taken by Zacharie Rabehi, on assignment for The Citizen. Zacharie covered the impact of a drought in rural Tamil Nadu, Karnataka and Maharashtra, and the human toll of the crisis, including farmer suicides. This photograph shows residents filling their jugs from a broken pipe in Anna Nagar, Thiruvennainallur district in Tamil Nadu