Farmers’ Suicides and Psychosocial Intervention:

Endline Assessment of Vidarbha Psychosocial Support and Care Program

U.Vindhya, Ph.D. & Sunayana Swain, Ph.D.

School of Gender Studies

Tata Institute of Social Sciences, Hyderabad

November 2018

1
2
 TABLE OF CONTENTS

Acknowledgements……………………………………………………………………………………………………………………………………4

List of Tables & Figures………………………………………………………………………………………………………………………………5

1. INTRODUCTION..........................................................................................................................................6

1.1. Objectives of the endline assessment..................................................................................................7

1.2. Structure of this report........................................................................................................................7

1.3. The context of community mental health programmes in India…………………………………………………….8

1.4. Agrarian distress, farmer suicides and the VPSCP model..................................................................12
2. METHODOLOGY OF THE ENDLINE ASSESSMENT.................................................................................14
2.1. Field site.................................................................................................................................................14
2.2. Key sources and procedure...................................................................................................................14
2.3. Sample.....................................................................................................................................................15

2.4. Tools....................................................................................................................................................... 15

3. FINDINGS OF THE ENDLINE ASSESSMENT...............................................................................................20

3.1. Perspectives of key stakeholders ..............................................................................................................20
3.2. Perceptions of psychosocial stress in the community.............................................................................25

3.3. Socio-demographic profile of surveyed sample.......................................................................................28

3.4. Present treatment status of PWMI..........................................................................................................29

3.5. Current clinical status of PWMI.............................................................................................................32

3.6. Satisfaction of users with services......................................................................................................34

3.7.Awareness about mental health in intervention and non-intervention villages..................................37

3.8. Impact of the VPSCP on suicide trends in Yavatmal district (2001-April 2018).......................................38
4. CONCLUSIONS AND WAY FORWARD..........................................................................................................46

5. REFERENCES...............................................................................................................................................50

6. APPENDICES...............................................................................................................................................51

3
 ACKNOWLEDGEMENTS

Grateful thanks are due to all the participants across the villages of Yavatmal and Ghatanji blocks
in Yavatmal district of Maharashtra who spared their time and responses on their association with
the Vidarbha Psychosocial Support and Care Program (VPSCP), even as they bear the tremendous
range of economic and psychosocial stresses in their everyday lives. We are indebted to the VPSCP
staff – the key functionaries, Praful, Shammi, Sachin, Sumit and the health workers/counsellors,
Chetan, Ankush, Prateek, for their inputs and reflections. To Sumit a special word of thanks for
the data entry and overall logistical coordination. Thanks are also due to the data collectors,
Rambhau, Bharti, Chandrakant, Pritam, Sheetal for the sincere and careful gathering of individual-
level data through the questionnaires.

Thanks are due to the funders of this project, Tata Education and Research Trust, for the
opportunity the project gave us to understand the interface of mental health and social justice in
the context of agrarian distress in the region, and to reflect on ways to reach care and support to
those in need.

U.Vindhya
Sunayana Swain

November, 2018

4
 LIST OF TABLES

Pg. No
1 Sample of the Study 14
2 Scope of VPSCP 20
3 Women’s & Men’s Perception of Psychosocial Stress 25
4 Socio-demographic characteristics of VPSCP users 27
5 Diagnostic Norms for PHQ-9 30
6 Norms for Overall Satisfaction 36
7 Frequency Distribution in Overall Satisfaction & its Dimensions 38
8 Socio-demographic characteristics of respondents in Intervention & Non-Intervention 40
villages
9 Norms for Level of Mental Health Awareness 41

LIST OF FIGURES

Pg. No
1 Relationship between Poverty and Mental Disorders 8
2 Diagnostic Categories Across Gender 21
3 Availing VPSCP Services 29
4 Availing VPSCP Services across Gender 29
5 Reasons for Discontinuation of VPSCP services 30
6 Intensity of Symptoms 31
7 Intensity of Symptoms across VPSCP categories 32
8 Source of Information amongst VPSCP users 34
9 Type of Service received from VPSCP 35
10 Feedback to the services availed from VPSCP 36
11 User’s Satisfaction with VPSCP services- Overall & Dimensions 38
12 Level of Mental Health Awareness in Intervention & Non-Intervention Villages 41
13 Farmer suicide trend pre- and post-VPSCP 44
14 Farmer Suicide Trend, 2001-18, Yavatmal District 45

5
 1. INTRODUCTION

This report is an attempt to provide an assessment of the effectiveness of the services of the
Vidarbha Psychosocial Support and Care Program (VPSCP) implemented in the economically
disadvantaged locale of Yavatmal district of Vidarbha region in the state of Maharashtra.
Specifically, the report aims to capture the perspectives of the key stakeholders on the process
and functioning of the programme, its strengths and challenges, perceptions of psychosocial stress
in the community; and to assess the current mental health profile of the users;factors contributing
to the continuation or discontinuation of treatment by users; awareness and attitudes about
mental health among the community; and satisfaction of users with the services provided by
VPSCP.

The VPSCP was initiated in April 2016 in response to the widespread phenomenon in recent
decades of suicides of farmers in the Vidarbha region of Maharashtra triggered by agrarian
distress and economic vulnerability. While there have been state and civil society interventions for
enhancing livelihood opportunities in the region, the issue of psychosocial support and care to
those affected by agrarian distress and its concomitant psychosocial distress has not been thus far
directly addressed.

It was therefore in this context that Tata Trust conceived and designed a multi-pronged strategy to
primarily address and alleviate the psychological consequences of adverse circumstances and
ensure the delivery of mental health care services to those in need in Yavatmal district in
Maharashtra.

The key objectives of the VPSCP project pertain to the following four domains:

1. Remedial: To identify people with psychosocial distress/mental illness and to provide

appropriate care and treatment and make referrals
2. Preventive: To conduct outreach activities for enhancing mental health awareness in the
community
3. Training: To provide training to a range of mental health care workers
4. Convergence: To formalize and strengthen linkages with the government, NGOs, and
public health institutes for livelihood programmes

The project’s commitment is driven by a public health approach and a social justice perspective
reflected in its emphasis on addressing the needs of the underserved and socially and

6
economically disadvantaged populations; and for whom a range of psychosocial services are
aimed to be provided in a manner that is accessible, affordable and acceptable.

The project is also embedded in the community mental health movement in India and its
recognition that one third of the chronically mentally ill in the community are in need of
treatment. It is the need to “reach the untreated” that is the key factor providing impetus to the
community mental health approach and programmes (Thara et al, 2008) and that is the driving
force for the current project too.

This report is based on the field visit of the evaluation team in September 2018 to know and
understand first-hand the implementation and impact of the programme and analysis of the data
gathered during the visit and from the programme functionaries.

1.1. Objectives of the endline assessment

The specific objectives of the end line assessment are as follows:

1. To assess the perspectives of key stakeholders on various dimensions of the referral
system, facilitating and constraining factors, content and quality of training and the modes
of convergence with state livelihood schemes.
2. To understand perceptions of psychosocial stress in the community
3. To assess the present treatment status of people identified with mental illness (PWMI) and
factors contributing to the continuation or discontinuation of treatment by the PWMI
4. To evaluate the post-intervention clinical status of PWMI
5. To determine the satisfaction of clients with care services provided by VPSCP and thereby
the usefulness of the services
6. To assess levels of mental health awareness in the community.

1.2. Structure of this report

Chapter one of the report will provide a brief overview of the larger context of community mental
health care in India, and the location of theoverarching vision and objectives of the VPSCP project
in this larger context. Chapter two will detail the methodology of the research study carried for
purposes of the evaluation. Chapter three will present and examine the findings in each of
thecomponents of the evaluation:

7
 1. Perspectives of key stakeholders on the process and functioning of the programme,
training and capapcity building of the health care workers and level of convergence
with livelihood programmes of the state and non-governmental organziaitons.
2. Perceptions of psychosocial stress in the community
3. Remedial: a) current treatment status and post-intervention clinical status of users;and
b)satisfaction expressed about the type and nature of services provided by VPSCP.
4. Preventive: nature of awareness and attitudes about mental health and mental health-
seeking behaviour of the users.

Chapter four will pull together lessons learned about what constitutes the VPSCP model of
community mental health care and present recommendations of the evaluation team based on
the data gathered, interactions with personnel and the documents perused.

1.3.The context of community mental health programmes in India

Recent literature on mental health in low and medium income countries (LMIC) indicates the
emergence of mental disorders as a major public health problem (Funk et al., 2010; Shidhaye and
Patel, 2012). Estimates in India point to the enormous magnitude of the problem – about 150
million persons are in need of mental health care (Gururaj et al, 2016) and mental and substance
use disorders contribute to 5.6 per cent of the total Disability Adjusted Life Years (Dandona et al,
2017).Two key themes are evident in this literature: a) the socio-economic correlates of mental
disorders and b) the uneven gap in mental health care services. A growing body of research points
to the association of mental disorders both as causal and consequential factors with socio-
economic vulnerabilities such as poverty and food insufficiency (Gururaj & Isaac, 2004),
urbanization, migration, housing (Desjarlais, et. al. 1999; Patel, 2005, 2007; McKenzie, 2008);
gender disadvantage, low education, conflict, social exclusion, loss, trauma and displacement due
to war, disasters and civil violence, with vulnerable groups reporting high rates of mental health
conditions(Kururvilla & Jacob, 2007; Lund et al, 2010; Saxena et al, 2007; Patel & Kleinman,
2003).Increasing psychological distress is seen in countries with rapid socio-economic change such
as India with increasing urbanization, disparities between expectations and reality, and
accompanying social upheaval in terms of eroding family support systems and new forms of
external emotional support few and scattered (Chatterjee, 2009). Together with social upheaval
and change in our country, is the huge burden of poverty whose relationship with mental health is
complex and multidimensional (Figure 1).

8
 Figure 1. Relationship between poverty and mental disorders

The second theme relates to the uneven gaps in the availability of mental health care services and
the inability of traditional psychological and psychiatric models to provide the quantity and quality
of mental health services required.

In low-income countries, the relatively few existing estimates of mental ill health suggest that
prevalence levels are not significantly lower than those found in wealthier countries (Bijl, de Graaf,
Hiripi, Kessler, Kohn, Offord, et al., 2003; Patel, Araya, de Lima, Ludermir, & Todd, 1999).
Resources and services for mental disorders are disproportionately low compared to the burden
caused by these disorders and large proportions of severely mentally ill populations in the
developing world receive no treatment for their disorders, suggesting widespread under-
utilization, poor access and hence unmet mental health needs (Das et al, 2008; Funk et al., 2010).
Between 75% and 90% of people with mental disorders are said not to receive medical treatment
in these countries (Saxena et al., 2007; Patel, Boyce, Collins, Saxena, & Horton, 2011).In most
developing countries, care programmes for the individuals with mental health problems have a
low priority. For instance, in low-income countries, depression represents almost as large a
problem as does malaria (3.2% versus 4.0% of the total disease burden), but the funds
apportioned for battling depression are only a tiny fraction of the latter (Mathers&Loncar, 2006).
Provision of care is limited to a small number of institutions which are usually overcrowded and
9
under staffed (Shah, 2005). Despite their vulnerability and the high prevalence, people with
mental health conditions have been largely overlooked as a target of development work (Funk et
al., 2010).

1.4.The need for a community mental health approach: Advocatesof thecommunity mental
health approach underscore the view that the huge burden of unmet mental health needs cannot
be addressed by a mere extension of the existing traditional psychological and psychiatric services
(Campbell & Burgess, 2012). They are critical of the tendency to medicalise peoples’ responses to
life problems such as unemployment or social displacement and other adverse social
circumstances which serves to cloak the health-damaging effects of social and economic inequities
and the ensuing stress (Campbell & Burgess, 2012). The limitations of the professionally-
controlled, medicalized approaches have led to the socio-political recognition of those with
serious mental health problems as an oppressed group with lack of power and control, stigma, and
lack of resources as tangible manifestations if their lived realities (Nelson, Lord, & Ochocka, 2001).

The psychosocial, socio-economic and cultural correlates of mental health and its significant
impact in low and middle income countries, the large mental health burden and its vastly unmet
status, and the poor resource availability build therefore, a strong case for the adoption of a
community mental health approach.

Developing community mental health services has been a key recommendation of the WHO
(2010) in addition to deinstitutionalization fo mental health care and integration fo mental health
into general health care. The community mental health approach is visualized as going beyond a
treatment-oriented approach and includes vital features such as promotion of well-being, removal
of stigma and providing psychosocial support, and rehabilitation of those in need.

1.4.1. The community mental health programme in India: The District Mental Health Programme
(DHMP) set up under the aegis of the National Mental Health Programme (NMHP), envisaged a
decentralized community based approach that aimed at developing effective partnerships and
active collaborations between the district mental health team, and various stakeholders such as
the primary health care teams, community based organizations, non-governmental organizations,
users, family groups and various government departments to deliver a comprehensive and
sustainable mental health care service that ensured accountability and focused on the local needs,
and aspirations of the people with regard to mental health. Key components of the DMHP were

10
listed as early identification and treatment, short-term training to general physicians for diagnosis
and treatment and to health workers for detection of the mentally ill, raising public awareness
about mental health, and monitoring(Salhan&Thara, 2007; Murthy, 2011).

However, despite the ambitious initiatives of the central government in the form of the DHMP and
increased resource allocation as also other initiatives towards enhancing the accessibility and
quality of mental health services, research evidence on the functioning, effectiveness and impact
of the community mental health programme has not been very promising (WHO’s Mental Health
Atlas, 2005; Murthy, 2004; Jacob, 2001). A vast imbalance in access persists with most specialist
centres concentrated in urban areas (Murthy, 2004) and several instances of human rights
violation of the mentally ill being reported (Shidhaye& Patel, 2012). Evaluations of the DMHP also
indicates that the programme is to a large extent dysfunctional and ineffective in practicewith its
implementation in only 127 of 640 districts in India and its lack of fine tuning and inadequate
utilization of funding allocated (Murthy, 2011; Shidhaye& Patel, 2012; Chatterjee, 2009).

Reasons for the disappointing performance of the DMHP have been stated to be a ‘top-down’,
‘one size fits all approach’ to service delivery, inability to include diverse realities, poor
governance, lack of a robust mentoring framework (Shidhaye& Patel, 2012); ill-paid and
overburdened primary health care personnel (Goel,2011); the lack of a policy document clearly
stating goals, objectives, strategies and tasks with the result that the programme is variously
interpreted and implemented at the district level (Ministry of Health and Family Welfare, 2008);
and disproportionate reliance on psychiatric and psychopharmacological management with
minimal engagement with community health workers, psychosocial counselling, access to
livelihood and employment generation programmes, support groups and family-based
interventions (Goel,2011; Ministry of Health and Family Welfare, 2008).

Researchers in the field underscore the point that delivering mental health care in India will
require task-shifting to community and non-physician health workers who are trained and
supervised (Patel, 2009, Chisholm, Flisher, Lund, Patel, Saxena, Thornicroft, & Tomlinson, 2007).
Empirical evidence for such a perspective and efficacy of such a practice is to be found in
programmes such as MANAS (Patel, et al, 2010), community based rehabilitation of schizophrenia
in rural Madhya Pradesh (Chatterjee, Patel, Chatterjee, & Weiss, 2003; Chatterjee, Pillai, Jain,
Cohen, & Patel, 2009); the integration of a community-based mental health programme with a

11
community-based palliative care initiative as in Kerala by MHAT; and the Rural Mental Health
Programme by Banyan in Tamil Nadu (Balagopal&Kapanee, 2014), to name a few.

1.5. Agrarian distress, farmer suicides, and the VPSCP model. The suicides of farmers and
weavers in India is a telling example of socio-economic vulnerabilities being a powerful
determinant of their physical and psychological well-being. Of the more than quarter million
farmer suicides in the country in the last 15 years (1997-2011), more than one-fifth are from the
state of Maharashtra with the western parts of the Vidarbha region in the state reporting very
high incidence of farmers’ suicides (National Crime Records Bureau, 2012). The suicide mortality
rate estimated for farmers in the region, based on mixed methods comprising a field survey and
qualitative focus group discussions, was found to be 116 for 100,000 persons (Mishra, 2014). The
same study identified factors such as higher indebtedness, lower value for produce even when
normalized by land size, larger family size, and higher number of daughters (implying a higher
economic liability of dowry) and the absence of bullocks required for cultivation as significantly
associated with households that reported farmer suicides compared to control cases (Mishra,
2014).

It is in this context of widespread agrarian distress in the Vidarbha region that the VPSCP
intervention aimed to address and alleviate the psychological consequences of adverse
circumstances characterized by socio economic disadvantage. In order to do so, the
modeldesigned sought to carry out the following:

o Identification of individuals with mental health problems

o Making referrals to existing medical or psychiatric services in the vicinity

o Counsellingservicesand offering emotional support to individuals and small groups,

and improving people’s coping mechanisms.

o Community education aimed to break down taboos about mental health and
psychosocial problems, to increase awareness about mental health and counselling
services.

o Making linkages with state livelihood programmes

12
The range of services provided by VPSCP therefore seeks to demonstrate its underlying
commitment to a comprehensive mental health care paradigm that in addition to making available
necessary bio-medical attention, aims to offer humanized care to the client. The following table
presents the number of users as per the diagnostic categories across the villages in Ghatanji and
Yavatmal blocks that were the sites of the intervention programme.

13
 2. METHODOLOGY OF THE ENDLINE ASSESSMENT
2.1. Field site
Yavatmal district is one of the 11 districts in Vidarbha region of the state of Maharashtra and
consists of 16 tehsils or blocks and 2137 villages (District Census Handbook, 2011). With its agro-
climatic zone being categorized as receiving moderate rainfall, agriculture in the district is
principally rainfed and/or dependent on well irrigation. Principal agricultural crops are cotton,
followed by sorghum and soybean (Krishi Vigyan Kendra).

The endline assessment was carried out in the two blocks –Yavatmal and Ghatanji – of Yavatmal
district, wherein the VPSCP intervention program is currently being implemented. While the
intervention is implemented in 64 villages of the two blocks of Yavatmal and Ghatanji, the
assessment was carried out in 27 villages – 12 in Yavatmal and 15 in Ghatanji, including four non-
intervention villages in Ghatanji block.

2.2. Key sources and procedure

The assessment is based on data gathered on

1. Perspectives of key informants such as the VPSCP project coordinators, community health
care workers/counsellors in the project, hospital staff to whom VPSCP makes referrals;
community-level front line paid volunteers called Krishidoots; and ASHA workers on the
origins and process of the programme, and its strengths and challenges.

2. Perceptions of psychosocial stress in the community

3. The current mental health status profile of PWMI who have used VPSCP’s services in the
two blocks of Yavatmal district (population of around 50,000 individuals)

4. The present treatment status of PWMI

5. Awareness in the general community about mental health issues and mental health-
seeking behaviour.

6. Satisfaction expressed with regard to the type and quality of services and care provided by
VPSCP; perceived impact of the services on psychosocial coping mechanisms and perceived
improvement in functionality and reduction of psychological distress from the perspective
of the user.
14
 2.3. Sample

The samples constituted for the different components of the present study were as follows.

Table 1. Sample Size of the present Study

S.No. Domain Sample
1. Perspectives of significant 21
stakeholders (Project coordinators,
Representatives of public health
institutes; health care workers )
2. Perceptions of psychosocial stress in 66
the community
3. PWMI Present Treatment Status -- 119***
factors contributing to continuation
or discontinuation of treatment
4. PWMI Post-intervention Clinical 119***
Status
5. Levels of mental health awareness 267***

6. Satisfaction with care services 119***

*N = 1274; Using Cochran’s Formula with correction, CI = 95%, p =0.5, e = .05

**N= 23905; Using Cochran’s Formula with correction, CI = 95%, p=0.5, e=.05

***Note: Due to time constraints, the final sample size was pared down to the current figures

2.4.Tools

Theassessment used a combination of quantitative and qualitative research tools to gain a

better understanding and insights into the effectiveness of the programme. Specifically the
tools used were as follows:

1. Qualitative semi-structured interview schedules with 21 key informants -- the programme

coordinators, representatives of public health care system, grass-root level health care
workers/counsellors, about the genesis and evolution of the VPSCP programme, the nature
of services provided and their perceived impact

2. Qualitative focus group discussions with four different age cohorts – adult men and
women, and adolescent girls and boys (total of 66 individuals) -- for understanding of the
patterns, perceived causes and consequences, help-seeking behaviours and coping
mechanisms related to psychosocial stress in the community.

15
 3. A brief 9-item schedule for the socio-demographic profile of and evaluation of present
treatment status of those identified as people identified with mental illness (PWMI) by
VPSCP and of factors contributing to the continuation or discontinuation of treatment by
the PWMI.

4. The Primary Health Questionnaire (PHQ-9), a nine-item standardized questionnaire for

evaluation of the post-intervention clinical status of PWMI.

5. A 22-item questionnaire adapted from the Knowledge, Attitude and Practice Questionnaire
for Health Workers (Department of Psychiatry, NIMHANS, Bangalore); andthe ICMR
evaluation study of DMHP for assessment of levels of mental health awareness.

6. A 24-item scale developed and adapted from the Mental Health Service Satisfaction Scale
(Mayston et al, 2017) and Verona Service Satisfaction Scale (Ruggeri &Dall’Agnola, 1993)
for assessment of levels of satisfaction of users with type and quality of services, and
perceived improvement in functionality and alleviation of psychological distress was done.

[all the instruments used are listed in Appendix 1].

Five data collectors (two women and three men) recruited for the prupose gathered the
quantitative data using the structured interview schedule and the questionnaires on awareness
about mental health and satisfaction with the services. Four of them were post-graduate students
of Social Work while one of them had a Master’s degree in Women’s Studies.

The two consultants for the project conducted the key informant interviews and the focus group
discussions. The visits and meetings were facilitated by VPSCP staff. Notes were taken during the
observations and interviews. This report draws on all these sources. Informed consent was taken
from all the study participants, and other ethical guidelines such as maintaining participants’
anonymity and confidentiality were followed.

The data analysis framework is presented below.

16
 DATA ANALYSIS FRAMEWORK

I. QUALITATIVEANALYSIS
Sn Objective Tools Date Location Sample Domain & Analysis
o

1. To understand the FGD 1 20/9/18 Undarni 18 women

perceptions of
psychosocial stress FGD2 20/9/18 Undarni 5 men
in the community
FGD3 20/9/18 Sasani 8 women

FGD4 20/9/18 Sasani 8 men

FGD5 21/9/18 Wadgaon P.S 11 men

[Milk
Collection
Centre)
Sources of stress;
FGD6 21/9/18 Varzadi, 6
SarojinibaiLon adolescent Coping mechanisms
kar High boys
School and
Junior College Thematic analysis

FGD7 21/9/18 Varzadi,Saroji 13

nibaiLonkar adolescent
High School girls
and Junior
College

2. a. To assess the FGD 8 19/9/18 Aakpuri 10 Frontline Process & functioning

perspectives of Key workers ofVPSCP
stakeholders (ASHA, AWC
i.Getting involved;
sevika, ii.Identification&
Volunteers, recognition of MI
Krushidoot, symptoms; iii.Responding
VDO, Gram to cases ofPWMI;
Panchayat iv.Impact of VPSCP
clerk) Thematic analysis

17
b. Key 18/9/18 Yavatmal, 4: Origins of the program
inform and how it was rolled
19/9/18 Ghatanji Project
ant out; Specific objectives of
Intervi Coordinator theprogramme and
20/9/18 Programme
ews changesmade if any
Officer, subsequently’ Staff,
Block structure & functions;
Coordinator Ongoing &
Cluster continuingchallenges in
Coordinator implementation;
Strengths of the
programme

Thematic analysis

Key 19/9/18 Yavatmal 3:Psychiatris Involvement with VPSCP;

inform t,Psychiatric Strengths and challenges
ant Social of the programme
intervi Worker,
ews Psychologist Thematic analysis

c. Key 19/9/18 Yavatmal, 4 Recruitment; Content of

inform Ghatanji counsellors training andmethods;
ant 20/9/18 Roles & responsibilities;
intervi Compliance
ews withtreatment regimen;
Periodic follow-
up[assessment &
treatment]; Outreach
programmes; Challenges

Thematic Analysis

18
 II. QUANTITATIVE ANALYSIS

S.n Objective Tools Date Location Sample Domain & Analysis

o
1. To assess Survey 18th – Pimpri Butti (Y), Hatgaon 119 Factors contributing to
present Questionn 21st (Y) Undarni (G) Sasani (G) continuation/discontin
treatment aire Sept Aakpuri (G) Nakapardi (G) uation
status of 2018 Karmana (G) Chorkund (G) of treatment
PWMI Kumbhari (G) Malmhasola
(Y) Manpur (Y) Kolmbi (Y) Cross tabulations
Ramnagar (Y) Wadgaon (Y)
Kinhi (G) MothaMowada
(G) Dahegaon (G) Ratnapur
(G) Hivari (Y) Bechkheda (Y)
Ghatan (Y) Dhanora (Y)
Ganeshpur (Y)
2. To evaluate Survey 18th - As above 119 Level of Depression &
the present Questionn 21st Dysfunction
clinical aire (PHQ- Sep
status of 9)
PWMI
3. To Survey 18th – As above 119 Components of the
determine Questionn 21st VPSCP
satisfaction aire Sep services
of clients (VPSCP Cross tabulations
with VPSCP Satisfactio
services n Scale)
4. To assess & Survey 19th - Intervention villages Interve Level of Awareness
compare Questionn 21st (Undarni, Sasani, Aakpuri, ntion
the levels of aire Sept Chorkund, Karmana); villages Comparative statistics
Mental (Awarenes (135) +
Health s about Non-intervention villages Non-
Awareness Mental (Murli, Belora, Anjin, interve
in the Health Manoli) ntion
community Scale) (132)
in
intervention
& non-
intervention
villages
Y refers to Yavatmal; G to Ghatanji

19
 3. FINDINGS OF THE ENDLINE ASSESSMENT

3.1. Perspectives of key stakeholders on genesis and process of VPSCP, and

convergence of the programme with state livelihood schemes

Tracing the origins of the VPSCP, the key functionary said that the funding agency (Tata Trust) had
initially given grants to various non-governmental organizations for addressing mental health
consequences of agrarian distress in the Vidarbha region. For instance in 2007, Tata Trust had
funded interventions in agriculture based activities such as soil and water conservation but there
had been no let up in the number of suicides in the region. It was in 2014 that there was therefore
a shift in approach and the funding agency came directly on board to design a programme that
would offer psychosocial counselling services for farmers in psychological distress. Started on a
pilot basis, it became a full-fledged intervention in 2016 with the following objectives

1. To identify people with mental illness and psychological stress in the district
2. To provide counselling services to farmers
3. To create awareness about mental health issues in the community
4. To create and provide mental health resources at the community level such as health
care workers

The VPSCP began in April 2016 with orienting the various stakeholders such as the ASHA workers,
Gram Sevak, and Sarpanch about the scope of the programme, training of counselors and
allocating one counselor for every 10 villages, identification of PWMI by these counsellors through
standardized screening tools such as the PHQ-9, Cross-cutting Symptom Measure (CSM), and
making referrals.

A conscious decision was not to have a psychiatrist on board but instead to ensure the reach,
accountability and sustainability of the government health facility. A significant linkage was made
with the Project Prerana, which was a government scheme initiated to help the farmers wherein
14 districts were identified as districts in agrarian distress with Yavatmal being declared as one of
them in the state of Maharashtra and the recruitment of a psychiatrist, psychologist, and two
social workers (as in the District Mental Health Programme) to provide mental health services.
Linkages were made with this programme which deputed a psychiatrist to conduct regular village
camps for diagnosis and treatment.The following table shows the total scope of work undertaken
by VPSCP from April 2016 till March 2018.

20
 Table3 : Scope of VPSCP, April 2016-March 2018

S.no Component/Sub-Component /Indicator

1. Sensitization and Capacity Building of Stake Holders Number

1.1 No. of ANM trained/sensitized 193
1.2 No. of ASHA trained/sensitized 562
1.3 No. of Awareness/Sensitization programs at Gram Panchayat 342

1.4 No. of members who attended awareness programme at GP level 4,004

1.5 No. of schools covered in Awareness program on Mental health 20

1.6 No. of Students participated in awareness program on mental health 996

1.7 No. of new household visited to build awareness and identification of 9,148
PWMI
2. Identification, Referral, Treatment, and Follow-up care of PWMI
2.1 No. of OPD/ Clinic organized (Health Camp) 7
2.2 No. of people participated in Health Camp 251
2.3 No. of people screened for mental illness 23,233
2.4 No. of PWMI identified 1,644
2.5 No. of PWMI enrolled in the programme 1,106
2.6 No. of clients enrolled on the programme outside catchment 18

2.7 No. of (New) PWMI referred for the Pharmacological Treatment 509

2.8 No. of (New) PWMI Received Pharmacological Treatment 223

2.9 No. of Persons enrolled with Severe Mental Disorders 170

2.10 No. of persons enrolled with Common Mental Disorders 553
2.11 No. of person enrolled with Other Mental Disorders (Epilepsy, Mental 127
Retardation, Alcohol)
2.12 No. of PWMI undergoing psychosocial intervention 3,324
2.13 No. of family members undergoing psychoeducation 3,149
3. Multisector Response
3.1 No. of PWMI assessed for the livelihood support 175
3.2 No. of PWMI referred for the livelihood support 143
3.3 No. of PWMI facilitated for the welfare scheme 27
3.4 No. of PWMI received welfare scheme 3

The two major components of the programme: a) identification of PWMI and the referral system
and b) provision of home-based counselling services and follow-up were thus designed to put in
place a pathway to mental health care that was aimed to empower the patient and his/her family
to seek help.

21
Process of mental health intervention, training and capacity building of counsellors. The
identification of PWMI is the cornerstone of the programme. As can be seen from the table above,
23,233 people were screened for mental health symptoms, following which 1644 were identified
as PWMI. A diagnostic category profile across gender indicates the following (Figure2):

 The proportion of both men and women affected by CMD is significantly more than that of
SMD, following the trend observed in earlier literature.
 More men have reported mental health issues which could imply that their access to
health care is better and also given the fact that there was no female counsellor in the
team could have been a factor hindering access of more women to come forward and seek
help.
 More men (56.1%) compared to 43.9% women have reported CMD symptoms which is not
in accordance with the general trend of more women being represented in CMD found in
earlier research. This can perhaps be attributed to the larger determinant of agrarian crisis
and related distress that is affecting the male farmers directly and more intensely than in
the case of men, leading to more depression, anxiety and substance use disorders in them.

Figure 2: Diagnostic Categories Across Gender

800

700

600

500

400 F

300 M

200

100

0
CMD SMD

The counsellors recruited for VPSCP are all men, and hold Master’s degree in Social Work. They
have received training in patient identification and counselling skills from faculty of the Institute of

22
Psychological Health, Thane and three trainings of two days each have been conducted so far with
particular focus on how to conduct home-based counselling in the community. The nature of work
of the counsellors was as follows.

Identification of PWMI Counseling techniques

Using standardized screening tools Use of BT – help with making a daily routine
chart
Making referrals to the hospital if patient had Use of CBT – working on cognitive distortions
SMD
Follow-up for adherence to medication, and Use of progressive muscular relaxation and
side effects deep breathing techniques
Psycho-education for the caregiver Occupational therapy
Changes in diet

The counseling sessions are terminated after the patient reports feeling better and follow-up
assessment of mental helath symptoms is done using scales such as IDEAS, and Quality of Life
Scale.

The Project Prerana had involved ASHA workers and provided training to them too in the initial
stage to identify symptoms of mental illness through the PHQ. On the basis of the scores these
workers would either inform Prerana or the 104 Helpline for referral to the psychiatrist in the
District Medical College/Hospital. The involvement of the ASHA workers was planned initially in
the VPSCP too but was given up since these workers would have to be incentivized. Subsequently,
VPSCP enlisted Krishidoots who are community-level front-line volunteers paid by the VPSCP to
implement the agricultural programme, and became a part of the network of health care workers
for this programme. The Krishidoots were given an orientation and training session to identify
PWMI with the help of standardized screening tools and also taking the assistance of the
Counselors and those above the cut-off score were interviewed by them to decide whether the
patients had active sympatology. Although intitially there was some resistance from the
Krishidoots saying that mental health issues were not within their domain, the resistance reduced
after they saw the benefits of the programme and the recovery of the patients.

Signficant features of the programme including assistanceand facilitation of the visit and
transportation to the hospital of those with severe mental orders, accessing medicines for them
(generic medicines were identified in order to reduce costs), follow up by the counsellors for
checking the adherence and compliance with medication and for side effects, free counselling

23
services for those with mild depression, significantly reduced the out-of-pocket expenditure for
mental health care following the intervention.

Outreach for prevention. A major activity of the VPSCP is conducting mental health education and
awareness programmes for the community and key stakeholders for publicizing the VPSCP with
the twin objectives of facilitating and strengthening help-seeking behaviour and for removing the
stigma associated with mental illness. These informative sessions conducted in schools and junior
colleges, in the gram panchayats commonly cover topics of what is mental health, what are
mental illnesses, identification of symptoms, avenues to report such cases to different front line
health workers like the ASHA workers (Sahiyoginis), erstwhile patients, Sarpanch, Krishidoot, and
the VPSCP staff. Recognizing the importance of psychological support in the lives of students,
discussions are also held on academic stress and methods to cope with them. The number of new
households (9,148) visited in order to build awareness about mental health and help-seeking
behaviour is an indicator of the active community engagement of the programme (Table ).

Convergence with state livelihood schemes. According to the chief functionary and a key architect
of the programme, the integration of mental health concerns with issues of livelihoods was an
underlying objective right from the beginning with the understanding that one response such as
counselling was not enough anda multi-sector response to an issue such as farmer suicide was
needed ...such as creating livelihood opportunities to support the farmers [interview excerpt].

Therefore a deliberate attempt was made to facilitate the farmers’ linkages with government
livelihood schemes so as to prevent occurrence of suicides among them. Efforts to engage with
the following governmental programmes and non governmental organizations were hence made
keeping in mind the underlying objective of prevention of suicide.

 Sanjay Gandhi Nirakar Yojana

 NAM Foundation
 Bal Sangopan Yojana
 CIAM (Convergence of Agricultural Integrated Maharastra) - Poultry,
Fishery
 MNREGA
 Chetna Bali Raja Abhiyan

24
Providing agriculture-related information and using technology such as MKrishi, to which the
farmers can give a SMS for any agricultural query or difficulty; showcasing through a
demonstration plot the procedures for growing cotton and soya; using Integrated Pest
Management for pest-detection are examples of handholding for improved agricultural practices.
Concurrently, those identified and recovered from mental illness from the ultra-poor category are
provided assistance by informing them about bank schemes and government programmes, and
financial help to set up goatery, dairy, and poultry. The cluster coordinator of the SukhiBaliraja
scheme highlighted how in earlier times only personal consumption of milk was present in the
villages but now with increased production, milk collection centres started by Tata Trust in various
places served to augment the income of the villagers.
3.2. Perceptions of psychosocial stress in the community

Patterns and sources of distress. Four Focus group discussions were conducted with different age
cohorts – adult men and women, and adolescent school-going girls and boys in order to explore
and guage the patterns/sources of psychosocial stresses they experience. The anlaysis of the date
corroborates the picture that has emerged from several earlier studies too. For instance, the study
by Mishra (2014) cited earlier mentions the following cluster of interrelated factors identified as
significant risk factors in order of their frequency and importance:

 Indebtedness
 Deteriorating economic status
 Not sharing problems with other family members
 Crop failure
 Decline in social position
 Daughter’s/sister’s marriage
 Suicide occurrence in the nearby villages recently
 Addictions
 Change in the behaviour of the deceased before the incident
 Disputes with neighbours or others
 Health problems

The patterns of perceptions of pyshcosocial stress that emerged from our Focus group discussions
with the adult men and women were fairly similar to the one mentioned above. What was rather
striking however was the difference in the perceptions of the men and women. All the men and

25
women who participated in the Focus group discussions mentioned farming as their principal
occupation and for a few, as the only occupations. The stresses described by them in order of
importance to them are as follows:

Table 3 : Women’s and men’s perceptions of psychosocial stress

Alcohol addiction of husband

Indebtedness
Caregiving for patients at home
Women Children’s education (payment of fees)
Balancing work at home and in the field
Burden of work in farm and at ahome and changes in eating and sleeping habits
Discrimination in wages
No work after December (kharif season) for 4 months
Rainfed agriculture, cannot sow another crop
Lack of support from government
Family conflicts
Indebtedness
Loss of honour
Crop damage and inadequate compensation from Forest department
Drinking alocohol
Education of children and payment of fees
Men Dowry and marriage expenses of daughter
Late coming of son
Distress sale of land
Lack of government support
No loan waiver
No supply of medicines in govt hospital and buying of medicines is costly

While alcohol addiction of the husband was cited as the most important psychosocial stress for
the women, closely followed by financial problems, for men it was indebtedness that was
identified as the most stressful. The women’s group described a variety of sources from which
loans are taken – banks, self-help groups, private micro-finance companies and private money
lenders – while the men mentioned the high interest rates of private money lenders in particular,
with some of them pointing to money lenders coming from neighbouring Telangana state, as a
significant cause of stress. The men clearly said it was a cycle of distress – beginning with taking of
loans, inability to make the repayments leading to frequent drinking and culminating in suicide.

It is significant that the men mentioned ‘loss of honour’ -- when moneylenders come and publicly
demand repayments and when others take pleasure when one is thus humiliated – as a key source
of stress. Earlier research has clearly shown that 90% of the farmer suicides are those by men
26
(Deshpande & Arora, 2011; Mishra, 2006a & b; 2008; Mohanty, 2005). This erosion in the provider
role of masculinity brought about due to chronic indebtedness and financial crisis aggravated by
the often public humiliation by money lenders due to defaulting of repayments seems to be an
important source of psychosocial stress experienced and reported by the men in the focus group
discussion.

For women, the disproportionate burden of domestic work and caregiving responsibilities,
following the traditional dichotomy of labour, was another significant source of stress. One
woman rather tellingly said Sometimes the work is so heavy, I feel like cursing my husband, fate,
god or someone... [from FGD].

Crop damage due to wild animals in the vicinity, distress sale of land, and the perception that
agriculture is no longer sustainable because of the increasing gaps between investments and the
returns on crops were expressed by both the men and women groups as contributing to their
levels of stress. For instance, one of the male farmers said In earlier days, quantity of crop was less
but net profit was more, but now the situation is reverse... Prices of seeds, fertilizers, pesticides
have gone up but our profits have come down... I made about Rs. 20,000 net profit last year which
is not enough at all ...luckily, I have a second source of income, if it is there, we are saved or else
we are doomed.

Both the groups were vocal in expressing their dissatisfaction with the kind of support received
from the government. From the insufficient compensation (of about Rs. 3000) given by the Forest
Department for crop damage due to wild animals and the frustrating delay in getting a compound
wall erected to prevent their entry despite repeated representations made to the government,
both the groups expressed several views about their perceived lack of support from the
government. For instance, several of them cited lack of timely support as loans are needed in June
when the kharif season starts but they are given in September which is too late. Similarly, with the
increased prices of seeds, fertilizers, pesticides, machinery such as tractors, the men’s group said
farmers would be benefited if seeds, pesticides and fertilizers could be supplied on subsidized and
low prices.

Children’s education and marriage figured as a prominent source of psychosocial stress with
several of the men in particular voicing their apprehensions about the ‘bad company’ of sons, their
drinking and smoking habits, coming home late, and being unemployed. One of them said Earlier
it was marriage of daughter that was a source of tension, now it is of both.
27
The psychosocial stresses perceived by the community, both men and women were thus largely
related to the agrarian and social context of the farming community wherein indebtedness due to
frequent crop failure and damage, difficulties in procuring seeds, fertilizers and pesticides, lack of
timely support from the government in terms of either compensation or loan waivers were the
principal stressors. A commonly cited stressor also regarded as a consequence of stress was
alcohol addiction which was traced to the vulnerabilities originating in the agrarian context.

3.3. Socio-demographic profile of the surveyed sample

The quantitative analysis included use of structured interview schedules and questionnaires to
assess the current mental health profile of the users of the VPSCP services, the levels of
satisfaction expressed with the services and awareness and attitudes about mental health and
illness. A socio-demographic profile of the surveyed sample in terms of the categories of age,
gender, education, marital status, caste and religion, income and occupation indicates the
following.

Table 4:Socio-demographic characteristics of VPCSP users [N=119]

Socio-demographic Range Number Percentage

category distribution
1. 0-14 3 2.5
15-29 34 28.6
Age group (in years) 30-44 37 31.1
45-59 33 27.7
60+ 12 10.1
2. Male 69 58
Sex Female 50 42
Total 119 100
3. Not literate 24 20.2
Primary school 45 37.8
Educational status Secondary 26 21.8
school
High school 17 14.3
College 7 5.9
4. Hindu 115 96.6
Religion Other 4 3.4
SC 11 9.2
5. Caste ST 24 20.2
BC & others 84 70.6
6. Less than 1000 8 6.7
1001-3000 70 58.8
Monthly household 3001-5000 31 26.1
income 5001-10000 9 7.6

28
 Above 10000 1 0.8
7. Farmer 58 48.7
Daily wage 57 47.9
Occupation labourers
Unemployed 4 3.4
8. Marital Status Married 87 73.1
Unmarried 16 13.4
Widow/Widower 12 10.1
Separated 4 3.4

As can be seen from this table the most and least represented categories in the sample were

 Age: 30-44 age group was the most represented and 0-14 the least represented
 Gender: 58% were men and 42% of the sample were women
 Education: Those who were educated till the primary school level were the most
represented while those who had received college education were the least represented in
the sample
 Religion: Hindus formed an overwhelming majority of the sample
 Caste: BCs and others constituted the largest category while SCs were the least
represented
 Monthlyhouseholdincome: Those reporting Rs. 1001 to 3000 were the most represented
while those who had mentioned above Rs 10000 as monthly income constituted the least
represented.
 Occupation: Those who were farmers were the most represented, with agricultural daily
wage labourers coming a close second, and those who identified as without any
occupation were the least represented.
 Marital Status: Those who were married were the most represented with individuals
separated from the spouses were the least represented.

3.4. Present treatment status of PWMI

A survey was conducted with a sample size of 119 to assess the present treatment status of
PWMI. The first question asked in the survey was whether or not the respondent availed the
VPSCP services. The responses to that question was captured in categorical form with a YES or NO.
The survey revealed that 83.2% of the sample has availed the VPSCP services and remaining 16.8%
reported as not availing the VPSCP services as presented in Figure 3.

29
 Figure 3: Availing VPSCP Services

16.8%

83.2%

Yes No

Out of the 83.2% availing the services, 34.5% were women and 48.7% were men while in the
16.8% of those not availing the services, 9.2% were men and women were 7.6% as presented in
Figure4.

Figure 4: Availing VPSCP services across Gender

34.5%

48.7%
7.6%
9.2%

Yes No

Male Female

Following the earlier query of availing the VPSCP services, we attempted to understand the
reasons for the discontinuation of the services. The results are presented in Figure 5.

30
 Figure 5: Reasons for Discontinuation

35% 35%

10%
5% 10% 5%

Recovered Distant facility

Loss of time non-availibility of doctor/staff
no improvement others

35% of the reasons for discontinuation were attributed to the recovery of the patients which is a
positive indicator of the effectiveness of the programme. The second reason for discontinuation
from the VPSCP services was in the category of ‘loss of time’ with 10% respondents perceiving it as
that. More often than not, the whole family is working in the fields of their own or for others
which makes it difficult to lose even a day of work that would result in loss of wages. A 10% of
respondents discontinued because they reported not seeing any improvement in the mental
health condition of the PWMI.Distant facility was another reason with 5% reporting it as the
reason for discontinuation. The health centres being 60 -70 kms from the villages, it becomes a
whole day affair to visit the hospital where the psychiatrists are available and discourages the
people to access the services. The same percentage of 5% respondents pointed to the non-
availability of doctor/staff as a reason for discontinuation. As part of the DMHP there is one
psychiatrist posted at the district hospital Yavatmal who caters to the entire district, making it a
huge task for the single mental health professional to fulfill all the requiremnts of the
communities. So the factor of loss of time combined with the lack of access to professionals and
the distance contributes to the poor help seeking behavior of the people. The category of ‘others’
got 35% of respondents with reasons being non-availability of medicine, etc. The government-run
initiatve Project Prerna provided free psychiatric medicines to the farmer communities. However,
the Project does not provide free medications anymore. That has become one of the biggest
factors in the discontinuation with the services. Even though the VPSCP was not providing the
medicines but its association with Project Prerna had brought about a better pharmacological

31
management. Other reasons reported were side-effects of the medications, no one to accompany
them to the hospital, etc. that led to discontinuation.

3.5. Current mental health profile of users

The PHQ-9 was administered on 119 respondents to determine the present clinical status of
PWMI. The established norms to determine the clinical status are as follows in Table no 5.

Table 5: Diagnostic Norms for PHQ 9

Score Depression Comments

severity
0-4 Minimal or Monitor; may not require treatment
none
5-9 Mild Use clinical judgment (symptom duration, functional
10-14 Moderate impairment) to determine necessity of treatment
15-19 Moderately Warrants active treatment with psychotherapy, medications,
severe or combination
20-27 Severe

A frequency analysis of the categories across the respondents revealed that 54.6% of respondents
presented with minimal or no symptoms at all, with 20.2% with mild symptoms of depression,
15.1% with moderate symptoms. 7.6% reported with moderately severe symptoms and 2.5%
presented with severe symptoms. In other words, more than half of the representative sample,
had minimal or no symptoms of depression (Figure no. 6)

Figure 6: Intensity of Symptoms

Severe 2.5%

Moderately severe 7.6%

Moderate 15.1%

Mild 20.2%

Minimal or none 54.6%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%

32
A cross tabulation was carried out to assess the intensity of symptoms present in the two
categories of respondentsi.e. who are availing VPSPCP services and not availing. The results
(Figure 7) are discussed further. Among the 83.2% of respondents who were availing VPSCP
services, 47.1% reported to have minimal or none of the symptoms of depression, 15.1% with mild
symptoms, 12.6 % with moderate symptoms, 5.9% were categorized with moderately severe
symptoms and 2.5% reported with severe symptoms. Out of the 16.2% of respondents who were
not availing the VPSCP services during the time of survey, 7.6% presented with minimal or no
symptoms, 5% with mild symptoms, 2.5% with moderate, 1.7% with moderately severe and none
of them reported as having severe symptoms. With a higher percentage of respondents in the
availing of VPSCP category indicates a positive trend where the services have managed to identify
and initiate the treatment of the people who presented with even minimal symptoms, as is the
case with other categories of intensity of PHQ 9 symptoms.

Figure7:Intensity of Symptoms across VPSCP categories

Severe 2.5%

Moderately Severe 1.7%

5.9%

Moderate 2.5%
12.6%

Mild 5.0%
15.1%

Minimal/None 7.6%
47.1%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0%

Non-availing Availing

Depepending on the intensity of symptoms present, further cross-tabulations were done to

understand the level of difficulty the respondents faced in fulfilling their responsibilities. Out of
the 54.6% of the respondents in the minimal or none symptoms category, 47.9% reported having
no difficulty at all to do their work, do household work, and got along with other people, with
4.2% reported as finding it to be somewhat difficult, 1.7% finding it to be very difficult and 0.8%
described it as extremely difficult. Amongst the 20.2% of respondents who reported as having mild
symptoms, 11.8% found it to be not difficult at all to manage the work, household and social

33
responsibilities, 6.7% found it to be somewhat difficult, 1.7% as very difficult and none of them
were in the extremely difficult category. Out of the 15.1% respondents who reported as having
moderate symptoms, 2.5% reportedly found not difficulty at all to manage their responsibilities,
while 4.2% found it to be somewhat difficult, 8.4% found it to be very difficult to manage work,
household and social responsibilities. 7.6% of respondents reported having moderately severe
symptoms, out of which 4.2% found it not difficult at all to manage their responsibilities, 1.7%
found it as somewhat difficult, 1.7% found it extremely difficult with none of them reporting it as
very difficult. Out of 2.5% of respondents who reported it having severe symptoms, 1.7% found it
to be very difficult and 0.8% found it to be extremely difficult to manage their responsibilities.

3.6. Users’ satisfaction with services

This section presents the results of the survey on Satisfaction with VPSCP services conducted to
elicit users’ satisfaction with the type of services, competencies and attitudes of the staff, and
perceived impact of these services on their functionality and well-being. A 20-item questionnaire
was administered across the sample of 119 respondents to determine the level of stasfaction,
along with the following four categorical questions:
 Source of information about VPSCP
 Whether the users received any kind of services frm VPSCP
 Kind of service availed from VPSCP
 Feedback to the services availed

Source of information.The frequency analysis of responses to the question from which source
they had received information about VPSCP showed that out of 119 respondents

 2.5% came to known about VPSCP services from a neighbor or a friend

 14.3% got to know about it from street plays, awareness programmes, and display charts
pasted across villages.
 The majority of the respondents i.e. 83.2% became aware about the VPSCP services as a
result of the home visits made by the VPSCP staff, making it the most successful strategy
of creating awareness about the presence and availability of a service such as VPSCP in the
community (Figure 8).

34
 Figure8: Source of Information (in percentage)

0 2.5

14.3

83.2

from neighbor
from awareness program/street play/dsiplay chart
from home-visit
others

Whether received any kind of service from VPSCP. Out of 119 respondents, 111 (93.3%) agreed to
receiving some kind of service from VPSCP while the remaining 8 (6.7%) reported not receiving
any service from VPSCP. The respondents who informed in affirmative, were further asked about
the kind of services they availed from VPSCP. That formed the third categorical question.

Type of service received. Out of the 99.3% of respondents who have received some kind of service
from VPSCP, 6.3% reported to have got a chance to discuss their problems with a VPSCP staff,
12.6% as receiving VPSCP service in the form of referral to PHC/RH or DH. 3.6% reported as having
received service in the form of assistance in linkage to government welfare schemes or benefits.
The majority of services received from VPSCP was in the category of provision of medicines that
constituted the majority of 76.6% (Fig. 9).

35
 Figure 9:Type of Service Received from VPSCP

NA 0.9%

Assistance in linkage to govt.welfare schemes 3.6%

Provision of medicines 76.6%

Referral to PHC/RH/DH 12.6%

VPSCP Staff spoke to me about my problems 6.3%

With 99.3% of respondents having availed some or the other kind of services offered by VPSCP,
further analysis was done to understand the responses to the services rendered.

Feedback to services availed. A frequency analysis done to determine the responses of the people
who have received services from VPSCP indicates the following (Fig. 10):

 4.3% of the respondents got emotional relief and support,

 12.6% got clarity in problem resolution,
 26.1 reported improved ability to function and
 32.8% reported as having acquired new coping/life skills.

Other responses constituted 5% and 9.2% of responses were not eligible.

36
 Figure 10:Feedback to the services availed from VPSCP

NA 9.2%

Others 5.0%

New coping skills 32.8%

Ability to function better 26.1%

Clarity in problem solving 12.6%

Emotional relief 14.3%

Overall satisfaction with VPSCP services.The satisfaction of the users with the VPSCP services was
measured on a 4-point rating scale with responses ranging from Strongly Agree to Strongly
Disagree, with scores ranging between 20-80. The scale pertained to the satisfaction derived from
the VPSCP services on three dimensions i.e. Skills & Attributes of the staff, Facilities, and the
satisfaction with the Impact of the services. The analysis begins with the overall satisfaction and is
followed by the dimension-wise satisfaction of the users.

Based on the scoring method, higher the score indicated less satisfaction with the services and low
score referred to better satisfaction. The norms developed were as following:

Table 6: Norms for Overall Satisfaction

Norms Description
20-40 Highly Satisfied
41-60 Moderately Satisfied
61-80 Less Satisfied

The descriptive analysis revealed that mean satisfaction of the users was 36.61 (SD = 7.49), with
the mean score being in the highly satisfied category. Based on the norms, a frequency analysis
was carried out. The results revealed that 79% of the users were highly satisfied, and 21% were
moderately satisfied with the services provided by VPSCP.

37
Satisfaction of Users: Dimensions. The survey on the satisfaction of users on the various
dimensions. The three dimensions related to the skills & attributes of the workers (frontline health
workers, VPSCP staff, etc.), facilities provided by the VPSCP and the associated public health
institutions, and third dimension is the impact of the program as perceived by the users.

Dimension 1- Skills & Attributes

Satisfaction of the users with skills & attributes referred to the competency of the VPSCP staff
working on the intervention sites, interpersonal skills and the technical competencies in providing
support to the communities coping with mental health issues. In the Satisfaction with VPSCP
Services Scale, nine items pertained to measuring the competencies of the VPSCP workers in the
intervention sites. The maximum score one user could give was 36 and minimum was 9, wherein
higher the score indicated less satisfaction and lower scores implied more satisfaction. Based on
the responses, the following norms were evolved where a score between 9-18 was regarded as
highly satisfied, 19-27 as moderately satisfied and 28-36 as less satisfied. The mean score on this
dimension is 16.95 (SD = 3.27). A frequency analysis of the scores showed that 78.2% are highly
satisfied on this dimension and 21.8% are moderately satisfied.

Dimension 2 – Facilities

This dimension referred to the adequacy of the interface of the services of facilities in terms of
mental health services provided by the District Hospital like information sharing, follow up on the
treatment plan, referral to hospitals, accompanying the families to the hospital, etc. There are six
items on the scale that measured the adequacy of the facilities. Hence the maximum one could
rate this dimension is 24 with minimum being 6. Based on the responses, the following norms
were evolved where a score between 6-12 was regarded as highly satisfied, 13-18 as moderately
satisfied and 19-24 as less satisfied. The analysis showed the mean score being 11.49 (SD = 2.39).
The percentage of users that rated the adequacy of the facilities as highly satisfied was 74.8%
while 25.2% were moderately satisfied.

Dimension 3 -Impact

The third dimension is the perceived impact of the VPSCP in totality with reference to reduction in
symptoms, decline in relapse rate, better chances of engaging in livelihood activities, etc. The
dimension has four items with maximum score being 16 and minimum being 4. The norms for this
particular dimension were 4-8 being highly satisfied, 9-12 showed moderate satisfaction and 13-18
38
as highly satisfied, with higher score indicating less satisfaction and less score meant higher
satisfaction. The mean score was found to be 7.67 (SD = 2.17). The frequency analysis revealed
that 75.6% of the respondents were highly satisfied, 21.8% were moderately satisfied and 2.5%
were less satisfied with the perceived impact of the program.

The results of overall satisfaction along with the dimensions are presented in Table no 7.

Table7: Categorization of Users across Overall Satisfaction and the Dimensions

Component Highly Satisfied (f) Moderately Satisfied (f) Less Satisfied (f)

Skills & Attributes 93 (78.2%) 26 (21.8%)

Facilities 89 (74.8%) 30 (25.2%)
Impact 90 (75.6%) 26 (21.8%) 3 (2.5%)
Overall Satisfaction 94(79%) 25 (21%)

The results are depicted graphically in Figure 11 below.

Figure 11: Users’ satisfaction with VPSCP services

Overall Satisfaction 21.0%

79.0%

2.5%
Impact 21.8%
75.6%

Facilities 25.2%
74.8%

Skills & Attributes 21.8%

78.2%

Less Satisfied Moderately Satisfied Highly Satisfied

The ratings of the respondents on the three dimensions are a combination of variety of factors.
The multitude of factors that contribute to the quality of the services as perceived by the users are
a manifestation of number of variables involved like in case of Skills and Attributes, it can relate to
the characteristics of the frontline health workers like a Krusihdoots, ASHA workers, a government
appointed psychologist, with the majority of the workers being the VPSCP staff themselves. The
skills of the staff are particularly useful in identifying people with psychosocial distress or mental
illnesses, to provide counselling, provide appropriate care and make referrals if required to the
39
nearest Health Centre. With majority of the users reporting as being highly satisfied with the skills
and attributes dimension, it can be said that the training of the health workers has been effective
in setting the stage for the very first level of the mental health services i.e. building a rapport and
earning the trust of the community members.

The Facilities dimension refers largely to the increased accessibility to the mental health services
provided by the District Hospital. The VPSCP facilitated the process of referrals, hospital visits
including follow-ups, with the VPSCP providing transportation to the community in case of
referrals, etc. While the DMPH program was present prior to VPSCP, there was huge lacuna when
it came to usage of the services by the community. The VPSCP has managed to bridge this gap to
an extent as revealed in the survey.

As for the Impact dimension, the perception of the users is reflected in the individual’s prognosis
and general well-being in tangible terms like reduction of symptoms, lesser relapse rate, increased
ability of the user to engage in productive work (wages). The small percentage of users who
reported as being less satisfied with the impact could be perhaps attributed to personal factors
like non-adherence to medications, etc. to larger environmental factors like inability to purchase
psychiatric medicines. It must be noted here that free medication was provided under Project
Prerna till 2017, after which the provision was ceased. So, although the VPSCP could facilitate the
treatment process, it could not help when it came to purchase of psychiatric medicine that could
contribute to non-adherence.

Overall, a large percentage of users reported high levels of satisfaction in all the dimensions of
VPSCP services, revealing that the program is well-received by the community and the program
has successfully managed to fulfil the Remedial aspect of its objective.

3.7. Awareness about mental health in intervention and non-intervention villages

To understand the impact of the awareness programs and activities that VPSCP has conducted in
the past 2 and half years, an attempt was made to compare the levels of awareness about mental
health among the communities in intervention (V1) and non-intervention(V2) villages across the
blocks of Ghatanji and Yavatmal. Five villages from each category were surveyed with a sample of
135 (n1 = 135) from Intervention villages and a sample of 132 (n2= 132) were selected to
participate in the survey. A socio-demographic profile including age, gender, educational

40
qualification, occupation, caste, religion, monthly income and marital status of the sample of both
categories surveyed is presented below.

Table8 : Socio-demographic characteristics of respondents in Intervention & Non-Intervention

Villages

Numbers (N = 267)
Intervention Non- Intervention
(n = 135) (n = 132)
1. Age 15-29 39 (28.9%) 40 (30.3%)
3.6.1. 30-44 50 (37%) 48 (36.4%)
3.6.2. 45-59 35 (25.9%) 28 (21.2%)
3.6.3. 60+ 11 (8.1%) 16 (12.1%)
3.6.4.
2. Sex Male 75 (55.6%) 73 (55.3%)
3.6.5.
Female 60 (44.4%) 59 (44.7%)
3.6.6.
3. 3.6.7. Not literate 18 (13.3%) 12 (91.1%)
3.6.8. Primary school 46 (34.1%) 36 (27.3%)
3.6.9. Educational Secondary school 35 (25.9%) 53 (40.2%)
status
l High school 25 (18.5%) 13 (9.8%)
College 11 (8.1%) 18 (13.6%)

4. Hindu 111 (82.2%) 124 (93.9%)

Muslim 1 (0.7%) 3(2.3%)
Religion Other 23 (17%) 5 (3.8%)

Total
19 (14.1%) 8 (6%)
5. SC
Caste ST 30 (22.2%) 26 (19.7%)
Other 86 (63.7%) 98 (74.2%)

6. Less than 1000 18 (13.3%) 20 (15.2%)

1001-3000 75 (55.6%) 86 (65.2%)
Monthly 3001-5000 22 (16.3%) 20 (15.2%)
household 5001-10000 12 (8.9%) 5 (3.8%)
income Above 10000 8 (5.9%) 1 (0.8%)

7. Marital Status Married 114 (84.4%) 95 (72%)

Unmarried 18 (13.3%) 32 (24.2%)
Widow/widower 3 (2.2%) 5 (3.8%)

8. Occupation Farming 95 (70.4%) 54 (40.9%)

Others 39 (28.9%) 76 (57.6%)
Farming & others 1 (0.7%) 2 (1.5%)

41
Based on the responses in the Awareness about Mental Health Scale, the scores of the
respondents ranged between 4 to 21. Accordingly, the scores were classified into three levels as
shown in Table 9.

Table 9: Norms for Awareness about Mental Health

Score Range Level of Mental Health Awareness

0-7 Poor
8-14 Average
15-22 Good

A cross-tabulation was performed to assess the levels of awareness about mental health in the
communities of the Intervention and Non-Intervention villages. The results are presented in Figure
12

Figure 12: Awareness about Mental Health Across Intervention and Non-Intervention
Villages

76.3%

52.3%
43.2%

23.0%

4.5%
0.7%

Intervention Non-Intervention

Poor Average Good

From Figure 12, we can see that in the Intervention villages, 76.3% had good awareness about
mental health, with 23% average awareness and only 0.7% had poor levels of mental health
awareness. A look at the performance of the Non-Intervention villages, show comparatively
differential scores. With 4.5% revealing poor awareness about mental health, 43.2% have average
levels, and 52.3% had good awareness. Since the socio-demographic composition of the two
categories of villages are similar, an attempt was made to determine if the differences between
the Intervention and Non-Intervention villages are statistically different.

42
To determine the difference in the level of awareness in the community members of the
Intervention and Non-Intervention villages, the total score on the Mental Health Awareness Scale
was determined and a Student’s t-Test was done.

The results showed a statistically significant difference in the mental health awareness scores
between the Intervention villages (M = 15.94; SD =2.38) and non-Intervention villages (M = 14.20;
SD = 3.87), t(265) = 4.53, p<.01.

In other words, the statistically significant differences can be attributed to the VPSCP i.e. the
program had significant effect on increasing awareness among the communities with regards to
mental health.

Since the two categories of villages i.e. intervention (V1) and non-intervention (V2) were found to
have statistically significant differences when it came to awareness about mental health, further
attempts were made to understand the differences on each concept presented in the Awareness
about Mental Health Scale that contributed to the difference on the overall/core awareness. The
concepts are showcased through each of the 22 items on the scale. To compare the awareness, 22
independent t-tests were run. Out of the 22 items, the two categories of sample from intervention
& non-intervention villages, did not differ significantly from each other on seven items. The results
of the 15 remaining items on which there were significantly different responses are presented
below.

 People in the intervention villages did not view that mental illness was contagious, while
those from the non-intervention villages perceived otherwise (t = 3.43, p<.01)
 The respondents from the intervention villages believed that the mentally ill need support
and care from the community and family (t = 5.35, p<.01)
 People from the intervention villages believed that the mentally ill should be taken to the
nearest health centre for treatment.
 Similarly, people from the intervention villages believed that mental illness can be treated
by effective and safe drugs (t = 4.01, p<.01)
 The respondents from the intervention villages were aware about the efficacy of
pharmacological treatment for epileptic fits (t = 3.05, p<.01)
 People from the intervention villages believed that excessive alcohol dependence or drug
abuse can cause mental illness (t=3.55, p<.01)

43
  Respondents from the intervention villages perceived that it is the responsibility of the
family and community to keep a look-out for change in the behaviour of others around
them (t = 1.98, p<.05)
 The knowledge that mental illness is curable is an important indicator of awareness about
mental health and in fact contributes to the reduction of stigma against PWMI. The
respondents of V1 & V2 are statistically different from each other on this with the former
endorsing this belief (t = 3.94, p<.01)
 Acknowledgement of the fact that mental health problems can be discussed with a
counselor and help can be sought from them, indicates a positive health-seeking behavior.
On this item, the respondents from the intervention villages believed that this was indeed
so (t = 6.92, p<.01)
 The identification of symptoms like irregularity in sleeping patterns or eating habits is a
basic indicator of mental health awareness and the people from the intervention villages
acknowledged this fact (t= 3.92, p<.01)
 The relationship between meeting the daily demands of life, they way people value
themselves, interpersonal relationships is often linked to the quality of mental health in
people. Awareness regarding this is important and the respondents from the intervention
villages believed so (t = 4.31, p<.01)
 The respondents from the intervention villages perceived that sharing sharing one’s
feelings & concerns is good for mental health (t =4.71, p<.01)
 Suicide being the worst outcome in case of mental health problems, it is of absolute
importance that the people are aware of methods to identify individuals who has suicidal
thoughts. It assumes a great significance in the context of these villages where farmer
suicide is the biggest concern. In this item, people surveyed in the intervention villages
appeared to be aware of suicidal ideation (t= 4.63, p<.01)
 The understanding that socio-economic factors can contribute to mental health problems
is a robust indicator of awareness about mental health. Since the mental health issues that
plague these villages stem out of agrarian concerns, this understanding is important and
the two categories of villages are significantly different from each other on this item with
people from the intervention villages expressing higher awareness (t = 2.91, p<.01)

Together, these differences can explain for the differences we see in the core awareness and
attitudes about mental health and illness.

44
 3.8. Impact of the VPSCP on suicide trends in Yavatmal district (2001-2018 April)

A quick comparison, based on the farmer suicide data avilable from the Farmer Suicide
Department, District Collectorate, of the suicide trends in Yavatmal district and in the two blocks
of Ghatanji and Yavatmal, the two intervention sites of VPSCP yielded the following picture (Figure
13). As can be seen from the graph below, there is a marked downward trend in number of farmer
suicides in these two blocks since 2016 when the VPSCP began its operations. While the numbers
peaked in 2014-15 prior to the introduction of the intervention, the figures have shown a
signfiicant reduction in the period 2016-April 2018).

Figure 13: Famer Suicide Trend Pre & Post VPSCP

35
30
25
20
15
10
5
0
2013 2014 2015 2016 2017 2018
Yavatmal 19 16 32 13 5 2
Ghatanji 6 22 32 7 11 3

Yavatmal Ghatanji

Source: https://yavatmal.gov.in/

However, it may be rather ambitious to attribute this reduction solely to the intervention
alone in view of the overall downward trend in the number of farmer suicides in the district
as a whole (Figure 14). There could have been a combination of factors related to more
timely and effective agricultural support for farmers that could have been responsible for
the reduction. In particular, the Project Prerana and the Baliraja Chetna Abhiyan, launched
in 2016 as an agricultural scheme which entailed allocation of a fund of Rs one lakh to every
Gram Panchayat from which nearly 10,000 rupees could be given to any person for any
support could have alleviated the financial distress emanating from agricultural crisis.
However, large-scale corruption in the scheme reportedly led to its scrapping in 2017. Since
a detailed examination of the impact of the agricultural schemes was not within the
45
 purview of evaluation of this report, it may be rather speculative to attribute the reduction
in the number of farmer suicides as reported in the data above to the support received
from the government. All that can be said is that there is a perceptible decrease in the
number of farmer suicides in the last two years which coincides with the time period of the
VPSCP intervention.

Figure 14: Farmer Suicide Trend 2001-2018, Yavatmal District

300
252
250
191
200
146 148
150 124
97 103 101
92 90
100 82 78

38 35
50 23 30
7 11
0

4. CONCLUSIONS AND WAY FORWARD

This chapter pulls together the strengths and challenges of the programme, situating it within the
community mental health approach to addressing the socio-economic, political and cultural
determinants and correlates of mental health vulnerabilities.

Strengths of the programme. The key strength of the programme is the active community
engagement with pathways to mental health care. This was established through the network of
home-based counselling services which enabled recognition of PWMI and the creation of
sustainable access to appropriate services through referrals and ensuring help-seeking behaviour.
The programme thus was able to effectively demonstrate that the community can be
strengthened to seek mental health services, and with minimal psychosocial support, it was able
to draw them out from illness to the path of recovery. The corner meetings conducted by the
counsellors, the interface of the programme with local village governance structures such as the

46
Panchayat, Gram Sevak, Police Patil, the publicizing of the programme through leaflets with the
helpline number and contact details of the counsellor were significant outreach activities that
helped to strengthen the links with the community.

The chief functionary of the programme emphasized the need for the government to be
accountable and hence the linkage with the government health facility so as to ensure the
sustainability of the pathway to mental health care even after the withdrawl of the present
funding agency. As he expressed, The patients know where to go even if Tata Trust stops the
project. Furthermore, the assistance in referral made by the VPSCP counsellor, helping them to
reach the hospital and receive the consultation ensured that the first treatment contact was made
impressive so that it gets reinforced for the patient. Furthermore, what was signalled through the
network of counselors and other front-line health workers was that seeking help for mental health
problems was important... service points can be private or public.

The acceptance of the counsellors by the community in the village was facilitated initially by the
fact that they were introduced by the gate-keepers (the ASHA workers, the Krishidoot volunteers,
Gram Sevak) and was reinforced by the individual and personalized home-based visits of the
counsellors. Referring to the safe space for ventilation and sharing accorded by the home-based
visit, one of the counsellors recalled one of his first cases – wife of a farmer who had committed
suicide – and dealing with her after she was identified with severe depression due to loss of her
husband at a relatively young age, the financial crisis of the family, with debts to repay, and
children’s marriage pending. The regular visits of the counsellor – thrice a month, medication for
a month led to improvement in her condition. She was able to resume farming which gave her
strength to rebuild her life.

The emphasis laid on engaging with lay volunteers and health workers is in line with the
community mental health paradigm that views such an engagement to be embedded in the local
socio-cultural framework, and that helps to deliver expanded services in resource-poor contexts
with few trained personnel, increase the reach of these services through community participation,
enhance the possibility of effective prevention, care, treatment and local advocacy, provide better
access to practical, emotional and material support for the ill and the confidence to cope with or
challenge social stigma, thereby leading to empowerment (e.g., increased income generation
opportunities, enhanced social recognition, opportunities for community activism), and increasing

47
opportunities for health, both at the individual and the collective levels (Campbell & Burgess,
2012).

The necessity to link with state livelihood schemes reveals the programme’s underlying
empowerment philosophy which views mental health as a construct that needs to be addressed
beyond the mental health system and to be supported and coordinated with programmes for
housing, education and employment (Carling, 1995; Spindel, 2000). However, compared to the
scale of services needed, the programme is still limited by the relatively small number of people
benefited by livelihood linkages (Table ) and the nature of support provided through dairy,
poultry, goatery activities.

Challenges of the programme. The challenges identified by the project staff in implementation
were the following

 Since the past one and half years or so, the post of psychiatrist had fallen vacant and the
absence of a psychiatrist was identified as a key handicap for ensuring prompt and
responsive mental health services to those in need.
 In the absence of a psychiatrist, appropriate use of the services of psychologist and social
workers is not being made as they are allocated other work by the Civil Assistant Surgeon
to whom they have to report
 Ensuring regular supply of free medicines in the government hospital was identified as a
major limitation, hampering the access of the farmers to health care
 Government’s indifferent attitude and delay in processing applications for the livelihood
schemes result in the patient losing interest or having a relapse
 Difficulty in maintaining confidentiality of information owing to the home-based nature of
counselling services
 Breaking the stigma and taboos associated iwth mental disorders and the challenges of
demystification of mental illness
 Family conflicts/issues of gender leading to problems in mental health could not be
explored and resolved because of the absence of a woman counsellor in the team

Final Observations and Recommendations

 The VPSCP programme is only two years old but has been able to achieve a fair amount of
effectiveness in its reach and impact. This is borne out by the levels of awareness and
48
 attitudes regarding mental health and illness, and help-seeking behaviour in the surveyed
sample. The positive impact of the progamme is also reflected in the users’ satisfaction
with the services provided by VPSCP. A key contributor to the satisfaction is the
competencies of the counsellors and other health care workers in terms of their
accessibility, communication, and personal attributes of empathy and warmth.
 As the programme has shown the way for at least managing psychosocial distress without
worsening and further negative outcomes, the VPSCP can be taken as a template for
integration of mental health and socio-economic determinants in the agrarian context in
order to reduce self-harm and suicide.

 From our interactions, we could not gather whether systematic supervision of the
counselling work is being done and whether it is being documented. Furthermore,
feedback from the users can be elicited through brief exit interviews that can provide in-
house evaluation of the impact of the counselling services.
 The identification of people with mental illness as well as those with varying levels of
psychosocial stress manifested in mild depression and anxiety is a considerable
achievement of the programme. However, its viability and sustainability can be ensured
only with firmer linkages with the government health care programme as well as with
livelihood/welfare schemes.
 Given the experience and expertise of the personnel involved, efforts must be made to
upscale the programme in order to provide services on a larger scale in the region.

49
 REFERENCES

Balagopal, G., &Kapanee, A. (2014). Documentation of five Community Mental Health Programmes
in India: Janamanas (Anjali), Antara, ASHWINI, Rural Mental Health Programme
(The Banyan) and Mental Health Action Trust.Mumbai:Navajbai Ratan Tata Trust.

Carling, P.J. (1995).Return to community: Building support systems for people with psychiatric
disabilities.New York: Guilford.

Deshpande, R.S., & Arora, S. (2011). Agrarian crisis and farmer suicides. New Delhi: Sage.

Dandona, L., Dandona, R., Kumar, G.A., Shukla, D.K., Paul, V.K., Balakrishnann, K., Swaminathan, S.
(2017). Nations within a nation: Variations in epidemiological transition across the states of India,
1990-2016 in the Global Burden of Disease Study. Lancet, 390, 2437-2460.

Gururaj, G., Varghese, M., Benegal, V., Rao, G.N., Pathak, K., Singh, L.K. (2016). National mental
health survey of India, 2015-16: Prevalence, pattern and outcomes, NIMHANS Publication no. 129.
Bengaluru: National Insitute of Mental Health and Neurosciences.

Mishra, S. (2006a). Farmers’ suicides in Maharashtra. Economic & Political Weekly, 41, 1538-1545.

Mishra, S. (2006b). Suicide mortality rates across states of India, 1975-2001: A statistical note,
Economic & Political Weekly, 41, 1566-1569.

Mishra, S. (2008). Risks, farmers’ suicides and agrarian crisis in India: Is there a way out? Indian
Journal of Agricultural Economics, 63 (1), 38-54.

Mishra, S. (2014). Farmers' suicides in Maharashtra, India: A mixed-method study leading to policy
suggestions. SAGE Research Methods Cases. doi:10.4135/978144627305013500200.

Mohanty, B.B. (2005). ‘We are liking the living dead’: Farmer suicide in Maharashtra, western
India, The Journal of Peasant Studies, 32, 243-276.

Nelson, G., Lord, J., &Ochocka, J. (2001). Empowerment and mental health in community:
Narratives of psychiatricconsumer/survivors. Journal ofCommunity and Applied Social Psyhcology,
11,125-142.

Spindel, P. (2000). Polar opposites: Empowerment philosophy and Assertive Community

Treatment (ACT). Ethical Human Sciences and Services, 2, 93-100.

50
 APPENDICES

Questionnaires

1. PWMI PRESENT STATUS TREATMENT SCHEDULE

[either PWMI or family member in case of non-availability of PWMI can be interviewed]
1. Socio-demographic profileof PWMI

Socio-demographic characteristic Tick relevant

category
1. 0-14
15-29
Age group (in years) 30-44
45-59
60+
2. Sex Male
Female
3. Not literate
Primary school
Educational status Secondary school
High school
College
4. Agriculture
Primary occupation Others
5. Hindu
Muslim
Religion Christian
Other
6. SC
Caste ST
Other
7. Less than 1000
1001-3000
Monthly household income 3001-5000
5001-10000
Above 10000
8. Occupation Farmer
Daily wage labourer
Other

2. Are you/your family member currently receiving treatment from the VPSCP centre referred to?
YES/NO

3. If no, what are the reasons for not receiving/discontinuing treatment?

a. Recovered now and patient doing well

51
b. Health facility too far from home

c. Cannot afford cost of travelling to health facility

d. Loss of time and income of accompanying person

e. Lack of availability/irregular presence of medical doctor/other staff in health facility

f. Lack of improvement in patient’s condition

g. Any other reason (please specify)

52
 2. PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?
(Use “✔” to indicate your answer)

Not at all Several days More than half the days Nearly every day

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling or staying asleep,

or sleeping too much 0 1 2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

6. Feeling bad about yourself — or that

you are a failure or have let yourself
or your family down 0 1 2 3

7.Trouble concentrating on things,

such as reading thenewspaper or
watching television 0 1 2 3

8.Moving or speaking so slowly that other

people could havenoticed? Or the opposite
— being so fidgety or restlessthat you
have been moving around a lot more
than usual
0 1 2 3
9. Thoughts that you would be better off
dead or of hurtingyourself in some way 0 1 2 3

If you checked off any problems, how difficult have these problems made it for you to do your
work, take care of things at home, or get along with other people?

Not difficult at all Somewhatdifficult Very difficult Extremely difficult

� � � �
__________________________________________________________________________________

FOR OFFICE CODING 0 + ______ + ______ + ______

=Total Score: ______

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an
educational grant fromPfizer Inc. No permission required to reproduce, translate, display or distribute.

53
 3. AWARENESS ABOUT MENTAL HEALTH SCALE

ITEM RESPONSE
1. Mental illness is due to evil spirits, black magic, or wrath of gods YES/NO
2. Mental illness is contagious YES/NO

3. Mentally ill individuals can have strange experiences like hearing voices and false YES/NO
firm beliefs
4. Mentally ill people are dangerous and should be avoided as they might cause YES/NO
harm
5. Mentally ill people need support and care from the family and the community YES/NO

6. Mentally ill individuals should be taken to the nearest health centre for treatment YES/NO

7. Mental illness can be treated by effective and safe drugs YES/NO

8. Epileptic fits can be controlled by taking medicine regularly YES/NO

9. Excess dependence on abusive drugs or alcohol may cause mental illness YES/NO

10. Family and/or members of the community should recognize any change in YES/NO
behavior of people and discuss it with their doctors/health workers
11. If I am feeling very sad and depressed, it is better to keep it to myself YES/NO

12. Mentally ill persons can be best helped by getting them married YES/NO

13. Mentally ill people are less human than “normal” people and hence do not YES/NO
deserve equal rights and equal respect
14. Mental illness is curable YES/NO

15. If I feel excessively anxious or sad, I ask the health worker/counselor for help YES/NO

16. I prefer to go to the occult practitioner if I or any member of my family feel over YES/NO
excited and moody, or has experiences like hearing voices
17. Mental health problems can be resolved by talking to a counselor YES/NO

18. Not getting sleep or not eating properly can indicate some mental health problem YES/NO

19. Mental health is about how good people feel about themselves, how comfortable YES/NO
they are with others, and how they are able to handle demands of everyday life
20. Expressing and sharing with someone about my feelings and concerns is good for YES/NO
mental health
21. Someone who can listen with understanding to a person who has suicidal YES/NO
thoughts can prevent suicide
22. Adequate housing, employment and education opportunities have nothing to do YES/NO
with mental health

Adapted fromKnowledge, Attitude and Practice Questionnaire for Health workers (National
Institute of Mental Health and Neuro-Sciences, Department of Psychiatry, Bangalore); ICMR
evaluation study of DMHP
54
 4.SATISFACTION WITH VPSCP SERVICES SCALE

1. How did you come to know about VPSCP services?

a. From neighbour/friend

b. From awareness program/street play/display chart

c. From home visit by VPSCP staff

d. Any other (please specify)

2. Have you received any kind of service from VPSCP? Yes/No

3. If yes, what kind of help did VPSCP provide? [can tick more than one]

a. VPSCP staff visited me and spoke to me about my problems

b. Referred to PHC/RH/DH for general health checkup

c. Provided medicines

d. Assisted in linkage with govt. welfare schemes/benefits (Specify which one)

f. Any other (specify)

4. If availed any of the services above, what did you feel thereafter? [can tick more than one]

a. Emotional relief and support

b. Clarity in problem resolution/solving

c. Ability to function better

d. New coping/life skills

e. Any other

[continue with asking respondent to choose one of the following responses]

S.No. Item Response

1. The health worker* treated me Strongly Agree/Agree/Disagree/Strongly Disagree
with courtesy
2. The health worker listened to me Strongly Agree/Agree/Disagree/Strongly Disagree
carefully
3. The health worker explained to me Strongly Agree/Agree/Disagree/Strongly Disagree
things in a way I understood
4. The health facility was clean Strongly Agree/Agree/Disagree/Strongly Disagree

5. The waiting time was acceptable Strongly Agree/Agree/Disagree/Strongly Disagree

6. I had enough time to discuss with Strongly Agree/Agree/Disagree/Strongly Disagree

health worker

55
S.No. Item Response
7. I was given information in a way I Strongly Agree/Agree/Disagree/Strongly Disagree
understood
8. I received helpful advice Strongly Agree/Agree/Disagree/Strongly Disagree

9. Administrative staff treated me Strongly Agree/Agree/Disagree/Strongly Disagree

with courtesy and respect
10. The health worker involved my Strongly Agree/Agree/Disagree/Strongly Disagree
family helpfully
11. I have the opportunity for follow up Strongly Agree/Agree/Disagree/Strongly Disagree
with the same health worker
12. My personal information is kept Strongly Agree/Agree/Disagree/Strongly Disagree
confidential
13. Referral to specialist is possible Strongly Agree/Agree/Disagree/Strongly Disagree

14. The treatment reduced my Strongly Agree/Agree/Disagree/Strongly Disagree

symptoms
15. The treatment reduced relapse of Strongly Agree/Agree/Disagree/Strongly Disagree
my illness
16. The treatment helped me to Strongly Agree/Agree/Disagree/Strongly Disagree
improve my income
17. I can get a health worker’s help any Strongly Agree/Agree/Disagree/Strongly Disagree
time I need
18. It was easy to come to the health Strongly Agree/Agree/Disagree/Strongly Disagree
facility
19. I had enough money to come and Strongly Agree/Agree/Disagree/Strongly Disagree
get treatment
20. I would advise my family to come Strongly Agree/Agree/Disagree/Strongly Disagree
to the health facility
*Health worker refers to counsellor/CHW/Sahyogini/ASHA/Krushidoot

Adapted from Mental Health Service Satisfaction Scale (Mayston et al, 2017) and Verona Service
Satisfaction Scale (Ruggeri &Dall’Agnola, 1993)

56