ORIGINAL ARTICLE
Impact evaluation of the community mental health program at habra Kamlesh Kumar Sahu
Department of Psychiatric Social Work, Institute of Psychiatry, Kolkata, West Bengal, India
Abstract
Background: It is a well‑known fact that there is a huge gap between mental health service availability and needs of people in the community. Community Mental Health Program (CMHP) appears as a solution for it. Paripurnata (a non‑governmental organization) has been running a CMHP at Habra, West Bengal, India since 2000. Since 2005 a psychiatric out‑patient department is functioning and community work is focused on capacity building of different stakeholders. Several awareness camps, community preparedness workshops have been organized. However, the work is yet to be consolidated with initiatives from the community. It has to be facilitated more with an objective analysis of the situation. The need of the hour is to assess the previous work. So an evaluation study was planned. Aims: The primary aim of the following study is to assess the impact of the CMHP on the local population and secondary aim is to evaluate that what extent the CMHP have been able to prepare them to take responsibility of the CMHP as a whole. Materials and Methods: Using systematic random sampling method 1486 respondents were selected and data collect using a questionnaire. In‑depth interviews, focus group discussions, participant’s observation and secondary data sources were also used. Inferences drown based on above all data sources. Results and Conclusion: Two‑third of the studied population and more so in the target area expressed that the community can take responsibility of running their own CMHPs. Though, the larger population of them is still not acquainted with the activities of the CMHP, the program deserves support to sustain. Key words: Community mental health program, community psychiatry, health education, mental health promotion
INTRODUCTION Community Mental Health Care Programs imply that all mental health and well‑being needs of the community are met in the community, using community resources and the primary health care (PHC) system. It goes much beyond only treatment and includes: Promotion of well‑being and mental health promotion, stigma removal, psychosocial support, rehabilitation of those in need, prevention of harm from alcohol and substance use and treatment of the ill using the PHC system.[1] The World Health Organization states that community mental health services are more accessible and effective to lessen social exclusion and are likely to have less Address for correspondence: Mr. Kamlesh Kumar Sahu, Department of Psychiatric Social Work, Institute of Psychiatry, 7 D.L. Khan Road, Kolkata ‑ 700 025, West Bengal, India. E‑mail: [email protected]
How to cite this article: Sahu KK. Impact evaluation of the community mental health program at Habra. Indian J Psychiatry 2014;56:143-9. Indian Journal of Psychiatry 56(2), Apr-Jun 2014
possibility for the neglect and violations of human rights that were often encountered in mental hospitals.[2] India has a long history of community mental health initiatives. The Bhore Committee Report of 1946, which laid the foundation for the community health movement.[3] The 1970s and 1980s brought more initiatives in mental health care and culminated in the National Mental Health Program (NMHP) in India, one of the earliest in the world.[4] Two programs that have influenced the development of India’s Community Mental Health Program (CMHP) are the Raipur Rani Program and the Bellary District Program.[5‑8] The results of the experiments in integrating mental health care with general health care were used in formulating the NMHP in Access this article online Quick Response Code Website: www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.130487
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1982 which was and reviewed in 1995 and subsequently District Mental Health Program (DMHP) was launched 1986, sought to integrate mental health care with PHC.[9] This model has been implemented in all the states and currently there are 125 DMHP sites in India. The Ministry of Health, Government of India envisages extension of DMHP to all the districts in the country as part of the 11th five year plan. The Ministry of Health and Family Welfare Government of India has revitalized the DMHP based on the available evidence.[10] The limited success of the NMHP and the community mental health movement has to be recognized and accepted.[3] Recent literature on community mental health activities show that various forms of community care for the persons with mental illness are emerging in India and the non‑governmental organizations (NGOs) are playing a pivotal role in filling the gap existing between mental health services and the growing and substantial need for such services. Various strategies that have been employed in community care have attempted to utilize existing community resources for implementation. Resources like manpower from the community combined with specialist psychiatric care and integrated with existing health care facilities have become general strategies of CMHPs. Whereas the feasibility and cost‑effectiveness of the NGO operated community outreach programs for the persons with mental illness have been demonstrated, various factors are seen to influence the planning and execution of such programs.[11] Paripurnata (means hope for the wholeness, it is an NGO), the center for psycho‑social rehabilitation, established in 1991, has been running a CMHP at Habra, West Bengal, India since 2000, with the goal of community preparedness to take responsibility of their mental health needs. It was started at Banipur and later shifted to Habra municipal area in 10th November 2005. Since then a psychiatric out‑patient department (OPD) is functioning and community work is focused on capacity building of different stakeholders. Several awareness camps, community preparedness workshops in the community have been organized with a set of long‑term objectives. However, the work is yet to be consolidated with initiatives from the community. It has to be facilitated more with an objective analysis of the situation. The need of the hour is to assess the previous work and hence an evaluation study was planned. Description of the program Program location and demography Habra is a town, a municipality and a police station of Barasat Sadar subdivision in North 24 Parganas district in the Indian state of West Bengal.[12] As per the 2001 Census report, the total population of Habra municipality was 1,27,602, males constitute 51% of the population and females 49% and the population density was 5,626 respectively. The number of scheduled caste was 25,780 and scheduled tribes 1,478 in the population. Literacy percentage was 86.3, which was 91% among the male population and 81.4% among the female. 144
The percentage of total workers was 34.6% of the total population, among which 1% was cultivator, 3% agricultural laborers, 5.4% household industry workers while rest 90.6% constituted the category of other workers respectively.[13] West Bengal (0.34%) in general and North 24 Parganas district in particular have higher (0.39%) prevalence of mental disabilities, as found from the Census report 2001.[14] In Habra 555 (0.43%) persons were identified with mental health problem in a baseline survey conducted by Paripurnata. The actual figure of prevalence of mental health affected population is much higher than the mental disabilities, as found from the census report 2001. Habra State General Hospital is only one medical center in the Habra municipal area with a capacity of 131 beds and 29 attending doctors. The hospital did not have a department to treat persons with mental illness. Hence, the health department of the state government agreed to hand over a portion of the Habra State General Hospital to Paripurnata for running the clinic for persons with mental health illness. Since November 2005 a psychiatric OPD is functioning there being a perfect instance of public‑private partnership. The catchment area of the program is entire 23 wads of Habra municipality and surrounding of around 50 km radius. The CMHP was initiated as a pilot program with the goal to prepare the local community to take responsibility of their mental health needs and handover the CMHP to local community and withdraw from there but it was extended for various tenure and now completed a full decade but it is still in its “developmental stage;” obviously the withdrawal stage is yet to come. The task of handing over the CMHP to the community is a long‑drawn process, toward which little seems to have been done yet. At this stage needs to ensure complete attainment of program development and then think of handing over or withdrawal. CMHP revolves around the following activities: 1. Setting up of a base 2. Identification of stakeholders 3. Capacity building 4. Networking and convergence 5. Mental Health Services: Prevention, intervention and rehabilitation 6. Vocational training ‑ for post‑treatment rehabilitation sustainability 7. Research and documentation 8. Management and administration. Various activities such as awareness generation meetings, community preparedness workshops, family meets, house visits, training programs or workshops for the staff, the base line survey, counseling, OPD and day care center were carried out as planned. The program has been running since a decade but last 2 years for the community work is focused on four wards (wards no. 1‑4 out of total 23 wards) Indian Journal of Psychiatry 56(2), Apr-Jun 2014
Sahu: Impact of the CMHP at Habra: An evaluation
of Habra Municipality as a pilot program with an idea that if it proves viable, it could be replicated in other wards. Now the program has come to a crucial stage in its life. To move further, it has become absolutely necessary to develop a long‑term realistic and community‑based proposal based on known impact the past activities have made in the community. Keeping in view, the need of the hour, an evaluation study was planned. THE AIM AND OBJECTIVES OF THE EVALUATION To assess the impact of the CMHP on the local population with the aim to evaluate to what extent the activities have been able to prepare them to take responsibility of the CMHP as a whole. The following objectives were included for studying the impact: 1. The principal component was to study whether the attitude prevailing in the society toward mental health problems has undergone substantial changes due to the programs implemented by the program 2. As a corollary to the first point, whether the local community is increasingly feeling the necessity of running the mental health program in their locality 3. Whether there is increasing feeling of responsibility, confidence and empowerment among the local population to run such a program on their own? MATERIALS AND METHODS Both quantitative and qualitative tools were used to collect the data. Quantitative 1. Questionnaire: A questionnaire specially designed for the study in English and then translated to Bengali (regional language) by translation‑retranslation process and pre‑tested for final use in the study was administered on 1486 respondents selected from 88,364 (ration 1:68) total adult population as per voter list[15] using systematic random sampling method. Emphasis was given on the four wards (1‑4), where the community work has been focused since the last 2 years. 548 respondents were selected from the total population of 15879 in ward no. 1‑4 (ratio 1:29). Qualitative 1. In‑depth interviews: Selected persons from the different stake holders such as families of persons with mental illness, ward councilors, political leaders, club secretaries, doctors, teachers, self‑help group members, NGO personals etc., were interviewed in depth to assess their attitude toward the CMHP and the extent of their interest and participation in the program. 13 such In‑depth interviews were conducted. 2. Focus group discussions (FGD): 10 FGD with average Indian Journal of Psychiatry 56(2), Apr-Jun 2014
8‑12 persons from the different stake holders as mentioned above were conducted with the key points related to objectives of the study 3. Participant’s observation: Participant’s observation in the running of the OPD clinic and other programs pursued by the clinic members at Habra 4. Secondary data sources: Secondary data sources such as office records, various reports and available published or unpublished literatures were also used for the study. The analysis and inferences drown based on above all sources of data. First, we proceed from the general perception on mental health and persons with mental illness persisting in the community, then find out the impact of the OPD clinic on the community in general and the persons with mental illness families in particular. Finally, we evaluated the impact of other programs of the CMHP and the overall impact of the program on the whole population of Habra as well as on the community of the target area (i.e. ward no. 1‑4). RESULTS AND DISCUSSION The socio‑demographic composition Majority (97.65%) of the respondents were Hindu, while the rest belong to the Muslim community. Around two‑third (66.4%) of the studied population belong to the general caste category, 21.5% scheduled caste category and the rest to other backward class. Female respondents constitute 55.24% of the respondents, the rest being male. Nearly 7.6% were illiterate, 51.1% of the respondents having education up to class VIII, 17.46% up to X, 22.94% having higher education. Most (58%) of them have 18‑40 years of old. Most (67.8%) of the respondents have income below Rs. 5000/month. Perception about mental health in the community An overwhelming 84.5% of the respondents perceive that incidence of mental illness is increasing in the present days. Of these respondents, 55.65% opine that the main reasons behind increasing mental health problem is financial crisis, 22.85% mention familial problems, 11% social problems and 8% mention other problems such as increasing tension due to competition, rising living standard etc., [Figure 1]. Exposure to mental illness Nearly 11.67% of respondents are exposed to mental illness in their own family. In the target area, i.e. ward nos. 1‑4, 12.59% respondents are reported to have a person with mental illness in their own family. This is astoundingly higher than the national average.[16] 24.63% have exposure to mental illness in their locality. Knowledge and attitude toward persons with mental illness Almost the whole (98.45%) of the studied population is in favor of providing more care to the persons with mental 145
Sahu: Impact of the CMHP at Habra: An evaluation
illness instead of neglecting the same or treating them as a burden. Hence, a positive attitude toward the person with mental illness seems to exist in the local community this finding is inconsistent with various studies[17‑22] which suggests that there is negative attitude in the community toward the person with mental illness. Again a positive finding, 93% of the respondents would like to depend on a doctor for treating a person with mental illness and rest 7%, who would try for magico‑religious treatments or both, only 1% have greater faith on other methods of treatments. So there is almost a consensus in the community on preferring a doctor for treating mental illness. It is also important to note that an overwhelming 92.5% believe that mental problems can be cured through treatment. All these positive attitudes could be the impacts of the CMHP on the local community, consistent sensitization through awareness generation programs and involvement and participation have a greater impact on community.
Figure 1: Reasons for increasing mental health problems
Role of the community While 95.5% of the studied population believe that the community have some responsibility for mental health care, 22.6% think that the community have substantially sympathetic and caring attitude toward person with mental illness and 68.8% of the respondents think that such attitude exist in the community to some extent. Further, a lesser number of the studied population is hopeful on the question whether the attitude to take responsibility on the issue of mental health care exists in the society. 16.42% of the studied population believe such responsibility exist in the society to a great extent, when 65.2% think such attitude exist to some extent. That means altogether around 82% feel such responsibility exists in the society. It’s a good sign that the community has feeling of responsibility. Specifying the roles that the community and related issues are given in Table 1. The suggestions from the community received through both quantitative and qualitative studies are to take more necessary programs and steps to achieve the goal of the CMHP. Most of the findings were corroborated by the qualitative studies as well. Attitude toward the paripurnata OPD clinic 29.67% of the studied population is aware of the existence of the mental health OPD clinic run by Paripurnata, though 8.5% have just heard of it from somebody or seen the clinic while passing through the State General Hospital. In the target area, i.e. ward nos. 1‑4, 31% respondents are reported to have known the existence of the clinic. So the knowledge about the existence of the clinic is only marginally higher in the target area. Nearly 61.9% of those having some kind of knowledge of the clinic inform that they are aware of local persons with mental illness visiting Paripurnata clinic in case of mental health problems, whereas 33.9% have no idea whether local people visit the clinic or not. Only 4.2% reported that persons with mental illness in their area do not visit
Table 1: Role of the community in running CMHP Role of local people Local people should have some role in implementation May assist in implementation of the programmes May take initiative in implementing these programmes May play a role by participating in these programmes May mobilize people in these programmes Interest of local people Feel that local people have become interested Feel that local people are not interested Reasons behind no interest Lack of campaign is the reason behind Lack of awareness in the community Lack of interest on the mental health issue How local people take responsibility Local people themselves can take responsibility To facilitate it, extensive campaign is needed Local people have to be mobilized. Local social institutions have to be involved Interested to take part in organizing CMHP Personally feel extremely interested to take responsibility Personally feel interested to take responsibility 146
In all wards (n=149) 98.7% 34.23% 35.6% 19.46% 6% In all wards (n=149) 65.77% 34.23% In all wards (n=51) 64% 14% 11% In all wards (n=149) 67.8% 58.4% 28.3% 8.4% 64.4% 37.6% 51.8%
In the wards no. 1–4 (n=94) 98% 40.2% 35.9% 18.5% 5.4% In the wards no. 1–4 (n=94) 72.34% 27.66% In the wards no. 1–4 (n=26) 66.7% 13.3 20% In the wards no. 1–4 (n=94) 77.7% 53.2% 36.2% 5.3% 71.3% 40.4% 48.9% Indian Journal of Psychiatry 56(2), Apr-Jun 2014
Sahu: Impact of the CMHP at Habra: An evaluation
Paripurnata clinic. Of those who responded to the question as to what extent they think that the clinic is beneficial to the community, 33.5% consider that it is extremely beneficial while 43.9% think it to some extent beneficial. That means, 77.4% of those who have some knowledge on the running of the clinic have the opinion that the clinic is beneficial to the community. Among the rest, 8.6% have said that the services of the clinic are not significant and around 13.95% could not express any definite opinion. That means, among those who have better knowledge about the clinic, the overwhelming majority consider that the services of the clinic are beneficial to the community. Similarly, among those having some definite knowledge about Paripurnata clinic, 89.6% think that there are scopes to further develop the clinic to be more beneficial. Of these respondents, who think that the OPD clinic can be more beneficial, suggestions received are given in Table 2. In the qualitative studies, this suggestion is found to be widespread among the families of persons with mental illness, who have to face problems in the overcrowded clinic. Nearly 13.15% of the respondents having knowledge about the clinic find some sort of weaknesses in the running of the clinic, while the rest 86.85% have not found any. Among 13.15% who report some sort of weaknesses state that: 1. 32.76% find treatment in the clinic is unsatisfactory. The main reason behind this complaint is that the doctor is not giving proper attention and care to hear the problems of persons with mental illness 2. 25.86% find the clinic needs to be more regular, i.e. function more days in a week. Most of the weaknesses mentioned here are related to this problem. The quality of treatment cannot be good unless the pressure on the clinic is reduced 3. 8.6% have complaint on bad conduct of the clinic staff. This seems to be happening due to excessive pressure of persons with mental illness on the single day OPD clinic. Participant’s observation has revealed that the clinic staffs are sometimes losing patience in dealing with the persons with mental illness. There is a tint of bureaucracy in their dealing with the persons with mental illness Table 2 Suggestions to make OPD clinic more beneficial Suggestion of Respondents More awareness Frequency of the clinic needs to be increased more than one day a week Better treatment and better doctor More medicines are needed Improvement of infrastructure, i.e., sufficient sitting arrangement Opening indoor facility for persons with mental illness Doctor should visit the community suggests for more government help Political parties help will make the clinic more beneficial Indian Journal of Psychiatry 56(2), Apr-Jun 2014
In all wards (n=441) 28.9% 24.26% 17.9% 9.8% 7.2% 2.55% 1.7% 0.85% 0.4%
4. 32.76% mention other weaknesses such as, medicines not explained properly, inadequate sitting space and insufficient supply of medicines. The first problem mentioned here is related to some extent to the excessive pressure of persons with mental illness. The other problems can probably be solved only by the intervention of the government authority. Attitude of the families of persons with mental illness toward the paripurnata clinic 1. Of the total persons with mental illness reported in the study, 46.5% attend the Paripurnata clinic, while in the target area, 56.5% persons with mental illness visit the clinic. The impact of comparatively more intense CMHP work among the community might have made the distinction in the target area i.e. ward nos. 1‑4, from where more persons with mental illness are attending the clinic. However overall, the percentage of local persons with mental illness attending the clinic is quite low. Hence, much remains to be done to attract all or most of the persons with mental illness to the clinic 2. Asked about the impact of treatment in the Paripurnata clinic, of those attending the clinic, 34% have reported to have recovered substantially, 8% recovered fully and 42% slightly. Altogether 84% have reported to have recovered to some extent or other by treatment in the clinic 3. 39% of the families of the persons with mental illness attending Paripurnata clinic feel their wards recovery have been up to their expectation, while 61% feel to the contrary. Asked to specify the reasons, 20.25% consider that their persons with mental illness are not properly treated and 3.8% opine that their wards’ illness has not been properly diagnosed. Hence, around 24% of the families of persons with mental illness being treated in the Paripurnata clinic are not satisfied with the kind of treatment received there 4. Regarding assessment of the management of the clinic, 81% expressed satisfaction and only 19% of the families of persons with mental illness receiving treatment in the clinic felt dissatisfaction 5. Asked to suggest ways to improve the clinic, 25% want better treatment and more doctors, 12.7% suggest the doctor provide more time to the persons with mental illness. That means, 37.7% of the families of persons with mental illness feel that the treatment in the clinic should be improved more 6. 17.7% of the families of persons with mental illness studied suggest the clinic to provide more medicine along with more doctors attending the clinic. 2.5% feel more staffs and better behavior on the part of them would improve the quality of services provided in the clinic. These problems, like lack of doctor and medicine to serve the increasing number of person with mental illness attending the clinic along with lack of attention while treating a person with mental illness, have been 147
Sahu: Impact of the CMHP at Habra: An evaluation
Table 3: Impact of CMHP
Among those who said CMHP can be made more beneficial
Generating awareness about the CMHP Aware of the CMHP programmes Among those who are aware of CMHP Know only about awareness programme Know only of the family meeting programme Know both awareness programme and family meet Heard about Day-care centre Extent of participation in CMHP Participated in al lest one or more programmes Participated only in awareness programmes Participated only in family meetings Participated in both or more than one programmes Perception about the CMHP Consider CMHP to be beneficial CMHP programmes are extremely beneficial CMHP programmes are beneficial to some extent CMHP programmes have increased awareness Families’ of PWMI got benefited from these programmes Programmes have helped the patients to be self-reliant Local people become trained How to develop the CMHP CMHP programmes can be made more beneficial More awareness campaign is needed More cooperation from the community is needed Better treatment and twice a week OPD Day care centre should be reopened Indoor facility should be provided Good behaviour with the patients Local party and clubs have to be involved More government help is needed The extent of awareness generated by CMHP Effective on generating awareness in the community Quite effective to extend awareness Extend awareness to some extent
In all wards (n=1486) 10% In all wards (n=149) 63.8% 20.8% 15.4% 19% In all wards (n=149) 64.4% 36.9% 14.8% 12.75% In all wards (n=149) 88.6% 42.95% 45.64% 59.7% 22.8% 1.34% 3.4% In all wards (n=149) 66.44% 58.6% 5% 4% 1% 1% 1% 2% 2% In all wards (n=149) 90.6% 39.6% 51%
corroborated by the FGDs, case studies and our clinic observation as well. Impact of CMHP While analyzing the impact of awareness campaign and other programs of Paripurnata, we first looked at the impact generated by these programs on the whole population of Habra and then have a comparison with the target area, i.e. ward nos. 1‑4. Impacts are marginally higher in target area. This has been possible due to the focus of CMHP activities in the target area. Most of the findings were corroborated by the qualitative studies as well as the details are given in Table 3. All these show that work has already been started in the right direction by selecting certain areas and creating possibilities of community involvement by focusing its activities there. This might be construed as a good beginning for the re‑orientation of the Paripurnata CMHP toward the community, the beginning of a long journey to make it a model of community mental health work in the country. CONCLUSION Though the impact of the CMHP programs on the population in Habra in general and in the target area in particular has 148
In the wards no. 1-4 (n=548) 17% In the wards no. 1–4 (n=94) 56.4% 25.5% 18% 5.3% In the wards no. 1–4 (n=94) 86% 46.8% 21.28% 18% In the wards no. 1–4 (n=94) 90% 49% 41.5% 64% 18% 0 4% In the wards no. 1–4 (n=94) 48% 68.8% 0 2.22% 0 0 0 4.44% 4.44% In the wards no. 1–4 (n=94) 91.5% 46.8% 44.7%
been good, but a large segment of the community remains unaware of the programs and hence non‑interested in the CMHP. Vast majority of the respondents think that local community should have some roles in the implementation of the CMHP programs. Two‑third of the respondents and more so in the target area expressed that the community can take responsibility of running their own CMHPs. Though the larger population of them is still not acquainted with the activities of the CMHP, It seems to a strong ground to involve the community in such program and make them prepare to take the responsibility for running their own mental health programs with the local resources. The CMHP at Habra deserves support to be sustained, yet the local community is not prepared to take responsibility of their community mental health needs by their own. Implications It is eminently feasible to start a wide spectrum of community mental health and psychosocial service programs in a rural area by an NGO but in spite of a decade presence of CMHP still sustainability is big question. So the model needs to actively workout with other stakeholders particularly with the government keeping in view of long‑term sustainability. Premature withdrawal could be very negative impact on the community. Indian Journal of Psychiatry 56(2), Apr-Jun 2014
Sahu: Impact of the CMHP at Habra: An evaluation
ACKNOWLEDGMENTS Paripurnata acknowledge Sir Ratan Tata Trust for funding and The Researcher for their contribution in this study. I would like to thank the staff and management of Paripurnata and also to all those who have contributed or supported in any ways for this work.
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World Health Organization. Report of the Regional Workshop Developing Community Mental Health Services. Bangkok, Thailand, 11‑14 December 2006. New Delhi: Regional Office for South‑East Asia; 2007. p. 2. 2. Health Organization press release. Available from: http://www.who. int/mediacentre/news/notes/2007/np25/en/index.html. [Last cited on 2009 Nov 01]. 3. Desai NG. Public mental health: An evolving imperative. Indian J Psychiatry 2006;48:135‑7. 4. Kumar A. mental health in a public health perspective. The Bihar Times. 2001 Available from: http://www.bihartimes.com/articles/anant/mental_ health.html. [Last cited on 2009 Nov 01]. 5. Sartorius N, Harding TW. The WHO collaborative study on strategies for extending mental health care, I: The genesis of the study. Am J Psychiatry 1983;140:1470‑3. 6. Wig NN, Murthy RS, Harding TW. A model for rural psychiatric services‑raipur rani experience. Indian J Psychiatry 1981;23:275‑90. 7. Murthy SR. Economics of mental health care in developing countries. In: Mak FL, Nadelson CC, editors. International Review of Psychiatry. Vol. 2. Washington, DC: American Psychiatric Press; 1996. 8. Murthy RS. Rural psychiatry in developing countries. Psychiatr Serv 1998;49:967‑9. 9. Khandelwal SK, Jhingan HP, Ramesh S, Gupta RK, Srivastava VK. India
mental health country profile. Int Rev Psychiatry 2004;16:126‑41. 10. NIMHANS, District Mental Health Program. Available from: http://www. nimhans.kar.nic.in/%E2%80%A6/default.htm%00%00. [Last cited on 2009 Nov 01]. 11. Padmavati R. Community mental health care in India. Int Rev Psychiatry 2005;17:103‑7. 12. Wikipedia.org. Habra. Available from: http://www.en.wikipedia.org/w/ index.php?title=Habra. [Last updated on 2009 May 16; Last cited on 2009 Nov 01]. 13. District Statistical Handbook of North 24 Parganas, Bureau of Applied Economics and Statistics, Government of West Bengal, India; 2005. 14. Web.cmc.net.in. New Delhi: Directorate of census operation Census of India; 2001. Available from: http://www.web.cmc.net.in/wbcensus/ DataTables/07/FrameTables 2_5.htm. [Last cited on 2009 Nov 01] 15. Eci.nic.in. Election Commission of India Voter list. Available from: http:// www.eci.nic.in/eci_main1/Linkto_electo_search.aspx. [Last updated on 2002 May 16; [Last cited on 2009 Nov 01]. 16. Kumar A. District mental health programme in India: A case study. J Health Dev Res 2005;1:24. 17. Oyefeso AO. Attitudes towards the work behaviour of ex‑mental patients in Nigeria. Int J Soc Psychiatry 1994;40:27‑34. 18. Albrecht GL, Walker VG, Levy JA. Social distance from the stigmatized. A test of two theories. Soc Sci Med 1982;16:1319‑27. 19. Cumming E, Cumming J. Stigma and mental illness. Community Ment Health J 1965;1:135‑43. 20. Prabhu G, Raghuram A, Verma N, Annette C. Public attitude toward mental illness: A review. NIMHANS J 1984;2:1‑14. 21. Cumming E, Cumming J. An experiment in mental health. Cambridge: Harvard University Press; 1957. 22. Crocetti G, Spiro H, Siassi I. Contemporary Attitude Toward Mental Illness. Pittsburgh: University of Pittsburgh Press; 1974.
Source of Support: Nil, Conflict of Interest: None declared
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Impact evaluation of the community mental health program at habra Kamlesh Kumar Sahu
Department of Psychiatric Social Work, Institute of Psychiatry, Kolkata, West Bengal, India
Abstract
Background: It is a well‑known fact that there is a huge gap between mental health service availability and needs of people in the community. Community Mental Health Program (CMHP) appears as a solution for it. Paripurnata (a non‑governmental organization) has been running a CMHP at Habra, West Bengal, India since 2000. Since 2005 a psychiatric out‑patient department is functioning and community work is focused on capacity building of different stakeholders. Several awareness camps, community preparedness workshops have been organized. However, the work is yet to be consolidated with initiatives from the community. It has to be facilitated more with an objective analysis of the situation. The need of the hour is to assess the previous work. So an evaluation study was planned. Aims: The primary aim of the following study is to assess the impact of the CMHP on the local population and secondary aim is to evaluate that what extent the CMHP have been able to prepare them to take responsibility of the CMHP as a whole. Materials and Methods: Using systematic random sampling method 1486 respondents were selected and data collect using a questionnaire. In‑depth interviews, focus group discussions, participant’s observation and secondary data sources were also used. Inferences drown based on above all data sources. Results and Conclusion: Two‑third of the studied population and more so in the target area expressed that the community can take responsibility of running their own CMHPs. Though, the larger population of them is still not acquainted with the activities of the CMHP, the program deserves support to sustain. Key words: Community mental health program, community psychiatry, health education, mental health promotion
INTRODUCTION Community Mental Health Care Programs imply that all mental health and well‑being needs of the community are met in the community, using community resources and the primary health care (PHC) system. It goes much beyond only treatment and includes: Promotion of well‑being and mental health promotion, stigma removal, psychosocial support, rehabilitation of those in need, prevention of harm from alcohol and substance use and treatment of the ill using the PHC system.[1] The World Health Organization states that community mental health services are more accessible and effective to lessen social exclusion and are likely to have less Address for correspondence: Mr. Kamlesh Kumar Sahu, Department of Psychiatric Social Work, Institute of Psychiatry, 7 D.L. Khan Road, Kolkata ‑ 700 025, West Bengal, India. E‑mail: [email protected]
How to cite this article: Sahu KK. Impact evaluation of the community mental health program at Habra. Indian J Psychiatry 2014;56:143-9. Indian Journal of Psychiatry 56(2), Apr-Jun 2014
possibility for the neglect and violations of human rights that were often encountered in mental hospitals.[2] India has a long history of community mental health initiatives. The Bhore Committee Report of 1946, which laid the foundation for the community health movement.[3] The 1970s and 1980s brought more initiatives in mental health care and culminated in the National Mental Health Program (NMHP) in India, one of the earliest in the world.[4] Two programs that have influenced the development of India’s Community Mental Health Program (CMHP) are the Raipur Rani Program and the Bellary District Program.[5‑8] The results of the experiments in integrating mental health care with general health care were used in formulating the NMHP in Access this article online Quick Response Code Website: www.indianjpsychiatry.org
DOI: 10.4103/0019-5545.130487
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1982 which was and reviewed in 1995 and subsequently District Mental Health Program (DMHP) was launched 1986, sought to integrate mental health care with PHC.[9] This model has been implemented in all the states and currently there are 125 DMHP sites in India. The Ministry of Health, Government of India envisages extension of DMHP to all the districts in the country as part of the 11th five year plan. The Ministry of Health and Family Welfare Government of India has revitalized the DMHP based on the available evidence.[10] The limited success of the NMHP and the community mental health movement has to be recognized and accepted.[3] Recent literature on community mental health activities show that various forms of community care for the persons with mental illness are emerging in India and the non‑governmental organizations (NGOs) are playing a pivotal role in filling the gap existing between mental health services and the growing and substantial need for such services. Various strategies that have been employed in community care have attempted to utilize existing community resources for implementation. Resources like manpower from the community combined with specialist psychiatric care and integrated with existing health care facilities have become general strategies of CMHPs. Whereas the feasibility and cost‑effectiveness of the NGO operated community outreach programs for the persons with mental illness have been demonstrated, various factors are seen to influence the planning and execution of such programs.[11] Paripurnata (means hope for the wholeness, it is an NGO), the center for psycho‑social rehabilitation, established in 1991, has been running a CMHP at Habra, West Bengal, India since 2000, with the goal of community preparedness to take responsibility of their mental health needs. It was started at Banipur and later shifted to Habra municipal area in 10th November 2005. Since then a psychiatric out‑patient department (OPD) is functioning and community work is focused on capacity building of different stakeholders. Several awareness camps, community preparedness workshops in the community have been organized with a set of long‑term objectives. However, the work is yet to be consolidated with initiatives from the community. It has to be facilitated more with an objective analysis of the situation. The need of the hour is to assess the previous work and hence an evaluation study was planned. Description of the program Program location and demography Habra is a town, a municipality and a police station of Barasat Sadar subdivision in North 24 Parganas district in the Indian state of West Bengal.[12] As per the 2001 Census report, the total population of Habra municipality was 1,27,602, males constitute 51% of the population and females 49% and the population density was 5,626 respectively. The number of scheduled caste was 25,780 and scheduled tribes 1,478 in the population. Literacy percentage was 86.3, which was 91% among the male population and 81.4% among the female. 144
The percentage of total workers was 34.6% of the total population, among which 1% was cultivator, 3% agricultural laborers, 5.4% household industry workers while rest 90.6% constituted the category of other workers respectively.[13] West Bengal (0.34%) in general and North 24 Parganas district in particular have higher (0.39%) prevalence of mental disabilities, as found from the Census report 2001.[14] In Habra 555 (0.43%) persons were identified with mental health problem in a baseline survey conducted by Paripurnata. The actual figure of prevalence of mental health affected population is much higher than the mental disabilities, as found from the census report 2001. Habra State General Hospital is only one medical center in the Habra municipal area with a capacity of 131 beds and 29 attending doctors. The hospital did not have a department to treat persons with mental illness. Hence, the health department of the state government agreed to hand over a portion of the Habra State General Hospital to Paripurnata for running the clinic for persons with mental health illness. Since November 2005 a psychiatric OPD is functioning there being a perfect instance of public‑private partnership. The catchment area of the program is entire 23 wads of Habra municipality and surrounding of around 50 km radius. The CMHP was initiated as a pilot program with the goal to prepare the local community to take responsibility of their mental health needs and handover the CMHP to local community and withdraw from there but it was extended for various tenure and now completed a full decade but it is still in its “developmental stage;” obviously the withdrawal stage is yet to come. The task of handing over the CMHP to the community is a long‑drawn process, toward which little seems to have been done yet. At this stage needs to ensure complete attainment of program development and then think of handing over or withdrawal. CMHP revolves around the following activities: 1. Setting up of a base 2. Identification of stakeholders 3. Capacity building 4. Networking and convergence 5. Mental Health Services: Prevention, intervention and rehabilitation 6. Vocational training ‑ for post‑treatment rehabilitation sustainability 7. Research and documentation 8. Management and administration. Various activities such as awareness generation meetings, community preparedness workshops, family meets, house visits, training programs or workshops for the staff, the base line survey, counseling, OPD and day care center were carried out as planned. The program has been running since a decade but last 2 years for the community work is focused on four wards (wards no. 1‑4 out of total 23 wards) Indian Journal of Psychiatry 56(2), Apr-Jun 2014
Sahu: Impact of the CMHP at Habra: An evaluation
of Habra Municipality as a pilot program with an idea that if it proves viable, it could be replicated in other wards. Now the program has come to a crucial stage in its life. To move further, it has become absolutely necessary to develop a long‑term realistic and community‑based proposal based on known impact the past activities have made in the community. Keeping in view, the need of the hour, an evaluation study was planned. THE AIM AND OBJECTIVES OF THE EVALUATION To assess the impact of the CMHP on the local population with the aim to evaluate to what extent the activities have been able to prepare them to take responsibility of the CMHP as a whole. The following objectives were included for studying the impact: 1. The principal component was to study whether the attitude prevailing in the society toward mental health problems has undergone substantial changes due to the programs implemented by the program 2. As a corollary to the first point, whether the local community is increasingly feeling the necessity of running the mental health program in their locality 3. Whether there is increasing feeling of responsibility, confidence and empowerment among the local population to run such a program on their own? MATERIALS AND METHODS Both quantitative and qualitative tools were used to collect the data. Quantitative 1. Questionnaire: A questionnaire specially designed for the study in English and then translated to Bengali (regional language) by translation‑retranslation process and pre‑tested for final use in the study was administered on 1486 respondents selected from 88,364 (ration 1:68) total adult population as per voter list[15] using systematic random sampling method. Emphasis was given on the four wards (1‑4), where the community work has been focused since the last 2 years. 548 respondents were selected from the total population of 15879 in ward no. 1‑4 (ratio 1:29). Qualitative 1. In‑depth interviews: Selected persons from the different stake holders such as families of persons with mental illness, ward councilors, political leaders, club secretaries, doctors, teachers, self‑help group members, NGO personals etc., were interviewed in depth to assess their attitude toward the CMHP and the extent of their interest and participation in the program. 13 such In‑depth interviews were conducted. 2. Focus group discussions (FGD): 10 FGD with average Indian Journal of Psychiatry 56(2), Apr-Jun 2014
8‑12 persons from the different stake holders as mentioned above were conducted with the key points related to objectives of the study 3. Participant’s observation: Participant’s observation in the running of the OPD clinic and other programs pursued by the clinic members at Habra 4. Secondary data sources: Secondary data sources such as office records, various reports and available published or unpublished literatures were also used for the study. The analysis and inferences drown based on above all sources of data. First, we proceed from the general perception on mental health and persons with mental illness persisting in the community, then find out the impact of the OPD clinic on the community in general and the persons with mental illness families in particular. Finally, we evaluated the impact of other programs of the CMHP and the overall impact of the program on the whole population of Habra as well as on the community of the target area (i.e. ward no. 1‑4). RESULTS AND DISCUSSION The socio‑demographic composition Majority (97.65%) of the respondents were Hindu, while the rest belong to the Muslim community. Around two‑third (66.4%) of the studied population belong to the general caste category, 21.5% scheduled caste category and the rest to other backward class. Female respondents constitute 55.24% of the respondents, the rest being male. Nearly 7.6% were illiterate, 51.1% of the respondents having education up to class VIII, 17.46% up to X, 22.94% having higher education. Most (58%) of them have 18‑40 years of old. Most (67.8%) of the respondents have income below Rs. 5000/month. Perception about mental health in the community An overwhelming 84.5% of the respondents perceive that incidence of mental illness is increasing in the present days. Of these respondents, 55.65% opine that the main reasons behind increasing mental health problem is financial crisis, 22.85% mention familial problems, 11% social problems and 8% mention other problems such as increasing tension due to competition, rising living standard etc., [Figure 1]. Exposure to mental illness Nearly 11.67% of respondents are exposed to mental illness in their own family. In the target area, i.e. ward nos. 1‑4, 12.59% respondents are reported to have a person with mental illness in their own family. This is astoundingly higher than the national average.[16] 24.63% have exposure to mental illness in their locality. Knowledge and attitude toward persons with mental illness Almost the whole (98.45%) of the studied population is in favor of providing more care to the persons with mental 145
Sahu: Impact of the CMHP at Habra: An evaluation
illness instead of neglecting the same or treating them as a burden. Hence, a positive attitude toward the person with mental illness seems to exist in the local community this finding is inconsistent with various studies[17‑22] which suggests that there is negative attitude in the community toward the person with mental illness. Again a positive finding, 93% of the respondents would like to depend on a doctor for treating a person with mental illness and rest 7%, who would try for magico‑religious treatments or both, only 1% have greater faith on other methods of treatments. So there is almost a consensus in the community on preferring a doctor for treating mental illness. It is also important to note that an overwhelming 92.5% believe that mental problems can be cured through treatment. All these positive attitudes could be the impacts of the CMHP on the local community, consistent sensitization through awareness generation programs and involvement and participation have a greater impact on community.
Figure 1: Reasons for increasing mental health problems
Role of the community While 95.5% of the studied population believe that the community have some responsibility for mental health care, 22.6% think that the community have substantially sympathetic and caring attitude toward person with mental illness and 68.8% of the respondents think that such attitude exist in the community to some extent. Further, a lesser number of the studied population is hopeful on the question whether the attitude to take responsibility on the issue of mental health care exists in the society. 16.42% of the studied population believe such responsibility exist in the society to a great extent, when 65.2% think such attitude exist to some extent. That means altogether around 82% feel such responsibility exists in the society. It’s a good sign that the community has feeling of responsibility. Specifying the roles that the community and related issues are given in Table 1. The suggestions from the community received through both quantitative and qualitative studies are to take more necessary programs and steps to achieve the goal of the CMHP. Most of the findings were corroborated by the qualitative studies as well. Attitude toward the paripurnata OPD clinic 29.67% of the studied population is aware of the existence of the mental health OPD clinic run by Paripurnata, though 8.5% have just heard of it from somebody or seen the clinic while passing through the State General Hospital. In the target area, i.e. ward nos. 1‑4, 31% respondents are reported to have known the existence of the clinic. So the knowledge about the existence of the clinic is only marginally higher in the target area. Nearly 61.9% of those having some kind of knowledge of the clinic inform that they are aware of local persons with mental illness visiting Paripurnata clinic in case of mental health problems, whereas 33.9% have no idea whether local people visit the clinic or not. Only 4.2% reported that persons with mental illness in their area do not visit
Table 1: Role of the community in running CMHP Role of local people Local people should have some role in implementation May assist in implementation of the programmes May take initiative in implementing these programmes May play a role by participating in these programmes May mobilize people in these programmes Interest of local people Feel that local people have become interested Feel that local people are not interested Reasons behind no interest Lack of campaign is the reason behind Lack of awareness in the community Lack of interest on the mental health issue How local people take responsibility Local people themselves can take responsibility To facilitate it, extensive campaign is needed Local people have to be mobilized. Local social institutions have to be involved Interested to take part in organizing CMHP Personally feel extremely interested to take responsibility Personally feel interested to take responsibility 146
In all wards (n=149) 98.7% 34.23% 35.6% 19.46% 6% In all wards (n=149) 65.77% 34.23% In all wards (n=51) 64% 14% 11% In all wards (n=149) 67.8% 58.4% 28.3% 8.4% 64.4% 37.6% 51.8%
In the wards no. 1–4 (n=94) 98% 40.2% 35.9% 18.5% 5.4% In the wards no. 1–4 (n=94) 72.34% 27.66% In the wards no. 1–4 (n=26) 66.7% 13.3 20% In the wards no. 1–4 (n=94) 77.7% 53.2% 36.2% 5.3% 71.3% 40.4% 48.9% Indian Journal of Psychiatry 56(2), Apr-Jun 2014
Sahu: Impact of the CMHP at Habra: An evaluation
Paripurnata clinic. Of those who responded to the question as to what extent they think that the clinic is beneficial to the community, 33.5% consider that it is extremely beneficial while 43.9% think it to some extent beneficial. That means, 77.4% of those who have some knowledge on the running of the clinic have the opinion that the clinic is beneficial to the community. Among the rest, 8.6% have said that the services of the clinic are not significant and around 13.95% could not express any definite opinion. That means, among those who have better knowledge about the clinic, the overwhelming majority consider that the services of the clinic are beneficial to the community. Similarly, among those having some definite knowledge about Paripurnata clinic, 89.6% think that there are scopes to further develop the clinic to be more beneficial. Of these respondents, who think that the OPD clinic can be more beneficial, suggestions received are given in Table 2. In the qualitative studies, this suggestion is found to be widespread among the families of persons with mental illness, who have to face problems in the overcrowded clinic. Nearly 13.15% of the respondents having knowledge about the clinic find some sort of weaknesses in the running of the clinic, while the rest 86.85% have not found any. Among 13.15% who report some sort of weaknesses state that: 1. 32.76% find treatment in the clinic is unsatisfactory. The main reason behind this complaint is that the doctor is not giving proper attention and care to hear the problems of persons with mental illness 2. 25.86% find the clinic needs to be more regular, i.e. function more days in a week. Most of the weaknesses mentioned here are related to this problem. The quality of treatment cannot be good unless the pressure on the clinic is reduced 3. 8.6% have complaint on bad conduct of the clinic staff. This seems to be happening due to excessive pressure of persons with mental illness on the single day OPD clinic. Participant’s observation has revealed that the clinic staffs are sometimes losing patience in dealing with the persons with mental illness. There is a tint of bureaucracy in their dealing with the persons with mental illness Table 2 Suggestions to make OPD clinic more beneficial Suggestion of Respondents More awareness Frequency of the clinic needs to be increased more than one day a week Better treatment and better doctor More medicines are needed Improvement of infrastructure, i.e., sufficient sitting arrangement Opening indoor facility for persons with mental illness Doctor should visit the community suggests for more government help Political parties help will make the clinic more beneficial Indian Journal of Psychiatry 56(2), Apr-Jun 2014
In all wards (n=441) 28.9% 24.26% 17.9% 9.8% 7.2% 2.55% 1.7% 0.85% 0.4%
4. 32.76% mention other weaknesses such as, medicines not explained properly, inadequate sitting space and insufficient supply of medicines. The first problem mentioned here is related to some extent to the excessive pressure of persons with mental illness. The other problems can probably be solved only by the intervention of the government authority. Attitude of the families of persons with mental illness toward the paripurnata clinic 1. Of the total persons with mental illness reported in the study, 46.5% attend the Paripurnata clinic, while in the target area, 56.5% persons with mental illness visit the clinic. The impact of comparatively more intense CMHP work among the community might have made the distinction in the target area i.e. ward nos. 1‑4, from where more persons with mental illness are attending the clinic. However overall, the percentage of local persons with mental illness attending the clinic is quite low. Hence, much remains to be done to attract all or most of the persons with mental illness to the clinic 2. Asked about the impact of treatment in the Paripurnata clinic, of those attending the clinic, 34% have reported to have recovered substantially, 8% recovered fully and 42% slightly. Altogether 84% have reported to have recovered to some extent or other by treatment in the clinic 3. 39% of the families of the persons with mental illness attending Paripurnata clinic feel their wards recovery have been up to their expectation, while 61% feel to the contrary. Asked to specify the reasons, 20.25% consider that their persons with mental illness are not properly treated and 3.8% opine that their wards’ illness has not been properly diagnosed. Hence, around 24% of the families of persons with mental illness being treated in the Paripurnata clinic are not satisfied with the kind of treatment received there 4. Regarding assessment of the management of the clinic, 81% expressed satisfaction and only 19% of the families of persons with mental illness receiving treatment in the clinic felt dissatisfaction 5. Asked to suggest ways to improve the clinic, 25% want better treatment and more doctors, 12.7% suggest the doctor provide more time to the persons with mental illness. That means, 37.7% of the families of persons with mental illness feel that the treatment in the clinic should be improved more 6. 17.7% of the families of persons with mental illness studied suggest the clinic to provide more medicine along with more doctors attending the clinic. 2.5% feel more staffs and better behavior on the part of them would improve the quality of services provided in the clinic. These problems, like lack of doctor and medicine to serve the increasing number of person with mental illness attending the clinic along with lack of attention while treating a person with mental illness, have been 147
Sahu: Impact of the CMHP at Habra: An evaluation
Table 3: Impact of CMHP
Among those who said CMHP can be made more beneficial
Generating awareness about the CMHP Aware of the CMHP programmes Among those who are aware of CMHP Know only about awareness programme Know only of the family meeting programme Know both awareness programme and family meet Heard about Day-care centre Extent of participation in CMHP Participated in al lest one or more programmes Participated only in awareness programmes Participated only in family meetings Participated in both or more than one programmes Perception about the CMHP Consider CMHP to be beneficial CMHP programmes are extremely beneficial CMHP programmes are beneficial to some extent CMHP programmes have increased awareness Families’ of PWMI got benefited from these programmes Programmes have helped the patients to be self-reliant Local people become trained How to develop the CMHP CMHP programmes can be made more beneficial More awareness campaign is needed More cooperation from the community is needed Better treatment and twice a week OPD Day care centre should be reopened Indoor facility should be provided Good behaviour with the patients Local party and clubs have to be involved More government help is needed The extent of awareness generated by CMHP Effective on generating awareness in the community Quite effective to extend awareness Extend awareness to some extent
In all wards (n=1486) 10% In all wards (n=149) 63.8% 20.8% 15.4% 19% In all wards (n=149) 64.4% 36.9% 14.8% 12.75% In all wards (n=149) 88.6% 42.95% 45.64% 59.7% 22.8% 1.34% 3.4% In all wards (n=149) 66.44% 58.6% 5% 4% 1% 1% 1% 2% 2% In all wards (n=149) 90.6% 39.6% 51%
corroborated by the FGDs, case studies and our clinic observation as well. Impact of CMHP While analyzing the impact of awareness campaign and other programs of Paripurnata, we first looked at the impact generated by these programs on the whole population of Habra and then have a comparison with the target area, i.e. ward nos. 1‑4. Impacts are marginally higher in target area. This has been possible due to the focus of CMHP activities in the target area. Most of the findings were corroborated by the qualitative studies as well as the details are given in Table 3. All these show that work has already been started in the right direction by selecting certain areas and creating possibilities of community involvement by focusing its activities there. This might be construed as a good beginning for the re‑orientation of the Paripurnata CMHP toward the community, the beginning of a long journey to make it a model of community mental health work in the country. CONCLUSION Though the impact of the CMHP programs on the population in Habra in general and in the target area in particular has 148
In the wards no. 1-4 (n=548) 17% In the wards no. 1–4 (n=94) 56.4% 25.5% 18% 5.3% In the wards no. 1–4 (n=94) 86% 46.8% 21.28% 18% In the wards no. 1–4 (n=94) 90% 49% 41.5% 64% 18% 0 4% In the wards no. 1–4 (n=94) 48% 68.8% 0 2.22% 0 0 0 4.44% 4.44% In the wards no. 1–4 (n=94) 91.5% 46.8% 44.7%
been good, but a large segment of the community remains unaware of the programs and hence non‑interested in the CMHP. Vast majority of the respondents think that local community should have some roles in the implementation of the CMHP programs. Two‑third of the respondents and more so in the target area expressed that the community can take responsibility of running their own CMHPs. Though the larger population of them is still not acquainted with the activities of the CMHP, It seems to a strong ground to involve the community in such program and make them prepare to take the responsibility for running their own mental health programs with the local resources. The CMHP at Habra deserves support to be sustained, yet the local community is not prepared to take responsibility of their community mental health needs by their own. Implications It is eminently feasible to start a wide spectrum of community mental health and psychosocial service programs in a rural area by an NGO but in spite of a decade presence of CMHP still sustainability is big question. So the model needs to actively workout with other stakeholders particularly with the government keeping in view of long‑term sustainability. Premature withdrawal could be very negative impact on the community. Indian Journal of Psychiatry 56(2), Apr-Jun 2014
Sahu: Impact of the CMHP at Habra: An evaluation
ACKNOWLEDGMENTS Paripurnata acknowledge Sir Ratan Tata Trust for funding and The Researcher for their contribution in this study. I would like to thank the staff and management of Paripurnata and also to all those who have contributed or supported in any ways for this work.
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Source of Support: Nil, Conflict of Interest: None declared
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