Psychiatr Q DOI 10.1007/s11126-015-9342-x ORIGINAL PAPER

Impact of Community Interventions on the Social Representation of Depression in Rural Gujarat I. Mindlis • J. Schuetz-Mueller • S. Shah • R. Appasani A. Coleman • C. L. Katz

•

Ó Springer Science+Business Media New York 2015

Abstract There is a pressing need to develop community interventions that will address stigma against mental illness in rural India. This cross-sectional study will compare social representations of depression in villages where educational programs have targeted mental illness and stigma versus control villages. Participants from the villages exposed to the educational interventions (n = 146) will be compared with a sample from six control villages (n = 187) in the same geographic region, using a structured questionnaire. The impact of the intervention as a predictor for questionnaire score will be assessed along with socio-demographic variables. The intervention villages showed higher levels of literacy regarding depression and lower levels of stigma, after adjusting for all other sociodemographic variables. While some demographic factors associated with the knowledge and attitudes towards depression are not modifiable, our research provides evidence in favor of the positive influence a community grassroots intervention can have on mental health literacy in rural settings. Keywords India

Depression  Mental illness  Community health workers  Rural population 

Introduction With 10–15 % of people worldwide suffering from depression [1], this illness is projected to become the second leading cause of disease burden by 2030 [2], and is also projected to rank second in terms of disability adjusted life years (DALYs), calculated for all ages and both sexes, by 2020 [3]. While mental health in general is not regarded as a top priority in low income countries, the prevalence of depression in India, the second largest population

I. Mindlis (&)  J. Schuetz-Mueller  A. Coleman  C. L. Katz Icahn School of Medicine at Mount Sinai, New York, NY, USA e-mail: [email protected] S. Shah  R. Appasani The MINDS Foundation, Boston, MA, USA

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in the world, is 13–25 % [4, 5]. Recent studies indicate that at least 58 per 1,000 people in India have a mental illness and about 10 million suffer from severe mental illness [6–8]. Projected estimates for India reveal that by 2020 neuropsychiatric conditions will be the fourth leading cause of disease burden, with unipolar depression being the leading cause of disease burden among women [9]. With most of the mental health professionals clustered in India’s urban areas, the rural population has very limited access to treatment for mental health problems. Only about 10 % of the rural population has access to mental health care [7]. Due to the comorbidity of mental and physical conditions, people with mental disorders frequently seek treatment in primary health care facilities, where available. In a study by Weiss et al. [6] as many as 28 % of patients aged 18 and over attending a primary health care facility in a Mumbai slum had psychiatric diagnoses. In the population based epidemiological study carried out by Saddichha et al. [10] in Gujarat and Andhra Pradesh, a total of 40,541 cases of behavioral emergencies were recorded, and found to be associated with being young, from a poor socio-economic background, coming from a rural area, and backward caste. In a study on the prevalence and recognition of depression in a general hospital in Vadodara, 30 % of patients were found to have moderate or severe depression, while the treating primary care physicians missed the diagnosis of depression in two-thirds of these patients [11]. These studies highlight the need for psycho-educational programs on mental illness in populations with high prevalence of depression and low access to specialized care. Social Representation Jodelet [12] states that a social representation is where the social meets the psychological. It relates to the way in which human beings comprehend the events of daily life, the information that circulates in their environment, and the people in it. It is built upon experiences, information, and knowledge that are passed on through tradition, education and social communication. The theory of social representations provides a framework for conceptualizing ‘common sense’ theories that circulate in a community about socially meaningful objects [13]. Social representations can be understood as constellations of beliefs, social practices and shared knowledge that exist both individuals’ minds and in the fabric of society [14]. Research into lay representations of mental illness have characterized the phenomenon as negative, associated with fear and suspicion. Mental illness seems to be associated with abnormality, danger and difference, which in turn leads individuals and groups to reject, exclude and separate themselves from the mentally ill [15]. Because the work carried out by mental health professionals involves the practical application of scientific knowledge, it is reasonable to expect that these professionals will have a key role in translating knowledge into forms that can be integrated into ‘common sense’. Mental health professionals are involved in constructive processes through which social representations of mental illness evolve, turning expert theories into practices that filter into the existing stock of ‘common sense’ knowledge about mental illness [16]. Knowledge and Attitudes Towards Depression Studies in India have indicated that knowledge and understanding of mental disorders are poor in many communities, and even among community health workers [17, 18], which in

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turn influences the beliefs and attitudes towards mental health and treatment seeking behavior [19]. Studies on Indian patients with depression [20] and post-partum depression [21] have shown that non-medical causal models of illness are common, which is highly correlated with the choice of visiting village faith healers. This is especially true in communities where mental health professionals are not easily accessible [22]. Other studies [23–25] also found that the beliefs held in regards to mental illness influences help seeking behavior in a way that causes those who subscribe to supernatural causes to be more likely to consult with traditional or religious healers. Jambunathan [26] described a fatalistic attitude amongst Indians regarding both physical and mental illnesses, where these are considered God’s will or past karma. In a study carried out by Campion and Bhugra [27], the likelihood of visiting a healer was found to be linked to income, and to having schizophrenia over other diagnoses. The majority of patients surveyed reported having discontinued healer treatment after gaining access to healthcare services. The explanatory models for mental illness also seem to be related to gender. In a study by Grover et al. [28], significant differences were found between men and women with respect to the explanatory models for mental illness, with males reporting more explanation categories based on ingestion, weakness and work problems, and females attributing mental illness to more supernatural causes such as evil eye. Stigma is defined as ‘‘the endorsement of a set of prejudicial attitudes, negative emotional responses, discriminatory behaviors, and biased social structures toward members of a subgroup’’ [29]. In a systematic review [30], it was found that the tendency to discriminate against people with mental illness is widespread in Asian countries, in comparison to western countries. This in turn influences social distance towards people with mental illness, difficulties in accessing care and social disapproval, shaped by prevailing supernatural, religious and magical approaches to mental illness. Stigma and negative attitudes towards people with mental illness can have detrimental effects on many areas of life, such as employment seeking, where employers or managers may be less likely to hire people with these conditions [31]. A study about the attitudes and knowledge towards depression from Turkey [32] showed that people with negative views reported being more reluctant to marry a person with depression, or renting a house to a person suffering from this disorder, while a quarter of those surveyed believed patients should not be allowed to live freely in the community. Training programs for community health workers [33] found that 4 days of training effectively reduced participant’s faith in unhelpful and potentially harmful pharmacological interventions (appetite stimulants, vitamins, tonics, herbal medicines, and sleeping pills), as well as decreased stigmatizing attitudes among community health workers in Bangalore Rural District, Karnataka, India. In this study, the changes found in stigmatizing attitudes were mainly related to depression. In a study of medical students [34], a greater proportion of students exposed to psychiatric training endorsed positive attitudes to mental illness than those not exposed in Vellore, Tamil Nadu. Grass-Roots Approaches & Community Health Workers The World Health Organization (WHO) has been promoting the integration of mental health into primary healthcare to address the mental health gap, especially in rural and remote areas [35]. Many programs that provide education to community health workers have been successfully implemented to promote the health of the people in rural areas [36, 37], while

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other projects have trained volunteers and lay persons to extend their reach in addressing mental health [38–42]. A great number of studies and recommendations have been made to increase the coverage of mental health care through non specialized health workers [43–47]. Other studies have investigated the different components of mental health literacy as the outcome in grassroots approaches to mental health in India, especially regarding schizophrenia [42, 48, 49]. Mental Health Literacy (MHL) can be defined as ‘knowledge and beliefs about mental disorders which aid their recognition, management and prevention’ [50]. While community health workers (CHW) are seen as a great resource to bridge the mental health gap, the evaluation of their efficacy has always been focused on evaluating the CHW themselves, and not the impact they had on the community members. As mental health through primary care and grassroots approaches to mental health problems becomes more widespread in low income countries like India, a need for monitoring and evaluating the efficacy of these interventions arises. This study sought to evaluate the impact that community interventions in mental health through a grass-roots approach had on the knowledge and attitudes towards depression in a non-psychiatric population in rural Gujarat, India.

Methods Villages were categorized as being either ‘‘intervention’’ or ‘‘control’’ villages depending on whether they had received psycho-social educational campaigns through The MINDS Foundation (see below). For the control villages, a cross-sectional survey was carried out from June to August, 2014. A 41-item questionnaire was used to survey 187 participants, recruited from six villages in rural areas of Gujarat, India. For the intervention villages, the sample from the 146 participants was collected from August to September, 2013 [51]. All participants were aged C18 years (scores from the intervention sample with participants under 18 years of age were excluded from this analysis). The local study partner was the MINDS Foundation (www.mindsfoundation.org), located in Vadodara, Gujarat. Ethics approval was obtained from the Icahn School of Medicine at Mount Sinai’s IRB, and Sumandeep Vidyapeeth Institutional Ethics Committee (SVIEC). Villages were selected for their accessibility from the SVU campus. A social worker from The MINDS Foundation contacted local village leaders to facilitate the recruitment of subjects. Participants were recruited face-to-face. The purpose of the study was explained to the participants; they were recruited after obtaining written informed consent. Only responses to structured questions with pre-coded response options are reported in this paper. The Knowledge and Attitudes towards Depression questionnaire (KATD) was administered face-to-face by trained interviewers and took around 15 minutes to complete. Throughout this study we used local facilitators (research assistants at The MINDS Foundation) who were culturally and linguistically fluent, to administer a Gujarati version of the questionnaire, used previously [51, 52]. The KATD consists of demographic questions and closed-ended statements, to which respondents can indicate their level of agreement with a 5-point Likert scale: strongly agree, agree, neutral, disagree, and strongly disagree (with reverse scoring on some items), and a single open-ended question asking the following: ‘‘What do you understand by the term depression?’’ A higher total score indicates higher literacy regarding depression, and low levels of stigma. The maximum score is 68. Answers to the three qualitative items are not reported here.

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The Intervention The MINDS Foundation (www.mindsfoundation.org) addresses mental health in rural India through a series of interventions: – Organizing mental health education workshops for each village – Free-of-charge program for individuals with mental illness and their families to receive transportation to and from the Psychiatry Team who will formally diagnose, counsel and provide appropriate treatment – Community mental health workers training – Community Reintegration through social and vocational rehabilitation programs for patients Statistical Analysis A descriptive analysis was conducted to arrive at the mean and standard deviation for the continuous variables and frequency for ordinal and nominal variables. For the effect of the intervention on the knowledge and attitudes towards depression, the analyses consisted of a regression model (PROC GLM; SAS Version 9.3, SAS Institute, Cary, NC, USA) in which several potential predictors (village, age, sex, occupation, education and marital status) were entered simultaneously into the model and related to KATD score. We used regression analysis to examine the association between the intervention (control vs. intervention villages) and score in the KATD questionnaire, while adjusting for sociodemographic indicators. The steps for the regression analysis were developed after analyzing the socio-demographic variables and reviewing the existing literature. In the first model KATD score was included as the dependent variable, with village and all sociodemographic variables as predictors. At step two, marital status (which was found to be non-significant as a predictor in the first model) was excluded from the model. A p value \0.05 was considered statistically significant. All statistical analyses were performed utilizing SAS Version 9.3 (SAS Institute, Cary, NC, USA).

Results The overall sample consisted of 333 participants. Table 1 shows the socio-demographic characteristics of the participants. The intervention sample consisted of 146 participants, that ranged in age from 18 to 78. The control sample consisted of 187 participants, that ranged in age from 18 to 75. KATD Questionnaire Scores Regression analysis was used to assess the effect of being a member of an intervention versus a control village on KATD score, after controlling for socio-demographic variables. First, in Model 1, the dependent variable (KATD score) was regressed on all the predictors (village, age, education, occupation, sex and marital status). In model 2, the dependent variable (KATD score) was regressed only on those variables that had shown to be significant predictors in model 1 (village, age, education, occupation and sex). Both models accounted for about 24 % of the variance in KATD scores. In model 1, village was found to be a significant predictor of KATD score (F = 25.03, p \ 0.00) after controlling for all

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Psychiatr Q Table 1 Demographic characteristics of participants

Variables

Intervention (N = 146)

Control (N = 187)

p

Mean (SD) Age in years

38.9 (14.3)

40.2 (14.6)

0.38*

Male

93 (64.1)

78 (41.7)

\.01 

Female

52 (35.9)

109 (58.3)

132 (87.2)

166 (88.77)

18 (12.8)

21 (11.23)

Sex (N, %)

Marital status Married Unmarried

0.67 

Education (N, %) Less than intermediate

102 (72.9)

175 (94.6)

Intermediate graduate

23 (16.4)

10 (5.4)

College

15 (10.7)

0 (0)

\.01 

Occupation (N, %) * Calculated using t test

Farmer

94 (65.3)

122 (65.2)

 

Calculated using Chi squared test

Housewife

27 (18.7)

55 (29.4)

5 (3.5)

3 (1.6)

** Calculated using Fisher’s exact test

Other

18 (12.5)

7 (3.7)

Professional

\.01**

socio-demographic variables (sex, age, occupation, education, marital status). In model 2, village was found to be a significant predictor of KATD score (F = 23.62, p \ 0.00) after controlling for sex, age, occupation and education. Except for marital status, all other socio-demographic variables were found to be significant predictors of KATD scores. Tables 2 and 3 display the results from the models predicting KATD score. In both models, village was a significant predictor after adjusting for all other socio-demographic variables, where the mean KATD score for participants from intervention villages was significantly higher than the mean score for participants from the control villages. In Model 1, male gender, being a housewife for occupation and being an intermediate graduate were positively associated with KATD score (b ¼ 3:03; p\0:01; b ¼ 7:00; p\0:01; b ¼ 4:82; p ¼ 0:02), while age and being a member of a control village was inversely associated with KATD score (b ¼ 0:05; p ¼ 0:04; b ¼ 3:83; p\0:01). Marital status was not a significant predictor. In model 2, all predictors remained significant, with male gender, being a housewife for occupation and being an intermediate graduate remaining positively associated with KATD score (b ¼ 2:98; p\0:01; b ¼ 6:98; p\0:01; b ¼ 4:73; p ¼ 0:02), while age and being a member of a control village remained inversely associated with KATD score (b ¼ 0:05; p ¼ 0:03; b ¼ 3:71; p\0:01). The mean for the KATD questionnaire score for intervention villages was 22.49 (SD = 8.96), while the mean for the control villages was 17.61 (SD = 4.17). Women had an overall KATD score mean of 18.77 (SD = 6.42), and men had an overall mean score of 20.56 (SD = 7.51). The overall KATD score for unmarried was 20.07 (SD = 6.31) while for married it was 19.73 (SD = 7.16). For farmers, the overall score was 18.84 (SD = 7.27) while it was 21.32 (SD = 5.67) for housewives, 19.5 (SD = 9.04) for professionals, and 21.6 (SD = 7.94) for others. People with a less than intermediate education had an overall KATD score of 19.00 (SD = 6.68), while Intermediate graduate had a mean score of 25.42 (SD = 6.95) and college educated 21.00 (SD = 9.54).

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Psychiatr Q Table 2 Results of the regression analysis with KATD score as the dependent variable Predictor

b

SE

t

p

Model 1 Intercept

18.84

3.03

6.23

\0.01

Village: control (ref: intervention)

-3.83

0.76

-5.00

\0.01

3.03

0.90

3.35

\0.01

-0.05

0.02

-1.98

0.04

Occupation farmer (ref: professional)

1.75

2.50

0.70

0.48

Occupation housewife (ref: professional)

7.00

2.52

2.78

\0.01

Sex men (ref: women) Age

Occupation other (ref: professional)

3.50

2.76

1.27

0.20

Education intermediate graduate (ref: college)

4.82

2.04

2.37

0.02

Education less than intermediate (ref: college)

-0.28

1.74

-0.16

0.87

0.12

1.10

0.11

0.91

Marital status unmarried (ref: married) Model 2 Intercept

19.00

3.01

6.31

\0.01

Village: control (ref: intervention)

-3.71

0.76

-4.86

\0.01

2.98

0.90

3.30

\0.01

-0.05

0.02

-2.11

0.03

Occupation farmer (ref: professional)

1.70

2.48

0.68

0.49

Occupation housewife (ref: professional)

6.98

2.52

2.77

\0.01

Sex men (ref: women) Age

Occupation other (ref: professional)

3.55

2.75

1.29

0.20

Education intermediate graduate (ref: college)

4.73

2.00

2.35

0.02

Education less than intermediate (ref: college)

-0.39

1.74

-0.23

0.82

b (beta) standardised regression coefficients, adjusted Model 1 regression analysis with all variables Model 2 regression analysis without marital status as predictor variable

Table 3 Villagers’ knowledge of etiology of depression Statement (Question no.)

Yes n (%)

No n (%)

Neutral n (%)

A traumatic event or shock can be a cause of depression (8)

159 (85.03)

14 (7.49)

14 (7.49)

Brain disease can be a cause of depression (9)

154 (82.80)

11 (5.91)

21 (11.29)

Genetic inheritance may be a cause of depression (10)

108 (57.75)

57 (30.48)

22 (11.76)

Depression can be punishment from God (11)

122 (65.24)

36 (19.25)

29 (15.51)

Poverty can be a cause of depression (12)

117 (62.57)

36 (19.25)

34 (18.18)

Depression is due to possession by evil spirits (13)

133 (71.12)

39 (20.86)

15 (8.02)

93 (49.73)

63 (33.69)

31 (16.58)

175 (96.69)

2 (1.10)

4 (2.21)

Only people who have a family history of depression can experience depression themselves (14) Do you think that depression is caused solely by unfavorable social circumstances? (41)

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Frequencies and percentages for the Likert-scale questions answers are grouped according to theme in three categories: knowledge of the etiology of depression, perceptions of depression, and knowledge of the treatment of depression (Tables 3, 4, 5, respectively). Results for the intervention villages has been previously reported [51]. Knowledge of the Etiology of Depression Participants tended to agree with both the biomedical (e.g. Question 9 ‘‘Brain disease can be a cause of depression’’) and the supernatural (e.g. Question 11 ‘‘Depression can be punishment from God’’) explanations for the causes of depression. Most subjects (96 %) agreed that unfavorable social circumstances are a major cause for depression, while still considering depression as a punishment from God (65 %) or due to possession by evil spirits (71 %). Villagers’ Perceptions of Depression The participants tended to agree with both the favorable and stigmatized statements toward depression (e.g. questions 8 and 11). Of the stigmatized statements, the ones with the largest consensus were ‘‘People with depression are unpredictable’’ (78 %), ‘‘People with depression are hard to talk with’’ (77 %), and ‘‘You would be afraid to have a conversation with someone who has depression (76 %).’’ Table 4 Villagers’ perception of depression Statement (Question no.)

Yes n (%)

No n (%)

Neutral n (%)

Depression is a sign of weakness and sensibility (7)

137 (73.66)

14 (7.53)

35 (18.82)

People with depression can live in the community (15)

146 (78.07)

17 (9.09)

24 (12.83)

People with depression can work in regular jobs (16)

161 (86.10)

12 (6.42)

14 (7.49)

People with depression can be as successful at work as others (17)

155 (82.89)

21 (11.23)

11 (5.88)

You would be afraid to have a conversation with someone who has depression (18)

143 (76.47)

37 (19.79)

7 (3.74)

You would be willing to maintain a friendship with someone who has depression (19)

163 (87.17)

12 (6.42)

12 (6.42)

You would be willing to share a room with someone who has depression (20)

148 (79.14)

20 (10.70)

19 (10.16)

People with depression are unpredictable (21)

146 (78.07)

26 (13.90)

15 (8.02)

People with depression are hard to talk with (22)

144 (77.01)

19 (10.16)

24 (12.83)

A person with depression has only himself/herself to blame for his/her condition (23)

135 (72.19)

25 (13.37)

27 (14.44)

A person with depression could pull himself/herself together if he/she wanted (24)

136 (72.73)

16 (8.56)

35 (18.72)

It is shameful to have depression (25)

119 (63.64)

51 (27.27)

17 (9.09)

You would be ashamed to mention if someone in your family has depression (26)

112 (59.89)

48 (25.67)

27 (14.44)

Depression is a sign of failure (27)

127 (67.91)

10 (5.35)

50 (26.74)

People who attempt suicide are weak (31)

120 (64.17)

23 (12.30)

44 (23.53)

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Psychiatr Q Table 5 Villagers’ knowledge of treatment Statement (Question no.) A person with depression would improve if given treatment and support (28)

Yes n (%) 172 (91.98)

No n (%) 2 (1.07)

Neutral n (%) 13 (6.95)

Treatment can help people with depression lead normal lives (29)

184 (98.4)

0 (0)

People with depression can eventually recover (30)

172 (91.98)

4 (2.14)

11 (5.88)

3 (1.6)

People with depression can be successfully treated with medication (34)

156 (83.42)

7 (3.74)

24 (12.83)

Medications to treat depression will cause addiction (35)

109 (58.29)

35 (18.72)

43 (22.99)

People with mental illness can be successfully treated using psychotherapy (36)

152 (81.28)

16 (8.56)

19 (10.16)

Traditional healers can successfully treat depression (37)

96 (51.34)

52 (27.81)

39 (20.86)

If someone close to me were showing signs of depression, I would take him/her to a healer (38)

68 (36.36)

59 (31.55)

60 (32.09)

Psychiatrists can successfully treat depression (39)

124 (66.31)

23 (12.3)

40 (21.39)

If someone close to me were showing signs of depression, I would take him/her to a psychiatrist (40)

115 (61.5)

33 (17.65)

39 (20.86)

Villagers’ Knowledge of Treatment Almost all participants in the control villages shared optimistic views on treatment and the possibility of recovering from depression, as observed in their answers to questions 28 ‘‘A person with depression would improve if given treatment and support’’ (91 %), 29 ‘‘Treatment can help people with depression lead normal lives’’ (87 %) and 30 ‘‘People with depression can eventually recover’’ (91 %). Answers to questions regarding the type of treatment showed opinions to be more divided: while 51 % answered that traditional healers can successfully treat depression, the remaining participants either disagreed (27 %) or reported neutral views (20 %). The same patterns was observed for other questions, such as question 38 ‘‘If someone close to me were showing signs of depression, I would take him/her to a healer’’ and 35 ‘‘Medications to treat depression will cause addiction’’. This category, related to knowledge of treatment, showed a wide departure from the views reported in the intervention villages, where views were more homogenous and subjects reported more negative views towards traditional faith healers.

Discussion This study of the knowledge and attitudes towards depression in a rural area of Gujarat surveyed 333 village members on a range of variables using a structured questionnaire. The issue of measuring the efficacy and overall impact of community interventions is of broad interest, especially in the field of global mental health. This study contributes to the existing literature by measuring the impact interventions can have on the knowledge and attitudes towards depression. The results lend support to our hypothesis that the participants from the intervention villages would show higher levels of literacy regarding depression and lower levels of stigma, as assessed by the KATD questionnaire.

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Overall, a high number of participants reported highly stigmatized attitudes towards depression alongside with coexisting fatalistic and biomedical explanations of the etiology of depression. The widest divergence between the control and the intervention villages is observed in regards to the treatment of depression, with the intervention villages showing a higher level of trust in psychiatrists than the control villages. This could be attributed to the intervention community members experience with psychiatrists’ role in treating mental illness through the educational campaigns and treatment offered by The MINDS Foundation. Throughout both the intervention and control villages, there is a fear of medication and the possibility of it having an addictive effect on patients. This is in line with previous research that showed rural community members reporting high levels of negative or supernatural beliefs about mental illness, a distrust for psychiatrists, and high levels of trust in the efficacy of faith healers to treat mental illness [53]. Being a member of a control or intervention village was a highly significant predictor of score in the KATD questionnaire after adjusting for all other socio-demographic factors. In regards to these variables in particular, and perhaps not surprisingly, certain differences were observed in scores depending on gender, level of education and occupation, which were strong predictors, and age to a lesser extent. Marital status was not found to be a significant predictor of KATD score. The role of gender on the explanatory models for depression has been reported in previous studies [28] in a similar population, where different beliefs were reported by males and females. In our study, males scored on average significantly higher than females. This information allows us to target the groups that would benefit the most from psychoeducational interventions. Campaigns should be especially geared towards women with lower levels of education, and especially address treatments for depression, prejudice against medications, and beliefs regarding the etiology of depression. Consistent with other previous studies [17, 18], baseline knowledge and attitudes towards depression, or mental illness in general, is poor in rural areas. In turn, this translates into greater social distance [18], inability to find employment [31], and diminished likelihood of seeking professional care [19, 25]. The fact that stigma surrounding mental illness has even been reported among community health workers that have been trained to recognize symptoms [17, 18] highlights the importance of psycho-educationally oriented interventions for both community health workers and the community itself, to specifically address explanatory models and stigma. Because there is a relation between the perceived cause of depression and the degree of stigma displayed by a subject [51], psycho-educational workshops in rural villages that address the underlying beliefs can effectively influence the social representation of depression, and overall reduce the stigma surrounding the disorder. There is an increasing number of grassroots approaches to mental health that have been scaled up in the last few decades [38–47] in order to provide care in underserved populations. There is overwhelming evidence of the effectiveness of community health workers in delivering treatment for both physical and mental disorders [54–56], however the impact of training community health workers on the rest of the village members, along with educational workshops and rehabilitation programs, has not been evaluated thoroughly in the available literature. These interventions, by addressing the underlying beliefs, can help reduce stigma and therefore change the social representations on both mental illness and people living with a mental disorder. Measuring the impact of interventions such as the ones reported here can help better manage resources and understand which programs make the highest impact on a community, allowing for evidence-based programming.

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Psychiatr Q

There are several limitations to our study. We did not compare the knowledge and attitudes of a cohort of village members before and after the interventions. It is therefore not possible to comment on the causality, and whether exposure to the interventions changed the attitudes of individual community members, or those of the community as a whole, given that this is a cross-sectional study and does not provide definitive evidence of this association. The ideal study design would be one where a cohort of members from a community is followed in time throughout the intervention to see if their individual attitudes and knowledge towards depression change as a result to their exposure to the interventions. Because a convenience sample was used, the results may not be generalizable or particularly representative of the entire population. There may be limits to the cross cultural application of the KATD questionnaire. Even though this survey has already been utilized with similar populations and developed through careful local consultation for its applicability in rural Gujarat, the western models of depression and specific terminology do not have an exact equivalent across different cultures. To reduce any possible effect of confounding, local research assistants conducted the interviews to ensure the correct interpretation of both questions and answers to the questionnaire items. The data collection between the intervention and the control villages occurred 10 months apart. It is possible that a relevant event occurred in the communities in the area that may have influenced the knowledge and attitudes towards depression between these points in time, influencing participant’s answers. Despite these limitations, this study was one of the few studies that quantitatively measured the impact a community intervention in mental health has in rural settings in India. It highlights the importance of grassroots approaches to mental health to shape positive attitudes, influence awareness and reduce stigma.

Conclusions Widespread stigma [30] regarding mental illness is common throughout Asia. Alongside efforts to improve access to health care and scale up mental health services, there is a pressing need to develop psycho-educationally oriented community interventions that will address the stigma surrounding mental illness, as highlighted by the lower scores observed in the control villages. Following the social representation theory, it is reasonable to argue that the interventions provide community members with experiences, information and knowledge that will then be transmitted through tradition and social communication, changing the system of values, ideas and practices in the community, and ultimately positively affecting social relations. From a public health perspective, while some sociodemographic factors associated with the knowledge and attitudes towards depression are non-modifiable, our research provides evidence in favor of the positive influence a community grassroots intervention can have on mental health literacy in rural settings. Acknowledgments We are grateful to The MINDS Foundation, the Department of Psychiatry at SVU, and the Icahn School of Medicine at Mount Sinai’s Arnhold Global Health Institute for their support; Megha Dalal for her crucial role as interpreter and interviewing participants; Dr. Hung-Mo Lin, from the Department of Population Health Science and Policy at Mount Sinai for her expertise and guidance in statistical analysis; and the villages and its members for their time and cooperation to this study. Conflict of interest All authors declare no conflicts of interest.

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Psychiatr Q Funding Arnhold Global Health Institute at the Icahn School of Medicine at Mount Sinai. Informed consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). Informed consent was obtained from all patients for being included in the study. Partnering Institutions The MINDS Foundation (Vadodara, Gujarat)/Sumandeep Vidyapeeth/Dhiraj General Hospital (Vadodara, Gujarat, India), Icahn School of Medicine at Mount Sinai (New York, USA).

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Irina Mindlis, Licenciate is a psychologist (Argentina, Licenciate) and an MPH Candidate at the Icahn School of Medicine at Mount Sinai in New York, NY. Her research interests are psychiatric epidemiology and community interventions in global mental health. Jan Schuetz-Mueller, MD is an Assistant Professor in Psychiatry and Associate Director of the Program in Global Mental Health at the Icahn School of Medicine at Mount Sinai in New York, NY. Sandeep Shah, MD is a psychiatrist, Professor of Psychiatry, and Board Member of The MINDS Foundation.

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Psychiatr Q Raghu Appasani, BA is the Founder & CEO of The MINDS Foundation. Amanda Coleman, BS is an MPH Candidate at the Icahn School of Medicine at Mount Sinai in New York, NY. Craig Katz, MD is an Associate Clinical Professor in Psychiatry and Medical Education, and Director of the Program in Global Mental Health at the Icahn School of Medicine at Mount Sinai in New York, NY.

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