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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 14  |  Issue : 3  |  Page : 215-220

Perception of mental health problems and coping strategies among rural women living in vidarbha region


1 Department of Mental Health Nursing, Smt. Radhikabai Meghe Memorial College of Nursing, Wardha, Maharashtra, India
2 Department of Mental Health Nursing, Datta Meghe College of Nursing, Nagpur, Maharashtra, India

Date of Submission14-Jul-2019
Date of Decision02-Aug-2019
Date of Acceptance22-Aug-2019
Date of Web Publication2-May-2020

Correspondence Address:
Asso. Prof. Jaya Gawai
Department of Mental Health Nursing, Smt. Radhikabai Meghe Memorial College of Nursing, Sawangi (M), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_179_19

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  Abstract 


Background: Mental Health of women is the most neglected area worldwide. In India due to poverty, unemployment, low level of education contributes to the inferior status of women in homes and in society. In addition, the introvert culture in many parts restricts the women any access to the health services leave along the mental health services. Under the circumstances the investigator seeks to do an in-depth study on, how the rural women are experiencing mental health problems and their coping strategies. Aim:To evaluate the perception of mental health problems and coping strategies practiced by rural women of the Vidarbha region. Research Design: Qualitative study Participants: Rural women above 18 years. Setting of the study: Two villages namely, Mohi and Ghorad; of Vidarbha region in Maharashtra state of Central India. Results: Married women had common somatic complaints like sleeping disorders, headache, chest pain, tiredness, and giddiness etc. not related to physical efforts. They were using certain maladaptive coping strategies like physically abusing their children, tobacco addiction and forcing their children for school dropout. Among the unmarried women, poor academic performance, school dropouts and peer and family pressure for early marriage were the major issues for mental distress leading to helplessness, and inadequate knowledge. Conclusion: The rural women perceive and attribute mental health problems to physical exertion and factors like lack of mental health care services. Hence a targeted intervention is needed to bring awareness among women of rural Vidarbha for promoting mental health and well-defined scientific coping strategies.

Keywords: Coping strategies, helplessness, mental health problems, perception, rural women


How to cite this article:
Gawai J, Tendolkar V. Perception of mental health problems and coping strategies among rural women living in vidarbha region. J Datta Meghe Inst Med Sci Univ 2019;14:215-20

How to cite this URL:
Gawai J, Tendolkar V. Perception of mental health problems and coping strategies among rural women living in vidarbha region. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 Jun 4];14:215-20. Available from: http://www.journaldmims.com/text.asp?2019/14/3/215/283580




  Introduction Top


Mental health is considered as national wealth because just as one needs to physically fit to be productive; he/she should be mentally healthy to be productive in all dimensions of life. Good mental health is essential to overall well-being. More than 1 in 5 women in the United States experienced a mental health condition in the past year, such as depression or anxiety. Many mental health conditions, such as depression and bipolar disorder, affect more women than men or affect women in different ways from men. Most serious mental health conditions cannot be cured. However, they can be treated, so one can get better and live well.[1]

Women in general are ignorant about the mental health issues. Their concept of well-being is mostly restricted to the physical health. In many parts of the underdeveloped world, the health services for physical health are lacking or inadequate. Even in developing countries, the health services for exclusively women are limited. Under the circumstances, the mental health services for women are a remote reality in most areas of the world. India is no exception to this. Rather, the magnitude of problem is doubt due to male domination in all cultures in addition to low educational levels, poverty, and financial dependence of women on men.[2]

A meta-synthesis by F. R. Choudhary et al. reveals multiple causes of, descriptions of, and treatment options for mental health problems, thereby providing insight into different help-seeking behaviors. Clarity is offered by highlighting cultural differences and similarities in mental health beliefs and perceptions about the causes of mental health problems.[3]

One in three Americans struggles with a mental illness, but the rate is much higher in women. Research suggests that women are about 40% more likely than men to develop depression. They are twice as likely to develop posttraumatic stress disorder, with about 10% of women developing the condition after a traumatic event, compared to just 4% of men. It is easy to write off this epidemic of mental illness among women as the result of hormonal issues and genetic gender differences, or even to argue that women are simply more “emotional” than men.[4]

The National Mental Health Programme and the National Rural Health Mission have introduced some interventions through various organizations such as state government and nongovernmental organizations. These programs essentially use the existing infrastructure and treatment modalities first to identify mentally ill, thereafter providing treatment to the affected rural women. Certain obstacles still restrict the rural women in overcoming problems related to mental disorders.

To bridge the gap between rural population and mental health services,[4] the Government of India has introduced various schemes and programs through primary health-care centers. The health-care services in these areas are covered by one district hospital, two subdistrict hospitals, six rural hospitals, twenty-seven primary health centers, 181 subcenters, and two private medical colleges. Currently, the mental health services are rendered with existing general health-care services.[5] Yet, access to mental health services eludes 90% of the rural population till date in India.[6] The revised National Mental Health Programme has allotted some funds in 2014 to each district. Wardha among other districts still lacks adequate mental health services for its large number of rural women populations around 144,874, due to insufficient funds.[7]

Mental illness is a cause of social humiliation leading to the unacceptance of such in the society and family in spite of the measures taken to bring awareness. Poverty and access to mental health-care services further aggravates the situation among the rural women. The aim is to bring the people with mental disorders have any access to mental health-care services in deprived rural India. Therefore, the present study is being conceived to help the Indian rural women.[8]

The third issue that plagues the rural women is the age-old traditions, rituals, in view of social taboos and cultures defining standards of existence. The mentally ill are treated at home by the family members, without professional support. Some adopt traditional medicine, religious healers, faith healers, and astrologers.

The present study is conducted in the Vidarbha region of Maharashtra. It comprises eleven districts and 138 villages. The population belongs to low socioeconomic status as well as literacy levels.[2] It is access to knowledge regarding mental health and mental illness. The health services in India are covered by 43 state-run mental hospitals, three psychiatrists, and 0.47 psychologists per million people. Scarcity of trained mental health personnel is another factor aggravating the mental health issues.

Ethical considerations

The permission to conduct the study was obtained from the Institutional Ethical Committee Board, Datta Meghe Institute of Medical Sciences (Deemed to be University) (Ref. No. DMIMS (DU)/IEC/2018-19/7158, Date: 28.03.2018), India. First, investigator approached the rural women, door to door, to gather them in a designated place. The nature of the visit was explained to the village “Sarpanch” and an informal gathering was arranged. To begin with, the purpose and objectives were announced and any doubts of the participants were clarified. The participants were assured about the confidentiality of their information and its applications for this study only. Written consent of participation in the study, protecting their identity, was taken from each participant. This was essential in view of the nonavailability of information and rampant social discrimination faced by the mentally ill in these areas. As a result, the participants were unhesitant in sharing their feelings and opinion in a close talk circle. Both local vernacular Marathi and Hindi languages were chosen as the medium of conversational exchange and information.


  Materials and Methods Top


The study was planned as a qualitative one as the felt experiences of women their perceptions and coping strategies were to be studied. Perceptions were determined on the basis of the problems experienced in everyday life, by the participating rural women. Evaluative approach was used to understand the mental health problems among the rural women and their adopted coping strategies. This approach was based on group inquiry in the context of initiating mental health promotion among these women. Focus group discussion method was used to collect the information from the study participants.[9] This also helped them to voice their problems freely instead of voicing them alone face to face. Population consisted of 9 married and 6 unmarried rural women. The villages were selected randomly. The women clusters were then selected conveniently. The participants were divided into two groups, namely, one that of married ones and the other one of unmarried women. The information was collected through focus group discussion held in natural setting in a courtyard of a participant's house.

The conversation during the focus group discussion was audiorecorded after the permission of the participants, with the help of smartphone. The sessions in each group lasted for 35–45 min, where all the women participants showed interest and enthusiasm by their contribution.

Focus group discussion was conducted as per the procedure stated by Glaser BG (1994).[10] The team comprised one moderator and an assistant. The moderator was responsible for facilitating the discussion, stimulating, and controlling every member in the participation. The proceedings of the discussion were noted by the moderator. The moderator subjected the participants, to a series of questions regarding their perception of mental health problems and their adopted coping strategies. The assistant moderator recorded the whole discussion. The focus group discussion for the married and unmarried rural women was conducted separately, in both the villages on alternate days. The recorded audio was then analyzed to avoid repetition and saturation of information. The moderator then transcribed the data of verbatim among married and unmarried rural women separately, classifying the content into themes with similar categories compiled together.

The moderator and assistant moderator were nurses with postgraduate qualification in medical surgical nursing and community health nursing, respectively. After the information was coded by the moderator, it was handed over to the investigator. The investigator then drew inferences on the basis of codes and categories generated. Based on the analysis, these data were presented in matrices. Thereafter, the transcribed content of the discussion and the codes derived were placed before the participants for review and validation. During such validation, subject expert from Mental Health Nursing and a counseling psychologist were also present [Table 1] and [Table 2].
Table 1: Matrix of identified mental health problems

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Table 2: Matrix of coping strategies

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Outcomes of focus group discussions

The results show that perceptions of mental health and help-seeking behavior are influenced by a lack of knowledge and a mix of traditional and modern views. However, the women in joint families could have some social support system of the other women in the family. In nuclear family norms of today even in rural India, this social support is severed. The women are lonely and mostly treated a housemaid and child-bearing machines. With this background, the investigators proposed to study in depth the mental health problems faced by the rural women and the coping strategies used by them to overcome these problems. Another blend is to study whether the coping strategies are healthy or unhealthy.

The major issues reported by the participants were:

  1. Lack of psychiatrists and trained mental health-care professionals
  2. Inadequate mental health-care infrastructure in these areas
  3. Lack of provision of information regarding mental health problems
  4. Lack of access to mental health-care services to the rural women.


Outcomes of married women discussion

Most of the married women were unaware of mental health, mental health services, and mental health issues. Many women reported social and gender discrimination, neglect and being victims of domestic violence and abuse.[11]

The main observations were nonexistent public or private sector initiatives in mental health-care aspect of the villagers. Negligible to no awareness about mental health care and mental health disorders. Therefore, there were no coping strategies adopted for self-edification in view of socioeconomic and psychologically discriminative state. Current mental hygiene and well-being of rural communities are poorly understood in these areas especially among rural women.[12]

“I face constant insult in front my children by my husband. Many times, he beats me in front my children. Once he hit very severely at the back of my ear ever since then, I have a difficulty in hearing. My husband has never taken me to hospital for a proper treatment as it is very far away. The primary health care centre does not offer much help as most of the times the physician is not present.”

“My husband started drinking since the age of 12 years and my parents compelled and wedded me to him. I have completed my 12th standard, he did not allow me to work and he provides all the provisions, having two children they are studying in Government school. One day I took my husband to local man one who gives medicine to stop drinking and he took that powder for seven days since then he stopped drinking now almost three years over, he doesn't drink at all. Now we are very happy.”

Physical complaints

Common physical complaints reported by rural women were of sleeping disorders, headache, chest pain, nonphysical tiredness, giddiness, etc., Financial insecurities were found to play the main role. Somatic symptoms were common among the women as found in few studies. Generalized anxiety disorder is 2–3 times higher among females than males.[13] Some researchers have also concluded that the women with common mental disorders, suffer from excessive alcohol, sexual and physical abuse by their spouses; no authority/right to take decisions as women; total lack of support from their own parents.[13]

“I go for work every day as a laborer and I have bouts of headache, feel giddy and get tired very soon, but my husband never takes me to hospital nor is there anyone to help me find relief.” This verbatim suggesting lack of family support is very common among the rural women.

Infertility

Two participants complained aridity/childlessness as their spouses were found to be chronic alcoholics. There appeared no support from both the parents or in laws, as these participants showed generalized apathy in appearance and attitude. On inquiry, it was found that these participants were compelled to take herbs from a local quack, in the absence of a qualified gynecologist/medical professional/physician.

“I had been married over four years and don't have children. My husband drinks every day, he goes to work in others field. He doesn't give any money at home; I don't get any help from my parents also because their condition too is the same. My husband has taken me only once at fertility clinic, otherwise he doesn't bother. He once took me to one Hindu priest who gave me some powder which I ate for 21 days, still I could not conceive. Now my mother in law and my husband beat me and scold me for not bearing children and they are planning for my husband to get marry second time with another girl.”

Investigator observation: Sad, lack of genuine smile on her face, introvert, pessimistic, and melancholy.

“I have been married for two years and don't have children and my husband drinks occasionally, works in Private company. My husband took me to the Gynecologist and I am taking treatment continuously but I don't want to stay in the village, my husband and my mother in law forcing me to stay in the village. I feel like I'll leave my husband and stay with my mother in the city, sometimes I feel very helpless and insecure here.”

Emotional, psychological, and social issues

Substance abuse

Seasonal employment due to low educational status results in financial crises addicting to stress which is relieved by alcoholism, tobacco addiction, and in worst cases substance abuse.[14]

This infers that the women mental health issues and their triggers are neglected/ignored in rural India at both the state and domestic levels. As the World Health Organization has observed, depression will remain the second largest mental illness by 2020, 1 out of every 5 women and 1 in every 12 men will be affected.

Alcoholism is a social problem of a developing country like India.[15] Mostly the women and children are the victims subjected to the adverse effects of substance abuse in any form.

“My husband drinks a lot and addicted to Ganja (Marijuana) also. Whatever the earning he spends it all in drinking and buying ganja. He is not bothered about children, their studies and the basic needs at home. He fought with me one night and badly assaulted me, to the extent that I poured kerosene all over my body as I was about to light myself up, my daughter rushed and hugged me (Married rural women 6).

Destitution

Employment opportunities in rural India are grim.[16] Most of the population remains either school dropouts or illiterate. Unpredictable seasonal/climate changes affect the agriculture and farming. Household income is limited, due to unemployment.

“My daughter has crossed her adolescence and attracts much attention from the other sex. With limited, borrowed of lent clothes she is more prone to sexual abuse. She is a school dropout and is not willing to continue education as there appears no proper guidance. She has picked up the habit of chewing tobacco in company of other girls around.”

“There are regular arguments between us and our children find it very repulsive. Therefore, they have stopped going to school” (Married rural women 4).

Unmarried women

The mental health related-themes identified for an unmarried woman based on self-reports were different from those of married women. Hence, direct comparison was difficult for there were no common themes. However, the problems of married and unmarried women as per their self-reports lead to common mental health issues.

Mentally disturbed: Chronic illness in the family

Few mentally ill are confined to a room at home and are being looked after by the household. Affordable medical treatment is being given, but most of the time, it is discontinued due to lack of funds. Most of the people do not seek any professional help or treatment. Some seek the help of quacks, traditional medicine, tantriks, religious healers, faith healers, and astrologers.

“I failed in 10th standard since then not attended school, as my mother goes for field work and I have to do all the work at home. My father was drunkard and now he is paralyzed whom I take care of. I am having one sibling, she is married. I suffered depression; I was taken to a tantrik/quack by my mother. I am fine now but my mother is compelling me to get married with a known drunkard (participant 3).

The young rural girls are forced into early marriage, in the sense of getting rid of this as a thought burdensome responsibility. The grooms sought are mostly the local or near related without jobs and often alcoholics. Lack of proper basic education leaves the girls unaware of the essential information needed to start a family in relationship at a different set up. Lack of sex education makes them vulnerable to infections, transmitted diseases, and related mental disorders.

Discrimination and isolation

Mental illness is considered as a stigma to the society. These families remain isolated from the society either voluntarily of by deliberations of social taboo. Belief is made common that such sickness is imparted due to black magic. Malnutrition and negligence are the cause for mental illness among adolescent girls. These never get to the hospital for professional attention.

Young girls are mentally disturbed with physical and hormonal changes. Lack of education, limited finances and unavailable facilities, distant schools, no transportation, above all household tasks, and labor in vacation has rendered them unable to gain much academically or otherwise general knowledge. Every three kilometers, a different culture or tradition defines another scenario, but the victims are the young girls as they happen to keep the family well-knit in the rural setup. The female representation of the rural has never been the focus; therefore, the facilities are unavailable to the part of the society. A well-developed structured model will help in shaping the mental health programs in rural India.

Locus of control

The focused discussion during this study revealed that parents are the deciding members, who tend to be more compulsive in their verdict. Girls, to certain age, are allowed to do schooling. Most of the time under burden of the additional household chores the childhood is lost. And often then they force the girls to get married as soon as possible. One of the research articles also reveals that most of the girls from poor socioeconomic backgrounds, are school dropouts, and unequipped with adequate knowledge to pass on to the other generation. The girl's education is more strongly associated with reduced risk of partner violence.[17]

School dropout and financial crisis

“I am the eldest in the family. I have one younger brother and a sister. We lost our father two years back. He died in a road side accident. My mother had to take up field labour to earn daily wages. I being the elder had to give up my schooling to work along with her both at home and the fields. Though there exists a posing threat from the antisocial elements, we have to toil to make both ends meet. My brother also got disinterested in studies under the influence of the street guys and has been a dropout since long. He too is involved in anti-social activities and has turned to addiction (Participant 6).

Mental illness in the family

“My father essentially has mental illness almost eight years now, is confined to one isolated room at home. He is violent most of the time. He poses to be more violent at times and is a constant threat to the members of the family. His diet is irregular and behavior is unpredictable, more counseling is needed to make him have his food. Only two of us my mother and me have an access to his room. More often he has no control over his excretion and therefore soils the room, which is difficult to be cleaned to maintain hygiene. He is allowed out only late in the night when everybody else is sleeping comfortable in their houses in the village. He has not had a formal bath and has never groomed his hair since long. Unkempt hairs, over grown nails give him a weird repulsive look. My mother and I venture out early for work in the field, and return only in the evening. This leaves my father, being in confinement, very aggressive and often beats my mother. We ourselves feel neglected and the future appears grim.“


  Discussion Top


There are very few studies on identifying the mental health problems and coping strategies used by rural women in developing countries. However, the themes identified for common mental health issues are similar to those found by other researchers. These include financial problems leading to psychological stress, male domination, discrimination and destitution, mentally ill member in the family, and lack of treatment and care resources and services.

State sponsored mental health institutions in Vidarbha region are in a very bad shape. Mental hospitals do not have adequate facilities to treat the mentally ill persons although the reforms are being implemented in many mental hospitals. Mental problems are common among the women between the age of 30–40 years or above 60.[18] Added financial burden with management of the household affairs and physical and biological changes play a pivotal role in the mental health status of women. State-sponsored programs and schemes planned by the government are easily implemented to the urban population which has changed the perception by acceptance of mental illness and moving out for treatment. However, due to lack of awareness about mental health and nonavailability of access to the mental health services to rural people, has kept them unchanged. This in fact deteriorated mental health of the women in rural areas. The rural population financially cannot afford the private institution treatment and the prescribed medicine. This is the fact that compels the rural women to ignore mental health problems; thus, the rural India remains neglected in mental health-care matters.

One of the participants of this study had reported attempted suicide as a result of unscheduled excessive alcohol consumption by her spouse. Alcohol consumption in spite of ban in the district has resulted in bread earner's apathy toward household affairs. Most of the participants reported the involvement of their spouses causing public disturbance, domestic violence, and abuse with humiliation in front of children and neighbors.

Peer pressure has remained a dominant factor concerning the girls in the rural Indian population. Gender census shows unbalanced female ratio to the male population. With more unemployment, antisocial activities are posing a grave to the young school-going girls just as being reported in other studies in developing countries.

Women are found to be engaged in the role of bread earners, often responsible for the running the household affairs and family that too, without any authority/right to take decisions on her own. Due to her overbearing, most of the participants reported experience of menopausal symptoms at an early age. Mood swings resulting in domestic violence and verbal abuse toward their children was found to be common among the participants. Perception of rural women approaching justice system for domestic violence is less helpful than urban women.[19]


  Conclusion Top


From the focus group discussion and self-reports revealed during the discussion, it is found that the married women in rural Maharashtra have little knowledge about mental health and are totally unaware about the mental health services that may be available to them. The unmarried women suffer from psychological problems due to mental ill family member, stigmatization, and poverty.

A lot can be done at the local level by empowering the senior and influential ladies from the villages. Empowerment in relation to mental health, time management managing household and occupational matters can help the women have good mental health. Friendship circles among the women from “bachat gats” (self-help groups) pose a promise in this regard. The investigator proposes to work in this area for the promotion of mental health of rural women.

Acknowledgment

I am indebted to express my appreciation to Dr. Abhay Gaidhane for sharing his pearls of wisdom with me during the course of this research. I am also immensely grateful to Dr. Vaishali Tendolkar and also for her comments on an earlier version of this manuscript, although any errors are my own and should not tarnish the reputations of these esteemed professionals.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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