Lack of awareness and dearth of qualified professionals hinder mental health services for older people in rural areas. Primary mental healthcare, which involves the family and community, ensures that older people get the needed care.
Mental health is a major concern worldwide. Globally, one in eight people lives with mental health conditions. An epidemiological study by World Health Organization (WHO) has revealed a substantial disparity in care availability: for every 1,00,000 people, global availability of mental health practitioners is just nine; in low-income nations it’s less than one.
India is not far behind. A survey by India’s National Institute of Mental Health and Neurosciences (NIMHANS) found that nearly 150 million Indians need mental health services, but fewer than 30 million seek care.
There are many barriers to seeking care, especially in rural parts of India like the Thar desert. These barriers include existing public health priorities, its influence on funding, gaps in primary-care settings, lack of trained professionals and perspectives about mental health.
But community-based primary mental healthcare can bring about change.
Most of the older population residing in the rural and remote areas of India comprises people who are illiterate, live below the poverty line and show higher prevalence of cognitive impairments which affect their emotions, behaviour, overall wellbeing and their standing in society. This is especially true of women.
Their mental health conditions vary. Only a tiny percentage of older adults with mental illness in rural pockets gets identified and an even smaller number receives treatment.
Lack of appropriate mental health education to community and health personnel, poverty, stigma, poor quality of geriatric mental health services and indifference are the major roadblocks for primary mental healthcare in rural India.
Ageism is how we think, feel and act towards others or oneself based on age. It typically involves stereotyping and discriminating against older people just because they are old. There is tremendous stigma attached to age-related mental health conditions. Lack of knowledge on age-related mental health issues leads to under-identification of mental health conditions in the older population.
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In drought-prone regions, older people endure the dual burden of ageing and shortage of basic needs like water, food and nutrition. When families deal with scarcity of resources for years together, they unwittingly prioritise some needs, the burden of which falls on older people, especially women.
Older people’s psychological wellbeing is deeply affected as they start to believe that their needs are less important. Additionally, people are reluctant to speak openly about mental health issues. As a consequence, only severe cases get reported and taken up by the health system.
Primary mental healthcare is a decentralised system that requires the participation of the family and the community. While policies talk of the need to strengthen primary mental healthcare, strategies to promote an integrated care system are lacking.
India is promoting family and community-based mental healthcare of older people by integrating traditional care structures with a comprehensive primary health centre (PHC) system. Strengthening the PHC system will be essential to realise this, since its focus remains reproductive and child health services.
The limited infrastructure and insufficient funding for PHCs make primary mental healthcare for older people difficult to realise. The new care model of health and wellness centres (HWCs) also does not discuss how they are to offer mental healthcare for older persons.
To strengthen the healthcare system, it is critical to build the capacities of healthcare professionals and community health workers (CHWs) in mental and geriatric care.
The mental health policies do identify the gap between the need and availability of trained mental health professionals but do not specify educating health workers in old age mental healthcare. Training modules for doctors, nurses and CHWs at the PHC level do not include mental health components.
Community health workers are a link between the community and the healthcare system but guidance on how they can be enabled to provide old age mental healthcare, including case management and early identification of persons with mental health problems, is lacking.
Community-based organisations (CBOs) are a good model through which older people can come together to support each other, speak their minds without any fear of judgement and advocate for their issues.
Gramin Vikas Vigyan Samiti (GRAVIS) has been generating awareness about mental health issues in the Thar desert region, by bringing together local communities and health workers to put an end to stigma and misconceptions regarding mental health.
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By mobilising CBOs like village older people’s associations and intergenerational learning groups, GRAVIS encourages leveraging community as a resource to resolve issues. This enhances the self-confidence of older people to voice their views and raise concerns. It also helps them in creating a deeper connection with the community at large. Intergenerational communication and knowledge exchange between people of various age groups is encouraged. Community members from these groups engage in a variety of activities that cater to the basic needs of senior citizens including self-care, long-term care and health awareness sessions, in collaboration with community health workers.
GRAVIS also trains community health workers to address mental health needs of villagers. In addition, GRAVIS’ medical team supports mental health patients with treatment, counselling and much needed referrals and linkages with mental healthcare facilities.
While the impairing effects of old age cannot be avoided, risks can be minimised through careful planning and prevention by fostering age-friendly and responsive health care systems along with a range of coordinated services to address intricate needs of the ageing population.
Primary mental healthcare is in its nascent stage in India. To ensure a socially fair health system, the mode of service delivery must be defined and integrated in all care policies and programmes. Implementing these programmes will require cross-sector collaboration among various stakeholders, projects for the economic empowerment of populations vulnerable to mental health disorders.
Supporting families and communities have to be active participants in combating ageism and the negative attitudes about mental health. It is time to frame age-sensitive primary mental healthcare policies that focus on building safer eco-systems for older people.
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The lead image on top shows a group of women in the Thar desert, where community-based primary mental healthcare addresses the issues of older people. (Photo courtesy GRAVIS)
Krupa Gandhi is a communications professional currently working with GRAVIS as a consultant.
