The role of moral explanations and structural inequalities in experiences of mental illness stigma in Northern Minas Gerais, Brazil.

The process of stigmatization within different cultural contexts has long been viewed as essential in understanding the course and outcomes of mental illness. However, little research has examined which cultural constructs and categories are used to explain mental illness, and how they contribute to the way people with mental illness experience stigma and social exclusion, as well as how these beliefs affect healthcare practices. This study examines meanings ascribed to mental illness and experiences of stigma among four groups in urban settings of Minas Gerais, Brazil: persons with mental illness; their families; members of the lay public; and health professionals working at an alternative community-based psychosocial treatment service or a local university hospital. Qualitative methods, including semi-structured interviews and participant observation, were conducted with a purposive sample of 72 participants. Data were analyzed through content analysis. The findings suggest that stigma and discrimination are intrinsically rooted in a systemic process of social exclusion generated by meanings ascribed to mental illness and the structural vulnerabilities of the mental healthcare system. The findings further suggest that structural inequality is a powerful factor behind lay concepts of mental illness and that this is particularly harmful because it reinforces personal blame attributions instead of addressing the hidden structural forces that contribute to mental illness. The study highlights the subtle interrelations between cultural beliefs and structural vulnerabilities that should be addressed in mental health policy in order to diminish the effects of stigma on people with mental illnesses.

Women's circles as a culturally safe psychosocial intervention in Guatemalan indigenous communities: a community-led pilot randomised trial.

BACKGROUND: Indigenous Maya women in Guatemala show some of the worst maternal health indicators worldwide. Our objective was to test acceptability, feasibility and impact of a co-designed group psychosocial intervention (Women's Circles) in a population with significant need but no access to mental health services. METHODS: A parallel group pilot randomised study was undertaken in five rural Mam and three periurban K'iche' communities. Participants included 84 women (12 per community, in seven of the communities) randomly allocated to intervention and 71 to control groups; all were pregnant and/or within 2 years postpartum. The intervention consisted of 10 sessions co-designed with and facilitated by 16 circle leaders. Main outcome measures were: maternal psychosocial distress (HSCL-25), wellbeing (MHC-SF), self-efficacy and engagement in early infant stimulation activities. In-depth interviews also assessed acceptability and feasibility. RESULTS: The intervention proved feasible and well accepted by circle leaders and participating women. 1-month post-intervention, wellbeing scores (p-value 0.008) and self-care self-efficacy (0.049) scores were higher among intervention compared to control women. Those women who attended more sessions had higher wellbeing (0.007), self-care and infant-care self-efficacy (0.014 and 0.043, respectively), and early infant stimulation (0.019) scores. CONCLUSIONS: The pilot demonstrated acceptability, feasibility and potential efficacy to justify a future definitive randomised controlled trial. Co-designed women's groups provide a safe space where indigenous women can collectively improve their functioning and wellbeing. TRIAL REGISTRATION: ISRCTN13964819 . Registered 26 June 2018, retrospectively registered.

Toward a new architecture for global mental health.

Current efforts in global mental health (GMH) aim to address the inequities in mental health between low-income and high-income countries, as well as vulnerable populations within wealthy nations (e.g., indigenous peoples, refugees, urban poor). The main strategies promoted by the World Health Organization (WHO) and other allies have been focused on developing, implementing, and evaluating evidence-based practices that can be scaled up through task-shifting and other methods to improve access to services or interventions and reduce the global treatment gap for mental disorders. Recent debates on global mental health have raised questions about the goals and consequences of current approaches. Some of these critiques emphasize the difficulties and potential dangers of applying Western categories, concepts, and interventions given the ways that culture shapes illness experience. The concern is that in the urgency to address disparities in global health, interventions that are not locally relevant and culturally consonant will be exported with negative effects including inappropriate diagnoses and interventions, increased stigma, and poor health outcomes. More fundamentally, exclusive attention to mental disorders identified by psychiatric nosologies may shift attention from social structural determinants of health that are among the root causes of global health disparities. This paper addresses these critiques and suggests how the GMH movement can respond through appropriate modes of community-based practice and ongoing research, while continuing to work for greater equity and social justice in access to effective, socially relevant, culturally safe and appropriate mental health care on a global scale.

Adaptación cultural de instrumentos de medida sobre estigma y enfermedad mental en la Ciudad de México / Cultural adaptation of instruments to measure stigma and mental illness in Mexico City

This article forms part of a collaborative study in which research teams from Canada and Mexico participated. The general objective is to describe the cultural adaptation and semantic validation of three instruments for measuring stigma and mental illness in Mexico City. The criteria of understanding, acceptance, relevance and semantic integrity were used to adapt the following instruments: The Internalized Stigma Inventory (ISMI), the Opinions on Mental Illness Survey (OMI) and the Devaluation and Discrimination Scale (DDS). Four Individual interviews and four group interviews were carried out with 37 informants from different groups (health personnel, persons with diagnostic of mental disorders, relatives and the general population). Lastly, an analysis was carried out on the contents of the information obtained. The instruments proved to be culturally appropriate for the population in Mexico in the various groups studied. The adapted versions would be useful for establishing comparative analyses with other countries. The scope and limitations of the process of semantic equivalence were analyzed in the transcultural research.

Este trabajo forma parte de un estudio colaborativo en el que participan equipos de investigación en Canadá y México. El objetivo general consiste en describir el proceso de adaptación cultural y validación semántica de tres instrumentos de medición sobre el estigma y la enfermedad mental en la Ciudad de México. A partir de los criterios de comprensión, aceptación, relevancia e integridad semántica se adaptaron los siguientes instrumentos: el Inventario de Estigma Internalizado (ISMI), el Cuestionario de Opiniones hacia la Enfermedad Mental (OMI) y la Escala de Percepción de la Devaluación y Discriminación hacia la Enfermedad Mental (DDS). Para ello se llevaron a cabo cuatro entrevistas individuales y cuatro grupales con 37 informantes de diversos sectores (personal de salud, personas con diagnóstico de trastorno mental grave, familiares y población general). Finalmente se efectuó un análisis de contenido de la información obtenida. Los instrumentos adaptados fueron culturalmente apropiados para la población de los diferentes grupos estudiados en México. Las versiones adaptadas serán de utilidad para establecer análisis comparativos con otras regiones. Se analizan los alcances y limitaciones del proceso de equivalencia semántica en la investigación transcultural.

Strange but common bedfellows: the relationship between humanitarians and the military in developing psychosocial interventions for civilian populations affected by armed conflict.

This essay analyses how the relationships between Cold War and post-Cold War politics, military psychiatry, humanitarian aid and mental health interventions in war and post-war contexts have transformed over time. It focuses on the restrictions imposed on humanitarian interventions and aid during the Cold War; the politics leading to the transfer of the PTSD diagnosis and its treatment from the military to civilian populations; humanitarian intervention campaigns in the post-Cold War era; and the development of psychosocial intervention programs and standards of care for civilian populations affected by armed conflict. Viewing these developments in their broader historical, political and social contexts reveals the politics behind mental health interventions conducted in countries and populations affected by warfare. In such militarized contexts, the work of NGOs providing assistance to people suffering from trauma-related health problems is far from neutral as it depends on the support of the military and plays an important role in the shaping of international politics and humanitarian aid programs.

Llaki and ñakary: idioms of distress and suffering among the highland Quechua in the Peruvian Andes.

This article examines some of the long-term health outcomes of extreme adversities and the ways in which social inequalities and idioms of distress are historically and socially produced in the Peruvian context. We describe how the highland Quechua of northern Ayacucho construct and experience expressions of distress and suffering such as pinsamientuwan (worrying thoughts, worries), ñakary (suffering) and llaki (sorrow, sadness), in a context of persistent social inequalities, social exclusion and a recent history of political violence. It is concluded that the multiple expressions of distress and suffering are closely related to past and current events, shaped by beliefs, core values and cultural norms and, in this process, transformed, recreated and invested with new meanings and attributions.

Assessing mental health outcomes of political violence and civil unrest in Peru.

BACKGROUND: Sustained political violence (SPV) may have long-term effects. AIMS: To assess mental and residual effects of exposure to SPV. To validate a post-traumatic stress disorder (PTSD) assessment tool in Quechua-speaking Peru. METHOD: Survey of 373 individuals aged 15 and over using the General Health Questionnaire (GHQ-12), Hopkins Symptom Checklist (HSCL-25) and a Trauma Questionnaire (TQ), derived from the Harvard Trauma Questionnaire. Sociodemographics were recorded. Reliability was assessed. Data reduction used factor analysis and modelling multiple regressions. RESULTS: A quarter of the sample had symptoms compatible with PTSD. Questionnaire reliability ranged from 0.81 to 0.89. Factor analysis confirmed high construct validity for TQ and HSCL-25. Modelling showed a strong association of PTSD-related symptoms and expressions of distress with the degree of exposure to SPV, especially among returnees. CONCLUSIONS: Long-term consequences of exposure to SPV take the form of PTSD, anxiety and depressive disorders, and culturally formulated expressions of distress. Some implications for clinicians are discussed.

The sequelae of political violence: assessing trauma, suffering and dislocation in the Peruvian highlands.

In this article, we begin with a qualitative mapping of the multiple ways indigenous peoples in the Peruvian highlands construct their emotions, symptoms and specific disorders when confronted with an adverse environment of sustained political violence, multiple stressors and massive exposure to traumatic experiences. Second, we address the issue of magnitude (point prevalence) and distribution of mental health problems such as depression and anxiety, and sequelae of exposure to violence-related stressors as reported in the selected populations, by reviewing the quantitative results of a cross-sectional survey. Third, we examine the pathways and linkages between the social context (drawn from ethnography and secondary sources) and the collective experience, such as massive exodus, forced displacement, resilience and accommodation strategies for coping and survival. When assessing the overall mental health impact of exposure to protracted forms of extreme violence in civilian populations, we argue for the need to move beyond the limited notion of post-traumatic stress disorder, which is a useful but restrictive medical category failing to encompass the myriad of signals of distress, suffering and affliction, as well as other culture bound trauma-related disorders and long-term sequelae of traumatic experiences. Lastly, following the concluding remarks, we discuss some implications the results of the study may have at various levels, not only for the victims and survivors of massive exposure to traumatic events, but also their families and communities, as well as for interventions carried out by humanitarian and emergency relief organizations, and specialised agencies engaged in the promotion of social justice, prevention of human rights abuses, and mental health rehabilitation programs at both national and international levels.

Painful languages of the body: experiences of headache among women in two Peruvian communities.

This exploratory study focuses on the understandings of and experiences with headache in two settings in Peru: the Quechua-speaking district of Ayacucho, in southern Peru, and a poor urban district of Lima Metropolitana. More specifically, it explores the personal and collective meanings constructed around women's headache experiences. Structured and open-ended interviews were administered to patients suffering headache to elicit interpretations of headache episodes. An analysis of the collected narratives suggests that headache is often comprehended in a polysemic framework, where meanings ascribed in bodily, emotional, family, and social terms articulate individual and shared notions of suffering within larger contexts of social dislocation. Often woven into experiences of solitude, headache accounts are lived and told in dynamic temporal spaces, and narrate dissolution of family ties and tensions associated with women's roles. The results underscore the significance of patients' subjective interpretations of painful experiences and underscore the connections between bodily and emotional pain and distress experienced at family, community, and larger social levels.

Reframing political violence and mental health outcomes: outlining a research and action agenda for Latin America and the Caribbean region

In recent decades, the number of people exposed to traumatic events has significantly increased as various forms of violence, including war and political upheaval, engulf civilian populations worldwide. In spite of widespread armed conflict, guerrilla warfare and political violence in the Latin American and Caribbean region, insufficient attention had been paid in assessing the medium and long-term psychological impact and additional burden of disease, death, and disability caused by violence and wars amongst civilian populations. Following a review of the literature, a few central questions are raised: What is the short, medium and long-term health impact of extreme and sustained forms of violence in a given population? How political violence is linked to poor mental health outcomes at the individual and collective levels? Are trauma-related disorders, universal outcomes of extreme and sustained violence? These questions lead us to reframe the analysis of political violence and mental health outcomes, and reexamine the notions of trauma, after which a research and action agenda for the region is outlined. In the concluding sections, some basic principles that may prove useful when designing psychosocial interventions in post-conflict situations are reviewed.

Em décadas recentes, o número de pessoas expostas a eventos traumáticos tem aumentado significativamente, bem como formas de violência como guerras e revoluções políticas, que subjugam populações civis em todo o mundo. Apesar da dispersão dos conflitos armados, guerrilhas e violência política na América Latina e Caribe, atenção insuficiente tem sido dada para avaliar o impacto psicológico a médio e longo prazo e o peso das doenças, mortes, e invalidez provocadas pela violência e guerra contra populações civis. Algumas perguntas centrais são levantadas, a partir de revisão da literatura: qual o impacto na saúde da população, a curto, médio e longo prazo, ao vivenciar violências extremas e continuadas? Como a violência política se relaciona com saúde mental pobre, individual e coletiva? As desordens relacionadas aos traumas são conseqüências universais da violência extrema e continuada? Essas perguntas conduzem-nos a reformular a análise da violência política e de suas conseqüências sobre a saúde mental, e a reexaminar as noções de trauma e a agenda da pesquisa e ação para a região. Ao final, são apresentados alguns princípios básicos que podem ser úteis ao se projetar intervenções psicossociais.

Reformulando a violência política e efeitos na saúde mental: esboçando uma agenda de pesquisa e ação para a América Latina e região do Caribe / Reframing political violence and mental health outcomes: outlining a research and action agenda for Latin America and the Caribbean region

Em décadas recentes, o número de pessoas expostas a eventos traumáticos tem aumentado significativamente, bem como formas de violência como guerras e revoluções políticas, que subjugam populações civis em todo o mundo. Apesar da disseminação dos conflitos armados, guerrilhas e violência política na América Latina e Caribe, atenção insuficiente tem sido dada para avaliar o impacto psicológico a médio e longo prazo e o peso das doenças, mortes, e invalidez provocadas pela violência e guerra contra populações civis. Algumas perguntas centrais são levantadas, a partir de revisão da literatura: qual o impacto na saúde da população, a curto, médio e longo prazo, por vivenciar violências extremas e continuadas? Como a violência política se relaciona com pobre saúde mental individual e coletiva? As desordens relacionadas aos traumas são conseqüências universais da violência extrema e continuada? Essas perguntas nos levam a reformular a análise da violência política e de suas conseqüências sobre a saúde mental e a reexaminar as noções de trauma e a agenda da pesquisa e ação para a região. Ao fim, são apresentados alguns princípios básicos que podem ser úteis ao se projetar intervenções psicosociais.

In recent decades, the number of people exposed to traumatic events has significantly increased as various forms of violence, including war and political upheaval, engulf civilian populations worldwide. In spite of widespread armed conflict, guerrilla warfare and political violence in the Latin American and Caribbean region, insufficient attention had been paid in assessing the medium and long-term psychological impact and additional burden of disease, death, and disability caused by violence and wars amongst civilian populations. Following a review of the literature, a few central questions are raised: What is the short, medium and long-term health impact of extreme and sustained forms of violence in a given population? How political violence is linked to poor mental health outcomes at the individual and collective levels? Are trauma-related disorders, universal outcomes of extreme and sustained violence? These questions lead us to reframe the analysis of political violence and mental health outcomes, and reexamine the notions of trauma, after which a research and action agenda for the region is outlined. In the concluding sections, some basic principles that may prove useful when designing psychosocial interventions in post-conflict situations are reviewed.

Political violence, ethnic conflict, and contemporary wars: broad implications for health and social well-being.

Ethnic conflict, political violence and wars that presently shape many parts of world have deep-seated structural causes. In poor and highly indebted countries, economic and environmental decline, asset depletion, and erosion of the subsistence base lead to further impoverishment and food insecurity for vast sectors of the population. Growing ethnic and religious tensions over a shrinking resource base often escort the emergence of predatory practices, rivalry, political violence, and internal wars. The nature of armed conflict has changed substantially over time and most strategic analysts agree that in the second half of the 20th century, contemporary wars are less of a problem of relations between states than a problem within states. Despite the growing number of armed conflicts and wars throughout the world, not enough attention has been paid to the local patterns of distress being experienced and the long-term health impact and psychosocial consequences of the various forms of political violence against individuals, communities, or specific ethnic groups. The short or long-term impact assessment on civilian populations of poor countries affected by war have been scarce, and studies focussing on experiences of collective suffering and trauma-related disorders among survivors are beginning to emerge in the scientific literature. The medicalization of collective suffering and trauma reflects a poor understanding of the relationships among critically important social determinants and the range of possible health outcomes of political violence.

El desarrollo humano y la salud mental: Perspectivas socioculturales y apuntes metodológicos / Human development and mental health: sociocultural perspectives and methodological notes

Se discuten las perspectivas socioculturales de los conceptos salud mental y desarrollo bio-psico-social del ser humano. Se señala que en ciencias sociales, el abordaje de la salud y enfermedad se realiza desde dos tendencias principales: cultural y social; las cuales no son contrapuestas sino complementarias. La influencia de los patrones culturales en la generación de ciertas enfermedades se hace evidente en el reconocimiento de los efectos patogénicos y patoplásticos de los estilos de vida. Los cambios culturales y los patrones de crianza son otros ejemplos de lo anterior. El enfoque sociocultural considera al hombre como un ser biológico que vive en un grupo humano específico y que es portador y a la vez creador de cultura; es decir, estudia las diferentes estrategias culturales desarrolladas por los diversos grupos humanos en sus negociaciones con el ambiente. Las investigaciones socioculturales de la salud y enfermedad se realizan desde tres tendencias fundamentales: 1) El estudio del "discurso popular ", es decir lo que una población particular dice sobre la salud y enfermedad; 2) El estudio delo que una población hace por mantener la salud y luchar contrala enfermedad; 3) El estudio de los condicionantes culturales y los determinantes socioeconómicos de los fenómenos salud y enfermedad. Por último, se discuten algunos problemas de método que se enfrentan en la investigación en salud mental y desarrollo humano.

Sociocultural views about mental health and bio-psyco-social human development were reviewed. Health and illness in social sciences are discussed from cultural and social trends. The recognition of pathogenic and pathoplastic affects of life styles is evidenced by the influence of cultural models. Cultural changes and rearing models are other examples. Sociocultural view regards man as a biological existence living in specific social groups, being a carrier and creator of culture; sociocultural views study different cultural strategies develop by several human groups on their enviormental transactions. Sociocultural research considers three fundamental trends about health and illness: 1) The study of popular speechõ (what a particular population says about health and illness); 2) The study of what a particular population performs in order to maintain heatlh and fight against illness, 3) The study of cultural conditioners and socioeconomic determinants about health and illness phenomena /why(. Finally, methodological problems in health and illness research are reviewed.

El impacto de la pobreza, el racismo y la violencia política sobre la salud mental de los pueblos latinoamericanos / Impact poverty, racism and political violence on mental health of Latin American population

Se hace un análisis de la actual situación geográfica, económica y política de las minorías étnicas del mundo y de América Latina. Los conflictos armados ocasionan destrucción, muerte, desplazamientos internos y externos, desintegración social, pobreza extrema y aumento en la incidencia de enfermedades somáticas y mentales. Se plantea que en América Latina se está dando la tercera transición epidemiológica, donde coexisten las enfermedades infecciosas y degenerativas con problemas psicosociales y mentales y enfermedades derivadas de problemas comportamentales. Se analiza también el impacto de los proyectos de desarrollo, del racismo ambiental y de los nuevos estresores sobre las poblaciones indígenas locales. Se destacan los estudios peruanos sobre migrante y las repercusiones que la violencia política tiene sobre la salud individual y colectiva. Se plantea que la situación de salud de los pueblos y naciones indoamericanas es resultante de la interacción del pasado colonial, de una historia de violencia y aculturación forzada, de la situación de pobreza sostenida y marginación social y de continua proceso de cambio social. Se concluye que es necesario entender cuáles son los factores de orden político, social y cultural, relevantes en los problemas de salud física y mental y cómo interactúan entre sí; este conocimiento permitirá el desarrollo de estrategias alternativas e intervención innovadoras para aliviar el sufrimiento y promover la justicia, equidad, seguridad y la paz.

An analysis of the current geographic, economic and political situation of the ethnic minorities in Latin American and worldwide is carried out. Wars occasion destruction, death, internal and external migration, social disintegration, extreme poverty and increase of the incidence of somatic and mental diseases. It is outlined that Latin American is running into a third epidemiological transition where infectious and degenerative diseases coexist with psychosocial and mental disorders, as well as with diseases originated on behavioral problems. The impact of developmental projects, environmental racism and new stressors for local indigenous population are analyzed. The Peruvian study on migrant populations and the effects that political violence has on individual and collective health is enhanced. It is outlined that the health situation in Indo-American populations and countries is a result of the interaction of a colonial past, a history of violence and forced acculturation, a situation of extreme and sustained poverty and social margination, as well as the continuous process of social changes. As a conclusion, it is necessary to discover the outstanding factors of political, social and cultural order on the physical and mental health problems and their interaction. This knowledge will afford the development of alternative strategies and innovative interventions in order to light the suffering and to promote justice, equity, security and peace.