Understanding psychological distress among mothers in rural Nepal: a qualitative grounded theory exploration

BMC Psychiatry

Audrey Prost⁴  David Osrin⁴  Michael King¹  Dharma Manandhar³  Anthony Costello⁴  Rinku Tiwari³  Bhawana Thakur³  Bhim Shrestha³  Rinku Roy³  Jananee Magar⁵  Sonali Jha³  Meena Jha²  Mamita Ghising³  Kalpana Giri³  Bishnu Bhandari³  Naomi Saville⁴  Kelly Clarke⁴ 

[1]Research Department of Mental Health Sciences, University College London, Charles Bell House, 2nd Floor, 67-73 Riding House Street, London W1W 7EJ, UK

[2]St Albans, Hertfordshire, UK

[3]Mother and Infant Research Activities (MIRA), Thapathali, Kathmandu, Nepal

[4]University College London Institute for Global Health, 30 Guilford Street, London WC1N 1EH, UK

[5]Transcultural Psychosocial Organisation Nepal, Baluwatar, Kathmandu, Nepal

关键词: Rural health;    Maternal mental health;    Perinatal common mental disorders;    Postnatal depression;    Psychological distress;    South Asia;    Nepal;   

Others  :  1123737
DOI  :  10.1186/1471-244X-14-60

 received in 2013-09-12, accepted in 2014-02-19,  发布年份 2014

【 摘 要 】

Background

There is a large burden of psychological distress in low and middle-income countries, and culturally relevant interventions must be developed to address it. This requires an understanding of how distress is experienced. We conducted a qualitative grounded theory study to understand how mothers experience and manage distress in Dhanusha, a low-resource setting in rural Nepal. We also explored how distressed mothers interact with their families and the wider community.

Methods

Participants were identified during a cluster-randomised controlled trial in which mothers were screened for psychological distress using the 12-item General Health Questionnaire (GHQ-12). We conducted 22 semi-structured interviews with distressed mothers (GHQ-12 score ≥5) and one with a traditional healer (dhami), as well as 12 focus group discussions with community members. Data were analysed using grounded theory methods and a model was developed to explain psychological distress in this setting.

Results

We found that distress was termed tension by participants and mainly described in terms of physical symptoms. Key perceived causes of distress were poor health, lack of sons, and fertility problems. Tension developed in a context of limited autonomy for women and perceived duty towards the family. Distressed mothers discussed several strategies to alleviate tension, including seeking treatment for perceived physical health problems and tension from doctors or dhamis, having repeated pregnancies until a son was delivered, manipulating social circumstances in the household, and deciding to accept their fate. Their ability to implement these strategies depended on whether they were able to negotiate with their in-laws or husbands for resources.

Conclusions

Vulnerability, as a consequence of gender and social disadvantage, manifests as psychological distress among mothers in Dhanusha. Screening tools incorporating physical symptoms of tension should be envisaged, along with interventions to address gender inequity, support marital relationships, and improve access to perinatal healthcare.

【 授权许可】

   
2014 Clarke et al.; licensee BioMed Central Ltd.

【 图 表 】

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【 参考文献 】

• [1]Fisher J, Mello CD, Patel V, Rahman A, Tran T, Holton S, Holmes W: Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle- income countries: a systematic review. Bull World Health Org 2012, 90:139-149.
• [2]Kleinman A, Good BJ: Culture and Depression: Studies in the Anthropology and Cross-Cultural Psychiatry of Affect and Disorder. Berkeley and Los Angeles: University of California Press; 1985.
• [3]Rodrigues M, Patel V, Jaswal S, de Souza N: Listening to mothers: qualitative studies on motherhood and depression from Goa, India. Soc Sci Med 2003, 57(10):1797-1806.
• [4]Selim N: Cultural dimensions of depression in Bangladesh: a qualitative study in two villages of Matlab. J Health Popul Nutr 2010, 28(1):95-106.
• [5]Pereira B, Andrew G, Pednekar S, Pai R, Pelto P, Patel V: The explanatory models of depression in low income countries: listening to women in India. J Affect Disord 2007, 102:209-218.
• [6]Suvedi BK, Pradhan A, Barnett S, Puri M, Chitrakar SR, Poudel P, Sharma S, Hulton L: Nepal maternal mortality and morbidity study 2008/2009: summary of preliminary findings. In Family Health Division DoHS, Ministry of Health, Government of Nepal. Kathmandu, Nepal: Ministry of Health; 2009.
• [7]Ho-Yen S, Bondevik G, Eberhard-Gran M, Bjorvatn B: The prevalence of depressive symptoms in the postnatal period in Lalitpur district, Nepal. Acta Obstet Gynecol Scand 2006, 85(10):1186-1192.
• [8]Nepal MK, Sharma VD, Koirala NR, Khalid A, Shresta P: Validation of the Nepalese version of Edinburgh Postnatal Depression Scale in tertiary health care facilities in Nepal. Nepalese J Psychiatry 1999, 1:46-50.
• [9]Regmi S, Sligl W, Carter D, Grut W, Seear M: A controlled study of postpartum depression among Nepalese women: validation of the Edinburgh Postpartum Depression Scale in Kathmandu. Tropical Med Int Health 2002, 7(4):378-382.
• [10]Clarke K, Saville N, Shrestha B, Costello A, King M, Manandhar D, Osrin D, Prost A: Predictors of psychological distress among postnatal mothers in rural Nepal: a cross-sectional community-based study. J Affect Disord 2014, 156:76-86.
• [11]Ho-Yen S, Bondevik G, Eberhard-Gran M, Bjorvatn B: Factors associated with depressive symptoms among postnatal women in Nepal. Acta Obstet Gynecol Scand 2007, 86(3):291-297.
• [12]Shrestha BP, Bhandari B, Manandhar DS, Osrin D, Costello A, Saville N: Community interventions to reduce child mortality in Dhanusha. Nepal: study protocol for a cluster randomised controlled trial. Trials 2011, 12:136. BioMed Central Full Text
• [13]Koirala NR, Regmi SK, Sharma VD, Khalid A, Nepal MK: Sensitivity and validity of the General Health Questionnaire (GHQ-12) in a rural community setting in Nepal. Nepalese J Psychiatry 1999, 1(1):34-40.
• [14]Central Bureau of Statistics: National Population and Housing Census 2011. Kathmandu, Nepal: Government of Nepal; 2012.
• [15]Central Bureau of Statistics: Nepal Population Census 2001. Kathmandu, Nepal: Government of Nepal; 2001.
• [16]Corbin J, Strauss AL: Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 3rd edition. Thousand Oaks, USA: Sage; 2008.
• [17]Kleinman A: Culture, illness and cure: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med 1978, 88:251-258.
• [18]Lee DT, Yip AS, Leung TY, Chung TK: Screening for postnatal depression: are specific instruments mandatory? J Affect Disord 2001, 63:233-238.
• [19]Navarro P, Ascaso C, Garcia-Esteve L, Aguado J, Torres A, Martín-Santos R: Postnatal psychiatric morbidity: a validation study of the GHQ-12 and the EPDS as screening tools. Gen Hosp Psychiatry 2007, 29(1):1-7.
• [20]Shelton NJ, Herrick KG: Comparison of scoring methods and thresholds of the General Health Questionnaire-12 with the Edinburgh Postnatal Depression Scale in English women. Public Health 2009, 123(12):789-793.
• [21]QSR International Pty Ltd: NVivo Qualitative Data Analysis Software. 10th edition. : ; 2012.
• [22]Strauss A, Corbin J: Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park: Sage Publications; 1990.
• [23]Halliburton M: “Just some spirits”: the erosion of spirit possession and the rise of “tension” in South India. Med Anthropol 2005, 24:111-144.
• [24]Kostick KM, Schensul SL, Jadhav K, Singh R, Bavadekar A, Saggurti N: Treatment seeking, vaginal discharge and psychosocial distress among women in urban Mumbai. Cult Med Psychiatry 2010, 34(3):529-547.
• [25]Parkar SR, Nagarsekar BB, Weiss MG: Explaining suicide: identifying common themes and diverse perspectives in an urban Mumbai slum. Soc Sci Med 2012, 75(11):2037-2046.
• [26]Ministry of Health and Population, New ERA, ICF International Inc: Nepal Demographic and Health Survey 2011. Kathmandu, Nepal: Government of Nepal; 2012.
• [27]World Health Organisation: Country Health System Profile: Nepal [Online]. Geneva, Switzerland: Regional Office for South East Asia; 2007. [Accessed 12th December 2012]
• [28]Keyes CLM, Ryff CD: Somatization and mental health: a comparative study of the idiom of distress hypothesis. Soc Sci Med 2003, 57:1833-1845.
• [29]Isaac M: Somatization - a culture-bound or universal syndrome? J Ment Health 1996, 5(3):219-222.
• [30]Bennett L, Dahal DR, Govindasamy P: Caste, Ethnic and Regional Identity in Nepal: Further Analysis of the 2006 Nepal Demographic and Health Survey. Calverton: In. Edited by Macro International Inc; 2008.
• [31]Thapa N: Country Profile of Excluded Groups in Nepal. Nepal: Kathmandu; 2009.
• [32]Gone JP, Kirmayer LJ: On the Wisdom of Considering Culture and Context in Psychopathology. New York: Guilford Press; 2010.
• [33]Kirmayer LJ, Young A: Culture and somatization: clinical, epidemiological, and ethnographic perspectives. Psychosom Med 1998, 60:420-430.
• [34]Summerfield D: How scientifically valid is the knowledge base of global mental health? Br Med J 2008, 336(7651):992-994.
• [35]Abrejo FG, Shaikh BT, Rizvi N: ‘And they kill me, only because I am a girl’. a review of sex-selective abortions in South Asia. Eur J Contracept Reprod Health Care 2009, 14:10-16.
• [36]Lamichhane P, Harken T, Puri M, Darney PD, Blum M, Harper CC, Henderson JT: Sex-selective abortion in Nepal: a qualitative study of health workers’ perspectives. Womens Health Issues 2011, 21:S37-S41.
• [37]Unnithan-Kumar M: Female selective abortiondbeyond ‘culture’: family making and gender inequality in a globalizing India. Cult Health Sex 2010, 12:153-166.
• [38]Bennett L: Dangerous Wives and Sacred Sisters: Social and Symbolic Roles of High-Caste Women in Nepal. New York: Columbia University Press; 1983.
• [39]Howard LM, Oram S, Galley H, Trevillion K, Feder G: Domestic violence and perinatal mental disorders: a systematic review and meta-analysis. PLoS Med 2013, 10(5):e1001452.
• [40]Le Strat Y, Dubertret C, Le Foll B: Child marriage in the United States and its association with mental health in women. Pediatrics 2011, 128(3):524-530.
• [41]Patel V, Rodrigues M, DeSouza N: Gender, poverty, and postnatal depression: a study of mothers in Goa, India. Am J Psychiatr 2002, 159:43-47.
• [42]Rosaldo MZ: The use and abuse of anthropology: reflections on feminism and cross-cultural understanding. Signs 1980, 5(3):389-417.
• [43]Hankins M: The reliability of the twelve-item general health questionnaire (GHQ-12) under realistic assumptions. BMC Public Health 2008, 8:355. BioMed Central Full Text