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A COMMUNITY MENTAL HEALTH PROGRAMME IN RURAL TAMILNADU

R.Thara*, R.Padmavathi

This is a brief report of a community mental health rehabilitation programme carried out in a rural area in Tamil Nadu by the Schizophrenia Research Foundation (SCARF). SCARF is a non-governmental, non-profit organisation in Madras, working for people with chronic mental illness, and has been involved in community mental health work in the past decade in urban slums and rural areas. The community mental health project is funded by a Canadian donor (IRDC) and is carried out in Thiruporur. Covering an area of 14,181 square miles with over 100 villages, this area has a total population of 1,10,758 persons, most of whom live below the poverty line. One Primary health Centre (PHC), a few sub-centres, and rural dispensaries cater to the health needs of the population. Two major religious centres in the area, a Dargah and a Hindu Temple, are prominent healing sites for mental illness, and often are the first point of contact. Therapeutic measures in these centres include special prayers, offerings, special food and other rituals, undertaken over varying periods of time.

THE MENTAL HEALTH PROGRAMME

While the primary objective was to operate a community mental health programme in the defined catchment area, the other programme components included training lay volunteer workers to detect and manage mental disorders, operating a mental health service system in the area, planning and implementing an intervention programme for the identified mentally ill, integration of mental health with primary health care infrastructure in the area, and conducting periodic awareness programmes in the community.

TRAINING

The Community Rehabilitation Workers(CRWs) were lay volunteers identified from the community with the help of village leaders. The training consisted of five sessions each for ten groups of CRWs, followed by periodic reinforcing sessions. Medical officers and multi-purpose workers ( numbering 50 for the training ) from the PHC were also trained during four sessions. The choice of CRWs from the local population helped to facilitate easier acceptance and accessibility to the homes of the mentally ill. The training included detection of mental disorders in the community such as psychoses, neuroses, mental retardation, substance abuse disorders and epilepsy, implementation of simple intervention strategies, working closely with families of the mentally ill, and making appropriate referrals. Manual and audio-visual training materials were used for the sessions.

MENTAL HEALTH SERVICES

An active outpatient clinic was operated twice a month in Thiruporur town. Patients identified in the community by the CRWs were treated by a psychiatrist, and reviewed periodically. A similar procedure was followed in camps held in remote villages, which were not accessible to the clinic. Some simple interventions offered by the CRWs included support to the client, educating families on mental illness, management of behaviour problems, ensuring drug compliance, training patients in self care and activities of daily living, job placement, and initiating small businesses as a measure of rehabilitation. The emphasis was on utilising local resources and mobilising local support. Over a period of five years, 637 patients suffering from mental illness were registered and offered treatment, and at the end of the sixth year, 235 were being followed-up.

INTEGRATION OF MENTAL HEALTH INTO PRIMARY HEALTH CARE

This was initiated by training health care personnel in PHC services to detect and manage mental illness. Active liaison with the government health and medical service departments, as well as sustained efforts at ensuring a supply of basic psycho-tropic medicines at the PHCs have paid dividends. It was therefore possible to refer a number of patients to the PHCs in that area.

AWARENESS PROGRAMMES

These were periodically held in different villages, using local folklore, dance and music. The emphasis was on early recognition of mental illness and prompt treatment. Following the awareness programmes, it was noticed that referrals to the clinic increased, mainly from village leaders, traditional healers, community workers and general medical practitioners

COMMUNITY INVOLVEMENT AND EMPOWERMENT

The project has been community oriented in that over 80% of the staff were drawn from the same community facilitating easier acceptance and greater involvement. Village leaders, teachers, religious heads and others with influence were involved in the programme at various stages.

Most of rural India is devoid of formal mental health services. It was evident soon that communities by and large favoured traditional and religious forms of treatment, not only because it suited their explanatory models of mental illnesses, but also because of the easier availability of these services, in comparison with formal medical facilities. The project staff established good links with traditional healers in that area who gradually began referring cases to the centre. No efforts were made to thrust into the community a medical model of illness or to persuade them to give up the existing help they were used to. Within a few months, it was clear that this rural community was ready to abandon its traditional treatments for some of the mental disorders, while it continued to hold on to its view points regarding others. This is not an uncommon phenomenon, and it is probable that most stigmatising illnesses are faced with this kind of "mixed loyalties".

It is possible to train lay community volunteers to identify various mental disorders and implement simple psycho-social rehabilitation strategies. Involving and training lay community workers from the community facilitated easier acceptance by the patients and their families. The interventions offered as part of this programme have facilitated community integration of the mentally ill. Interventions have been individually tailored to the needs of the patients and their families. Establishing rapport with the family and the community through the involvement of local village leaders has ensured the acceptance of such a programme by the population.

The programme has shown that there are some basic elements of psycho-social intervention that are essential in any community mental health programme in a rural community, particularly in developing countries. These should include, besides provision of psycho-tropic drugs, the involvement of the family and the mobilisation of local community resources. Structured and skilled psycho-social rehabilitation programmes may be too complex for implementation and may not be necessary for the rural population. Besides, these cannot be implemented by the lay community volunteers.

Mental health care is undergoing a transition the world over from institutionalisation to community care. Understanding community perceptions, attitudes and coping styles will increasingly become more crucial in community based programmes. This is even more relevant in developing countries, where "stereotypes" about the mentally ill have existed for centuries. Making a change in this without antagonising or hurting the feelings of the community would be a challenge. In this respect, this project has been a kind of forerunner and provided a model which may be replicated in other parts of the world.

*Schizophrenia Research Foundation, Plot R/7A, West Main Road, Annanagar, (West extension),Chennai - 600 101, India.




Title:
ASIA PACIFIC DISABILITY REHABILITATION JOURNAL Vol. 10 @ No. 1 @ 2000

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