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SVKM’s NMIMS

MBA Trimester VI
Social Marketing
Therapy for India’s Distressed Farmers
Introduction: Many times misunderstood, mostly ignored or hushed-up, the mental ailments
always remain undercover in India. As per the latest data available, at least 60 million Indians
suffer from mental disorders. While people both in urban and rural areas suffer from various
mental illnesses, persons with mental illness in rural India are unable to receive quality care.
This is due to limited awareness, availability, accessibility, and affordability. The notion of
mental health is demonized among the rural population, and is thought to be the “possession
or embodiment of an evil spirit in an individual” that makes them behave in a bizarre manner.
Farmer suicides are a reflection of an ailing rural economy. It also shows a state of
hopelessness among farmers which make them so emotionally fragile that they are meekly
taking their own lives. Large swathes of cotton farms in the central India have been the
epicentre of a debt crisis that has gripped the rural population. For years now, it has driven
thousands of farmers to commit suicide. These suicides are not merely a loss of human lives;
they are debilitating scars on a nation’s development canvas. While debates continue to rage
on reforming the agricultural sector to improve the economic conditions of the farmer, there
has not been any attempt to focus on the possible psychological problems arising out of
economic stress that may be leading to suicides.
A field-based research study in the prestigious medical journal The Lancet (by Pandit et al)
concludes, “Most Indians do not have community or support services for the prevention of
suicide and have restricted access to care for mental illnesses associated with suicide,
especially access to treatment for depression, which has been shown to reduce suicidal
behaviours. Reduction in binge alcohol drinking through regulations, higher alcohol taxation,
or brief interventions in primary care might also reduce suicide cases.”
The abysmal state of mental health care in the country has made matters worse. Most
government-run hospitals do not have psychiatric drugs, and visiting a private counsellor and
sustaining the treatment—usually a long drawn out affair—is an expensive proposition for
most families. India spends 0.06 per cent of its health budget on mental healthcare. Most
developed nations spend above 4 per cent of their budgets on mental-health research,
infrastructure, frameworks and talent pool, according to a 2011 World Health Organization
report. India is short of health professionals to address psychological issues, particularly at the
district and sub-district levels. There are 3,800 psychiatrists, 898 clinical psychologists, 850
psychiatric social workers and 1,500 psychiatric nurses nationwide, according to a reply by the
ministry in the Lok Sabha in December 2015
The ignorance and the callous attitude towards psychiatric ailments, coupled with social
stigma, dissuade most from seeking help. The folks of agrarian societies have a huge deal of
respect for faith healers and consider them the primary approach for treatment, which
denies them the required medical/therapeutic intervention from mental health professionals.
VISHRAM comes as hope
There are silver linings on what most seem to see as a cloud of despair. There are several
selfless professionals who are using their talent and ingenuity to address some of our toughest
problems. One such is VISHRAM (Vidarbha Stress and Health Programme) designed by Dr
Vikram Patel, a professor at the Public Health Foundation of India. VISHRAM is a four-year

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community-based programme for the promotion of mental health and prevention and
management of psycho-social distress and mental disorders in agricultural communities in the
Vidarbha region — Amaravati and Wardha districts. While in Amaravati, it is being
implemented by Prakriti, in Wardha, it is being run by Watershed Organisation Trust with
technical support from Sangath an NGO based in Goa.
Local Scenario: Studies have shown that rural communities are widely recognised as a high
risk group for suicides as compared with most other occupations; moreover farmers have been
reported to have high prevalence of common mental health problems and there is a large
treatment gap for mental disorders. Vidarbha, in particular, has been badly affected by agrarian
crisis which have been linked to farmer suicides. “Unfortunately, people do not understand
basic things like stress and depression until it is too late. In India, insanity is the only word that
describes mental disorders of all kinds,” explains Suvarna Damle of Prakriti. “It is extremely
difficult to convince people that mental disorders are curable. The only response we get when
we talk of mental health is that there are no insane people around,” she says.
In any case, faith healing is the first line of treatment that people adopt. When the patients are
brought for medical help, the situation is generally out of hands. Suicide is an extreme step but
it begins with a very common and innocuous thing like stress or depression that can be a result
of a range of social and health factors, especially in rural communities. For example, the greater
insecurity of income, lack of access to credit, poorer access to appropriate health care and easier
access to lethal methods for suicides like pesticides.
Speaking about mental health services in the region Damle shared that prior to commencing
the VISHRAM project, they conducted a situational analysis. The research showed that there
was only one psychiatrist in the District Hospital in addition to one psychologist and two
psychiatric social workers. There were around 15 psychiatrists in private sector and all were
based in Amravati city. There were no psychiatrists or psychologists in public as well as in
private sector in the rural parts.

Goals: VISHRAM’s goal is to implement and evaluate a comprehensive, population-based


intervention programme to reduce psycho-social distress and the risk of suicide through
targeted interventions. “Agriculture is falling out of favour as an occupation in rural
communities. One study found that about 40 per cent of farmers would like to quit agriculture.
We spoke to 70 such children who do not want to take up agriculture as they do not find it
prosperous any more and would rather sell off their land. Personal tragedies and alcohol abuse
just add to this serious situation,” Ms. Damle points out.
“VISHRAM aims to be a community-based programme to promote mental health literacy and
awareness and deliver basic mental health care services by trained counsellors in community
settings in addition to providing specialised mental health care services through a collaborative
partnership with public and private health care providers,” explains Bhupali Mhaskar of
WOTR. Its ultimate goal is to integrate mental health with regular health care needs.
VISHRAM’s Model: The interventions included in VISHRAM were based on the principles
of accessibility, affordability, adaptability, acceptability and assessment of performance
elaborated in the National Mental Health Policy: vision 2020 and WHO model of organisation
of mental health care. The principle of universal interventions for promotion and prevention
for the entire village population alongside targeted interventions for individuals with mental
disorders formed the basis of program components for the implementation phase. (See Fig 1
below).

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The interventions were organised at the community level to promote self-care and provide
informal community care by Community Health Workers (CHWs), psychosocial interventions
by Health Counsellors (HCs) and referral/ follow-up for the persons requiring medications and
specialist care by psychiatrists based in primary health centres or rural hospitals. Improving
mental health literacy through participatory engagement with the community and incorporating
community attitudes and beliefs in the awareness interventions, for example avoiding the use
of psychiatric labels for common mental health problems was crucial in forming favourable
attitudes for recognizing mental health as an integral part of community health. The
intervention also provided care for suicide survivors and their families.
Fig 1
Organization of Services

Execution: VISHRAM was implemented in two phases each lasting for a duration of two
years. In the first “Development” phase (November 2011- December 2013), our goal was to
design an acceptable and feasible intervention to address psychosocial distress and provide care
for mental disorders in the community. This phase was implemented in 15 villages of Chandur
Bazaar taluka in Amravati district and 8 villages of Arvi taluka in Wardha district. The
evaluation of this phase revealed many important insights which were taken into account in the
designing of the program, in particular a strategic shift of focus from “mental disorders” and
their treatment to wellbeing and addressing distress to maximise help-seeking by people with
mental disorders. Providing care for suicide survivors and their families was explicitly added
as an important component. Provision of care close to the people was a key to enhancing access,
and therefore it was decided to have counselling centres in the villages.
The “Implementation” phase of VISHRAM (April 2014 to September 2015) covered 30
villages in two blocks in Chandur bazar and Dhamangaon talukas of Amravati district, covering
a population of 100,555.
Promotion: To spread community awareness IEC (information, education & communication)
strategy was developed. The mass awareness programs included lectures, screening of
documentary films like Prakashdoot with debriefing and street plays. Screening of films was
held at village square, panchayat building, tea shops, water pumps, local temple or mosque.
Weekly market days, special days specific to the village when people meet like village deity
days, village melas were also chosen. Meetings with key stakeholders including panchayat raj
institution members, farmers' groups, mitra mandal and bachat gat heads, other self-help

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groups, doctors in the village, religious heads prior to the intervention activity ensured
ownership of all the community members. An attempt was made to cover every
community/caste/religious group within the village. Commonly accessible public spaces like
school, panchayat and health clinic walls displayed the IEC material. This was supplemented
with advertisements in local magazines, announcements, songs for awareness from
autorickshaws/cycles/group-walks through every locality, films, and street plays within each
locality and on occasions when the entire village gathered.
Small group meetings were used to reach out to socioeconomically vulnerable parts of the
village particularly to improve their interest and participation in mental health program. The
meetings involved story-telling, games, lectures, role plays, case-studies including success
stories using posters, symptom cards, and other audiovisual aids like videos and powerpoints.

Family and one-to-one meetings were taken up to take the key messages at homes of the people
and provide an opportunity for informal interactions with the health workers. These activities
also promoted help seeking and thereby generating demand for mental health services.

A formidable team of volunteers


Patel used community volunteers and trained them as mental health workers for his project. He
conducted focus groups to gauge community acceptance and conduct trial sessions to train new
counsellors who imparted enhanced care. This included diagnosis by a doctor or a health
worker at a primary health centre, medication if necessary, and sympathy from the staff.
Counseling had a great role to play in alleviating stress and helping depressed people improve
their self-esteem and their ability to cope with despair.
Janrao Haware was one of the locals trained as a psychopathic counsellor. He was assigned the
care of Shubham Kitukale, a farmer living in Marlod village in Amravati district. Kitukale had
attempted suicide when his crippling farm and growing debt went out of control. Through a
series of counselling sessions, Haware and Kitukale were able to pin down the causes of despair
and the aggravating factors that led to the attempted suicide. Through simple sessions of
empathetic counselling by Harare and by sharing and ventilating his anxiety, Kitukale was
returned to full health. The young farmer recently got married and is now expecting a baby. He
says that when things get tough, he no longer considers suicide as a way out.
The two NGOs working with the communities mobilised self-help groups and village leaders
for early detection of mental disorders with focus on home-based care. More than 1,000 small
group meetings were held over 18 months. First aid for mental health was provided to 1,441
individuals with psychosocial distress. More than half of these people (793) were referred to
counsellors, while patients with severe mental illnesses like schizophrenia were referred to the
local medical hospitals. Psychiatrists from the government’s District Mental Health
Programme and the private sector provided medication for serious mental disorders.
Mental health awareness programmes in community included distribution of IEC material,
street plays and informal interactions with women’s groups and free distribution of medicines.
The next target involved schools in identifying children with such symptoms by training
teachers. “The issue of mental health is so sensitive that it takes lot of time and persuasion to
make people talk about it. Most people do not even relate to it,”' explains Arti Khangar, a
counsellor with WOTR. Initially when they were told the meeting would discuss mental health,
the villagers would say it is a meeting meant only for “insane people”. However, things seemed
to be moving in a positive direction with villagers providing information about families under

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stress due to economic or social distress, alcoholism and domestic violence in the
neighbourhood or even about someone in need of medical aid.
Existing front-line workers such as the ASHAs (Accredited Social Health Activists) worked at
the community level to raise mental health literacy. They were provided with psychological
first aid and treatment in community and primary health centres. Frontline workers interacted
directly with the people, talking about the “tension” they are experiencing and raising
awareness about the stress episodes and ways to cope with them. For many farmers, sharing
and ventilating their toxic and morbid thoughts was cathartic. Moreover, since healthcare
workers were drawn from the same community, they were familiar with the environment and
were able to empathise with the farmers.

Successful alternative to expensive psychiatric support


According to Patel, mental health support workers can be trained at a low cost. In countries
like India, where there is a shortage of trained doctors—especially in the field of psychiatry—
community treatment through these workers can prove to be a successful alternative support
system. Patel says, “We need to enhance the skills of doctors working in primary care units to
detect and treat mental health problems. There should also be a direct link between the
specialists teaching or practising in medical schools and district hospitals with basic medical
facilities. This is the same model of care used for chronic diseases. In fact, in the long term, the
most sustainable way to improve access to mental health care is to see mental disorders as a
chronic disease similar to diabetes.”

Monitoring & Evaluation: A robust M&E framework was designed to ensure quality of
mental health care. Real time monitoring was undertaken using mobile data entry by
Community health workers (CHW) and was checked by head counsellors (HC) on a daily basis.
Weekly targets were allotted to CHW. At the end of each day CHW reported to the central
database the name, contact number and village name of the individual screened, the result of
the detection and the date and time of the next step suggested. The M& E Officer at the end of
the day prepared a master list of individuals who had been screened and the people who had
been given appointments for counselling by the HCs. This list was then sent to HCs and
program coordinator by SMS or applications such as Whatsapp. HCs randomly visited those
individuals who were provided psychological first aid but were not referred to HC and assess
if the non- referral was appropriate.

According to Patel, mental health support workers can be trained at a modest cost. In countries
like India where there are significant doctor shortages, these mental workers can be a successful
alternative. Even family elders are sometimes the best counsellors. With training in basic
psychological skills, they can play a very useful role in curbing suicidal tendencies.
Surveys were done at the start and at the end of the programme. The researchers interviewed
1,887 subjects on mental health indices. The evaluation at the end found that:

 The proportion of people with depression who sought care rose from 4.3 percent to 27.2
percent.
 The prevalence of depression fell from 14.6 percent to 11.3 percent.
 The prevalence of suicidal thoughts in the previous 12 months fell from 5.2 percent to
2.5 percent.
 A range of mental health literacy indicators showed significant improvement.

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This in itself highlights the success of the programme in spreading awareness and raising
mental health literacy. As depression is one of the leading causes of suicide, this could explain
the sharp dip in suicide numbers as well.
The need to scale up the programme
The idea sprang from something Patel saw in Zimbabwe, where he worked as a psychiatrist in
the mid-1990s at the university in Harare. “I learned so much in Zimbabwe, in particular about
the need for humility in our ambition to extend mental health care in countries where there are
very few psychiatrists and where the local culture harboured very different views about mental
problems. The situation is not very different in India. The ratio between psychiatrists and the
population is worsening and so is the stigma of mental illnesses.”
Patel wants suicide to be seen as a public health issue. “In India, we haven’t done good research
on farmers’ suicides in terms of mental health. This has always been seen as a social issue. But
if you look around the world, at least 50 percent of farmers and adults who kill themselves
would have had a depressive disorder or an alcohol use disorder--the two main mental health
conditions,” he says.
Patel and others are seeking to scale up the programme, spreading it to other states of the
country. VISHRAM is a cost effective and efficient model that can be scaled up or implemented
in different parts of the country, but it needs government help. Scaling up has challenges and
one of them is to retain the efficiency factor that a smaller and more closely monitored
programme has. “We’re no longer asking if we could use community workers, we’re asking
how do we deploy them,” says Patel.
For every Indian farmer who takes his own life, a family is hounded by the debt he leaves
behind, typically resulting in children dropping out of school to become farmhands. Farmers’
suicides have to be tackled on several fronts and addressing mental health problems is just one
of them, but certainly a major part of the solution.