Kaaren Mathias | Umeå University (original) (raw)

Papers by Kaaren Mathias

Caregivers are integral to health and social care systems in South Asian countries yet are themse... more Caregivers are integral to health and social care systems in South Asian countries yet are themselves at higher risk of mental illness. Interventions to support caregiver mental health developed in high-income contexts may be contextually inappropriate in the Global South. In this mixed-methods study, we evaluated the implementation and scaling of a locally developed mental health group intervention for caregivers and others in Uttarakhand, India. We describe factors influencing implementation using the updated Consolidated Framework for Implementation Research, and selected implementation outcomes. Key influencing factors we found in common with other programs included: an intervention that was relevant and adaptable; family support and stigma operating in the outer setting; training and support for lay health worker providers, shared goals, and relationships with the community and the process of engaging with organisational leaders and service users within the inner setting. We identified further factors including the group delivery format, competing responsibilities for caregivers and opportunities associated with the partnership delivery model as influencing outcomes. Implementation successfully reached target communities however attrition of 20% of participants highlights the potential for improving outcomes by harnessing enablers and addressing barriers. Findings will inform others implementing group mental health and caregiver interventions in South Asia. Impact statement Nearly every disabled person in South Asia (such as people with difficulties walking or with mental health problems) is supported by family caregivers for their activities of daily living. Caregivers are central in the disability ecosystem in settings like India, where there is limited public and social support for disabled people. Yet caregiving is heavy and unceasing work and most caregivers receive little support meaning that they are at higher risk of experiencing mental distress. Few studies describe what works to strengthen the mental health and well-being of caregivers, and even fewer describe how an intervention can work well when rolled out among other organisations. This is essential to know in order to deliver interventions to larger numbers of people. This study tries to address this gap. In 2021, we had evaluated this caregiver mental health intervention (Nae Umeed or New Hope) and found it was effective. In this project, we aimed to describe the process of rolling out Nae Umeed with seven other organisations to learn what works well and what does not. We found Nae Umeed was a relevant and adaptable intervention that participants were positive about. Participation went better when participants also experienced family support to join in group sessions and try out the new ideas at home. We identified factors that made it work well from the perspective of organisations such as finding that the community health workers who facilitated groups needed to connect relationally with the community and to be supported with resources and training. Nae Umeed did not go as well if participants were too overloaded with other responsibilities, or if they experienced stigma. The group format allowed people to form new friendships which also provided social support after the programme finished. Nae Umeed merits consideration and rollout in other settings in South Asia.

Global mental health, Dec 31, 2022

Caregivers are integral to health and social care systems in South Asian countries yet are themse... more Caregivers are integral to health and social care systems in South Asian countries yet are themselves at higher risk of mental illness. Interventions to support caregiver mental health developed in high-income contexts may be contextually inappropriate in the Global South. In this mixed-methods study, we evaluated the implementation and scaling of a locally developed mental health group intervention for caregivers and others in Uttarakhand, India. We describe factors influencing implementation using the updated Consolidated Framework for Implementation Research, and selected implementation outcomes. Key influencing factors we found in common with other programs included: an intervention that was relevant and adaptable; family support and stigma operating in the outer setting; training and support for lay health worker providers, shared goals, and relationships with the community and the process of engaging with organisational leaders and service users within the inner setting. We identified further factors including the group delivery format, competing responsibilities for caregivers and opportunities associated with the partnership delivery model as influencing outcomes. Implementation successfully reached target communities however attrition of 20% of participants highlights the potential for improving outcomes by harnessing enablers and addressing barriers. Findings will inform others implementing group mental health and caregiver interventions in South Asia. Impact statement Nearly every disabled person in South Asia (such as people with difficulties walking or with mental health problems) is supported by family caregivers for their activities of daily living. Caregivers are central in the disability ecosystem in settings like India, where there is limited public and social support for disabled people. Yet caregiving is heavy and unceasing work and most caregivers receive little support meaning that they are at higher risk of experiencing mental distress. Few studies describe what works to strengthen the mental health and well-being of caregivers, and even fewer describe how an intervention can work well when rolled out among other organisations. This is essential to know in order to deliver interventions to larger numbers of people. This study tries to address this gap. In 2021, we had evaluated this caregiver mental health intervention (Nae Umeed or New Hope) and found it was effective. In this project, we aimed to describe the process of rolling out Nae Umeed with seven other organisations to learn what works well and what does not. We found Nae Umeed was a relevant and adaptable intervention that participants were positive about. Participation went better when participants also experienced family support to join in group sessions and try out the new ideas at home. We identified factors that made it work well from the perspective of organisations such as finding that the community health workers who facilitated groups needed to connect relationally with the community and to be supported with resources and training. Nae Umeed did not go as well if participants were too overloaded with other responsibilities, or if they experienced stigma. The group format allowed people to form new friendships which also provided social support after the programme finished. Nae Umeed merits consideration and rollout in other settings in South Asia.

Christian Journal for Global Health, May 31, 2019

BMJ Global Health, Jun 1, 2019

The presence of common problems and initiating leadership provide the conditions for collaborativ... more The presence of common problems and initiating leadership provide the conditions for collaborative action in local health systems. ► Actors, however, need to learn how to collaborate through principled engagement. ► Trust and trust building are central to developing shared motivations for collaboration. ► Jointly developed new knowledge-through shared data, evaluations or reflective processes-creates capacity for collaboration. ► The considerable work involved in building and maintaining collaborative action needs to be acknowledged.

Transcultural Psychiatry, 2016

An asymmetric burden gendered experiences of caregivers of people with psycho-social disabilities... more An asymmetric burden gendered experiences of caregivers of people with psycho-social disabilities in North India

BMJ Open, Nov 1, 2015

This study sought to use a populationbased cross-sectional survey to describe depression prevalen... more This study sought to use a populationbased cross-sectional survey to describe depression prevalence, healthcare seeking and associations with socioeconomic determinants in a district in North India.

BackgroundGlobally, there is increasing emphasis on the importance of understanding the ways in w... more BackgroundGlobally, there is increasing emphasis on the importance of understanding the ways in which social inequality and injustice impact individual and community mental health. Set in the state ...

Community Mental Health Journal, Nov 15, 2017

Stigma is an important contributor to the large treatment gap for people with mental and psycho-s... more Stigma is an important contributor to the large treatment gap for people with mental and psycho-social disabilities (PPSD) in India. Social distance as assessed by willingness to engage in relationships with PPSD is a proxy measure of stigma and potential discrimination. In North India, investigations of community attitudes towards PPSD have been limited. To describe attitudes towards people with depression and psychosis, a community sample of 960 adults in Dehradun district, India from 30 randomised clusters, was surveyed using a validated tool to assess social distance, beliefs and attitudes related to mental illness. Participants preferred greater social distance from a person with psychosis than a person with depression. Beliefs and attitudes around mental illness were diverse reflecting a wide spread of belief frameworks. After controlling for confounding, there was increased social distance among people who believed PPSD were dangerous. Factors that reduced social distance included familiarity with PPSD, and belief that PPSD can recover. Attitudes to PPSD, stigma and social distance are complex and likely to require complex responses that include promoting awareness of mental health and illness, direct contact with PPSD and increasing access to care for PPSD.

Global Public Health, May 16, 2019

India has 600 million young people, more than any other country in the world. Mental illness is t... more India has 600 million young people, more than any other country in the world. Mental illness is the leading burden of disease for young people, and those affected experience restrictions in social participation that compromise recovery. The aim of this study was to assess the impact of a peer-led, community-based, participatory group intervention on social inclusion and mental health among 142 young people affected by psycho-social disability (PSD) in Dehradun district, Uttarakhand. Qualitative data were obtained via in-depth interviews and focus-group discussions. A realist evaluation identified contextual factors, mechanisms and outcomes to develop the programme theory. Group participants described intermediate outcomes including establishment of new peer friendship networks, increased community participation, greater selfefficacy (for young women particularly), and improved public image (for young men) that are likely to have contributed to the primary outcomes of greater (self-perceived) social inclusion and improved mental health (as assessed quantitatively). Mechanisms were identified that explain the link between intervention and outcomes. These findings demonstrate the effectiveness of a brief intervention to improve mental health and social inclusion for young people with PSD and are potentially relevant to programme implementers and policy-makers working with young people and promoting social inclusion, in other low-and middle-income settings.

Ssm - Mental Health, Dec 1, 2023

International Journal of Mental Health Systems, Aug 18, 2018

Background: Mental illness is a leading cause of the disease burden among young people. Poor ment... more Background: Mental illness is a leading cause of the disease burden among young people. Poor mental health is linked to childhood adversity such as gender inequality, poverty and low educational attainment. Psycho-social assets in adolescents can moderate these impacts and be strengthened. The aim of this study was to assess the effectiveness of a brief mental health and resilience intervention among disadvantaged young women in urban North India. Methods: We used an uncontrolled repeated measures design to evaluate the effectiveness of the 15-module mental health and resilience curriculum among young women residing in a slum in Dehradun, Uttarakhand. Standardised psychometric assessments were done to assess outcomes of the intervention at three time-points: pre-intervention (T1), post-intervention (T2), and 8-months post-intervention (T3), covering domains of self-efficacy, resilience, anxiety, depression and gender attitudes. Results: Young women completing the intervention (n = 106) had all left school before 10th class. A statistically significant improvement in all psychometric measures was found at T2. These improvements were sustained at T3 in the areas of anxiety, depression and gender equality attitudes, while the measures of resilience and self-efficacy had declined to baseline. Conclusions: This intervention delivered by community-based peers among highly disadvantaged young women can lead to sustained improvements in anxiety and depression and attitudes to gender equality. While other studies in LMIC have shown increased adolescent resilience through peer-led curriculums, this study demonstrates improvements in mental health and gender attitudes can endure 8-months post-intervention. This low-cost, brief intervention can improve mental health resiliency and self-efficacy among disadvantaged young people. Further research should explore how to bring sustained improvements in resilience.

International journal of health policy and management, Nov 23, 2020

Background: In India and global mental health, a key component of the care gap for people with me... more Background: In India and global mental health, a key component of the care gap for people with mental health problems is poor system engagement with the contexts and priorities of community members. This study aimed to explore the nature of community mental health systems by conducting a participatory community assessment of the assets and needs for mental health in Uttarkashi, a remote district in North India. Methods: The data collection and analysis process were emergent, iterative, dialogic and participatory. Transcripts of 28 in-depth interviews (IDIs) with key informants such as traditional healers, people with lived experience and doctors at the government health centres (CHCs), as well as 10 participatory rural appraisal (PRA) meetings with 120 people in community and public health systems, were thematically analysed. The 753 codes were grouped into 93 categories and ultimately nine themes and three meta-themes (place, people, practices), paying attention to equity. Results: Yamuna valley was described as both 'blessed' and limited by geography, with bountiful natural resources enhancing mental health, yet remoteness limiting access to care. The people described strong norms of social support, yet hierarchical with entrenched exclusions related to caste and gender, and social conformity that limited social accountability of services. Care practices were porous, pluralist and fragmented, with operational primary care services that acknowledged traditional care providers, and trusted resources for mental health such as traditional healers (malis) and government health workers (accredited social health activists. ASHAs). Yet care was often absent or limited by being experienced as disrespectful or of low quality. Conclusion: Findings support the value of participatory methods, and policy actions that address power relations as well as social determinants within community and public health systems. To improve mental health in this remote setting and other South Asian rural locations, community and public health systems must dialogue with the local context, assets and priorities and be socially accountable.

Transcultural Psychiatry

The field of Global Mental Health (GMH) aims to address the global burden of mental illness by fo... more The field of Global Mental Health (GMH) aims to address the global burden of mental illness by focusing on closing the “treatment gap” faced by many low- and middle-income countries (LMICs). To increase access to services, GMH prioritizes “scaling up” mental health services, primarily advocating for the export of Western centred and developed biomedical and psychosocial “evidence-based” approaches to the Global South. While this emphasis on scalability has resulted in the increased availability of mental health services in some LMICs, there have been few critical discussions of this strategy. This commentary critically appraises the scalability of GMH by questioning the validity and sustainability of its approach. We argue that the current approach emphasizes the development of mental health services and interventions in “silos,” focusing on the treatment of mental illnesses at the exclusion of a holistic and contextualized approach to people's needs. We also question the opport...

Caregivers are integral to health and social care systems in South Asian countries yet are themse... more Caregivers are integral to health and social care systems in South Asian countries yet are themselves at higher risk of mental illness. Interventions to support caregiver mental health developed in high-income contexts may be contextually inappropriate in the Global South. In this mixed-methods study, we evaluated the implementation and scaling of a locally developed mental health group intervention for caregivers and others in Uttarakhand, India. We describe factors influencing implementation using the updated Consolidated Framework for Implementation Research, and selected implementation outcomes. Key influencing factors we found in common with other programs included: an intervention that was relevant and adaptable; family support and stigma operating in the outer setting; training and support for lay health worker providers, shared goals, and relationships with the community and the process of engaging with organisational leaders and service users within the inner setting. We identified further factors including the group delivery format, competing responsibilities for caregivers and opportunities associated with the partnership delivery model as influencing outcomes. Implementation successfully reached target communities however attrition of 20% of participants highlights the potential for improving outcomes by harnessing enablers and addressing barriers. Findings will inform others implementing group mental health and caregiver interventions in South Asia. Impact statement Nearly every disabled person in South Asia (such as people with difficulties walking or with mental health problems) is supported by family caregivers for their activities of daily living. Caregivers are central in the disability ecosystem in settings like India, where there is limited public and social support for disabled people. Yet caregiving is heavy and unceasing work and most caregivers receive little support meaning that they are at higher risk of experiencing mental distress. Few studies describe what works to strengthen the mental health and well-being of caregivers, and even fewer describe how an intervention can work well when rolled out among other organisations. This is essential to know in order to deliver interventions to larger numbers of people. This study tries to address this gap. In 2021, we had evaluated this caregiver mental health intervention (Nae Umeed or New Hope) and found it was effective. In this project, we aimed to describe the process of rolling out Nae Umeed with seven other organisations to learn what works well and what does not. We found Nae Umeed was a relevant and adaptable intervention that participants were positive about. Participation went better when participants also experienced family support to join in group sessions and try out the new ideas at home. We identified factors that made it work well from the perspective of organisations such as finding that the community health workers who facilitated groups needed to connect relationally with the community and to be supported with resources and training. Nae Umeed did not go as well if participants were too overloaded with other responsibilities, or if they experienced stigma. The group format allowed people to form new friendships which also provided social support after the programme finished. Nae Umeed merits consideration and rollout in other settings in South Asia.

Global mental health, Dec 31, 2022

Caregivers are integral to health and social care systems in South Asian countries yet are themse... more Caregivers are integral to health and social care systems in South Asian countries yet are themselves at higher risk of mental illness. Interventions to support caregiver mental health developed in high-income contexts may be contextually inappropriate in the Global South. In this mixed-methods study, we evaluated the implementation and scaling of a locally developed mental health group intervention for caregivers and others in Uttarakhand, India. We describe factors influencing implementation using the updated Consolidated Framework for Implementation Research, and selected implementation outcomes. Key influencing factors we found in common with other programs included: an intervention that was relevant and adaptable; family support and stigma operating in the outer setting; training and support for lay health worker providers, shared goals, and relationships with the community and the process of engaging with organisational leaders and service users within the inner setting. We identified further factors including the group delivery format, competing responsibilities for caregivers and opportunities associated with the partnership delivery model as influencing outcomes. Implementation successfully reached target communities however attrition of 20% of participants highlights the potential for improving outcomes by harnessing enablers and addressing barriers. Findings will inform others implementing group mental health and caregiver interventions in South Asia. Impact statement Nearly every disabled person in South Asia (such as people with difficulties walking or with mental health problems) is supported by family caregivers for their activities of daily living. Caregivers are central in the disability ecosystem in settings like India, where there is limited public and social support for disabled people. Yet caregiving is heavy and unceasing work and most caregivers receive little support meaning that they are at higher risk of experiencing mental distress. Few studies describe what works to strengthen the mental health and well-being of caregivers, and even fewer describe how an intervention can work well when rolled out among other organisations. This is essential to know in order to deliver interventions to larger numbers of people. This study tries to address this gap. In 2021, we had evaluated this caregiver mental health intervention (Nae Umeed or New Hope) and found it was effective. In this project, we aimed to describe the process of rolling out Nae Umeed with seven other organisations to learn what works well and what does not. We found Nae Umeed was a relevant and adaptable intervention that participants were positive about. Participation went better when participants also experienced family support to join in group sessions and try out the new ideas at home. We identified factors that made it work well from the perspective of organisations such as finding that the community health workers who facilitated groups needed to connect relationally with the community and to be supported with resources and training. Nae Umeed did not go as well if participants were too overloaded with other responsibilities, or if they experienced stigma. The group format allowed people to form new friendships which also provided social support after the programme finished. Nae Umeed merits consideration and rollout in other settings in South Asia.

Christian Journal for Global Health, May 31, 2019

BMJ Global Health, Jun 1, 2019

The presence of common problems and initiating leadership provide the conditions for collaborativ... more The presence of common problems and initiating leadership provide the conditions for collaborative action in local health systems. ► Actors, however, need to learn how to collaborate through principled engagement. ► Trust and trust building are central to developing shared motivations for collaboration. ► Jointly developed new knowledge-through shared data, evaluations or reflective processes-creates capacity for collaboration. ► The considerable work involved in building and maintaining collaborative action needs to be acknowledged.

Transcultural Psychiatry, 2016

An asymmetric burden gendered experiences of caregivers of people with psycho-social disabilities... more An asymmetric burden gendered experiences of caregivers of people with psycho-social disabilities in North India

BMJ Open, Nov 1, 2015

This study sought to use a populationbased cross-sectional survey to describe depression prevalen... more This study sought to use a populationbased cross-sectional survey to describe depression prevalence, healthcare seeking and associations with socioeconomic determinants in a district in North India.

BackgroundGlobally, there is increasing emphasis on the importance of understanding the ways in w... more BackgroundGlobally, there is increasing emphasis on the importance of understanding the ways in which social inequality and injustice impact individual and community mental health. Set in the state ...

Community Mental Health Journal, Nov 15, 2017

Stigma is an important contributor to the large treatment gap for people with mental and psycho-s... more Stigma is an important contributor to the large treatment gap for people with mental and psycho-social disabilities (PPSD) in India. Social distance as assessed by willingness to engage in relationships with PPSD is a proxy measure of stigma and potential discrimination. In North India, investigations of community attitudes towards PPSD have been limited. To describe attitudes towards people with depression and psychosis, a community sample of 960 adults in Dehradun district, India from 30 randomised clusters, was surveyed using a validated tool to assess social distance, beliefs and attitudes related to mental illness. Participants preferred greater social distance from a person with psychosis than a person with depression. Beliefs and attitudes around mental illness were diverse reflecting a wide spread of belief frameworks. After controlling for confounding, there was increased social distance among people who believed PPSD were dangerous. Factors that reduced social distance included familiarity with PPSD, and belief that PPSD can recover. Attitudes to PPSD, stigma and social distance are complex and likely to require complex responses that include promoting awareness of mental health and illness, direct contact with PPSD and increasing access to care for PPSD.

Global Public Health, May 16, 2019

India has 600 million young people, more than any other country in the world. Mental illness is t... more India has 600 million young people, more than any other country in the world. Mental illness is the leading burden of disease for young people, and those affected experience restrictions in social participation that compromise recovery. The aim of this study was to assess the impact of a peer-led, community-based, participatory group intervention on social inclusion and mental health among 142 young people affected by psycho-social disability (PSD) in Dehradun district, Uttarakhand. Qualitative data were obtained via in-depth interviews and focus-group discussions. A realist evaluation identified contextual factors, mechanisms and outcomes to develop the programme theory. Group participants described intermediate outcomes including establishment of new peer friendship networks, increased community participation, greater selfefficacy (for young women particularly), and improved public image (for young men) that are likely to have contributed to the primary outcomes of greater (self-perceived) social inclusion and improved mental health (as assessed quantitatively). Mechanisms were identified that explain the link between intervention and outcomes. These findings demonstrate the effectiveness of a brief intervention to improve mental health and social inclusion for young people with PSD and are potentially relevant to programme implementers and policy-makers working with young people and promoting social inclusion, in other low-and middle-income settings.

Ssm - Mental Health, Dec 1, 2023

International Journal of Mental Health Systems, Aug 18, 2018

Background: Mental illness is a leading cause of the disease burden among young people. Poor ment... more Background: Mental illness is a leading cause of the disease burden among young people. Poor mental health is linked to childhood adversity such as gender inequality, poverty and low educational attainment. Psycho-social assets in adolescents can moderate these impacts and be strengthened. The aim of this study was to assess the effectiveness of a brief mental health and resilience intervention among disadvantaged young women in urban North India. Methods: We used an uncontrolled repeated measures design to evaluate the effectiveness of the 15-module mental health and resilience curriculum among young women residing in a slum in Dehradun, Uttarakhand. Standardised psychometric assessments were done to assess outcomes of the intervention at three time-points: pre-intervention (T1), post-intervention (T2), and 8-months post-intervention (T3), covering domains of self-efficacy, resilience, anxiety, depression and gender attitudes. Results: Young women completing the intervention (n = 106) had all left school before 10th class. A statistically significant improvement in all psychometric measures was found at T2. These improvements were sustained at T3 in the areas of anxiety, depression and gender equality attitudes, while the measures of resilience and self-efficacy had declined to baseline. Conclusions: This intervention delivered by community-based peers among highly disadvantaged young women can lead to sustained improvements in anxiety and depression and attitudes to gender equality. While other studies in LMIC have shown increased adolescent resilience through peer-led curriculums, this study demonstrates improvements in mental health and gender attitudes can endure 8-months post-intervention. This low-cost, brief intervention can improve mental health resiliency and self-efficacy among disadvantaged young people. Further research should explore how to bring sustained improvements in resilience.

International journal of health policy and management, Nov 23, 2020

Background: In India and global mental health, a key component of the care gap for people with me... more Background: In India and global mental health, a key component of the care gap for people with mental health problems is poor system engagement with the contexts and priorities of community members. This study aimed to explore the nature of community mental health systems by conducting a participatory community assessment of the assets and needs for mental health in Uttarkashi, a remote district in North India. Methods: The data collection and analysis process were emergent, iterative, dialogic and participatory. Transcripts of 28 in-depth interviews (IDIs) with key informants such as traditional healers, people with lived experience and doctors at the government health centres (CHCs), as well as 10 participatory rural appraisal (PRA) meetings with 120 people in community and public health systems, were thematically analysed. The 753 codes were grouped into 93 categories and ultimately nine themes and three meta-themes (place, people, practices), paying attention to equity. Results: Yamuna valley was described as both 'blessed' and limited by geography, with bountiful natural resources enhancing mental health, yet remoteness limiting access to care. The people described strong norms of social support, yet hierarchical with entrenched exclusions related to caste and gender, and social conformity that limited social accountability of services. Care practices were porous, pluralist and fragmented, with operational primary care services that acknowledged traditional care providers, and trusted resources for mental health such as traditional healers (malis) and government health workers (accredited social health activists. ASHAs). Yet care was often absent or limited by being experienced as disrespectful or of low quality. Conclusion: Findings support the value of participatory methods, and policy actions that address power relations as well as social determinants within community and public health systems. To improve mental health in this remote setting and other South Asian rural locations, community and public health systems must dialogue with the local context, assets and priorities and be socially accountable.

Transcultural Psychiatry

The field of Global Mental Health (GMH) aims to address the global burden of mental illness by fo... more The field of Global Mental Health (GMH) aims to address the global burden of mental illness by focusing on closing the “treatment gap” faced by many low- and middle-income countries (LMICs). To increase access to services, GMH prioritizes “scaling up” mental health services, primarily advocating for the export of Western centred and developed biomedical and psychosocial “evidence-based” approaches to the Global South. While this emphasis on scalability has resulted in the increased availability of mental health services in some LMICs, there have been few critical discussions of this strategy. This commentary critically appraises the scalability of GMH by questioning the validity and sustainability of its approach. We argue that the current approach emphasizes the development of mental health services and interventions in “silos,” focusing on the treatment of mental illnesses at the exclusion of a holistic and contextualized approach to people's needs. We also question the opport...

Purpose Mental disorders are one of the leading causes of years lived with disability, yet fewer ... more Purpose
Mental disorders are one of the leading causes of years lived with disability, yet fewer than 10% of people with common mental disorders (CMDs) in India have access to care. This emphasizes a clear priority for communities who can work collectively to facilitate more effective prevention, care, treatment and advocacy in mental health (community mental health competence). This study, set in Uttarakhand in Northern Indian, investigates processes of building knowledge, safe social spaces, and partnerships for action and health promotion taken by groups of women with CMDs in communities in rural and semi-urban Uttarakhand. Research is locally based with co-authors KM and PP long term residents in Dehradun.

Focus/Content
The study was set in three communities (rural, urban and semi-urban) in Dehradun district, Uttarakhand where Burans, a partnership project of four non-governmental organisations, has been working. Burans works collaboratively with alongside communities to improve mental health by supporting community organisations and community dialogues on mental health, facilitating access to care, and supporting families with psycho-social disabilities. Eight focus group discussions were held with members of ‘self-help groups,’ comprised of women primarily with CMDs, with additional participant observation by co-investigators. Ten key informant interviews (KIIs) were also conducted with local health care providers and community members. Translated transcripts of discussions were analysed deductively using an adapted model of community mental health competence focussing on Knowledge, Safe Social Spaces and Partnerships for Action (see Appendix One).

Significance for the sub-theme area/field-building dimension of relevance and target audience
This research emphasizes the importance of prioritizing the health of marginalized and vulnerable communities with a focus on gender and health equity. The innovation in this research is that it analyzes and articulates learnings and outcomes from new community-based actions for improving mental health that build on local resources. This research offers community-based solutions in low-resource contexts as a first step towards improving health system responsiveness and resilience while providing access to care.

Greater mental health competence and control may empower women to contribute to household and community decisions, and participate economically. Understanding community models for women to improve their mental health by increasing their agency and control creates communities that have the ability to advance their own health and social interests.
It also provides integrated knowledge translation to the only community mental health project in Uttarakhand state, and feeds into ongoing project actions to improve the project’s self-help and support groups.