Primary mental health care in India for older people: stigmatization and community-orientation

Abstract Background In India, older persons are among the fastest growing population groups that are particularly vulnerable to an impaired mental health. Strengthening public primary mental health care (PMHC) has been one of the political priorities in recent years, including efforts to provide more old age-inclusive care. Many factors play a role in shaping equitable access to PMHC. In this study, we focus on how social norms and perceptions of mental health in old age on the community-level facilitate or hamper access to inclusive PMHC. Methods Semi-structured interviews with key informants (n = 14) from the fields of mental health and old age policy and practice have been conducted and analyzed. Results The interviewees describe barriers and opportunities towards old-age inclusive and community-oriented PMHC that go beyond the availability of services. The stigmatization of mental health - especially in old age - is a major barrier that is deeply rooted within the family and community care system. While experts stress the relevance of relatives in fostering mental health of older people, a lack of awareness of facets of mental health and a fear of stigmatization within communities prevents older persons and their family caregivers to seek formal mental healthcare. Moreover, experts describe an increasing disintegration of family support systems in rural and urban areas. Therefore, a more prominent role for outreach-support provided by community health workers (CHWs) is suggested. However, according to experts, transforming the scope of practice of CHWs to include mental healthcare for older persons is still predicted to be a major challenge. Conclusions To improve equitable access to and participation of older persons and their families in PMHC, the perceptions and attitudes towards mental health and old age need to be considered.


Background:
In Germany, distinct parts of the population, such as undocumented persons, uninsured German nationals, EU citizens without employment and asylum seekers, do not have adequate access to health care.Civil society organisations provide humanitarian medical aid for these individuals.However, the offered care is not comprehensive, but depends on volunteers and is restricted to acute conditions.The local initiatives are often underfinanced.To receive funding, they experience increasing pressure to provide evidence of the impact of their work.

Methods:
The applied research project was conducted in cooperation with a German medical Non-Government Organization.A routine patient survey, including items on patient satisfaction and patient reported outcomes, was developed and implemented.The NGO aimed to use it as an instrument for patient participation as well as to strengthen their impact assessment.

Results:
Survey results show high satisfaction levels and a reported increase in health status and system competence.They provide valuable answers for organisational development and fundraising but do not correlate with the extent of care provided.

Conclusions:
Patient surveys are particularly helpful in humanitarian care to legitimatize the efforts of compensatory initiatives.Since the affected persons still suffer from undersupply, results are not a valid measure of care standards but rather demonstrate appreciation for the mere existence of volunteer help.For an effective participation, one should not confound involvement in surveys with access to care.To illuminate existing barriers, alternative methodical approaches such as qualitative multilevel case studies are promising, as they allow data on local support settings to be linked with individual care histories and underlying institutional frameworks.
Abstract citation ID: ckac129.719Primary mental health care in India for older people: stigmatization and community-orientation

Tom Kafczyk
T Kafczyk 1 , K Ha ¨mel 1 1 Health Services Research and Nursing Science, School of Public Health, Bielefeld University, Bielefeld, Germany Contact: tom.kafczyk@uni-bielefeld.de

Background:
In India, older persons are among the fastest growing population groups that are particularly vulnerable to an impaired mental health.Strengthening public primary mental health care (PMHC) has been one of the political priorities in recent years, including efforts to provide more old ageinclusive care.Many factors play a role in shaping equitable access to PMHC.In this study, we focus on how social norms and perceptions of mental health in old age on the community-level facilitate or hamper access to inclusive PMHC.

Methods:
Semi-structured interviews with key informants (n = 14) from the fields of mental health and old age policy and practice have been conducted and analyzed.

Results:
The interviewees describe barriers and opportunities towards old-age inclusive and community-oriented PMHC that go beyond the availability of services.The stigmatization of mental health -especially in old age -is a major barrier that is deeply rooted within the family and community care system.While experts stress the relevance of relatives in fostering mental health of older people, a lack of awareness of facets of mental health and a fear of stigmatization within communities 15th European Public Health Conference 2022 prevents older persons and their family caregivers to seek formal mental healthcare.Moreover, experts describe an increasing disintegration of family support systems in rural and urban areas.Therefore, a more prominent role for outreach-support provided by community health workers (CHWs) is suggested.However, according to experts, transforming the scope of practice of CHWs to include mental healthcare for older persons is still predicted to be a major challenge.

Conclusions:
To improve equitable access to and participation of older persons and their families in PMHC, the perceptions and attitudes towards mental health and old age need to be considered.

Background:
Nursing homes in Germany are still often associated with the idea of a daily routine determined by the institution, linked to losses of self-determination and participation.Residents, as well as carers and caregivers, perceive chances for codetermination and co-creation as limited.

Methods:
The research project PaStA (Participation in Inpatient Care for Older People) examined and analyzed opportunities and limits of improved participation in nursing homes in Germany with the help of a participatory action research design.Experiences and findings with participatory research processes in two nursing homes are presented.

Results:
Access to people both living and working in nursing homes is demanding and time-consuming.Building a trusting cooperation requires commitment and resources.However, if a research team -including residents -is successfully installed, the participatory process enables all those involved to explore, try out and shape participation possibilities.The reflection that takes place in the process leads to learning processes that (can) result in empowerment.Discussion: However, there is a danger that participatory research may primarily reach people better provided with resources for participation based on life-long circumstances (participation dilemma), highlighting the need for responsibly designed access.Likewise, the question of impact must be critically discussed.Sustainability must be considered from the beginning.

Conclusions:
Participatory action research is a worthwhile endeavor, even in settings that are rather unfamiliar with participation, such as Background: Many chronically ill persons are challenged by integrating the illness in everyday life and making 'competent' decisions on their life and care.In multiprofessional primary care, promoting clients' self-management and strengthening their abilities to participate in everyday life is increasingly recognized as a nursing task.This study investigates facilitating and inhibiting conditions that nurses experience when exercising this task.Methods: Drawing upon a phenomenological approach, we conducted guided interviews with 34 practicing nurses and 23 key informants with advanced knowledge of primary health care nursing practice in Brazil, Germany, and Spain.The interviews were analysed using structuring content analysis.

Results:
The interviewees see competencies of nurses to establish trusting relationships with chronically ill clients as key to greater client participation.Nurses, however, state that bonding with clients can be time-consuming and exhausting.They consider it fundamental that physicians and other professionals value nurses' efforts towards stronger client participation as a way forward to reach for person-oriented primary care.They criticize that especially physicians value biomedical tasks more than enabling participation.Referring to primary health care organisation, nurses experience that pressure of time through a growing number of routine and administrative tasks inhibits their efforts to strengthen clients' participation.

Conclusions:
To promote the participation of clients with chronic illnesses in their everyday life and in care, relationship building with clients and self-management support needs to be acknowledged as an important scope of practice approached by nurses.To be able to unfold the potentials nurses need to be equipped with sufficient time and skills.