Perception of employees on mental health at a leading botanical garden, India: A qualitative study.

BACKGROUND: The prevalence of mental health issues in India is increasing. The lack of knowledge about mental illnesses and negative beliefs about treatment usually lead to delayed treatment. Mental health literacy is a prerequisite for early recognition and intervention in mental disorders. AIMS: The study was undertaken with the aim to explore the awareness of mental health among the employees of the botanical gardens to address this massive issue.
MATERIALS AND METHODS: Two focus group discussions were carried out with five and ten members from two diverse groups of population respectively.
RESULTS: The study highlights that the signs and symptoms of mental illness were not well recognized by the participants except few.The study also shows the presence of misconceptions among the sample regarding mental health and the role of mental health professionals. This indicates the need for mental health literacy among the community.
CONCLUSION: The study shows that the knowledge of the employees of the botanical garden regarding mental health was limited. This limited knowledge may be a prominent cause of poor treatment turn up. Therefore a need of systematic sensitization program to increase mental health literacy is highlighted through the study. Copyright:

Mental health is a major concern; about 450 million people suffer from it worldwide.[12] Approximately 10% of adults are experiencing a mental disorder at any time.[1] 14% of the global burden of disease as well as years lived with disability is attributed to neuropsychiatric disorders globally.[34567] The prevalence of mental health conditions in India is about 9.5-370/1000 population, which means, statistically, out of the 10-20% of the population having mental health conditions, 2-3% are known to suffer from major mental illness[89] who require professional help[101112]

Up to 90% of persons with mental disorders in low and middle-income countries do not receive even basic mental health care[1314] and is given very low priority.[2131516] Poor awareness and knowledge about mental illness and related misconceptions have huge impact on the care seeking behavior and participation in the treatment which also contribute to the stigma and discrimination against them which is a key barrier and a challenge to mental health services in India[15171819202122] This knowledge gap can be reduced with increased awareness and timely treatment.[2324252627282930]

The ability to recognize, manage, or prevent mental disorders among the community, based on their knowledge and beliefs about mental disorders is defined as mental health literacy.[3132] It has several components, such as (a) knowledge of how to prevent mental disorders, (b) recognition of when a disorder is developing, (c) knowledge of help-seeking options and treatments available, (d) knowledge of effective self-help strategies for milder problems, and (e) first aid skills to support others who are developing a mental disorder or are in a mental health crisis.[33]

Studies show that knowledge about mental health and related disorders promote early identification of the latter thereby improving the outcomes and use of health services.[343536] Therefore, community’s perspectives and attitude towards people with mental illness (PWMI) play a dominant role in mental health care.[343536373839] People can be a driving force in the community in the prevention, treatment seeking, and drug compliance behaviors; however, community members commonly play a negative role and worsen the consequences of mental illness among patients.[1]

Raising public awareness about mental health is one of the ten recommendations to reduce the treatment gap.[38] Unfortunately, the efforts to enhance the mental health literacy among the Indian population are minimal or poor.[20] Few studies in India give an understanding of the mental health literacy in the communities, which emphasizes the poor awareness on mental health.[2026]

Mental health literacy is a prerequisite for early recognition and intervention in mental disorders.[20] Thus, promoting mental health literacy thereby reducing the negative attitude and discrimination is very important.[40] Hence, there is a need to understand local contexts/beliefs in order to develop effective programs to deal with mental health illiteracy. Therefore, this study was undertaken to understand different views and perspectives of the people at the botanical garden, Bangalore, India, prior to developing a mental health awareness-cum-training program for the same population.

MATERIALS AND METHODS

Ethics

The study was approved by the Institutional Ethics Committee.

Design

The study included a cross-sectional qualitative research design and was a part of a training and awareness program on Mental Health Disorders and Mental Health Literacy.

Setting

The focus group discussion (FGD) was conducted at a renowned botanical garden which comes under the state government, of Bengaluru, based on a request by the organization to conduct a training program on Mental Health Literacy for the employees.

Sample

The total sample size comprised 15 employees (age range: 35–45 years) from Bengaluru Urban District. Purposive sampling method was used for the study.

Procedure

Two FGDs were conducted in Kannada and English with five female gardeners (only versed in Kannada) and ten Junior level officials (versed in both Kannada and English) respectively. Each of the FGDs had a moderator and took approximately an hour to be completed. The FGDs were audiotaped for verbatim transcription in order to be analysed. The investigators explained the need of such a FGD to the participants and informed consent was taken from them prior to the conduction of the FGD. The FGD was focused on examining the following: understanding of mental illness, its symptoms, causes, impact, and treatment.

Analysis

The moderator recorded the FGD. The data were analyzed manually by the method of Directed Content Analysis. In this, the transcripts of the two groups were first examined separately to identify the key themes with frequency counts being noted. Then the same were collated under the broad predetermined themes derived by the researches namely the signs and symptoms of mental illness, causes of mental illness, impact of various mental illness, issues and capacity-building with regard to mental illness.

RESULTS

The average age of the participants at the botanical garden was 40 years. Everyone was married. Most of them were educated till 7th standard and others till 10th standard. The subthemes that were identified under the broad predetermined themes are described below:

Theme 1 - Signs and symptoms of mental illness

The participants did not interpret the term mental illness in terms of signs and symptoms. All of them described mental illness in terms of symptoms associated with psychosis, which includes symptoms like delusions, hallucinations, talking incoherently and agitation. Some (n = 3) were able to recall incidences that they felt were not normal but were not able to understand the cause. They identified symptoms such as “excessive drinking,” “talking about life after death,” “lost complete interest in work and life.” Few (n = 6) told they could sense “Asahaja Nadavalike,” Kannada term for “Abnormal behaviour.” They even used the term “Manaroga,” Kannada word for “Mental illness.”

Theme 2 - Causes of mental illness

The employees of the botanical garden explained the causes of various mental health problems to (n = 4) traumatic situations such as witnessing a severe accident, death in family, (n = 6) social stressors such as nonacceptance in society, poverty, (n=4) divorce and sexual abuse, and (n = 5) physical health ailments, either in family or to oneself.

Theme 3 - Impact of mental health issues

The participants did not have any clear idea about what it was to be diagnosed with disorders other than physical ailments such as fever and body pain. They (n = 5) were aware of the fact that people do behave in a different manner and exhibit sadness many times. They (n = 6) were aware of “Khinnathe,” a Kannada term for Depression and opined that “Depression leads to death” indicating suicidal ideations and committing the act. Apart from depression, and inappropriate behavior in social settings, they were not aware of any other manifestations of mental health problems.

Theme 4 - Capacity building with regard to mental health problems

The participants expressed the need for getting more awareness programs and guidance to work with persons with mental illness in the community, provide first aid in cases of mental health crisis and create awareness about mental health among community members. As many of them indicated, there may be a large number of people who could be affected by mental health problems. Providing training with regard to identifying people with mental health problems could help in prompt identification and referring them to treatment.

DISCUSSION

Based on the analysis of the FGD four major themes have come up, like symptoms of mental health issues, perceived causes of mental illness, impact of mental health issues, and community capacity building with regard to mental health issues. It is interesting to note that the participants emphasized the pressing need to have more awareness and services about mental health. This is in fact correlates with other studies[324142] also.

The prevalent belief that mental illness is caused by supernatural forces including sorcery, witchcraft and punishment from God for sin testify the poor knowledge about mental illness in the community.[4344] The current study revealed that the employees at the botanical garden were not well aware of mental health problems and described mental health problems in terms of psychosis (symptoms such as delusions, hallucinations, talking incoherently, and agitation) [Table 1]. We need to say that lack of knowledge and awareness about mental health treatment is one of the major barriers to treatment turn-up,[45464748] A few of them were able to, with proper probing, recall incidences that they could feel were not normal but were not able to to understand the cause. They reported symptoms like “excessive drinking,” “talking about life after death,” “lost complete interest in work and life” and “Asahaja Nadavalike,” Kannada term for “Abnormal behaviour.” They even used the term “Manaroga,” Kannada word for “Mental illness.”

Table 1

Signs and symptoms of depression (Theme 1)

Sub themes	Participants (n)	Sample quotations
Description of mental illness in terms of psychosis, which includes symptoms like Delusion, Hallucinations	15	“She kept shouting when no one was around” “He talks in an incomprehensible language”
Finding it abnormal but could not get to the cause	3	“He keeps saying he wants to go home, while he was in his own room”
Excessive drinking, talks about life after death, etc., (verbatim)	4	“He just does not reduce his quantity of alcohol consumption”
Description as abnormal behaviour or “Asahaja Nadavalike”	6	“He would start laughing very loudly, even in serious situations” “He kept playing with match-box and tried to burn a few things around him

The belief in supernatural causations refer PWMI as dangerous and distasteful.[49] But in the present study the participants explained the causes for mental illness could be due to traumatic situations, physical health ailments and sexual abuse, etc., [Table 2]. Relationship between stressors and other psychosocial factors are also depicted well in this study as causation for mental health problems. Similar findings from various other studies prove the point. Stress is believed to be a significant cause of mental health problems.[44] Previous studies assessed the positive relationship between stress and mental illness.[47] This is a common belief found among different people from different walks of life and is also implied by the psychosocial model of disease that view stress and trauma-related stress as significant factors in the development of mental health problems.[48] Thus, the present findings are supported by existing literature on psychosocial models of stress and distress, which propose that psychological mechanism plays a vital role in mental health of an individual.

Table 2

Causes of mental illness (Theme 2)

Sub themes	Participants (n)	Sample quotations
Attribute various mental health problems to traumatic situations	4	“He had seen a very dangerous accident where a family died on spot”
Attribute mental health problems to social stressors	6	“She was left out even during her school time and even in college, she was left out from her peer group”
Attribute mental health problems to sexual abuse	4	“She was sexually harassed when she was young, she told me that incident yet haunts her"
Attribute mental health problems to physical health ailments	5	“She fell ill very often”

Furthermore, with regard to impact of mental health problems, the participants expressed their views by stating that mental illness can impact one’s life adversely and can even lead to death [Table 3]. They expressed that in case of mental health problems, it can be severe and impact the person’s ability to work and to look after their children. The study also described the various causes of mental health issues as explained by the participants. This shows a need to educate the community regarding the various causes and treatment options available, which is backed up by the findings of various other studies.[49] The employees at the botanical garden lacked a clear understanding of the role of mental health professionals health professionals of various disciplines who are part of the mental health delivery system. The study also provides a clear understanding of the need of awareness programs for the community regarding mental health problems so that the treatment gap can be considerably reduced [Table 4]. The study has limitations in terms of the generalizability of findings due to its small sample size and circumscribed geographical area from which the sample was recruited.

Table 3

Impact of mental health issues

Sub themes	Participants	Sample quotations
People behave differently and exhibit over sadness	5	“He does not come to work and when he comes, he sits in a corner and does not even talk”
Death because of depression	6	“She was bright but she committed suicide after a long period of being in seclusion”

Table 4

Capacity building with regard to mental health problems

Sub themes	Participants	Sample quotations
Need for capacity-building with regard to early identification and simple psychosocial intervention of mental health problems	15	“In villages, towns and rural areas and even in big cities, people are not very aware of what mental health problems are and how serious they can get”
Need for capacity-building with regard to awareness creation in community with regard to mental health problems	15	“Many people know nothing about mental illnesses (manasika asvasthate (needs to specific) – Kannada term for mental illness), therefore training will help such people to understand various things about mental health issues”

Implications

The study was aimed to explore the level of mental health literacy of the employees of the botanical garden. As the study shows that the knowledge of mental health is limited among the employees, a well-structured training program to increase the mental health literacy thereby bringing down the level of stigma will be beneficial. Increased mental health literacy will help in acceleration of early identification and prompt referrals.

CONCLUSION

The study explicitly exhibits the limited awareness about mental health among the employees of the botanical garden. This may lead to poor recognition of mental health problems that in turn may lead to delayed treatment turn up. There is a need of structured training programs to increase mental health literacy among the community to reduce the disability and increase the functionality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.