Day 2

2016

Submissions for the Annual Kathmandu Conference 2016

Disaster Mental Health Intervention Research with Earthquake-affected Communities in Nepal: Enhancing Well-being and Increasing Engagement in Disaster Preparedness
Leah E. James, Research Associate, Natural Hazards Center, Institute of Behavioral Science, University of Colorado, Boulder, CO; Courtney Welton-Mitchell, Director, Humanitarian Assistance Applied Research Group Josef Korbel School of International Studies University of Denver (DU), Denver, CO; and Shree Niwas Khanal, Program Coordinator, Transcultural Psychosocial Organization (TPO), Nepal

Abstract: This manuscript describes results of a DFID and Wellcome Trust funded disaster mental health intervention in Bhaktapur district Nepal. The culturally-adapted intervention was tested in two earthquake affected communities (N = 240 persons), across three time points, using a matched cluster comparison design. Consistent with hypotheses, the intervention increased disaster preparedness, increased attributions to natural causes for the earthquake, reduced mental health symptoms (PTSD, depression), increased social cohesion, along with associated peer-based help-giving and help-seeking, and increased utilization of new forms of coping. Implications of the results are discussed, with emphasis on future research directions to determine the ‘active ingredients’ associated with treatment effects.

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The Socio Economic Impact of British Army Recruitment in Nepal
Dawa Tshering Sherpa, Research Assistant, Centre for Study of Labour and Mobility (CESLAM), Social Science Baha, Nepal; and Noah Coburn, Faculty Member, Bennington College, USA

Abstract: The British army remains one of the most attractive career paths for young men in Nepal. Recruitment for first the East India Trade Company in the 1800s, later the British Imperial Army and today, the British and Indian armies has long provided an economic incentive that has shaped the way that young men in Nepal make decisions about their career paths. Following World War II, however, as the number of Nepalis in the British army has declined, the selection process has become more challenging. Furthermore, the promise of British citizenship for anyone who serves more than six years has swelled the number of applicants.

In 2015, out of 6,000 applicants between the ages of 18 and 22, only 230 were selected. In the hope of improving their chances, thousands of young men now rely on private training centers. In the months before the selection process these young men often leave school, travel miles from home and spend months training. While there is abundant literature regarding British Gurkhas, little research has explored the effect of the recruitment process on those who have not been selected and why the number of applicants continues to grow despite the incredibly high likelihood of failure.

Drawing on interviews and recent ethnographic data, this paper is a primary attempt to analyze some of the effects of the ongoing British recruitment process, particularly for those young men who are not ultimately selected and what this demonstrates about the socio-economic lives of young Nepalis.

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Shifts in the Strategy of Caste-Representation: Links between Commercial Negotiations in the Meat Markets and Identity Politics
Kanako Nakagawa, Research Fellow, Japan Society for Promotion of Science, Graduate School of Asia African Area Studies, Kyoto University, Japan

Abstract: This paper analyzes shifts in the strategy of caste representation during the democratization movements of 1950s, 1990s, and 2000s in Nepal by focusing on the Khaḍgī caste who have been engaged in slaughtering, processing and trading of livestock as a caste-based role in Newar society.

I will investigate how Khaḍgī formed their networks in the meat markets, and what kind of identity politics they engaged. I will describe the shifts in strategies in Khaḍgī’s caste representation by three periods, the first period (1951-1990), the second period (1990-2006), and the third period (since 2006).

On the first period, Khaḍgī formed“samaj sudar sewa”with Deula, Kusule , Dhobi who were excluded from schools because of their ‘water-unacceptable’ status, and formed their own schools. Khaḍgī also engaged in ‘mandir pravash movement’, which intends to protest against their exclusion from temples together with Damai, Kusule, Deula. They move as ‘sano jati’ or ‘communist’ and identify their belongings depending on their demand. Sometimes, they joined together even beyond their caste, and ethnicity. In 1973 Khaḍgī formed their caste association Nepal Khadgi Sewa Samiti (NKSS) mainly to negotiate with Muslims brokers in meat markets collectively. Since the political activities were prohibited, NKSS started their activities as social service. The activities by NKSS focused on the grass-rooted social welfare activities such as donating drinking water tanks and holding blood donation programs.

On the second period, they focused on their individual commercial activities to catch up the expansion of the meat markets. During that period, many non- Khaḍgī people joined the meat business in chicken, goat, pork markets, but Khaḍgī still occupy the buffalo markets. They collect buffalo skins within caste which profits their communities. Thus, during the second period, they involved in the competition individually in the meat markets, but they utilized caste memberships collectively to keep their commercial advantage.

On the third period, they again act collectively and involve in identity politics to be categorized as indigenous group. In March 2008, NKSS requested National Dalit Human Right Council to remove them from the Dalit list. In addition to these activities as ‘indigenous Newar’, they are engaging in the campaign to change their registered surname of Kasāī in the nāgarikatā (citizenship) into Khaḍgī or Śāhī, which is the term of their mother tongue, by insisting that Kasāī is not an original term, but foreign derogatory term means ‘butcher’.

The caste representation is usually regarded as an example of identity politics, centering on public meetings and agitations by caste associations. In contrast, I will examine how people’s everyday-life practices in public health, income generation are linked to the caste representations.

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The Gurkha Wives of United Kingdom: Challenges to Social Integration
Neha Choudhary, Research Associate, Centre for the Study of Labour and Mobility (CESLAM), Social Science Baha, Nepal

Abstract: Integration of immigrants has been a pertinent issue both theoretically and at the policy level in major migrant receiving states. In the case of the United Kingdom (UK), this has been reflected in the rise of extreme right-wing parties and increasing public resistance, who see immigration as a threat to national solidarity as the immigrants are seen as refusing to ‘integrate’ into mainstream society. The Nepali community residing in the UK, majority of which constitutes of families of Nepali men who served or are still serving in the Gurkha Regiment of the British Army, has been no exception to this resistance.

However, scant attention has been given to the examination of integration process of this group. Furthermore, like the majority of the migration literature, the gender dimension, i.e. the process by which the wives of the British Gurkha servicemen become part of British society, has only been cursorily treated in the handful of studies that have been conducted. This paper aims to address this gender-gap in the existing social integration literature. Recognizing that human experience is gendered, this paper takes a feminist approach to analyse the wives’ perspectives of their migration and settlement experiences. The paper is based on an empirical study conducted in the town of Aldershot in New Hampshire, UK, considered to be the home of the British Army. Over the years, Aldershot has been labelled as “Little Nepal” owing to the large inflow of Nepalis following the granting of settlement rights in 2009. The study utilises in-depth interviewing to explore the extent to which this group of first-generation dependents have integrated in the British society and to identify the challenges that they have been facing in the process. As feminist methodology gives primacy to personal narratives as the primary source of information, personal narratives of women belonging to three overlapping groups – pensioners, middle-aged females, and recent migrants- was collected.

The findings from the small-scale study indicate that the age-group or the generation one belongs is a crucial factor in shaping these women’s migration experiences. While language emerges as the major barrier, active labour market participation demonstrates a great degree of integration. The conclusion is, then, divided into two parts: firstly, the diversity of experience within a single group demonstrates that heterogeneity of migrant experiences needs to be taken into account, especially for the enforcement of effective integration-related policies and programs. This leads to the second conclusion which suggests that there needs to be a shift away from traditional conception of social integration as rigid, linear process of immigrants adopting commonly held host society values, towards seeing it as process of constant renegotiation.

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Not the Women but their Remittance Contribution is Acknowledged: Women Labour Migration and their Exclusion in Nepal
Ramji Prasad Adhikari, Lecturer, Faculty of Humanities and Social Engineering, Pokhara University, Nepal; and Rishikesh Pandey, PhD Candidate, The University of Adelaide, Adelaide, Australia

Abstract: There is a considerable difference between thinking about sex differences with the dichotomous variable and integrating more complex gender analysis in migration research.This paper makes a rigorous analysis of migration from gender perspective that highlights the livelihood contribution of women labour migrants of Nepal and assesses the exploitation and exclusion they have faced during the migration process. The study is conducted in Pokhara Valley with particular focus on the women going to Gulf Countries. The findings are derived from the information collected from 80 respondents selected using the chain-snow-ball sampling. Information was collected through in-depth interviews. The social and educational networks of researchers were used to identify the respondents at first; afterwards, network of already identified respondents was also used.

The contribution of women labour migration in household economy is discussed in relation to the changes in household livelihood assets while their exploitation and exclusion were dealt through gender related constraints prevailing in labour migration. Contemporary forms of exploitation and exclusion prevailing in the societies, families and in the states of origin and destination countries are documented. This study deals exploitation and exclusion in reference to the place of origin and destination; hence the concept of ‘space’ is used as ‘social space’ or ‘the position’ the migrant women workers have gained in the place of origin and in destination although the places of origin and destination also represent geographic ‘space’.

Feminization of poverty was identified as the prime force leading women to labour migration abroad. Labour trafficking by brokers and forceful adoption of illegal or informal routes are fostering exploitation and abuse while policy constraints are causing structural inequalities and exclusion of women labour migrants. Existing exploitation and exclusion have devalued the contribution of migrant women workers in the household economy and remittance contribution to the state despite the earning of migrant women worker effectively utilized in the welfare of family and household livelihoods and remittance from migrant women worker is notably high and is ever increasing in Nepal. In the host societies, exploitation and exclusion demoralised the migrant workers’ invaluable contribution to the welfare of the families of host household. This form of exclusion can have serious implication in the ever growing demand for foreign workers in Gulf region. Furthermore, exploitation and exclusion of migrant women workers also implicate negatively in the household economy of the labour supplying households.

The migrant women also experienced psycho-social suffering during the stay abroad. Broken families, spousal break-ups, rejection from family and society on arrival are notably reported forms of exclusion. The state mechanisms demonstrates women labour migration as a matter of pride on the basis of their remittance contributions, however, migrant women have a lot of constrains and suffering and neither the households and communities nor the state is acknowledging the overall contribution of migrant women workers. Consequently, the issues of labour migration such as easy, safe and exploitation free engagement of women in foreign labor migration have not been addressed well by the migration policy of Nepal.

Key Words: Women Labour Migration, Remittance Contribution, Social Exclusion, Exploitation of Women, Social cost, Gulf Region, Pokhara, Nepal.

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Return of the Nepalese Coal Mine Migrant Workers
Rashmi Upadhyay, PhD Candidate, Department of Anthropology, NEHU and Aarhus University, Denmark

Abstract: The present paper is an ethnographic account of the Nepalese migrant workers living and working in the coal mines in Jaintia Hills, Meghalaya. Most of the workers working in the selected coal mining area of the Jaintia Hills hail from Bhojpur district of Eastern Nepal. The paper works on return migration and it argues that, for the majority of the Nepalese migrant workers, working in the coal mines is not temporary; rather an experience of circular migration. Return, here is used as an analytical concept which can both be seen as an imagined and actual return migration of the Nepalese migrant workers. The meaning of home and belonging for Nepalese migrant workers changes overtime. On the one hand, the Nepalese migrant workers continuously complain about the grueling condition of the coal mines and repeatedly insist that they would leave this ‘foreign land’ and return to Nepal permanently and on the other hand, those who already left for Nepal or find jobs outside often return to the coal mines within a few months. Thus, based on multi-sited fieldwork among the a population of Nepalese coal mine migrant workers who move between the coal mines in Meghalaya, India and their core areas of origin in eastern Nepal, this paper gives a detailed description about those who return to Nepal; those who stay back in the coal mines and also for those who experience circular migration.

Key words: Nepalese migration, coal mines, Nepal, return

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Transparency and Disaster: Tales from the Reconstruction of Post-Earthquake Nepal
Andrew Haxby, PhD Candidate, Anthropology (Expected), University of Michigan, Ann Arbor, USA

Abstract: Though it is banal to say the series of earthquakes that hit Nepal this last spring will radically change the country, what this change will consist of still remains undetermined. As government-led reconstruction efforts meander forward with little noticeable effect, and as many earthquake victims learn to make do in broken houses, tents or corrugated tin structures, post-earthquake Nepal seems held within a frustrating kind of stasis, wherein temporary hardship is often impossible to distinguish from lasting consequence. Yet this sense of stasis is in part misleading. While the act of building houses remains stymied for many, reconstruction has nevertheless radically changed the relationship between everyday life and bureaucratic documents. This, I argue, is an effect of major importance. While historically the relationship between everyday life and bureaucratic documentation—including land ownership registration, building approvals or the collateralization of land for bank loans—has been deeply mediated by informal arrangements, now families are being forced to create documents that renders their lives “transparent” in order to access government aid and receive permission to rebuild. Whether it be updating land deeds that remain registered to deceased relations or dealing with their destroyed house’s encroachment onto government land, this reckoning between life and its documentation has created a cascade of interpersonal drama as families scramble to create representations of themselves that best suit their economic interests. My paper follows this process. Focusing on two heavily damaged areas—namely central Patan and a village in Rasuwa—I analyze how this reckoning between life and bureaucracy continues to disrupt informal arrangements, while also making space for new arrangements to emerge. Indeed, informality is hardly disappearing, but is adapting quickly to the new procedures being imposed on earthquake victims. By telling this story, I aim to critique those who see Nepal’s reconstruction program hinging on its transparency, arguing instead that this pursuit of unmediated representation can itself lead to unintended consequences and disenfranchisement, and also may in part be to blame for Nepal’s delayed rebuilding.

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Dashain Celebration among the Tamang Community and Producing Doxa: An Indigenous Perspective
Tek Bahadur Dong, M. Phil. Anthropology (Ongoing), Tribhuvan University, Nepal

Abstract: This paper examines the celebration of Dashain, the most celebrated Hindu festival in Nepal, by the Buddhist Tamang people of Kavre district.  Many ethnic activists and scholars argue that Dashain and its patronizing by the state is a continual process of creating Hindu cultural hegemony in Nepal. Since the early 1990s, indigenous and other non-Hindu groups have also ‘boycotted’ Dashain as a way of resisting the Hindu state and reclaiming their distinct cultural and religious identities.  However, many indigenous and non-Hindu groups such as the Tamangs of Kavre district continue to celebrate Dashain as one of their own cultural events.  In this paper, I focus on the ways in which the Tamangs of Kavre areas have indigenized the Dashain festival, and how they debate about the festival.  Drawing on the practice theory of Pierre Bourdieu, his concept of ‘doxa’; interviews with different age groups and genders of the study area; and my own observations and reflections from this village, I discuss how the interplays of peoples’ habitus based on the centrality of kinship, the ways in which people objectify their social structure through Dashain, and the dominant local cultural interpretations contribute towards the continual celebration of the festival by the local Buddhist Tamangs.

In terms of the social and cultural significance of the Dashain, there exist multiple meanings and even conflicting understandings about the festival. Some groups want to continue celebrating Dashain as a communal event while others emphasize that they should boycott it.  The continual celebration of Dashain by the Buddhist Tamang should not be simply seen as an example of Hinduization and their acceptance of Hindu cultural hegemony. I argue that we need to understand how Dashain has become a doxa through people’s collective practice and what meanings people assign to these practices.  According to Bourdieu, doxa is condition of people’s thinking where cultural practice fit the objective structure. The doxic reality of Dashain is now also being challenged, particularly by the young generations. However, their effort of boycotting Dashain and promoting Lhochhar as the alternative to the Dashain has not become effective so far at the local level. The paper also highlights this cultural politics for and against the celebration of Dashain in order to demonstrate cultural equality in multicultural society. One group of activist-scholars argue in favor of cultural identity, recognition, and respect of other’s culture while others hardly accept it as these issues were driving from nationalist movements lead by minority groups and subaltern groups. Nonetheless, social justice is become a key and common issue in contemporary society in order to create a new humanity and social dignity.

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Panel: Evaluating the Impact of Migration in Nepal
Paper 1: Migration of Health Workers from Nepal
Bandita Sijapati, Research Director, Centre for the Study of Labour and Mobility, Social Science Baha; Jeevan Baniya, Researcher, Social Science Baha;  Neha Choudhary, Research Associate, Centre for the Study of Labour and Mobility, Social Science Baha

Paper Abstract: Nepal has witnessed the out-migration of health personnel, especially doctors and nurses to the countries of the Global North. A few studies have explored the out migration of health workers from Nepal but little is known about the actual numbers of health workers leaving the country, the policies governing such movement and the consequent impact of the migration of this section of skilled population. The major destination countries for the migration of nursing professionals include United Kingdom, United States of America and Australia. Since Nepal stands as one of the 57 countries listed by the WHO facing critical shortages of health workers, the current outflows is likely to exacerbate the negative impacts already visible in terms of the effectiveness and quality of health service delivery.

The paper will be based on findings from a survey conducted in the Kathmandu Valley among 600 participants consisting of final-year MBBS and nursing students along with literature review, focus group discussions with different groups of medical professionals, and interviews with key individuals and organisations. The paper will provide a comprehensive overview of the patterns, governance and consequences of out-migration of health workers from Nepal while also contributing to knowledge-building that will inform policy to effective management of migration of health workers abroad. More specifically, it will look at major trends, push and pull factors, legal framework and mechanisms; initiatives taken to retain health workers, and impact of the outflow of such a group, among others.

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Paper 3: Urbanization and the Transient Migrant Labourer
Bandita Sijapati, Research Director, Centre for the Study of Labour and Mobility, Social Science Baha; Sambriddhi Kharel, Researcher, Social Science Baha; Anish Bhandari, Research Associate, Social Science Baha

Paper Abstract: In Nepal, as in other developing countries, migration has been considered a powerful factor for social change. The construction industry and contemporary investments in infrastructure are potentially acting as powerful pull factors for internal labor migration, including for more specialized construction labor throughout the year –the share of the construction industry in non-agricultural wage employment in Nepal has grown from 30% during 1995/96 to 37% during 2010/11

This paper will present findings of research on the urbanization-migration nexus with the construction industry as a proxy for urbanization in Kathmandu, Nepal.  It examines how investments in urban construction and its concurrent demand for labour is giving rise to new and varied temporal forms of migration. The study is based on 83 in-depth interviews conducted with people working in the construction industry, mainly laborers (men and women), professionals, contractors and petty contractors engaged in three different construction sites in Kathmandu valley from September 2014 to March 2015.  More specifically, the study explores the migrant workers’ paths and trajectories leading them from their place of origin to the present construction project. It also highlights the contractual arrangements between the worker and the contractor/company with a focus on the contracting process, wages, and benefits, the worker’s living arrangements and access to services. Finally, it looks at the aspiration of workers vis-a-vis their future plans for work and residence and their assessment of what has been lost and gained in the migration process.

Study results indicate that unless there is an explicit policy privileging the recruitment of locals, urbanization as exemplified by the growth of construction industry, is fuelled largely by migrants, both internal and from India. The study also demonstrates that due to benefits accruing to migrant workers and their families especially in the form of internal remittances, internal migration serves as a crucial livelihood strategy for the poor and hence can have a positive impact on development and poverty reduction. There is a need to create increased awareness, especially through additional study on the potential contribution of internal migration to poverty reduction and economic development.

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Panel: The Use of Social Sciences Methods in Mental Health Research and Intervention Design in Nepal
Proposed Chair: Brandon Kohrt, MD, PhD Assistant Professor, Psychiatry, Global Health and Cultural Anthropology, Duke Global Health Institute, Durham, USA
Proposed Discussant: Kapil Dahal, PhD Candidate, Faculty of Humanities and Social Science, Tribhuvan University, Kathmandu, Nepal (2012-2016).

Panel Abstract: There has been limited use of sociological and anthropological methods for understanding public health issues in Nepal [1-3]. In the area of mental health, specifically, these methods may provide unique insights into the experiences, expressions and healing of mental illness in Nepal [1, 3]. With increasing biomedical psychosocial interventions in Nepal, it is crucial to employ social science approaches that inform the development of mental health services.

In this panel, we emphasize the importance of social science methods in the field of mental health research and intervention. First, Angdembe discusses on the use of traditional qualitative social sciences method of focus group discussions (FGDs) and key informant interviews (KIIs) to design a culturally adapted, community-based mental health intervention in Pyuthan. Second, Rai talks about the use of anthropological techniques of Life Trajectory Interviews (LTI) and Card Sorting techniques to identify potential areas of mental health intervention aimed at improving well-being across the lifespan in Jumla. Finally, Subba explains on moving away from the traditional biomedical model of top-down symptom checklists towards the use of innovative, narrative-based mental illness detection strategies in Chitwan.

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Paper 1: Qualitatively Exploring the Adaptation of Community Mental Health Services in Pyuthan, Nepal
Mangesh Angdembe, Project Coordinator, Transcultural Psychosocial Organization (TPO) Nepal; Kohrt Brandon, Assistant Professor of Psychiatry, Global Health, and Anthropology; Mark Jordans, Director, War Child Holland, Department of Research and Development; Damodar Rimal, Senior Officer/Research, Transcultural Psychosocial Organization (TPO) Nepal; and Nagendra Prasad Luitel, Research Manager, Transcultural Psychosocial Organization (TPO) Nepal

Paper Abstract: There is long history of using social sciences theory and methods in the fields of health and development to examine a range of public health issues in Nepal. Anthropologists have used interdisciplinary approaches to make public health interventions more culturally relevant in community settings[1-3].

However, there is a lack of systematic approaches to identify and address barriers to development and uptake of community-based mental health and psychosocial programs [4].

This formative study aims to qualitatively identify resources, challenges, and potential barriers to development and implementation of culturally adapted community-based mental health programs in accordance with the mental health Gap Action Programme (mhGAP) for persons with severe mental disorders and epilepsy. Focus group discussions (n=9) and key informant interviews (n=26) were conducted in the community including key policy makers, health workers, service users, community leaders and traditional healers. Purposive and snowball sampling techniques were used to recruit participants. The coding structure included a priori themes based on the study objectives. Grounded theory was used to code emergent themes and analyses was conducted using the Framework Analysis Method [5].

The study led to a range of recommendations for the adaptation and implementation of community mental health programs. This included duration of mental health trainings, content for myths and facts related to mental health and treatment, availability of psychotropic medication, government medication policies, selection of community resource persons and using technology to support integration of mental health services into existing health systems with an ultimate aim to narrow the treatment gap in the sector of mental health in Nepal.

Reference:
1. Harper, I., Interconnected and interinfected: DOTS and the stabilisation of the tuberculosis control programme in Nepal. The aid effect: Giving and governing in international development, 2005: p. 126-149.
2. Pigg, S.L., The Politics of Development and the Politics of Health : Contradictions of AIDS Prevention in Nepal. Feminist Political Economy – Marie – France Labrecque, 2011: p. 1-24.
3. Justice, J., Policies, Plans, & People. Foreign Aid and Health Development, Berkeley. 1986, Los Angeles: University of California Press.
4. Jordans, M.J.D., et al., Setting priorities for mental health care in Nepal: a formative study. BMC psychiatry, 2013. 13(1): p. 332.
5. Lacey, A. and D. Luff, Qualitative data analysis. 2001: Trent Focus Sheffield.

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Paper 2: Adolescent Aspiration Models and Mental Health
Sauharda Rai, Research Associate, Duke Global Health Institute (DGHI), Duke University, USA; and Kohrt Brandon, Assistant Professor, Psychiatry, Global Health, and Anthropology, Duke University

Paper Abstract: Adolescent aspiration models influence people’s behavior choices and exposure to risk and protective factors, which influence adult mental health [1]. There have been various public health and clinical studies that are aimed at improving these models to try to change behavior and decrease risk factors with the ultimate aim of improving psychological wellbeing [2]. The objective of this study was to identify adolescent aspiration models in a high-risk, rural Nepali setting to identify potential areas of intervention to improve adolescent mental health. The study used well-established social sciences elicitation techniques to understand the cultural pathway for adult life course [3, 4](Bernard, 2011 #1). Life Trajectory Interviews (LTI) were conducted among adolescents aged 15-19 years, their parents and teachers (n=20). Qualitative analysis of the interviews formed the basis for identification of items for a card sorting activity. Card sorting was then conducted among adolescents aged 15-19 years (n=72).

Culture and the transition process to adulthood were seen as the major factors shaping the adolescent’s perception of how an “ideal person” should look. This, along with gender as a confounding factor, shaped their life goals. Education and employment were seen as top priorities, both in terms of importance and timeline. Four risk factors were identified: violence, disruptive behavior, alcoholism and suicide. Alcoholism was the strongest risk factor that further led to violence and suicide. Increased acceptability of alcohol across caste and gender was also identified.

There is a need to engage in culturally compelling models for promotion of adult mental health. In Jumla, interventions need to be focused on improving education and opportunities for employment with delayed engagement in marital and family goals. Interventions should also focus on peer transmission of cultural models related to risky behaviors such as alcohol use, violence and attempted suicide [5].

Reference:
1. Clarke, P., et al., The social structuring of mental health over the adult life course: advancing theory in the sociology of aging. Social Forces, 2011. 89(4): p. 1287-1313.
2. Jordans, M.J.D., et al., Evaluation of a classroom‐based psychosocial intervention in conflict‐affected Nepal: a cluster randomized controlled trial. Journal of Child Psychology and Psychiatry, 2010. 51(7): p. 818-826.
3. Bernard, H.R., Research methods in anthropology: Qualitative and quantitative approaches. 2011: Rowman Altamira.
4. Brown, R.A., et al., The Life Trajectory Interview for Youth (LTI‐Y): method development and psychometric properties of an instrument to assess life‐course models and achievement. International journal of methods in psychiatric research, 2006. 15(4): p. 206-15.
5. Birmaher, B., et al., Psychosocial functioning in youths at high risk to develop major depressive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 2004. 43(7): p. 839-846.

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Paper 3: Narrative Approaches for Community Detection of Mental Health Problems in Chitwan, Nepal
Prasansa Subba, Masters of Philosophy (MPhil) in Public Mental Health, University of Cape Town, South Africa; Nagendra Prasad Luitel, Senior Officer/Research, Transcultural Psychosocial Organization (TPO) Nepal; Mark Jordans, Director, War Child Holland, Department of Research and Development; and Kohrt Brandon, Professor of Psychiatry, Global Health, and Anthropology, Duke University

Paper Abstract: Historically, assignment of mental health diagnoses has relied more on completion of top-down checklists of symptoms that are administered by trained health professionals. [1].  This approach may be problematic due to its limitations on the fact that they are developed in different settings and lacks the local touch.  Community-based detection approaches that provide agency to patients and community members may be a viable alternative to the standard biomedical approach. Highlighting this, we developed a culturally contextualized, picture based narrative instrument called the Community Informant Detection Tool (CIDT) for the detection of five common mental health problems in Nepal – epilepsy, alcoholism, depression, psychosis and behavioral disorder.

This study describes the stepwise development of the tool. First, a draft tool consisting of narrative descriptions of each 5 disorder using symptom descriptions grounded in local language was developed in collaboration with 25 mental health professionals. Anyone with some degree of match with the picture- narrative and identifying with “need for support” and/or “functional impairment” was deemed to be at risk for having the identified mental health problem and advised to seek clinical services. Second, two rounds of qualitative data collection consisting of key informant interviews and focus group discussions were conducted with purposively selected community informants (n=31). These methods assessed the comprehensibility and applicability of the tool, and specifically identified possible improvements that could be incorporated. Upon integrating these recommendations, a pilot survey (n=105) was conducted to assess the feasibility of the tool. The survey findings indicated that all five vignettes were feasible and comprehensible in the detection of community individuals. Nearly 75% of the sample considered the tool feasible and easy to understand. Further, all respondents were willing to use the tool to identify persons with mental illness.

As Patel [4] states,, paying attention to cultural nuances facilitates accurate detection and help seeking behaviors among persons with mental illness. As a feasible and comprehensible instrument, CIDT is a narrative-based tool that may be used by lay community members with low literacy levels.

Reference:
1. Holloway, R., Illness narratives: facts or fiction? Sociology of Health & Illness, 2001. 23(3): p. 263-285.
2. Lewis, B., Narrative and Psychiatry. Current opinion in psychiatry, 2011. 24(6): p. 489-494.
3. Petraglia, J., Narrative Intervention in Behavior and Public Health. Journal of Health Communication, 2007. 12(5): p. 493-505.
4. Patel, V., Cultural factors and international epidemiology Depression and public health. British Medical Bulletin, 2001. 57(1): p. 33-45.

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