Understanding psychological distress among mothers in rural Nepal: A qualitative grounded theory exploration

Kelly Clarke; Naomi Saville; Bishnu Bhandari; Kalpana Giri; Mamita Ghising; Meena Jha; Sonali Jha; Jananee Magar; Rinku Roy; Bhim Shrestha; Bhawana Thakur; Rinku Tiwari; Anthony Costello; Dharma Manandhar; Michael King; David Osrin; Audrey Prost

doi:10.1186/1471-244X-14-60

Understanding psychological distress among mothers in rural Nepal: A qualitative grounded theory exploration

Kelly Clarke^*, Naomi Saville, Bishnu Bhandari, Kalpana Giri, Mamita Ghising, Meena Jha, Sonali Jha, Jananee Magar, Rinku Roy, Bhim Shrestha, Bhawana Thakur, Rinku Tiwari, Anthony Costello, Dharma Manandhar, Michael King, David Osrin, Audrey Prost

^*Corresponding author for this work

Research output: Contribution to journal › Article › peer-review

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Abstract

Background: There is a large burden of psychological distress in low and middle-income countries, and culturally relevant interventions must be developed to address it. This requires an understanding of how distress is experienced. We conducted a qualitative grounded theory study to understand how mothers experience and manage distress in Dhanusha, a low-resource setting in rural Nepal. We also explored how distressed mothers interact with their families and the wider community.Methods: Participants were identified during a cluster-randomised controlled trial in which mothers were screened for psychological distress using the 12-item General Health Questionnaire (GHQ-12). We conducted 22 semi-structured interviews with distressed mothers (GHQ-12 score ≥5) and one with a traditional healer (dhami), as well as 12 focus group discussions with community members. Data were analysed using grounded theory methods and a model was developed to explain psychological distress in this setting.Results: We found that distress was termed tension by participants and mainly described in terms of physical symptoms. Key perceived causes of distress were poor health, lack of sons, and fertility problems. Tension developed in a context of limited autonomy for women and perceived duty towards the family. Distressed mothers discussed several strategies to alleviate tension, including seeking treatment for perceived physical health problems and tension from doctors or dhamis, having repeated pregnancies until a son was delivered, manipulating social circumstances in the household, and deciding to accept their fate. Their ability to implement these strategies depended on whether they were able to negotiate with their in-laws or husbands for resources.Conclusions: Vulnerability, as a consequence of gender and social disadvantage, manifests as psychological distress among mothers in Dhanusha. Screening tools incorporating physical symptoms of tension should be envisaged, along with interventions to address gender inequity, support marital relationships, and improve access to perinatal healthcare.

Original language	English
Article number	60
Pages (from-to)	1-13
Journal	BMC Psychiatry
Volume	14
Early online date	1 Mar 2014
DOIs	https://doi.org/10.1186/1471-244X-14-60
Publication status	Published - 1 Mar 2014

Keywords

Maternal mental health
Nepal
Perinatal common mental disorders
Postnatal depression
Psychological distress
Rural health
South Asia

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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Understanding psychological distress among_CLARKE_Accepted19Feb2014_ePublished1March2014_GOLD VoR (CC BY)Final published version, 603 KBLicence: CC BY

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Clarke, K., Saville, N., Bhandari, B., Giri, K., Ghising, M., Jha, M., Jha, S., Magar, J., Roy, R., Shrestha, B., Thakur, B., Tiwari, R., Costello, A., Manandhar, D., King, M., Osrin, D., & Prost, A. (2014). Understanding psychological distress among mothers in rural Nepal: A qualitative grounded theory exploration. BMC Psychiatry, 14, 1-13. Article 60. https://doi.org/10.1186/1471-244X-14-60

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abstract = "Background: There is a large burden of psychological distress in low and middle-income countries, and culturally relevant interventions must be developed to address it. This requires an understanding of how distress is experienced. We conducted a qualitative grounded theory study to understand how mothers experience and manage distress in Dhanusha, a low-resource setting in rural Nepal. We also explored how distressed mothers interact with their families and the wider community.Methods: Participants were identified during a cluster-randomised controlled trial in which mothers were screened for psychological distress using the 12-item General Health Questionnaire (GHQ-12). We conducted 22 semi-structured interviews with distressed mothers (GHQ-12 score ≥5) and one with a traditional healer (dhami), as well as 12 focus group discussions with community members. Data were analysed using grounded theory methods and a model was developed to explain psychological distress in this setting.Results: We found that distress was termed tension by participants and mainly described in terms of physical symptoms. Key perceived causes of distress were poor health, lack of sons, and fertility problems. Tension developed in a context of limited autonomy for women and perceived duty towards the family. Distressed mothers discussed several strategies to alleviate tension, including seeking treatment for perceived physical health problems and tension from doctors or dhamis, having repeated pregnancies until a son was delivered, manipulating social circumstances in the household, and deciding to accept their fate. Their ability to implement these strategies depended on whether they were able to negotiate with their in-laws or husbands for resources.Conclusions: Vulnerability, as a consequence of gender and social disadvantage, manifests as psychological distress among mothers in Dhanusha. Screening tools incorporating physical symptoms of tension should be envisaged, along with interventions to address gender inequity, support marital relationships, and improve access to perinatal healthcare.",

keywords = "Maternal mental health, Nepal, Perinatal common mental disorders, Postnatal depression, Psychological distress, Rural health, South Asia",

author = "Kelly Clarke and Naomi Saville and Bishnu Bhandari and Kalpana Giri and Mamita Ghising and Meena Jha and Sonali Jha and Jananee Magar and Rinku Roy and Bhim Shrestha and Bhawana Thakur and Rinku Tiwari and Anthony Costello and Dharma Manandhar and Michael King and David Osrin and Audrey Prost",

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Clarke, K, Saville, N, Bhandari, B, Giri, K, Ghising, M, Jha, M, Jha, S, Magar, J, Roy, R, Shrestha, B, Thakur, B, Tiwari, R, Costello, A, Manandhar, D, King, M, Osrin, D & Prost, A 2014, 'Understanding psychological distress among mothers in rural Nepal: A qualitative grounded theory exploration', BMC Psychiatry, vol. 14, 60, pp. 1-13. https://doi.org/10.1186/1471-244X-14-60

TY - JOUR

T1 - Understanding psychological distress among mothers in rural Nepal

T2 - A qualitative grounded theory exploration

AU - Clarke, Kelly

AU - Saville, Naomi

AU - Bhandari, Bishnu

AU - Giri, Kalpana

AU - Ghising, Mamita

AU - Jha, Meena

AU - Jha, Sonali

AU - Magar, Jananee

AU - Roy, Rinku

AU - Shrestha, Bhim

AU - Thakur, Bhawana

AU - Tiwari, Rinku

AU - Costello, Anthony

AU - Manandhar, Dharma

AU - King, Michael

AU - Osrin, David

AU - Prost, Audrey

PY - 2014/3/1

Y1 - 2014/3/1

N2 - Background: There is a large burden of psychological distress in low and middle-income countries, and culturally relevant interventions must be developed to address it. This requires an understanding of how distress is experienced. We conducted a qualitative grounded theory study to understand how mothers experience and manage distress in Dhanusha, a low-resource setting in rural Nepal. We also explored how distressed mothers interact with their families and the wider community.Methods: Participants were identified during a cluster-randomised controlled trial in which mothers were screened for psychological distress using the 12-item General Health Questionnaire (GHQ-12). We conducted 22 semi-structured interviews with distressed mothers (GHQ-12 score ≥5) and one with a traditional healer (dhami), as well as 12 focus group discussions with community members. Data were analysed using grounded theory methods and a model was developed to explain psychological distress in this setting.Results: We found that distress was termed tension by participants and mainly described in terms of physical symptoms. Key perceived causes of distress were poor health, lack of sons, and fertility problems. Tension developed in a context of limited autonomy for women and perceived duty towards the family. Distressed mothers discussed several strategies to alleviate tension, including seeking treatment for perceived physical health problems and tension from doctors or dhamis, having repeated pregnancies until a son was delivered, manipulating social circumstances in the household, and deciding to accept their fate. Their ability to implement these strategies depended on whether they were able to negotiate with their in-laws or husbands for resources.Conclusions: Vulnerability, as a consequence of gender and social disadvantage, manifests as psychological distress among mothers in Dhanusha. Screening tools incorporating physical symptoms of tension should be envisaged, along with interventions to address gender inequity, support marital relationships, and improve access to perinatal healthcare.

AB - Background: There is a large burden of psychological distress in low and middle-income countries, and culturally relevant interventions must be developed to address it. This requires an understanding of how distress is experienced. We conducted a qualitative grounded theory study to understand how mothers experience and manage distress in Dhanusha, a low-resource setting in rural Nepal. We also explored how distressed mothers interact with their families and the wider community.Methods: Participants were identified during a cluster-randomised controlled trial in which mothers were screened for psychological distress using the 12-item General Health Questionnaire (GHQ-12). We conducted 22 semi-structured interviews with distressed mothers (GHQ-12 score ≥5) and one with a traditional healer (dhami), as well as 12 focus group discussions with community members. Data were analysed using grounded theory methods and a model was developed to explain psychological distress in this setting.Results: We found that distress was termed tension by participants and mainly described in terms of physical symptoms. Key perceived causes of distress were poor health, lack of sons, and fertility problems. Tension developed in a context of limited autonomy for women and perceived duty towards the family. Distressed mothers discussed several strategies to alleviate tension, including seeking treatment for perceived physical health problems and tension from doctors or dhamis, having repeated pregnancies until a son was delivered, manipulating social circumstances in the household, and deciding to accept their fate. Their ability to implement these strategies depended on whether they were able to negotiate with their in-laws or husbands for resources.Conclusions: Vulnerability, as a consequence of gender and social disadvantage, manifests as psychological distress among mothers in Dhanusha. Screening tools incorporating physical symptoms of tension should be envisaged, along with interventions to address gender inequity, support marital relationships, and improve access to perinatal healthcare.

KW - Maternal mental health

KW - Nepal

KW - Perinatal common mental disorders

KW - Postnatal depression

KW - Psychological distress

KW - Rural health

KW - South Asia

U2 - 10.1186/1471-244X-14-60

DO - 10.1186/1471-244X-14-60

M3 - Article

C2 - 24581309

AN - SCOPUS:84896715628

SN - 1471-244X

VL - 14

SP - 1

EP - 13

JO - BMC Psychiatry

JF - BMC Psychiatry

M1 - 60

ER -

Understanding psychological distress among mothers in rural Nepal: A qualitative grounded theory exploration

Abstract

Keywords

UN SDGs

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