COVID-19 is a global health crisis that has challenged everyone, with severe implications for vulnerable groups across the globe. Countries are adopting several strategies to curb the spread of the pandemic through contact tracing, quarantining, lock-down measures, and creating containment zones. Whilst seen as necessary, these measures are contributing to the significant Mental Health repercussions of the pandemic.

Furthermore, though these strategies claim to halt the spread of the pandemic, they have not included in their design an understanding of the needs and realities of many vulnerable groups, thereby miserably failing them.

News reports highlight scenes from the urban context that cover myriad issues ranging from economic, political, human rights, public health measures and marginal groups; however the focus on the impact of COVID-19 on the rural community in India is scarce. With increasing uncertainties about future, eroding livelihood options and existing deprivations, there are obvious mental health consequences of the COVID-19 lock down in rural context, and thus it is crucial to improvise mechanisms to mitigate the stress experiences.

Exploring rural mental health:

The rural population of India forms approximately 68% of the total according to the data provided by Census 2011. Even with the large majority of the population residing in rural

areas we see comparatively lesser mental health interventions and initiatives in rural areas than urban contexts. Several studies have articulated the reasons as insufficient mental health workforce, limited accessibility to structures providing mental healthcare and poor mental health literacy amongst the population ^{[1, 2, 4].}

The dismal number of reported mental health professionals in India ^[6] reflects the need to build community-based models of healthcare ^[7] and work from a positive mental health perspective. This calls for appropriate training towards capacity building of human resources and has been demonstrated through the training of accredited social health activist (ASHA) workers through several initiatives to identify and respond to mental health issues ^{[1, 3, 4, 5, 7]}. These programs respond to the need to bridge the gap in access to mental health services and empower persons within the community, equipping them with skills to identify and respond to mental health issues and crisis situations.

Within the rural context, the tribal communities were always vulnerable to mental health concerns as on one hand they are exposed to risk factors for poor mental health, such as low socio-economic status, deprivations which are rooted in historical structural inequities and on the other hand lack resources to access mental health care, support and treatment; people in the rural context experience and articulate stress and anxiety in their everyday language.

Community based approach for tribal mental health:

Aghai Gram Panhayat, situated in Shahapur Taluk of Thane District in Maharashtra is 47.9 km far from its District Main City, Thane, and 14.9 Km from the main town of Shahpur. Pragati [Integrated Rural Health and Development Project (IRHDP)], a Field action project of TISS is located in Aghai GP and is working in 6 surrounding tribal padas. The project, has been working on the interlinked concerns-health, livelihood and skills enhancement in the tribal padas since 1986.

The work of the project is influenced by the correlation between poverty, place, health and mental health and its influence on various aspects of development, particularly economic which in turn influence mental health. Pragati adopts a Mental health promotion framework, particularly targeting the social determinants and engages with diverse stakeholders in the tribal community. Intervention strategy follows the understanding that involvement at a community level through a focus on nutrition, education, livelihoods, coping strategies, etc.

can provide a supportive frame for people to come out of poverty and experience positive mental health ^[9]

Figure 1: SOURCE: WHO [9]

The project also aims to equip the skills of diverse stakeholders in the community to respond to mental health concerns.

Over the years the project has built mechanisms for a holistic model of community mental health care addressing several social and economic determinants of Mental Health, always

recruiting local resources to work for the project, training them and engaging with them

systematically on varied concerns. In fact, this cadre of pada workers and youth volunteers proved to be the strength amidst this chaos created by the lock down – their existence meant that work could restart in the padas even after all travel channels were blocked.

For the past 2 years, the project has been intervening in the context of children studying in Ashramshalas with the intention to promote mental health by enhancing abilities through skill training and also to address the issue of suicide amongst children living in the Ashramshalas by working with the superintendents on a MH promotion and suicide prevention campaign. The idea is to not simply work with the children to promote wellbeing rather to also work with the environment through the capacity building of key stakeholders (pada workers and

other community stakeholders)enhancing their capabilities to address some of the social determinants of health particular to this context.

Despite all these mechanisms, as the gravity of the pandemic hit and lockdown ensued, the team was faced with many challenges. Identifying the emerging needs of the people through dialogue, the project team began to map out ways to respond to them. The fundamental intention held by the team was to understand and document the mental health consequences of the COVID-19 lockdown in the tribal padas; with goals to improvise existing resources in the community and to intervene from a distance. In order to understand the influence of the pandemic to mental health and explore intervention points amidst challenges and possibilities in a resource poor setting interactions are underway with:

1. Vulnerable groups (Ashramshala children, women) in the padas
2. Pada workers and youth volunteers

The more the social workers interacted with people during the pandemic the more the team began to reflect upon the challenges of operating from a distance with the given technological and economic constraints of the context.

Immediate interventions and reflections- Vulnerable groups and emerging needs:

The both virtual and real time group sessions with the children revealed that the lockdown and the pandemic is a vague concept yet for them. Predominantly, they know that there is an illness because of which they have to wear face masks, because of which their school schedules have changed and because of which they were unable to answer their 10^th grade geography papers. They have picked up the novel term ‘social distancing’, but for the vast majority, things haven’t really changed.

Figure 2 Session with Children by our pada worker

Most of them don’t have TV’s at home, and used to spend time in nature or playing in the open fields; girls are involved with household activities including fetching water from a water source near the home, while the boys are more involved in helping with the farming. Besides, this is the summer vacation period and it seems like an extension of the same to them. They have not found any drastic change in their routine and thus did not articulate stress during the sessions.

The adults on the other hand are affected acutely, particularly the men who are the heads of households, with the number of stressors increasing day by day.

For the men, the year is divided into 2 phases – January to May they work in cities to generate income, although this is meager given that the population does not have the formal educational certifications for skilled labour; and what they earn, they invest into farming for the rest of the year. The advent of the lock down situation has seen all of the men in the padas return in March itself. This means that they have less income this year and are anxious about the farming months. There has been no time to prepare and no clarity what to work towards. Many of them have told the community workers that there is very little money left over to invest in buying seeds for farming, and are stretching resources even for basic necessities and food. Women in the community articulated stress and fear. As the men are returning back from towns and ASHAs emphasizing on quarantine, they were gripped with anxiety over the sudden changes and uncertainty. The routine procurement of dry ration and access to PHC, water sources – suddenly became a challenge to access within the lockdown, fraught with risk and anxiety. To try and contextualize these responses, a pada worker

shares:“Life has always been difficult for us, now it has become much more difficult”. They are aware that this is not a short term issue, rather one with long term implications; and painfully aware that they neither have access to the resources nor a control on the supply chain. The angst that they are feeling is justified, with no income stability and uncertainty surrounding any measures for their welfare.

Adopting a social work perspective allowing space for the voices of the people to influence the flow of intervention, the projects ought to respond to these stressors and potential risk factors. Influenced by the lens that Mental Health exists within a context influenced by various social determinants that can be addressed to minimize risk, the immediate concerns as identified by the community members were addressed through these relief measures.

1. 1. Supporting the pada workers with information for the household quarantine, information on dispelling myths and the significance of empathetic communication. The project team with the support of some volunteers collated awareness materials regarding Corona Virus and the preventive measures for pada workers in Marathi. The social worker sent materials, trained the pada workers and clarified their doubts telephonically.
   2. Distribution of dry ration kits and essential nutrients for 150 households, masks and sanitisers to PHC and ASHAs
   3. Spreading awareness on precautionary measures to combat COVID-19 and dispel the myths and misconceptions on COVID-19

The coming months will see the project and the community workers working on economic stability and access to resources and livelihoods linking to government schemes; ensuring that the population is aware of and able to access their rights alongside working on direct mental health outcomes. It will also require the team to employ foresight to identify vulnerable groups within the community and work to build coping skills and directly address other risk factors.

Possibilities and challenges:

In terms of direct mental health promotion, the lockdown poses difficulties in getting trained personnel into the community, while the context holds technological impediments to virtual programs (connectivity, low economic resources) coupled with the difficulty in arranging group meets because of the nature of the pandemic and the essence of the lockdown.

The need to work with the youth to minimize the effects of the possibility of future adversity by building healthy coping skills is paramount, particularly when anticipating that the impact to children would be felt most in the period of June – July, when schools usually begin.

To work through these issues the team has proposed to undertake a 2 pronged method of intervention that relies on the resources available to us now:

1. Ongoing capacity building of the community workers who are already responding on the ground to the needs of the people, who are part of the community itself to identify and respond to mental health needs. The project will facilitate and evolve interventions to promote mental wellbeing by enhancing protective factors, optimizing the available social resources with an attempt to augment resilience amidst stress. This involves regular telephonic/virtual sessions with the community workers with and an attempt to build a peer support network
2. Direct intervention through the community workers including linking to services that exist in the community (telephone counseling services) and with important stakeholders in community mental health in the area – health care providers, teachers, authorities of school systems, parents and families

Conclusion

Working from a distance became feasible because of the project’s key strategy of enhancing local resources and training local community members, particularly women. Community engagement is vital not only for the sustainability and efficiency, but also proved effective during this unanticipated and unprecedented crisis. There is a sense of agency, ownership, mutual trust and willingness to respond and act.

Currently, the project has initiated conversations with all stakeholders and handholding of the people along the way to address their fears and anxiety. The uncertainty around livelihood and materialistic constraints add to their stress levels, the project takes an upstream approach to address these determinants. Working in resource poor settings is a definite challenge and continuous improvisation is crucial the upcoming months will be vital to social workers, community workers and mental health professionals to be able to understand, anticipate and innovate to minimize the impact of the social effects of the virus on mental health.

References

1. Maulik, P. K., Kallakuri, S., Devarapalli, S., Vadlamani, V. K., Jha, V., & Patel, A. (2017): Increasing use of mental health services in remote areas using mobile technology: a pre-post evaluation of the SMART Mental Health project in rural India. Journal of global health, 7(1), 010408.

Available on: https://doi.org/10.7189/jogh.07.010408 (last accessed 18/05/2020)

2. Kumar, A. (2011): Mental health services in rural India: challenges and prospects. Health, 3, 757-761.

Available on https://file.scirp.org/Html/9049.html accessed 19.05.2020, (last accessed 19.05.2020)

3. Kallakuri S, Devarapalli S, Tripathi AP, Patel A, Maulik PK. Common mental disorders and risk factors in rural India: baseline data from the SMART mental health project. BJPsych Open. 2018;4(4):192‐198. Published 2018 Jun 22. doi:10.1192/bjo.2018.28.

Available on: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6034434/(last accessed 19/05/2020)

4. Armstrong, G., Kermode, M., Raja, S., Suja, S., Chandra, P., & Jorm, A. F. (2011). A mental health training program for community health workers in India: impact on knowledge and attitudes. International journal of mental health systems, 5(1), 17.

Available on: https://doi.org/10.1186/1752-4458-5-17 (last accessed 18.05.2020)

5. Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al.: National Mental Health Survey of India, 2015-16: Prevalence, Patterns and Outcomes, NIMHANS Publication No. 129. Bengaluru: National Institute of Mental Health and Neuro Sciences; 2016.

Available on http://indianmhs.nimhans.ac.in/Docs/Report2.pdf. (last accessed on 18.05.2020)

6. WHO (2011) – Mental Health Atlas 2011, India Profile Available on:

https://www.who.int/mental_health/evidence/atlas/profiles/ind_mh_profile.pdf(last accessed on 18.05.2020)

7. Kallivayalil RA, Enara A.: Prioritizing rural and community mental health in India. Indian J Soc Psychiatry 2018, 34:285-8.

Available on: http://www.indjsp.org/text.asp?2018/34/4/285/245656. (last accessed on 19.05.2020)

8. Ng C, Chauhan AP, Chavan BS, Ramasubramanian C, Singh AR, Sagar R, Fraser J, Ryan B, Prasad J, Singh S, Das J, Isaac M.(2014): Integrating mental health into public health: The community mental health development project in India. Indian J Psychiatry 2014

Available on: http://www.indianjpsychiatry.org/text.asp?2014/56/3/215/140615 (last accessed 19.05.2020)

9. WHO: Breaking the Vicious Cycle between Mental Health and Poverty, The WHO MIND ProjectAvailable on: https://www.who.int/mental_health/policy/development/1_Breakingviciouscycle_Infosheet.p df?ua=1, accessed 24^th May 2020